Consultation responses analysis
RPS and The King’s Fund are developing a vision for pharmacy professional practice. A consultation on the themes opened on 15 August and closed on the 30 September 2022. 127 responses were submitted, with many participants providing additional narrative to expand upon and adapt the themes, enablers and barriers outlined in the consultation.
Over 670 additional comments were documented, they provide insight into the current context in which pharmacy teams are operating in England, detailing services delivered by specific organisations, challenges facing pharmacy teams and how they perceive the future of pharmacy professional practice in ten years’ time.
Whilst the vision is looking at professional practice in ten years, comments on current pressures such as acute workforce shortages and existing funding models were common.
Replies submitted were from a variety of stakeholders (graph 1) with representation from community pharmacy, primary and secondary care, Integrated Care Boards, BMA GPC, RCGP, NHS Confederation and academia within the responses. In addition, there were submissions from patients and their representative groups. Approximately 22% of responses were anonymous. Not all respondents answered every question, meaning some sections had fewer responses overall.
Graph 1 – Source of responses to the Vision consultation
2. Comments on the themes overall
Contributors indicated they were broadly comfortable with all six of the proposed themes, with at least 89% selecting that they felt neutral, agreed or strongly agreed with each theme (graph 2). The patient focused themes (1 to 3) which were concentrated on how pharmacy teams will better support patients and the general public, had particularly high positive engagement, along with theme 6, an enabling theme based around collaboration, integration and leadership.
The overall extent of acceptance indicates that the themes are generally representative of a vision for pharmacy practice in England over the next 10 years.
Graph 2 - To what extent do you agree the themes in the consultation document describe what pharmacy practice in England should look like in 10 years?
Theme 5, which centres around data, innovation, science and research had slightly lower rates of agree or strongly agree responses, and a higher proportion of answers indicating that participants felt neutral about the overall theme. Review of the neutral statements showed a slightly higher proportion of responses were from outside pharmacy. Conclusions are limited by the number of anonymous responses however the statements may not readily translate to a non-pharmacy audience.
Theme 1, supporting people and communities to live well for longer and theme 4, our pharmacy people, had the largest number of responses (10%) outlining that they disagreed or strongly disagreed with the themes. Several comments referenced strengthening the 3-5 year aims in theme 1, and it was noted that the Vision needed to resonate and be inclusive of the whole pharmacy workforce, including pharmacy support staff and speak to all sectors – “unless this consultation spans all pharmacy professionals it won't be a complete vision”. Adjustment of the language in the statements may help address the issues documented and feel more inclusive of the wider professions.
Responders had the opportunity to suggest additional themes for inclusion, many aligned with existing themes and statements and are therefore included for consideration within those specific areas. There were comments around overarching threads which should run throughout each theme – for example equality, diversity and inclusion, patient safety and sustainability and the approach to these areas needs to be considered in the final vision.
Graph 3 - Agreement with 3-5 year statements and 10 year descriptors
In addition to commenting on the overarching vision themes, participants were asked about the 3–5 year goals associated with each theme (graph 3). As with the themes, the 3-5 year goals had a high level of support however in almost every instance, the 10 year descriptors achieved a higher level of positive engagement compared to the shorter term goals. The 3-5 year statements for theme 1 had the lowest agreement rate at 76%. Although still well received, the 3-5 year goals can potentially be reviewed to align more closely with the themes that they support.
The next section gives detailed analysis, of each Vision theme, the associated 10 year descriptors and 3-5 year statements.
3. Analysis of consultation responses by theme
Theme 1 - Supporting people and communities to live well for longer
Many responses to theme 1 focused on integration of the whole pharmacy team within multidisciplinary teams, and across networks in the future – “the transition across the current levels of healthcare i.e. primary, secondary and tertiary would be less distinct and more seamless”. It was also noted that “all sectors of pharmacy can support this vision - not just community pharmacy” which was mentioned in several comments and may point to need to broaden the language used in some of the statements to ensure they are inclusive of all sectors.
