Local pharmacies are more than just a purveyor of pills. They have the potential to improve the health of communities if commissioners have the courage to invest in them

The global financial crisis reminds us just how interdependent the world's economies are. That the collapse of banks in Iceland can threaten to disrupt council services in England illustrates how one part of a system can have dramatic consequences for another. As it is in the financial system, so the rules of knock-on consequences apply in health services.

Consider a scenario where the opening of a new health centre on the west side of a town impacts on the social services covering its east side. The sequence begins with GPs co-locating to the health centre, thereby moving some distance from established community pharmacies in the east. Those pharmacies are rendered unviable by the loss of prescription income, so they either retrench services, close, or cluster around the new health centre.

As the retreating pharmacies had served as anchors for economic activity, so shopping parades and high streets in the east decline. Neighbourhood economic decay begins to manifests itself in social problems, including the isolation of less mobile older people and endemic poor health. Social services are left to pick up the additional burden of need.

Knock-on effects

To put things rather more positively, renewed investment in one part of the health service can see benefits reverberating widely around the system. If community pharmacies were supported to fulfil their potential as a first line for urgent care, then demand for accident and emergency departments and genito-urinary clinics might ease up.

National roll-out of pharmacy-based minor ailments schemes would free up consultation time for GPs to meet the intensifying needs of an ageing population living with long term conditions. And with pharmacy engaged as a key partner in the forthcoming vascular risk programme and other public health initiatives, benefits would accrue not only across services but also across time, as people add life to years, thanks to such interventions.

Commissioning and decommissioning

In short, community pharmacy is much more than a source of medicines supply - core and vital a service though that is. It is an infrastructure and workforce, whose fortunes are linked to the fortunes of the wider health system and the population it serves.

Primary care trusts need to be able to think broadly about their commissioning and decommissioning decisions, basing them on a projection of the consequences for the whole health and social care system. Where is this contained within the competency framework for world class commissioning? In no one place, but spread among several competencies.

Under the framework NHS commissioners are told they must manage the local health economy and within this develop root cause analysis skills. They should work with community partners to ensure they do not commission in isolation. They will manage knowledge, to understand current and future needs. They will collaborate with clinicians, who are acknowledged as the local care pathway experts.


And world class commissioners will communicate with the market not as a mere funder but as an investor in a richer and more involved relationship, giving PCTs a rounder view of the provider base. This can only be a good thing for those providers whose contribution and potential is often overlooked.

The efficient operation of the NHS market requires no provider group expecting commissioners to cosset them. Providers and their representative bodies have the primary responsibility to ensure quality is delivered consistently and to innovate services.

Nevertheless, world class commissioning states PCTs should "give providers direct support for innovation and change where necessary". And April's white paper Pharmacy in England tells PCTs they have a central role in "aligning pharmacy as part of the fabric of patient centred NHS services".

Only with the active engagement of PCTs will pharmacies grow into the healthy living centres envisaged by the Department of Health. PCTs looking to get maximum value from community pharmacy might find the NHS Primary Care Contracting team document Strategic Commissioning Tests a useful benchmarking guide.

Far-sighted, entrepreneurial commissioning staff do already operate and some engage meaningfully with pharmacists. Just in the time it has taken me to write this article, colleagues have bounded into the office with two separate reports of PCTs driving highly innovative pharmacy based sexual health schemes. Such good practice means lessons worth learning are available much closer to home than Iceland.