Terry Maguire outlines his vision for pharmacy in 2020, drafted in 1995, and reflects on what has come to pass
George Orwell and Stanley Kubrick were never exposed to this risk of humiliation. When 1984 arrived, the author was long dead and when 2001 dawned, Kubrick the film-maker was firmly in the heavens. No-one was scrutinising and comparing their fictional visions with the reality. I authored Vision 2020 in the late 1990s and now 2020 is here some, assuming they are still alive, may ask if the vision has become reality? Did Vision 2020 have an impact on the development of community pharmacy practice in Northern Ireland?
In 1998, the Pharmaceutical Society of Northern Ireland (PSNI) finally agreed Vision 2020 as its vision for the future of community pharmacy. It had been a slog, as there were important and influential dissenting voices. At that time, and perhaps today still, I find difficulty seeing the real concerns, the true agendas behind the fake excuses; they were there then and they still are.
In 1995, I started work on Vision 2020 because it was my view that real risks existed if pharmacy failed to adopt a clinical future. Supply services needed to change to clinical services or we risked no future. Pharmaceutical Care, defined by Charles Hepler and Linda Strand in the early 1990s, was the inspiration for, and the main thrust of, Vision 2020 as it offered the necessary change and sustainability for community pharmacy. But Hepler and Strand’s definition was, for me at least, too restrictive; it did not consider how pharmacists might make an impact on public health and improve self-care. Indeed, I had a number of frank discussions with Charles Hepler who, while always polite, found my argument on the limitations of Pharmaceutical Care somewhat irritating and stated during one discussion that I clearly misunderstood the fundamental essence of the idea. Pharmaceutical Care is not care by pharmacists; rather, it is care by pharmaceuticals (medicines, drugs) and I was fully aware of this but we needed something wider than this to transform the service our 500 pharmacies provided to their patients and communities.
Apart from the loss of investment into community pharmacy, it also triggered a major workforce crisis, as 450 pharmacists have taken jobs that are 9-to-5 and with a decent pension. Now, in my world, try getting a day off at short notice!
I added public health and self-care speculating on community pharmacy’s potential contribution to changing behaviours that impacted on health and wellbeing; smoking, alcohol, nutrition and exercise. Vision 2020 boiled down to three domains: ‘Pharmaceutical care’, ‘self-care’ and ‘public health’. Of course, these domains were not distinct and mutually exclusive — there is significant overlap. For example, the smoker collecting her inhaler to treat her COPD needs more than advice on proper inhaler technique; the pharmacist needs to consider smoking and how she might be supported to stop.
Vision 2020 was essentially a bold statement of what the PSNI saw as the roles and responsibilities of community pharmacists 20 years into the future. By making this statement, it was hoped that we would choose the right policies and create a momentum that would eventually make the vision a reality and do so by the year 2020. Now that 2020 is here, and I must confess it has come much too fast, what has been the success and has it brought us to sun-lit uplands?
It’s been a mixed bag. Some things have been successful, others have not and some have been delivered, but perhaps not successfully.
Using Vision 2020, the Department of Health (DoH) published its policy for community pharmacy, Making It Better, a few years into the new millennium. Sadly, discussions between DoH and the pharmacy negotiating body, now CPNI, hit a wall very early on. Negotiators wanted all-new commissioned activity — the clinical and public health services — to be paid as additional to the existing funding pot. DoH argued that it was a transition where there would be some new money but ultimately, it was necessary that fees for supplying medicines would need to be reduced to expand and fund new services. The next 20 years was a negotiating disaster; CPNI stalled where it could, DoH aggressively reduced funding, nearly bankrupting contractors. CPNI took three judicial reviews, losing in the end and paying a hefty legal bill. DoH got to such a point of frustration that CPNI was almost being ignored when, finally, in November 2018, a new contract was imposed and all the fighting just seemed to stop. The absence of a contract was causing considerable financial hardship and something had to give. Most contractors were happy to take what was on offer and see a way out of their hefty overdrafts.
The new contact is now commissioning services across the three domains. ‘Living Well’ is a public health service that supports pharmacists to engage in brief interventions on exercise, care in the sun, nutrition, and smoking. The smoking cessation service was a big win early on. The flagship of pharmacy public health is ‘Health + Pharmacy’. Sadly, this impressive scheme has run aground, as contractors won’t agree to some of the standards, such as a restriction on selling, confectionary, E-cigs and low-factor sunscreen. The minor ailments service, designed to keep patients out of GP practices and emergency departments, is part of ‘Pharmacy First’ and is currently allowing us to treat patients with cold and flu symptoms on the health service.
‘Pharmaceutical Care’, now called ‘medicines optimisation’, has been less successful for community pharmacy but has ensured a practice pharmacist in every GP surgery. Apart from the loss of investment into community pharmacy, it also triggered a major workforce crisis as 450 pharmacists have taken jobs that are 9-to-5 and with a decent pension. Now, in my world, try getting a day off at short notice!
Vision 2020 may have had an impact but perhaps things were moving this way anyway and we would have ended up here without it. Contractors did not buy into the vision as I would have wished and seemed too focused on monitored dosage systems, free prescription collection and delivery and investing in robotics. So, to say clinical services are now a part of the community pharmacists’ role is wrong, and the dangers I saw back in the 1990s remain a problem for the sustainability of the network. Like UK society in 1984 and space in 2001, community pharmacy in 2020 is certainly not what was envisioned.