Community pharmacies are invaluable assets, especially in areas with high deprivation or limited access to general practice. To relieve pressures in the NHS in England, pharmacies are increasingly integrated into neighbourhood and primary care services. It is important that these services are of good, consistent quality, which the Pharmacy Quality Scheme (PQS) aims to incentivise. Here, Professor Ellen Schafheutle presents findings evaluating the PQS, and what this means in the context of the 10 Year Health Plan and the shift from hospital to community.

• The PQS has helped establish baseline standards for quality in community pharmacy, particularly in clinical effectiveness, patient safety, and patient experience.
• Despite widespread participation, the scheme’s complexity, staff shortages, and financial pressures have hindered meaningful engagement.
• Health policymakers should collaboratively redefine “quality” in community pharmacy, and align the PQS with broader clinical service goals and other quality schemes.

The 10 Year Health Plan positions pharmacy as “bringing health to the heart of the high street”, securely joined up to general practice. Pharmacies have traditionally been places where people collect their prescriptions, get advice for minor ailments, and purchase over-the-counter medicines. Since 2005, however, pharmacies have offered publicly funded clinical and public health services, under the Community Pharmacy Contractual Framework (CFCP). But what do we know about the quality of services being delivered?

A study conducted by The University of Manchester showed that some of these services incentivised quantity (or volume), but not necessarily quality. Chain pharmacies in particular were found to set target numbers for provision of medicines services, with ease of service sometimes prioritised over more complex patient needs and hence potential benefit.

In 2017, NHS England (NHSE) introduced the Pharmacy Quality Scheme (PQS), which rewards community pharmacy owners to achieve quality criteria in three domains: clinical effectiveness, patient safety, and patient experience. Our research, commissioned by NHSE, sought to understand the implementation of the PQS.

How did the PQS affect service quality?

Overall, the PQS facilitated a shift from a focus on the sale and supply of medicines, to a wider, patient-centred, better integrated role for community pharmacy in professional service delivery.

Almost all pharmacies participated in the PQS, their main motivation being financial income; those not participating were mostly independent pharmacies. Frontline pharmacists and key stakeholders agreed with the fundamental principles underpinning quality: patient safety, patient experience, and clinical (or care) effectiveness.

Examples of positive outcomes on patients, pharmacies and staff, and the wider healthcare system were described. The PQS was viewed as incentivising or ensuring consistency: that is, setting ‘minimum’ or baseline standards. Patients experienced good services, and hence gained an increased understanding of, and confidence in, community pharmacy. PQS learning was linked to potential health benefits through increased knowledge and skills of pharmacy teams, such as identifying health or social problems (for example, domestic abuse); identification of wrongly prescribed medicines; and antimicrobial stewardship activities.

However, completion of the PQS is complex and cumbersome, and is weighed up against financial and other benefits to the business and patients. Head offices of multiple pharmacies developed their own guidance and timelines, with ‘bite-sized’ tasks facilitating PQS submissions; however, this may have led to pharmacies focussing on the submission tasks without fully engaging with the PQS criteria’s relevance to quality and patient care.

Community pharmacy has faced unprecedented financial challenges in the past few years. To fund the PQS, other pharmacy funding was cut, leading to resentment and a perceived need to recoup lost income. Furthermore, the purpose of the PQS (to incentivise quality) was not always clearly communicated with those completing it. Participating pharmacies were often unaware of the positive impact of PQS engagement, despite some impacts having been published by NHSE.

Finally, increased communication with other providers, particularly GPs, led to better awareness and collaboration with community pharmacy in delivering integrated patient care. This is a key element of the government’s aim for a neighbourhood health service, and demonstrates the role of community pharmacy in supporting the shift from hospital to community.

Incentivising quality

NHSE, the Department for Health and Social Care (DHSC), and Community Pharmacy England (in collaboration with community pharmacy organisations) must jointly define what “quality” means in community pharmacy. The PQS should be aligned with the broader shift toward clinical services, ensuring consistency and integration with primary care, while PQS criteria should be linked to clinical effectiveness, safety, and patient experience. Doing so will support the broader shift within the 10 Year Plan towards community-centred care models. To better integrate community pharmacy with other primary care services, the PQS could also be aligned with equivalent quality schemes, such as the Quality Outcomes Framework in general practice, to enable this.

To evaluate and incentivise PQS, better measurable objectives and indicators are needed by policymakers. These should focus on improving long-term outcomes, raising quality, and linking to new or improved clinical services. Shifting rewards away from effort – the number of services provided – and toward the impact of those services in improving patient outcomes, would help to transform patients’ experiences of care. This needs to be supported by robust data collection and analysis processes to evaluate effectiveness and inform improvements.

PQS and the community pharmacy workforce

Staff shortages and workload pressures were significant barriers to effectively resourcing the PQS. Criteria which incentivised communication and collaboration with local GP practices received varying views, with some feeling disadvantaged if they worked in an area with poor relations. However, integration is essential under the 10 Year Plan’s drive for better and more integrated primary care and neighbourhood services. The PQS is one way to ‘level the playing field’ and achieve consistency and better integration.

Some organisations noted how PQS criteria relating to training provided justification for a business case to create in-work and/or funded time for training to upskill the pharmacy team, which is commonly not supported otherwise. Our other research shows this is a key factor in recruitment and retention of the community pharmacy workforce.

Building a sustainable workforce

Integrating the PQS with professional development can ensure a more sustainable model of community pharmacy, a sector where vacancy rates are already as high as 20%. Aligning the PQS with the General Pharmaceutical Council (GPhC) revalidation which pharmacists and pharmacy technicians must complete each year would help to reinforce PQS relevance to career profession and patient outcomes. However, this must not mean putting the expectation and time commitment for all learning onto the individual to do in their own time, but rather, should remain part of funded, in-work learning and development.

Policymakers in DHSC must offer ongoing implementation support, especially for independent pharmacies. This includes developing toolkits for benchmarking and reflection to embed quality improvement practices. More practically, it means avoiding PQS deadlines during peak periods (such as flu season or pre-Christmas).

While facing staffing and funding pressures, community pharmacy is nonetheless a vital pillar of policymakers’ vision for the future of health and care services in the UK, particularly in the context of the 10 Year Plan. Building on the lessons learned from the PQS will allow it to perform the role outlined in primary care services.

The full research team who contributed to the latest evaluation of the PQS are; Aidan Moss, Emma Lovatt, and Katie Robinson (ICF Consulting), and Dr Ali Hindi, Dr Jon Gibson, Dr Sally Jacobs (The University of Manchester).