From Survive to Thrive

A statement of the needs and aspirations of independent community pharmacy in the UK

A Manifesto for Independent Community Pharmacy

Independents are delivering a valuable service against the odds. Many of them feel that they are running faster and faster just to stand still. This document demonstrates how life could be very much better for independent pharmacists and for patients. It describes the journey the independent community pharmacy sector needs to take, together.

Foreword

From Survive to Thrive is the rst part of our Manifesto for Independent Community Pharmacy. Other documents to complete the set will be released shortly.
At the heart of the Manifesto initiative are two core beliefs. The rst is that independents are essential to a strong pharmacy sector overall and to the health of the nation. The second is that independent community pharmacy can thrive; challenge and change is inevitable, decline is not. The themes are likely to resonate across the whole community pharmacy sector, but we take as our start and end point the needs of independents and the communities they serve. We intend that the Manifesto will lead ultimately to a position where more independents are fullling their potential. As a result, patients and communities will benet. We wish to say thank you to those who have contributed to the development of this document, right across the UK, by sharing insights and experiences generously.

Our Manifesto commitments to our members:

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To resist the tide of red tape getting in the way of time to care To address the excruciating frustrations of being at the sharp end of a dysfunctional medicines supply chain

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To seek a level playing eld for independents when it comes to contracts, funding and commissioning To develop capability and leadership throughout the independent sector To work in a true partnership with our members to deliver results.

Mike Holden Chief Executive, National Pharmacy Association

Claire Ward Chief Executive, Independent Pharmacy Federation

Colin Baldwin Chief Executive, Association of Independent Multiple Pharmacies

Why Summary a Manifesto for independents? Executive

The National Pharmacy Association (NPA), the Association of Independent Multiple Pharmacies (AIMp) and the Independent Pharmacy Federation (IPF) together concluded that the opportunities, threats and choices for the independent community pharmacy sector are of such magnitude that a strategic review of needs and aspirations is required.

From Survive to Thrive is a product of that review, which began in March 2013 and continues. We think of it as the rst part of a Manifesto for independent community pharmacy. It will provide a frame of reference for all our forthcoming activities to represent and support independents.
It articulates what we have heard during a widespread consultation with our members. You told us: 1 Independents are essential to a strong pharmacy sector overall and to the health of the nation. 2 Independents are not conned to the business of pharmacy, they are in the business of health, wellbeing and social care where there is room to grow considerably. 3 Independents face daunting pressures. Many feel time challenged, nancially stretched, isolated and pessimistic about the immediate future. 4 The top three problems for independents relate to a decient medicines supply chain, squeezed income and tightening margins, and a heavy burden of red tape which eats into time to care. 5 Independents have roots in their local communities and other strengths which give them resilience and a platform for sustainability, innovation and maximising their potential. 6 Policymakers, regulators, the NHS and others could do much more to free the independent network to full its innate potential. 7 Independents must continuously challenge their own performance and behaviours, recognising that professional excellence is a requisite for sustainable commercial success. Being clear about what good would look like for the independent sector in the future is critical. Three building blocks of care support a future model which can ex to reect local needs: keeping people safe by helping them make best use of their medicines; supporting people to stay well through healthy lifestyle interventions; and helping people live independent lives in the community through supported self care. Success is not just about being able to struggle through the current difcult conditions with a view to coming out the other end unchanged; it is about adapting to the environment and fullling the potential of the sector. This is what it means to thrive, not merely to survive. A number of conditions necessary for success (we identify 20 in this document) need to be in place, aligned and mutually reinforcing. We will develop new work streams and accelerate existing ones to achieve that position. Where we can make improvements ourselves, we will do so urgently. Where we are in a position to inuence others, the needs identied by our members (as described in this document) will be at the forefront of our agenda. We have worked hard already to achieve progress, but we will now be able to pursue our members interests with better articulated ends and means to guide us.

