Is a profit-first philosophy in retail pharmacy compromising working conditions and patient care?

The tension between the “business of pharmacy” and the professional responsibilities of pharmacists, as health care professionals, has always been present in retail (“community”) pharmacy practice.  For much of the past several decades, pharmacies have generally been owned by pharmacists, elevating pharmacy ethics and professional responsibilities to the level of the owner. But the era of the independent pharmacist-owner-operated pharmacy is disappearing, and the era of the massive pharmacy chain is upon us. In the United States, CVS and Walgreens command 50% of the retail pharmacy business in major cities. In Canada, Shoppers Drug Mart has been purchased by the grocery giant Loblaw, and the Rexall chain has been purchased by American giant McKesson.  And in the United Kingdom, retail pharmacy chain Boots has about 25% of pharmacy market share.

With this retail consolidation, are we seeing a decline in the autonomy of the front-line pharmacist? A scathing series of articles in The Guardian is raising questions about whether pharmacy giant Boots is putting  a drive for profits ahead of safe and appropriate pharmacy care. And pharmacists are speaking up.The Guardian column is scathing. “How Boots went Rogue” was the headline in a long piece by Aditya Chakrabortty:

This is the tale of how one of Britain’s oldest and biggest businesses went rogue – to the point where its own pharmacists claim their working conditions threaten the safety of patients, and experts warn that the management’s pursuit of demanding financial targets poses a risk to public health. (Boots denies this, saying that “offering care for our colleagues, customers and the communities which we serve…is an integral part of our strategy.”)

At the heart of this story is one of the most urgent debates in post-crash Britain: what large companies owe the rest of us – in taxes, in wages, and in standards of behaviour.

Boots is everywhere in the United Kingdom, and plays an integral (and integrated) role in the delivery of care, just like the National Health Service (NHS) itself – yet Boots is a fully private organization, unlike the public NHS:

Britain relies on Boots – and Boots relies on Britons. It is by far the biggest pharmacy chain in the country. Healthcare professionals refer to the firm as an “essential component” of the NHS. It is to outpatient care what the high-street banks are to the UK’s money system: a massive private-sector firm delivering a vital public service.

And it takes a lot of public money to do so: around £2bn a year for prescriptions alone, according to independent financial analysis, or a third of Boots’s annual income in the UK. Then come the patient-care services paid for by the taxpayer, and the contracts Boots is now taking over from the NHS – to host GP surgeries in its stores, to run pharmacies in hospitals, to manage hearing test centres and specialist clinics monitoring drugs that prevent blood clots.

The article points to changes in the organization that it claims started in 2007, when Boots was sold for £11 billion, in a deal backed by private equity group Kohlberg Kravis Roberts (KKR). And that’s when pharmacy-level changes apparently began:

Outwardly, 2007 changed nothing. The pharmacists still wore white coats. The sign outside the shop was still the same blue and white cursive logo dating back to 1883. But behind the trusty facade was “the story of how one business model colonises another,” according to Colin Haslam, professor in accounting and finance at Queen Mary University of London. The everyday needs and ailments of communities across the UK had been reconfigured as thousands of little revenue streams for a small transnational elite of ultra-wealthy investors, whose fortunes depended on those streams getting bigger, and fast.

The column goes on at length to describe the financial consequences. But what I want to focus on (and understand) is the pharmacist and patient impact. A staff pharmacist describes a reduction of pharmacist hours (no more pharmacist checking pharmacist), and new quotas to conduct medication use reviews (MURs):

Free for the customer, a way of keeping a patient out of a GP’s waiting room, and for each one the NHS pays the company £28. To prevent the system from being abused, every pharmacy in the country is limited to 400 MURs a year. Except Tony’s managers took that number as a target for his store to hit.

“Miss it and they get on your back,” said Tony. He adopted a manager’s whine: “You’ve done three MURs less than you should have done this week.”
A Boots pharmacist from another region described to me a recent staff awayday at which he and his colleagues were told: “400 MURs is an expectation now. We don’t need to tell you that.”

The focus on selecting appropriate patients waned:

So keen was Tony’s store to make that profit, he claims it did reviews on anyone, no matter how unsuitable. Tony himself was told to have one – and to give one to a patient with severe dementia. His manager came in for one – no sooner had it begun than she walked out, but it still went towards the total. All so the shop could earn that extra £11,200 from a scheme intended to help the sick. (Asked to comment, Boots said: “We make it clear to our colleagues that these services should not be undertaken inappropriately.”)

These forms of outpatient care are a good earner for Boots. Assuming each of its pharmacies churns out 400 MURs a year, that one NHS programme is worth an annual £30m to the company. Stack alongside that the new medicine service (NMS) for patients on heavy-duty drugs, worth at least £25 a time, NHS flu jabs at up to £17 a pop, stop-smoking clinics, and a lot of public money is being sent to private companies to look after our health.

