As a scheme has recently been implemented to incentivise quality in community pharmacy, Sally Jacobs and Ellen Schafheutle discuss the need for further research to inform the development of quality indicators.

• The role of the private sector in the NHS has expanded over the last 30 years to increase services and reduce costs.
• This has resulted in questions about the tensions between patient care and profit generation.
• Policymakers and commissioners have a role to play in ensuring high-quality services are provided.

The growth of private healthcare provision in the NHS

Over the past 30 years, UK governments have sought to develop a mixed economy of healthcare provision, expanding the role of the private sector in the NHS, to increase patient choice and access to services whilst driving down costs. However, questions have been raised over the quality and safety of patient care and the motivations of managers in private sector organisations where a tension exists between the generation of profit and the delivery of services for the benefit of patients and the public.

The expanding role of community pharmacy

Pharmacy is viewed by policymakers as a vital player in solving the workload and workforce problems currently facing the NHS, particularly general practice. Together with the accelerated development of clinical pharmacist roles in general practice and the creation of new integrated models of care (multispecialty community providers) involving both community and general practice pharmacists, a pharmacy integration fund was set up in 2016 to support collaborative working with pharmacy in primary, community and urgent care settings.

The role of community pharmacy in healthcare has been expanding rapidly since the introduction of a new pharmacy commissioning framework in 2005 which explicitly began to reimburse pharmacies not only for more traditional medicines supply roles (eg dispensing) but also for medicines use reviews (MURs – a one-to-one consultation with the pharmacist with a focus on a patient’s understanding of their medicines, adherence, interactions and side effects) and a range of other medicines-related healthcare and public health services. Most of these services are commissioned on a ‘fee-for-service’ basis.

However, as private sector organisations, there are concerns over the extent to which some community pharmacies prioritise service volume (which, in a fee-for-service funding model, equates to profit) over quality (which is not generally reimbursed or incentivised). NHS England has begun to recognise the need to incentivise quality in community pharmacy through the Quality Payments Scheme introduced in 2017.

A better understanding of the organisational drivers of and barriers to service quality, as well as quantity, would support commissioning for quality in this sector. Moreover, there could be wider lessons for the NHS in relation to commissioning healthcare services more generally from private sector providers.

What influences community pharmacy service quality and quantity?

Our research, funded by the NIHR, has identified a number of organisational (and extra-organisational) features associated with variation in service quality and quantity in community pharmacy.

Local population need Although a pharmacy’s dispensing volume is significantly related to the levels of deprivation and prevalence of long-term conditions in the local population, the volume of medicines use reviews (MURs) conducted is not; indeed there are some indications of an inverse relationship with disease prevalence.

Pharmacy ownership One of the strongest associations with the volume of pharmacy services provided is with the size of organisation: pharmacies belonging to the large national chains familiar to every high street dispense a greater volume of prescriptions and deliver a greater volume of MURs than smaller chains and independently owned pharmacies.

Organisational culture Sometimes related to a pharmacy’s ownership, its organisational culture (“the way we do things around here”) can influence both the quantity and quality of pharmacy services. Cultures which support teamwork and staff development are perceived to facilitate both the quality and quantity of services provided. However, cultures prioritising business targets, whilst encouraging service volume, may inhibit service quality and threaten patient safety.

Staffing and skill-mix Having enough staff, continuity of staffing, and the right combination of staff with the right skills facilitates both the range and volume of services which can be delivered and also the quality of those services.

Integration Patient awareness and expectations of the range of services a community pharmacy can offer are low and limit service uptake. Service uptake is further inhibited because community pharmacies are not well integrated into the wider primary healthcare system.

Commissioning/contracting The contractual framework and commissioning processes are also seen as barriers to increasing service quality, quantity and integration. Levels of remuneration are low; fee-for-service payments incentivise quantity over quality; commissioning cycles tend to be short, making staff planning and investment difficult; and the commissioning of services complex with a range of national and local commissioning bodies involved.

Lessons for policymakers and commissioners

Organisational culture may be key to the delivery of quality care in community pharmacies: our findings suggest that service volume may be driven more by corporate ownership than by population need and that the right levels of staffing and skill-mix can drive service improvement. However, funding cuts, fragmented commissioning and short commissioning cycles hinder community pharmacy investment in appropriate staffing.

Healthcare administrations need to take account of these organisational drivers and barriers when commissioning services from private sector providers such as community pharmacies to ensure that the quality of service provision is incentivised in addition to service quantity. Moreover, collaborative working across primary care providers, including general practice, should be encouraged through integrated commissioning mechanisms.

This is starting to happen, but despite recent changes to the contractual framework to encourage targeting of MURs and to provide some reimbursement against a limited range of quality indicators, the predominant fee-for-service reimbursement model still appears to incentivise quantity over the quality of services delivered. Moreover, the evidence base for the effectiveness of pay-for-performance in community pharmacy is weak, and research is urgently required to inform the development of quality indicators.