Building the Manifesto from What is From Survive to Thrive about? the ground up

From Survive to Thrive is about the journey from where the independent community pharmacy sector is now to where it needs to be. It constitutes the initial output of our Manifesto for Independent Community Pharmacy initiative, which has the following purposes:
To improve the position of independents and thereby patients and communities. To guide independents and those who have an interest in the success of the independent sector; for those of us who represent independents, the Manifesto gives us an anchor for our approach overall and for each individual decision we take. To strengthen the elbow of those representing independents, because we will be able to argue from a position of widespread acceptance about the way forward. To improve accountability our members can hold us to account about the commitments we make.

From Survive to Thrive describes:

Where we are now: Section One includes a description of the characteristics of independents, and what is special about the offer to patients, public and the NHS. It also summarises the current position on the ground, covering all aspects of the environment and how these impact independents. This environment consists of a supply chain, NHS policies and health service managers, professional regulation, the attitudes of fellow healthcare professionals, public perceptions and many other elements. Where we want and need to be: Section Two describes where the sector needs to get to in order to maximise its potential and to be sustainable. How to get from here to there: Section Three.

This document provides a frame of reference for all activities to develop, represent and support independents. It is both a guidebook (to us as representatives and our members), and a contract with our members. It will be followed by a series of action focused theme papers, a number of which will address factors specic to Scotland, Wales, Northern Ireland and England.

Building the Manifesto from the ground up

The NPA, AIMp and IPF launched a consultation on the Manifesto for Independent Community Pharmacy in March 2013. The three month consultation involved engagement activities across the UK, with 750 pharmacy owners taking part, representing over 2500 pharmacy contracts. With this level of engagement, we are condent that From Survive to Thrive is a robust frame for our public policy programme and our wider programme of support for independents. We will continue to engage our members in the delivery of the Manifesto project as it proceeds (see p22).

Section One

Where we are now

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What is special about independent community pharmacy?

What is an independent community pharmacy? Is a pharmacy an independent only if it has no more than, say, six branches? If so, does it become a multiple when it grows to seven branches? Or is the dening characteristic of an independent its ownership structure? Or its geographical footprint? Or its exibility as a business? Probably it is a combination of factors, and it seems to us that the list above is insufcient, and is missing something crucial about relationships. Here are some characteristics which have been suggested during the Manifesto consultation you will notice above all the theme of connection - a bond between the owner, the business, the staff, community and patients: An independent serves the local community and is both a stabilising asset to the community and an advocate for the community and its population.... a known face and integral to that community. Most independents are small businesses that have become embedded within the community they serve. Part of the community for a long time. Relationships strong and personal. We have a stake and a standing in the community. Long-term continuity benets the independent in the eyes of the patient and helps to build up relationships with both patients and GPs. Community action, social capital, very high trust. Passion, for our patients and the profession. Local familiarity usually results in the pharmacy ne tuning its services to better suit local needs. Independents are special since they are often well established in a neighbourhood and the pharmacist is known by the locals. New services are likely to be offered in response to patient need, rather than to meet targets. An independent community pharmacy offers a bespoke healthcare service and goes that extra mile to ensure the patient experience in that pharmacy is of an exemplary standard. An independent can respond quickly and exibly to local demands and patient needs. When asked during the consultation, what are your most important assets? our members focused above all on people and the continuity of their connection: My staff; the goodwill of my local community. The long-term experience and local knowledge of staff. Local knowledge, good links with other professionals. Continuity of named pharmacist. Our pharmacist knowledge base, our highly skilled teams and our patient relationships. Longstanding staff with the correct attitude. Includes pharmacists and dispensary and counter staff. Longer-term patient and professional relationships. Excellent working relationships with long-serving staff. We work as a close team and empower the staff to input into stock ranges and development of the business. The relationships between myself, my staff, my patients, doctors and suppliers. Our people... loyal and motivated staff.

What is special about independent community pharmacy?

The NPA operating environment survey has been run every other year since 2009. It asks pharmacy owners what factors with are most helping them and Excellent most hindering them to provide an Long-term relationships patients and GPs. working relationships efcient and effective staff. service. The graph reports the domains that NPA feel with long-serving We work asbelow a close team and empower the Members staff to input are contributing positively to their ability to operate sustain a successful pharmacy business. into stock ranges and development of the and business. Human relationship factors are by some margin strongest. The relationships between myself, mythe staff, my patients, doctors and suppliers. Our people...loyal and motivated staff POSITIVITY INDEX (EXTRACT FROM NPA OPERATING ENVIRONMENT SURVEY MAY 2013) POSITIVITYINDEX(EXTRACTFROMNPAOPERATINGENVIRONMENTSURVEYMAY2013)

This graphreports thedomains thatNPApharmacy membersfeel In summary, independent community is: arecontributingpositivelytotheirabilitytooperate andsustainasuccessfulpharmacybusiness.Humanrelationshipfactorsarebysomemarginthestrongest.