Pharmacists were feeling the pressure, and The Guardian notes several spoke up about their ability to provide appropriate care:

On the one hand, you have an NHS looking to move more of its patient care into the private sector. On the other, you have giant chains such as Boots chasing lucrative new business. And in the middle, you have the humble pharmacist, responsible for diagnosing ailments and dispensing medicines – and personally liable for errors. Yet under intense managerial pressure, they are being stripped of their professional discretion – and some feel they are being turned against their own patients.

Pharmacists are being blunt – these working conditions are affecting their ability to deliver patient care. A recent survey of UK pharmacists gives some worrying signals:

Asked “how often do you believe financial cutbacks imposed by your main employer have directly impacted upon patient safety”, 56% of Boots chemists said that was true “around half” or “most” of the time. A further 20% said it was the case “all the time”. Taken together, these numbers outstrip by 10 percentage points their counterparts at other chains, and should cause particular alarm given Boots’ position as Britain’s biggest pharmacy.

Three in every four of responding Boots pharmacists believe that the cuts imposed by their employer, whether the drop in staff numbers or increased workloads, threaten patient safety at least half the time or more. In response, Boots points out that it now employs more than 6,000 pharmacists in the UK, up from about 4,500 before the buyout. However, that rise tracks the increase in its number of stores, up from 1,400 in 2005 to around 2,400 today. I asked Boots what had happened to the number of dedicated pharmacy support staff, the dispensers and assistants that Boots chemists reported they were having to do without. The company did not respond.

Following the Guardian column, Boots pharmacists responded directly about the pressure, with comments like:

“Patient safety is severely compromised as pharmacists are asked to clinically check prescriptions while ensuring people are being served at the tills, taking phone calls, giving advice to patients, handing out prescriptions, re-ordering medication for patients, texting patients, storing prescriptions, recording clinical information, etc. Self-checking, which should only be done as a ‘last resort’ is actually done on a daily basis. Having two people involved in the dispensing and checking of a prescription is a fundamental hallmark of safe dispensing, which Boots is not taking seriously. Under pressure to meet several targets … in a Boots pharmacy it is extremely difficult to counsel a patient fully on how to use their medication correctly and how to get the most out of their medication, there is simply not a time provision for this.”

and

“I am a passionate pharmacist and love doing my job so that I can help patients and provide a brilliant service to them. However with the ongoing, worsening and unrealistic budget cuts, we are working on skeleton staff every day just battling to survive. We can no longer give even a half decent service even if we wish to. What is worse is that staff are taken away and more is expected of you in terms of targets, services! How can you cope? They are setting you up for failure even before you have begun. I wake up in the morning dreading work.”

Now it looks like the UK pharmacist regulator, the General Pharmaceutical Council (GPhC) is investigating claims that Boots is pressuring staff to conduct inappropriate and unnecessary MURs to drive revenue:

The General Pharmaceutical Council (GPhC) is calling in evidence on the allegations made in the report, which revealed that managers at Britain’s biggest chain of chemists have been forcing staff to milk NHS schemes, in order to increase company profits.

The report also detailed a recent and yet to be published survey by the pharmacy trade union of its members, to which more than one in 10 of all Boots chemists responded. Asked “how often do you believe financial cutbacks imposed by your main employer have directly impacted upon patient safety?”, more than 75% of those who responded to the Pharmacists’ Defence Association (PDA) said that was the case at least half the time.

The union has been asked to show the pharmacy regulator its survey and other relevant documents, in what are understood to be the first steps towards a possible full investigation of Boots.

The GPhC, however, continues to be criticized for what is felt to be a tendency to focus on individual pharmacist behavior, rather that focusing on the broader, system-level issues that compromise the ability of all pharmacists to deliver ethical patient care. Some pharmacists feel the same way, suggesting a focus on MURs distracts away from the profession-wide issues that continue to be a part of retail pharmacy. Pharmacist Anthony Cox notes:

The real story is the poor management culture and treatment of pharmacists, which the MUR outcome is symptomatic of. No other profession would have allowed this situation to fester for years. We need only to look at the concern for junior doctors to see how other professions attempt to create a professional environment where an individual can flourish, rather than merely survive.

Staff pharmacists, please describe your own experiences in your country, and at your pharmacy. Have you experienced new pressure to deliver unnecessary pharmacy services? Are staffing cutbacks affecting your ability to deliver safe patient care? Is it different in chain (vs. independent) pharmacies? How has the environment changed over the past several years?

Please share your thoughts in the comments, or send them to sciencebasedpharmacy at gmail dot com and I’ll post your feedback. Pharmacy is a self-regulated profession. It’s our profession. Without your advocacy for your profession and for patient care, there will be no change.