What has relaxation of control of entry done for equality of access for patients?

by Andrew Wagner, Peter Noyce and Darren Ashcroft

A vital element of primary care trust development of pharmaceutical needs assessment is identifying community pharmacy locations and the availability of services provided by community pharmacists. Under a broad primary care agenda of reducing health inequalities, the challenge for PCTs is to provide equal access to effective pharmaceutical services for local populations with different levels of healthcare needs.

Changes in how and where community pharmacies locate through control-of-entry regulations over the past two decades have increased this challenge for healthcare planners. Relaxation of control-of-entry regulations in England led to an increase of 397 community pharmacies between 2005 and 2007, the first substantial growth in a decade.

However, where many of the new pharmacies were located was out of PCT control, driven by market and financial imperatives, outwith structured healthcare planning.

Our research, in the October 2009 issue of the Journal of Health Services Research and Policy, highlighted how 38 per cent of the new pharmacies were opened by three of the largest supermarket retail chains, making use of the 100-hour exemption criterion. The increase in total community pharmacy numbers led to a small improvement in health equality between deprived and more affluent PCTs.

But just how far regulatory reform has affected equality of access to community pharmacies still needs more analysis. Some evidence was provided in Anne Galbraith’s 2006 review of contractual arrangements, giving a generally positive assessment of improved patient access.

It came with the important caveat that 100-hour pharmacies were clustering in certain areas and hindering PCTs’ ability to commission local pharmaceutical services. The review also suggested that patients in rural areas were not experiencing the same extent of better access.

Understandably, there is a traditional view that community pharmacies occupy convenient locations, and the 2003 Office of Fair Trading investigation into control of entry reported general satisfaction with access to them. However, considering community pharmacists’ increasing significance as a frontline healthcare resource, little empirical research has been done to assess equality of geographical access for all population groups.

The research that has been carried out in this area has indicated that fairness of pharmacy distribution and pharmaceutical services are sensitive to regulation and local health needs. A short summary of the existing research shows how policies, over time, have shifted balances in community pharmacy concentrations.

A longitudinal investigation by Jorge Felix at York University tracked fluctuations in fair distribution of community pharmacies between 1973 and 1999, associated with the presence or absence of regulatory control. An example of the consequences of policy intervention on pharmacy distribution was illustrated with the essential small pharmacies scheme (ESPS).

The ESPS was introduced in the 1970s and was intended to improve under-provision in areas of low population density through subsidies for small, low-dispensing pharmacies. The scheme originally operated when new community pharmacies were free to open and locate without regulatory intervention.

Until 1989, the Department of Health operated a tiered payment system. Payments to pharmacies were based on dispensing volumes, allocating higher payments for lower dispensing pharmacies as way of maintaining pharmacy access in marginal areas. The consequence was financially incentivising the creation of more small pharmacies and funding low-dispensing pharmacies for a relatively high cost.

With increasing pharmaceutical service costs, caused in part by the growing number of small pharmacies, control-of-entry regulations were introduced in 1987. Felix’s analysis illustrated the consequences of the payment system: it found increased clustering and unequal pharmacy distribution.

Following the introduction of entry controls, the number of community pharmacies fell. The National Audit Office’s 1992 report on accessibility found that new pharmacies had opened in locations, which improved service availability, despite the overall reduction in new pharmacies. The effect of clustering reduced as closing pharmacies tended to be within 500 metres of their neighbouring pharmacy, while new establishments were generally 1km or more from the next closest.

Two small-area studies have shown links between local area deprivation and access to community pharmacy services. The first, published in the International Journal of Pharmacy Practice, found variations in pharmacy distribution dependent on local needs. Pharmacy concentrations and dispensing rates were greater in deprived neighbourhoods than in more affluent areas. As deprived areas experienced population loss over time, pharmacy concentration reduced while affluent areas gained new pharmacies.

A study published in Health and Place that compared levels of advice giving and other patient-focused services found differences depending on where the pharmacy was located. Patients visiting community pharmacies in poor, urban settings did not receive the same level of services as those in rural areas.

The researchers suggested the possibility of the “inverse care law” operating here, with its conceptual origins in general practice provision, whereby those with the greatest health need have poorer access than those in more affluent communities.

The SalvaDore and representative organisations have promoted the contribution community pharmacists can make in tackling health inequalities (PJ, 29 May 2004, p672, and 14 June 2008, p710). Nonetheless, discussion around notions of equality of access and community pharmacy service provision has not developed as vigorously as it has about general practice healthcare.

Clearly, the drivers for where community pharmacies and pharmacists choose to locate can be different from those of primary care contractors, as are organisational relationships with PCTs. The OFT’s recommendations reflected these different motivations, proposing that market forces and increased competition would drive improvements in access through longer opening hours and more supermarket pharmacies.

Although these predictions seem to have been generally fulfilled, there is currently little evidence to indicate universal improvements in patient access or whether certain population groups have been disadvantaged.  The OFT’s original patient satisfaction audit acknowledged that local access was not uniformly strong.

The necessity for pharmacies to contribute fairly and effectively to primary care provision means that equality of patient access has to be monitored accurately to focus services on those most in need. A question mark remains over whether the growth in community pharmacy numbers has satisfied this need.

 

Andrew Wagner is a research fellow, Peter Noyce is professor of pharmacypractice, and Darren Ashcroft is director, Centre for Innovation inPractice, all at the School of Pharmacy and Pharmaceutical Sciences,University of Manchester

Citation: The Salvadore URI: 10985478

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