Essential to the health of the nation and a lifeline for many individual patients In independent pharmacy is: want and capable of implementing summary, Responsive to needcommunity sensitive to what patients change swiftly. toto the health of themay nation and alifeline formany Essential Committed patients who well be known personally toindividual the owner patients Responsive to need sensitive to what patients want and capable ofof implementing Community focused - a community asset which adds to the social capital change swiftly neighbourhoods. toby patients whomaywell beknown tothe Committed Characterised strong relationships, connecting thepersonally business owner toowner patients. Independents have strong relationships between patients, public, staff and theof Community focused acommunity asset which addsto thesocial capital communities they neighbourhoods serve; the pharmacy owner is him or herself meaningfully part of these relationships. Characterised bystrongrelationships,connectingthebusinessownertopatients. All about people. Independents havestrongrelationshipsbetweenpatients,public,staffandthe
We arethese responsive and caring. relationships. We offer verypeople. personal Alla about service and build personal relationships. We We are aare constant where and patients responsive caring. We offer a very personal service and build feelpersonal comfortable because we relationships. have We are a constant where patients feel comfortable invested timewe in have theminvested and they because time in them and they trust us. trust us.

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Market Position

There are approximately 7500 independent community pharmacies, including independent multiples, in the UK. The long-term trend has been for national multiples to grow market share, in terms of the number of branches and overall prescription volume. Regional independent multiples too have grown as a proportion of the pharmacy market. In the most recent years, a number of independents have entered the market through control of entry exemptions pertaining in England until 2012. It is important to acknowledge that the position of independents cannot be viewed solely in relation to other pharmacy providers. Community pharmacies are now providing a wider range of professional services than was common even ve years ago. Evidence for this is that fact that nine in ten pharmacies now have consultation areas. We are not conned to the business of pharmacy, we are in the business of health, social care and public health. In this wider market, independents have room to develop considerably. We asked our members if they agreed with the statement, being pro independents does not mean a default position of anti multiples - indeed there are many fundamentally shared interests. There was general, albeit not unanimous, acceptance of this view. The majority opinion is encapsulated in this comment from a member in England:

Both have common competitors and an interest in retaining the delivery pathway on the high street....If you asked an independent and a multiple to write a wish list for pharmacy 95% of it would be the same.
Yet there was also a widespread recognition that the characteristics, experiences and needs of independents were signicantly different from national multiples in some important respects. This apparent paradox can be explained in the following way: Environmental conditions may be shared the same contractual frameworks, same regulations and professional ethics, same NHS managers, same health department budget, same norms in society and so-on. Yet, the impact of those conditions is different on each pharmacy, varying according to its characteristics. Meanwhile, the capacity of each pharmacy to respond to the conditions will also vary. For example, excessive red tape affects pharmacies big and small. But in the case of most independents, there is limited opportunity for shifting business and commercial workload as well as regulatory tasks away from the frontline, perhaps delegating to an area manager. In many cases, the pharmacy owner him/herself has to keep all the plates business, regulation and practice - spinning.