The importance of getting patient pathways correct was the also mentioned in submissions in order to utilise the full potential of pharmacy team care, particularly in community pharmacy – “Pharmacy First needs to be prioritised to help change the patient pathway to correct care” and that there should be a focus on systems change to allow “pharmacy teams […] to seamlessly refer directly to social prescribers etc in next 3-5 years.”
There were further mentions of social prescribing initiatives to support the community - “pharmacists could have tools for people that they can prescribe, for example, gym passes, dieting programmes, counselling” to help further address health inequalities. Responses also indicated that references to public health needed to be strengthened. Submissions felt that “there needs to be more communication to help pharmacists understand health inequalities and how they truly can make a difference to this (whatever branch they are in)” and “more emphasis is needed on Social Prescribing and supporting people to keep well through healthy lifestyles.”
Furthermore, whilst digital poverty was referred to in point f of the 10 year descriptors, several contributions stressed that this was a significant issue. It was acknowledged digital technology can provide solutions and widen access to healthcare, but there are patients and professionals who are not equipped to work in this way, “the concept of 'digital poverty' is too vague and ignores the diversity of those who struggle with access to digital services”.
There were some comments around the 3-5 year statements, detailing they may need work to make them truly ambitious – “in the context of the 10 year vision the 3-5 year statements lack pace and ambition” with some comments indicating they felt that they were more reflective of current practice in some areas rather than goals to be achieved in 3-5 years.
Theme 2 - Enabling people to live well with the medicines that they choose to take
Theme 2 generated many additional comments around medicines optimisation – “if this is done well it can really improve health outcomes and reduce medicines risks, including avoiding prescribing cascades. Pharmacists need to be more involved in doing what they have been trained to do, further upstream in pathways”. Importance was placed upon widening accessibility to patient records to help support this. “An integrated healthcare record accessible to all healthcare professionals is important for continuity and research.”
There were comments around de-prescribing, with several referencing the important role pharmacy teams have in this area of shared decision making – “we wish to see a greater emphasis on the importance of pharmacy staff working with other healthcare professionals to de-prescribe medicines which are no longer working correctly or required by patients to improve outcomes. De-prescribing merits its own descriptor”. There were also observations around the language used, including the phrase “medicines they choose to take” with this generating some debate as to whether this was appropriate wording for the statements.
Other submissions suggested it was important to include non-medical interventions in this section. Responses also felt that pharmacogenomics could be included and highlighted further within this theme – “add descriptors such as pharmacogenomics and therefore the prescribing of medicines with the application of this science” however it was acknowledged that pharmacogenomics is a feature in theme 5.
Comments on education and training, whilst covered in theme 4, were also present in this section – “Clear training & career pathways to be articulated with assurance of competence embedded along the way (for the specified specialist, advanced and consultant level roles). Some specialist knowledge may be core for all pharmacists” which may lead us to consider how this could be included in the statements and descriptors for this theme.
Again, it was emphasised that the whole pharmacy workforce, and all sectors of pharmacy could support this theme, and this may require some of the language used in the theme and statements to be adjusted to reflect this.
Theme 3 - Enhancing patient experience and access
Many responses submitted within this theme centred around access and funding, several specifically referring to community pharmacy contracts.
It was noted that there are significant workforce pressures and that work is needed in order to support this area of pharmacy, particularly if the sector is to advance and develop. Although commentary on funding models is outside of the scope of this work, the comments give valuable context and may inform stakeholder engagement and post implementation plans.
Again, further comments were submitted to highlight digital poverty and the impact this has upon access, “Whilst it is appropriate to propose diverse avenues to access, digital poverty must be factored in as a barrier to access and alongside plans to further incorporate patient-facing technology into daily practice,” and “experience data must be built in to ensure innovations aren’t widening inequalities and patients are supported consistently to access pharmacy in a way that works for them.” There were also submissions which flagged that it was felt there were some existing services which are not being fully utilised and therefore may require review to consider how they could offer maximal benefit, “there are already services available, such as the Discharge Medicines Service, which rely on effective communication between different parts of the healthcare system. But these services aren’t used as widely as they should be.”
