Posted on 17/10/2018 by
Would a move towards the French model of community pharmacy be good for the UK sector?
After health secretary Matt Hancock spoke of his desire to move to a French model, C+D asks what community pharmacists could learn from their colleagues across the channel
Since his appointment in July, when he replaced Jeremy Hunt as health secretary, Matt Hancock has rarely spoken about community pharmacy, and even then, only in the vaguest of terms.
The sector only got a brief mention in his first speech, when he commited to investing “in primary care and community pharmacies so people don’t need to go to hospital”.
It wasn’t until C+D spoke to Mr Hancock following a fringe event at the Conservative party conference earlier this month (October 2) – and specifically asked the health secretary where community pharmacy fits into his plan for the NHS – that he revealed he wants to focus on “prevention rather than cure”.
“Pharmacy is incredibly important in the whole prevention agenda,” he told C+D. “I want to move towards the French model for pharmacies, where they do more, and I think [pharmacies] are absolutely vital to community health.”
Community pharmacists were left questioning Mr Hancock’s vision for the sector. “How can he suddenly expect a [UK] pharmacy model…to become a French model operated by individual owners?” one pharmacist asked on the C+D website.
Another welcomed Mr Hancock’s comments, albeit with qualified optimism, saying they “would love to do more in-depth, valuable, patient-centred work – if someone is prepared to pay”.
C+D asked the Department of Health and Social Care (DH) to shed some more light on what Mr Hancock’s vision for a “French model” means in practice. But the DH’s response – that pharmacy services on the continent offer a wider range of services than in the UK, and that it would be keen to see local pharmacies play a stronger role in the community – raised as many questions as it answered.
One reader, posting as ‘Barry Pharmacist’, asked: “I'm obviously missing something. Can someone please tell me what services French pharmacies provide that ours do not?”
What do French pharmacists say?
Luc Besançon, a community pharmacist in France and former CEO of the International Pharmaceutical Federation, says he believes the health secretary was “probably talking about the French model in terms of prevention in community pharmacy”. “Though [the model is] probably not as strong and structured as he may think it might be,” he adds.
10 facts about the French model of community pharmacy
- According to Stephane Pichon, a pharmacist in Marseille who sits on the National Chamber of Pharmacists’ central council representing pharmacy owners, there are 22,000 pharmacies and 54,000 pharmacists in the country
- A third of pharmacies are in locations with fewer than 5,000 inhabitants
- There are 33 pharmacies per 100,000 of the French population – compared with 21 per 100,000 of the population in England, according to 2016 figures from NHS Digital
- Market entry is based primarily on demographic criteria. New pharmacies are only allowed to open in areas above a certain threshold of population growth, which limits competition
- Medicines are exclusively dispensed and sold in community pharmacies. Pharmacy premises usually incorporate a ‘parapharmacie’, which sells medicines that do not require a prescription, as well as healthcare, beauty and herbal products
- Pharmacists can only directly own one pharmacy outright, and must serve as either its superintendent or responsible pharmacist
- Pharmacy owners can also have shares in a maximum of three other pharmacies, but can not be the responsible pharmacist for these premises
- Individual pharmacies often associate in purchasing groups or networks; however, these are still independently owned and operated. As a result, there are no formal pharmacy chains or multiples in the country
- For a decade, pharmacies have had access to a shared patient medical record – le dossier pharmaceutique. This has been funded for several years by the French pharmacy regulator, which stepped in when a government IT system was delayed
- Community pharmacies offer services such as: needle exchange programmes; rapid testing for HIV, flu, high blood sugar and strep throat; as well as distributing colon cancer testing kits, and being set targets for generic substitution.
The current health minister in France, Marisol Touraine, is a former head of the French equivalent of the UK’s National Institute for health and Care Excellence (Nice), and has placed a heavy emphasis on public health.
Ms Touraine may have endeared herself to community pharmacists by lobbying to preserve the sector’s monopoly, by blocking moves to allow medicines to be sold in shops or other premises.
“She is well informed, and you can see she has a strong public health policy approach – that may be why there is so much sudden interest from the UK,” Mr Besançon says.
The government’s latest policy documents on public health were released just days after Mr Hancock spoke to C+D – although “I doubt he would have known that at the time”, Mr Besançon adds.
They set out the ministry of health’s priorities for the country’s mainly centralised health service – and the role of pharmacies in meeting those priorities – in five areas: medicines management, health promotion, preventative health, collaboration with health authorities and other healthcare professionals, and preventing infectious and communicable diseases.
French flu vaccinations
Community pharmacy’s involvement in this last element includes piloting flu vaccinations in pharmacies. Previously the vaccine had been available from local doctors and nurses.
Dr Serge Caillier, vice-president of the National Chamber of Pharmacists’ central council of employed community pharmacists, says he is “very happy” with the decision to trial pharmacy flu vaccinations – which are currently being delivered in four of the country’s 18 local health authorities, where around 100,000 people have been vaccinated.
As a result, he feels “relations between community pharmacists and politicians are actually quite good. It’s possible to have a discussion with them”.
Mr Besançon agrees the pilot has “had a very positive impact on the relationship with the government”. “It demonstrated that pharmacists were keen – the first text authorising [the pilot] was in May, and more than half of the pharmacies in the regions had been trained, and certified by the local authority, by September.”
Positive funding talks
The discussion clearly has been positive, as pharmacy owners have entered into a new three-year funding agreement with the government and health insurers.
This will include three new clinical services: anticoagulation therapy and international normalised ratio (INR) monitoring, bi-annual consultations for patients with asthma, and a service that UK community pharmacists will be very familiar with, as it is similar to medicines use reviews.
Under the deal, pharmacies will still be paid primarily for their dispensing activity – with an increase in the fixed amount paid per line of the prescription. In addition, pharmacies will be paid a supplement for specific cases that require more focused care, such as elderly or very young patients.
Pharmacy owners have also negotiated an income guarantee that protects their revenue for the duration of the three-year transition period. “That’s a way for the transition period to be more positive,” Mr Besançon explains.
“Over the next three years – starting in 2018 and finishing in 2020 – they are transforming the remuneration model into something that is less connected to the price of the medicine. So any time the government cuts the price of a medicine, there will definitely be less impact [on pharmacies].
“Compared to the UK, where you have non-regulated margin, in France there are regulated margins, so there is maybe slightly more transparency [about] what pharmacists are earning.”
Verdict on the model
The new deal will bring the funding model for pharmacies in France more in line with that of doctors, Dr Caillier explains. But he tells C+D that he is yet to make his mind up about the newer, more public health-focused services that Mr Hancock may have been alluding to in his comments to C+D.
“We have had a good negotiation. Generally, I believe it’s a good thing, but the full story is not yet finished – we are still in the middle of it.”
A supportive health minister, positive relationships with politicians, a progressive funding contract and a push for more clinical services. It’s easier to see why a move towards a French model might appeal to some community pharmacists, as well as the health secretary, in the UK.