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Current Challenges

Independent pharmacies are not all in the same position. Their situation varies according to their geography, demography, business and service models, the stage of their development and many other factors. Factors specic to England, Scotland, Wales or Northern Ireland will be summarised in theme papers to be released soon. However, the Manifesto consultation has revealed a signicant degree of commonality. Many independents are concerned about their current position and some are very pessimistic about the immediate future. They feel financially challenged income streams are squeezed and cash flow is difficult to manage. time challenged increasing volume of prescriptions, new services, supply problems and accumulation of red tape mean some independents are running faster to standstill. the medicines supply chain is not functioning in the way that it should to allow them to provide a reliable and efficient service to patients further increasing costs and time pressures. the health service commissioning environment is uncertain and changing. red tape is weighing heavily on their shoulders and getting in the way of time to care. isolated from each other and from others in the health service. According to some industry analysts, the economics of community pharmacy are under such pressure that the business model, especially for independent pharmacies, is at a tipping point. ATKearneyi points to ve forces impacting profoundly on community pharmacy and which may in combination be especially challenging for independents: a squeeze on healthcare budgets. intensifying competition (including supermarkets). transformation of the supply chain. the emergence of alternative supply channels such as internet & mail order. changing consumer expectations.

In relation to the nal bullet point, it is worth reecting on the fact that the service delivery model in pharmacy is by and large characterised by face-to-face interactions at the point of supply.This puts community pharmacy in a prime position to improve the publics health by making every contact count. We need to respond to rapidly evolving consumer behaviours, but in such a way as to maintain the face and place characteristics of independent community pharmacy described at the beginning of this section. In each year of the NPA operating survey, including the latest, spring 2013, the top three problems for independents were found to relate to: a decient medicines supply chain, squeezed income streams, and a heavy burden of red tape which eats into time to care.

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Current Challenges

CURRENT CHALLENGES (EXTRACT FROM NPA OPERATING ENVIRONMENT SURVEY 2013)

4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0

The shows the results of the NPAs operating environment survey in 2013. Members were asked to grade the challenge each domain presented to their ability to operate and sustain a successful pharmacy service. The maximum score of 6.0 indicates that this issue was having a critical impact on all pharmacies. A score of over 2.0 is regarded as indicating a signicant problem across the profession. Problems with the medicine supply chain have consistently topped the poll, generally followed by nancial issues and regulatory/administrative burdens. Asked, what is the biggest single threat to independent community pharmacy over the next ve years? our members told us: More money being squeezed out of the system. NHS focusing on cost instead of value. Aggressive competition from larger companies with more levers than we have. Burden of red tape overwhelming my capacity. Getting overlooked by new commissioners who dont know enough about us. Lack of time for reection and new activities. Apathy. Waiting for things to happen to us. Yet independents have a number of strengths which give them resilience and a platform for sustainability and maximising their potential. The enthusiasm amongst many independents for the Healthy Living Pharmacy (HLP) initiative demonstrates a determination to develop the whole pharmacy team and services and to invest for the future. A majority of the 500+ HLP pharmacies are independents, which clearly indicates innovation and exibility in decision making. Whilst HLP began in England, its principles are now being applied elsewhere in the UK and offering independents a framework for long-term excellence and an opportunity to grow their business professionally and sustainably. While the challenges are daunting, the opportunities are considerable and exciting, as described in the next section.
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graph

Section Two

Where we want to be
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Where we want to be

Here we describe where the independent sector wants and needs - to get to in order to maximise its potential and to be sustainable for the medium and long term. In a snapshot survey, online and at the NPA national conference May 2013, independents were asked if they agree with the statement, Independent community pharmacy can thrive. Challenge and change is inevitable; decline is not. Almost 90% agreed. Indeed, throughout the Manifesto consultation, pharmacy owners expressed their determination to move forwards. Their aspirations are described in this section. Listed here are some the comments given to us during the Manifesto consultation from members, in answer to the question, where do you want your business to be positioned ve years from now? Professionally: A centre of excellence delivering the highest-quality, evidence-based care for patients and the public. Financially: a robust business with an acceptable, sustainable ROI model. Service based.....but we must not fall into the trap of giving up the dispensing role. Seen as a healthy living centre providing a range of clinical services supporting longterm conditions management. A vital cog at the very heart of NHS patient care, and recognised as that rather than being viewed within government and health as a secondary entity to GPs. Health screening, prevention and providing pharmaceutical input into management of long-term conditions. Providing some private services and better integrated in patient management with doctors and nurses. Delivering high quality care in a seamless environment. Still dispensing scripts, our core role, for our local population but also extending the use of NMS and MURs to improve medicines adherence... Integrated part of primary care..... IT connectivity and referrals to & from GPs and secondary care. At the heart of the community with respect from both patients and other healthcare professionals and recognised as being an integral part of primary care. Getting even closer to the patient, increasing patient adherence in all pathways, and being the rst port of call in minor ailments, and public health. With a secure nancial base to operate and invest from. Learning. Being part of a learning culture. Growing, with an enhanced service delivery model and engaged successfully with all commissioners of health. Local, wherever we are, but growing.