A further focus was again the need for cross boundary working, with comments similar to those submitted against theme 1. It was suggested that care would be delivered nearer to the patient, with virtual wards featuring as a solution. Some submissions mentioned the need to consider community care as part of the solution to improving access, with pharmacies acting as health hubs - “there needs to be greater integration with this sector to ensure those most vulnerable being seen in the community are not disadvantaged.”
The technical expertise of the pharmacy professions was mentioned “the unique technical knowledge that the pharmacy workforce has that supports the bringing of medicines to patients - manufacturing, quality, logistics, regulatory, analytical etc. All of these skills are as crucial as the continuing development of patient facing clinical skills” and consideration should be given as to how this area is included within the vision. Alongside this, responses also noted that skill mix, with the support of protected learning time was critical to achieve the goals - “the need for protected time to allow for clinical supervision to occur, especially for IPs and DPPs. How pharmacy technicians and pharmacy assistants can help with the skill mix required.”
Comments were received which indicated that the goals around patient experience should be strengthened, “patient experience and access - including satisfaction with service, and ability to input into planning. Enhance patient understanding and literacy around pharmacies their offer and use. Consistency of provision and service. Communication and removing barriers to access e.g. language”. Further feedback on the goals highlighted “the 3-5 year ambition does not match the vision descriptors and focusses on independent prescribing. There are better 3-5 year targets in the descriptors, e.g. embedding person centred care, referral pathways, putting the pharmacist front and centre when giving out medicines so they can interact with the patient and add value, automation and skill mix”.
When reviewing the 10 year theme descriptors in particular, responders referenced shared decision making and the need to “empower patients with their medicines”, it was felt this was a necessary and important focus, and that the entire pharmacy workforce should be equipped to contribute towards the medicines optimisation agenda.
Theme 4 – Our Pharmacy People
Several submissions in theme 4 again stressed the need to include all staff groups. There were references made to ensuring that the Vision speaks to all sectors of pharmacy, and to ensure the themes, descriptors and statements referred to other sectors as well as community pharmacy. Some comments additionally focussed upon a workforce plan – “the RPS should use this vision to describe in detail what a workforce plan for the sector should look like. Recommendations on how to improve the attractiveness of the sector and scale up recruitment must be front and centre of this theme”. There were many references to flexible working, developing the pharmacy workforce of the future and making pharmacy attractive as a profession, as well as using workforce data to plan services appropriately. “Pharmacy must be widely promoted to make it an attractive career choice to ensure the appropriate number of registrants needed is maintained. The role of the wider pharmacy support team should also be promoted so that pharmacies can attract, develop and retain the workforce” and “the need for benchmarking on safe pharmacy staffing levels to know what roles are needed and where” were also referenced.
Protected learning time was a strong theme amongst several responses – with many calling for this to be written into job descriptions and aligned to the medical job planning model “totally agree with protected learning time - but must add that this needs to be fully structured with fixed dates in the diary - very much in line with that offered to doctors”. In addition, it was felt that training opportunities which should span boundaries, with clear, accredited training pathways for the workforce, “ICS to work on streamlining rotational and training contracts to enable cross-sector training pathways” and that this should be reflected in the descriptors –“how transformation of roles for pharmacists and pharmacy technicians will be recognised in the structured post registration pathways and supports collaboration and partnership working on a greater scale than just locally.”
There were a small number of comments submitted which did not align with the RPS equality, diversity and inclusivity strategy and work which is ongoing around inclusive pharmacy practice. As such, these comments were not included as part of the analysis. Other comments felt that EDI should be more prevalent and represented in the goals and descriptors – “perhaps explicit mention of the need for equality, diversity and inclusion at all levels of the profession” and advice has been sought from the Head of Professional Belonging at RPS in order to ensure the document is inclusive.