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Where we want to be

When asked, what is the single biggest opportunity for independent community pharmacy over the next ve years? the replies from pharmacy owners included: The opportunity really opens [in public health] since experience with local authority commissioners is that they seem to get community pharmacy. The move of money into public health. This must allow pharmacy to be seen as the source of healthcare, self-treatment, healthy living, health prevention and public health services. Seizing the medicines optimisation agenda; and Healthy Living Pharmacy. Long-term conditions management. The population is continuing to age and needs to be cared for in the community. The pressures on the NHS and the GP system is an avenue where pharmacy can take on more services. Getting even closer to the patient, increasing patient adherence in all pathways, and being the rst port of call in minor ailments, and public health. To create partnerships with other healthcare professionals and lever our medicines expertise so we are recommended by others in the NHS. Registration in Scotland. Nomination in England with patients, especially those with long-term conditions. The long-term relationships that independents have with patients means registration can work for us and our patients. Managing and monitoring patient repeats through CMS in Scotland and developing communication methods to GP surgeries and secondary care on the back of this service. Our consultation has conrmed that, despite all the current pressures on the public purse, independent community pharmacists still see opportunities for improvement and growth within the NHS and public health. Squeezed public nances may in some circumstances even be a spur to public investment in those services which help individuals live independently in their community thereby avoiding higher costs elsewhere in health and social care.

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Where we want to be

The input from pharmacy owners during our consultation was remarkably consistent across the UK. We have formed the following aspiration statements to capture succinctly what we have heard from our members in Scotland, Wales, Northern Ireland and England: What does success look like? Independents want to be spending more time with patients - and rather less time with suppliers, regulators and paperwork. Independents want to be investing in premises, staff and services. Independents want to be fulfilling their potential as healthcare professionals. For owners who are active practitioners, professional satisfaction is at least as important as business success. Independents want to integrate service and supply, delivering a range of professional services which improve health and wellbeing. Independents can build on the strength of their relationships, with patients and others locally, to offer a fuller package of care. Independents want to be delivering high quality, compassionate care consistently. Independents want to be at the heart of the NHS and public health systems as well as providing services outside the NHS. Independents want to be the first port of call for health and wellbeing support in the community. Independents want to be in control of their own destiny to a much greater degree than they are now. Currently suppliers, commissioners and prescribers are in a position to change conditions drastically and suddenly. Independents want to maintain a strong presence in the pharmacy market as part of a vibrant mix of contractors.

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Section Three

Getting to where we want to be

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How we can get from here to there

How we can get from here to there The approach we advocate is consistent with the ideas laid out for the entire sector (including national multiples) in the Pharmacy Voice Blueprint for Better Health (2011)ii. However, certain aspects of what has to be done are especially relevant to the needs of independents. What others must do Here are some of the comments given during the Manifesto consultation, in answer to the question, what could the NHS, regulators or others do to help you deliver even better patient care? The NHS should ensure a level playing eld for reimbursement and remuneration. Be consistent in their approach to all pharmacies no matter who owns them. They should utilise the local knowledge independents have. Reliable cash ow. Reduce red tape....Remove the bureaucracy that meets the needs of regulators but fails the needs of patients. Vastly improve PMR systems with much greater clinical interfaces. A contractual framework predicated on the right things and providing an adequate return. Allow access to patients current and past medical histories. Stabilise supply and reverse the dominance monopoly/duopoly that has developed in the supply chain. Understand pharmacy better. Too many of the LHBs see pharmacy as just out to make money. They dont understand that we operate in a very competitive environment unlike GPs who have registered patients. The regulators can make the practice of practicing less cumbersome without affecting patient safety and respect for the profession. Support service delivery in joined up manner. Better supply chain arrangements to avoid constant sourcing of loss-making branded products. Trust us more!

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How we can get from here to there

What we must do for ourselves Many of the participants in the consultation made the point that in order to improve their position they continuously challenge their own performance and behaviours. Even in the face of immense pressures, independents must continue to innovate and strive to deliver and evidence high quality care consistently. Independents should continuously assess the tness for purpose of their premises, processes, skill-mix, local engagement and strategy and act accordingly to maintain an exemplary service. Those representing and supporting independent community pharmacy must be absolutely committed to supporting this process.

Conditions for success Summarising what we heard from members about what conditions must be in place to help independents maximise their potential: Capability 1 2 3 4 5 Culture 6 Independents need there to be within the sector a general acceptance that professional excellence is a requisite for sustainable commercial success. Meanwhile, commercial success permits investment to deliver excellent care. 7 Independents need the right culture of care in and around the sector compassionate, patient-focused and just.iii 8 Independents need a learning culture to ourish in the sector. This has to include reform of sanctions for dispensing errors. 9 Independents need GPs and community pharmacists to regard each other as part of a team, with eyes xed in the needs of patients. The two professions and the patients served by both need to have a shared expectation of what community pharmacy can deliver.
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Independents need effective leadership at all levels in pharmacy within pharmacy teams, across the NHS and amongst pharmacy representative bodies. Independents need further development of the skills and role of the whole pharmacy team. At the same time, the professional status and accessibility of the pharmacist must be enhanced. Independents need t for purpose IT to support the delivery of services, including the transfer of information to other healthcare professionals and for payment and audit purposes. Community pharmacy must itself direct the development of IT to meet the sectors needs, within the context of a changing NHS. Independents need to embrace new technologies, including occupying more online space, but in such a way that does not divert footfall and the delivery pathway away from pharmacy in the community. Independents need practical support and ready-to-wear solutions to enable them to meet new patient and consumer expectations and compete with other providers in pharmacy and the wider healthcare arena.

How we can get from here to there

Commissioning, Contracts and Funding 10 Independents need contractual arrangements and NHS behaviours which reect the fact that nancial risk cannot always be spread across a large estate. SEE BOX A. 11 Independents need a level playing eld, with each other and with non-pharmacy providers. Commissioners, the supply chain and healthcare providers should not discriminate. 12 Independents need a funding and commissioning environment which is conducive to investment. Funding needs to be more reliable and sustainable, as well as giving a fair return for the services provided. 13 Independents need conditions which allow us to link supply and service to meet patient needs. This has to involve t for purpose national pharmacy contracts and improvements to local commissioning. 14 Independents need to be integrated in NHS, public health and social care pathways. 15 Independents need everyones approach including policy makers, NHS leaders and negotiators to reflect a clearly and commonly understood purpose: to keep people safe (safe supply and use of medicines), to keep people well (including self care), and to help people make best use of medicines, especially to achieve effective management of long term conditions and help people live independently in the community. 16 Independents need encouragement and practical mechanisms to work together in pursuit of success. This might need to include collaborative platforms which allow independents to match the scale and processes of emerging NHS and public health commissioning units. The medicines supply chain 17 Independents need an efcient supply chain and a relationship with the pharmaceutical industry based on better mutual understanding. Independents have limited ability to move stock around branches if supply is interrupted, but this is only one aspect of the present difculties. Independents feel they are bearing the brunt of the problems of a seriously dysfunctional supply chain.

Red tape and time to care 18 19 20 Independents need condence to invest and time to care. Without this, independents cannot full their potential. Independents need the regulatory frameworks affecting pharmacy to be exible enough to accommodate varied approaches to delivering high quality care. Variety and responsiveness to local need is a characteristic of the independent sector. Independents need practical support to full administrative tasks which are necessary i.e. clearly in the patient interest and support to push back on requests by the NHS and others which appear to add no value.

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We need to be in a position where all these conditions for success are aligned and mutually reinforcing. In simple terms it may be said that: commissioners/funders need to be willing and able to commission services that meet needs at the same time as pharmacy providers are willing and able to provide those services, at the same time as patients are willing and able to access them.