Theme 5 – Data, innovation, science and research
Comments around this theme highlighted the need for collaborative working and wider investment “it is important to recognise in this section that many of the developments needed are not within the sole responsibility of the pharmacy profession. They will need both investment, and support from government and the NHS. Many of the principles are across professions and will need a coherent strategy of implementation”.
Many made references to a shared care record and use of technology as crucial for safety of care delivery – “facilitate improved interoperability between GP and pharmacy IT systems. Ensuring that pharmacists have timely, streamlined access to patient records is vital to progressing Government ambitions for integrated care, population health management, and an expanded remit for the pharmacy sector” and “The use of artificial intelligence, app and bar code technology can improve the dispensing process as well as monitor the patient's healthcare needs.” Others felt that upskilling the pharmacy workforce was necessary in order to ensure digital technology, data and innovation could be maximised in an effective manner, with some concerns raised about the IT literacy of staff to be able to truly unlock the potential of this theme – “train pharmacists and pharmacy teams on the use of digital shared care records and other relevant technologies. Colleagues from across community pharmacy sector will need support to successfully deliver on new ways of working.”
An important focus of comments was the need to widen access to research across all sectors, with the need to consider “how research can be embedded within early careers in pharmacy and links developed with HEIs” and that research leadership needed to be reflected within the theme.
Comments mentioned that “theme 5 appears to be one of the most relevant themes in my opinion and one of the most deliverable” but that it could possibly go further in what was being proposed for 3-5 years and 10 years, for example mentioning “future technology using Artificial Intelligence, 3D medicines printing, and nanotechnology should be supported with appropriate regulatory processes to ensure the highest levels of patient safety for new and emerging technology”
Theme 6 – Collaboration, Integration and Leadership
Responses received for this theme spoke of the changing landscape, particularly in the context of ICS implementation and some highlighted that it was hard to envisage longer term goals and ways of working given the changes coming in this area, “there will be a lot of change in that time and only think this can be looked at as a short-term plan first”.
Submissions concentrated on leadership roles, and highlighted that consideration needed to be given to other roles which would be leading across systems and services but may not be credentialled at Consultant pharmacist level – “point C should be expanded to cover all pharmacists and not just limited to consultant pharmacists. When enhanced services falling outside of national frameworks are locally commissioned, pharmacy teams must be appropriately represented” and “Pharmacists need to be supported to become systems leaders and have a place at top table as they will become major prescribers and deliverers of urgent and LTC care.” It is also acknowledged that technicians are already embedded and delivering in leadership roles, and this should be reflected in the statements. Further comments requested that other sectors of pharmacy should be included, particularly mental health and areas such as academia, and community pharmacy.
Pharmacogenomics was referenced as an area in which pharmacy should be at the forefront, and consideration should be given as to whether a specific goal should be included around this subject - “pharmacogenomics and stratified medicine - consider adding as a theme given the rapidly evolving field and IP becoming an integral part of pharmacist development. Professionally we need to take leadership in this field.” In addition, sustainability and medicines safety were also perceived as crucial areas for pharmacy teams to be leading on.
The comments above also speak to the need to be represented at the right levels and be part of decision-making processes - “strongly agree to collaboration & leadership [this] will only come from our leaders being visible in the right platforms. We need an increased presence in the political landscape as well as with the decision makers in the NHS” and “[we] need non-pharmacy national bodies to understand role of pharmacy and potential within profession to deliver innovative services.”
Education and training came across as a strong common theme, with some detailing that business, management and leadership skills were an area which should be included - “business and management skills. These need to be taught and nurtured. These are not the same as leadership, they may include that” and “there should be leadership mentoring programmes, with opportunities for shadowing at a very early stage.”