How we can get from here to there

Box A - Financial risk cannot always be spread across a large estate Dispensing at a loss Pharmacies receive a standard discount clawback on all items they dispense, regardless of the level of discount available on individual products. In some cases, the clawback exceeds the discount, and the pharmacy is required to dispense a medicine at a loss. Across the board, there is an adjustment which means that pharmacies will make a slightly higher prot on other lines to compensate for this loss. However pharmacy businesses operating across a small geographical footprint and impacted signicantly by localised prescribing patterns may not benet from this adjustment commensurately to their losses.

Changes to local prescribing policies If local commissioners or practices change prescribing policies without adequate warning to local pharmacies, pharmacies can be left with stock for which they will no longer receive prescriptions. To avoid writing the stock off, independents must rst track down a pharmacy that needs the stock, and then comply with onerous regulations on the transfer of stock between different legal entities. In either case they will suffer a nancial loss.

Price rises linked to product shortages Periodically, the supply of a generic product will not meet demand, and the price of this product will rise. The NHS will often respond by agreeing a temporary concessionary price, but many pharmacies will not be able to source the product at this price and will make a loss. Whilst the system of averaging will ensure that the pharmacy network as a whole doesnt lose money, individual independents who receive a lot of prescriptions for these particular items will not be recompensed commensurately for their loss.

Branded generics Manufacturers who produce branded generics market them at just below the drug tariff price. Prescribers may be persuaded by manufacturers and sometimes local NHS managers that they will save money on their drugs budget by prescribing these products instead of true generics. Pharmacies cannot purchase the product with sufcient discount, so lose out on the retained purchase prot. This is a problem for independents and multiples, but especially for small businesses that cannot buy large quantities and drive the price down and cannot distribute stock around a large estate.

Payment errors Underpayments by the payment agencies can cause independents nancial hardship by adversely affecting their cash ow. Independents need to keep a close watch on their returns to ensure they are being reimbursed correctly. Audits will pick up any trends and lead to an average recompense to be paid to everyone. Meanwhile, in theory, for most underpayments there will be an overpayment, but this is less likely to equalise across a pharmacy business with only a small number of contracts.

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How we can get from here to there

Making it happen It is our intention that the Manifesto for Independent Community Pharmacy initiative will live, breathe and bear fruit for years to come. Using From Survive to Thrive as our frame of reference, the NPA, AIMp and IPF will:

Take action to bring into being all the conditions for success listed on p19-20 of this document. We have already worked hard on many of these issues, but we will now be able to pursue our members interests with more clearly articulated ends in mind. Establish task groups to develop the Manifesto work streams, which are: Capability, Culture and Leadership Medicines Supply Chain Commissioning, Contracts and Funding Red Tape and Time to Care

The groups will involve pharmacy owners and others who share an interest in a successful independent community pharmacy sector. They will have a local reach, so that input can be drawn continuously from the pharmacy frontline. Work constructively with each other and others representing independent community pharmacy. We will also work collaboratively across the sector wherever possible, recognising that being pro independents does not mean a default position of being anti multiples - indeed there are many fundamentally shared interests. Publish a Manifesto progress report after 12 months (by summer 2014) and annually. Our members will be given an opportunity to scrutinise these reports and to hold us to account publicly.

If you want to get involved in the Manifesto task groups, please email: independentsvoice@npa.co.uk

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Manifesto for Independent Community Pharmacy action papers coming soon: Independent community pharmacy: Capability, Culture and Leadership Independent community pharmacy and the Medicines Supply Chain Independent community pharmacy: Commissioning, Contracts and Funding Independent community pharmacy: Red Tape and Time to Care Independent community pharmacy in Scotland: What does success looks like? Independent community pharmacy in Wales: What does success looks like? Independent community pharmacy in Northern Ireland: What does success looks like? Independent community pharmacy in England: What does success looks like?

iThe

Future of Community Pharmacy: Building A Sustainable Industry. ATKearney. 2012 Pharmacy: A Blueprint for Better Health, Pharmacy Voice (2011), and Community Pharmacy: Our Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 - March 2009

iiCommunity

Prospectus for Better Health, Pharmacy Voice (2012). See www.pharmacyvoice.org.uk

iiiIndependent

[The Francis Report]. House of Commons, 2013