Patients and patient representative groups made submissions to the consultation, and their views are welcomed. Comments often centred around access, “as a general member of the public I feel that with increased pressure on GPs, clinicians and hospitals, that we need to make sure that every opportunity is taken to maximise access to; and provision of; health care, from as wide a range of appropriate agencies as possible including Pharmacies” and provision of information “at a patient level, I want to be able to very simply understand what services are available (and how/when available) at my local pharmacy.” Included within responses were concerns about medicines supply and the impact this has “there are issues with timescales especially if a prescription is needed for a holiday or due over bank holiday weekend. There are more steps for patients to take and less power for them in managing their condition.”
There were also specific comments around patient experience of shared decision making, with some concerns raised about cessation of medication in particular which may indicate the need to improve communication around shared decision making. Patient representative groups provided insight into patient experience and provided an important reminder that this should be embedded within service planning and evaluation. They provided a helpful narrative around key issues which affect their population and how these could be addressed within the vision, for example, “health literacy must be given a greater emphasis in this pharmacy vision given the essential role pharmacy can play in proactively increasing people’s health knowledge and understanding, and in doing so impacting on health inequity in our communities.”
4. Barriers and enablers
Graph 4 – Enabling themes by ranking
The consultation asked responders to rank the three enabling themes in the vision consultation in order of importance (graph 4). There was a clear preference for the theme of Our Pharmacy People as the priority enabler, with over 56% selecting this as the first option – “having the right amount of appropriately qualified and experienced staff is paramount to all aims.” A quarter of responses selected collaboration and leadership as their first choice, with many more indicating this was their priority as the second enabling theme, with comments indicating “system development is important, as without creating systems for pharmacy staff to work in, that support the proposed vision, it is unachievable.” Data, innovation and research was selected by over 64% as their third option to unlock the goals and descriptors over the next 10 years, highlighting the need for “good IT equipment […] and good connectivity with sensible IG arrangements” and “basic (not advanced) ICT theory for trainee pharmacists, not just specialist ICT pharmacists.”
Suggestions were received for additional enabling factors, such as funding, which is acknowledged to be a key enabler behind many of the goals. Regulation and supervision were mentioned in several submissions and specifically as a potential extra enabling theme, with comments indicating “we would also suggest regulatory reform as an enabler and the corresponding changes in the culture of pharmacy practice”. EDI was also cited, and it was felt that references to this, particularly within theme 4, Our Pharmacy People, should be strengthened.
Other comments referenced the need to understand what the Vision would mean in practice, with the need for implementation plans and the strategy to achieve the goals as important to move the work onwards.
Graph 5 – barriers by ranking
When asked to rank the potential barriers to achieving the vision goals and statements, approximately 40% of responses each selected funding and workforce pressures as their first choices (see graph 5). Throughout the submissions, many comments were received around these two areas, with concerns raised about staffing levels – “a clear workforce strategy is critical and urgent in view of current shortages of the staff” and that “the current pharmacy [funding] model doesn't allow for achievement of the vision.” Comments gave detail about the pressures and issues facing the profession at present, and these offer a wealth of information about the current context of pharmacy practice, which is important to consider when offering up a vision for the next decade.
Interoperability was the first barrier selected in just 19% of responses, with 63% selecting this as their third-choice barrier overall.
Further suggestions for barriers to unlocking the themes and goals were focused on collaboration and leadership, with several indicating that this may be an issue, particularly around the role of the pharmacy team and other healthcare professionals and patients accepting this – “willingness of other healthcare professionals to collaborate with pharmacy” and “confusion and misunderstanding by the public”. Other proposals highlighted that “contractual and regulatory support, and/or removal of contractual and regulatory barriers to innovation” may need consideration. Sustainability and education and training were also mentioned and may need to be considered further within the themes.
This analysis of consultation responses has been produced with the aim of informing further discussion at the Project Advisory Group meeting on 12 October 2022.