Michael Holden, FRPharmS, FRSPH, associate director of Pharmacy Complete in the United Kingdom, discusses some of the key differences between the role of the pharmacist in the United Kingdom versus the United States.
Pharmacy Times interviewed Michael Holden, FRPharmS, FRSPH, associate director of Pharmacy Complete in the United Kingdom, to discuss some of the key differences between the role of the pharmacist in the United Kingdom versus the United States.
Alana Hippensteele: So, Mike, could you talk a little about Pharmacy Complete and its role in pharmacy in the UK?
Michael Holden: Good morning, Alana. Pharmacy Complete is a training consultancy organization. So, we provide training to pharmacies and pharmacy teams, and a wider audience, and not just in community pharmacy, but in a broader sense, in hospital and primary care settings, where medics sit dominantly, but pharmacists are also working in that field.
We also provide consultancy to pharmacy; we provide leadership through articles and presentations at conferences, and those sorts of things. But we also work as consultants with many of the global majors in the pharmaceutical industry.
Alana Hippensteele: Got it, yeah. Could you tell us a little bit about what the National Pharmacy Association (NPA) is, an organization in which you held a national role as chief executive, and what the role of this organization is in the field of pharmacy in the UK?
Michael Holden: Yeah, I was with the NPA for 4 years, and we transformed the organization at that point. What it does now is it's the professional trade association for the independent sector of community pharmacy owners in the UK across all the developed countries.
It provides support, it provides training, it provides insurance, it provides an element of lobbying, but working collaboratively with other organizations that represent the other sectors.
Alana Hippensteele: Got it, yeah. Could you tell me a bit about the role of the pharmacist on the health care team in the UK, and what are some of the key differences between why patients seek care from pharmacists versus physicians in the UK?
Michael Holden: Yeah, we have a very different setup to anywhere in the world because we have the NHS, or the National Health Service, and that provides free care at the point of care, or predominantly free care—doesn't always quite work that way—because people contribute towards medicines, and they contribute or they may buy private health, or they may contribute to dental care or optical care.
But, generally, it's the provider, so the physician in the community that may be working in a general practice. You don't pay to go and see them, whereas in many countries you would either do so either through insurance schemes or by direct payment to the medic.
So, it's a very different culture from that point of view. So, it seemed to be a free service, health is free, and therefore the desire and the ambition of people to buy a service, whatever it may be, from a pharmacy is slightly different. But it is shifting, and we're starting to see a growth in that area, which we can talk about as we go through.
So, that's one of the main differences between most of the rest of the world, I have to say. But we have an emerging role, which is increasingly integrated into the rest of the health system, whereby it's becoming more joined up. In fact, we do a lot of training around this joined up collaborative integration approach at the moment.
Alana Hippensteele: Yeah, very interesting. So, would you say pharmacists in the UK are able to provide services such as medication management, management of chronic conditions, point-of-care testing, and immunization screenings and administrations directly to patients? Is that something specific to pharmacists?
Michael Holden: Yeah, generally speaking, pharmacists working in a community are not prescribers, but, increasingly, a number of them are, and there's a program being developed at the moment, which is due to be launched soon, to increase the number of pharmacists who will be prescribers in the community to initiate or amend medication that might have been provided for a long-term condition or even an acute condition. But we're not there yet, by any means.
The main role, as far as medicines management is concerned, is around supporting people with adherence to the treatment that has already been initiated by usually a physician, either in hospital or in primary care.
As far as the role on immunization is concerned, pharmacies have been doing flu vaccination for many years now, and occasionally a few other vaccines on the private side of things, as opposed to the health systems’ side, which would be providing travel vaccinations and things like that in many of the pharmacies—not all, but many.
Of late, inevitably COVID-19 vaccinations—which is why I'm in scrubs at the moment because I'm just off to a clinic to do that—are dominating the scene here in the UK, like they are in many other countries.
I know in the US, pharmacies are heavily involved in that, and here we are increasingly involved, but it's not to the same level. So, not every pharmacy will be providing COVID-19 vaccinations; it's only 4500, I think, at the moment who are doing that across England.
Alana Hippensteele: Interesting, yeah. Would you say pharmacists are generally understood and acknowledged in the UK as being a direct source of many essential health care services in communities, or are there any issues around pharmacists’ authority to provide essential services that their communities need? I think you addressed this a little, bit but maybe just kind of more detail here would be helpful.
Michael Holden: Yeah, it depends on which lens you're looking through. So, if you're looking at it through the public’s lens, then yes, they're highly trusted.
One thing that's happened during the pandemic is that whilst the general practice physicians have been operating, generally behind closed doors, and therefore have been more difficult to access, pharmacies increasingly have become the place where people go to or contact, maybe by phone or even video consultation, in some cases, for minor ailments or common ailments, whether it's a skin condition or cough, cold, headache, bowel condition—whatever it may be, and treatment for that—we do have a specific service within the NHS that relates to that as well, in England.
Increasingly, they're the only health care place that people could walk into [during the pandemic]. We kept our doors open, admittedly with restrictions and queuing and flow, but our pharmacies tend to be a lot smaller than the ones in the US. I've been to the US a few times and witnessed the size of them, scale of them.
Here they tend to be a bit smaller, unless you get to some of the really big units. But the average pharmacy [in the UK] is pretty small, and therefore social distancing has to be managed very carefully. Hand hygiene, mask adherence, and things like that have to be managed very carefully.
But we kept the doors open, that's the main thing, and therefore became a very trusted provider of care from the public's perspective. But also, that meant that physicians were sending people to us. The difficulty there is who's paying for the service. Let's not get into the money at this stage.
But yes, that has accelerated the integration and the recognition of the role of pharmacists in health care undoubtedly, and that's been acknowledged from the Prime Minister downwards.
Alana Hippensteele: Yeah, that's similar to what's been going on in the United States as well, in terms of a real shift happening in awareness of the importance of the pharmacist as a direct access point for care.
So, diving in a little bit—independent community pharmacies in the UK, are they facing some similar issues as independent community pharmacies in the US in regard to problems with consistent reimbursement and payment models, and if this isn't happening, what are some of the issues independent community pharmacies are facing in the UK during the COVID-19 pandemic and on into the future?
Michael Holden: Yeah, let’s put aside the direct impact of the pandemic in terms of everything you had to put in place to make it’s safe for you, the team, and for the public, but the reimbursement element is a real challenge.
Just prior to the pandemic, some money was taken away from pharmacy and hasn't yet returned. Negotiations are going on around that to try and make a more sustainable model, but the current model is certainly not sustainable financially. So, there's too much being done for no fee, and there's too much being done for too low a fee.
So, the recognition that we've had in from the Prime Minister downwards around how they recognize the importance of pharmacy and health care in the community as the frontline of our NHS is not being followed. The rhetoric's not being followed by actions and money.
Alana Hippensteele: Got it, okay. So, that sounds like perhaps slightly different from the exact situation happening in the US, but similar in terms of some kind of financial issues facing specifically independent community pharmacies. Would you say that that would be correct?
Michael Holden: Yeah, absolutely. The route to it is different, but the end point's the same. The reimbursement on medicines as well—we have some of the cheapest medicines in the world in the UK, anything up to—when I was working in and around the US area—10 times less than some US products, particularly on the branded size, because we're very generics-driven. But there's still a desire to force those prices down further, cut the reimbursement, and cut any margin that might be made on those.
But again, it's a different funding stream. It's not a co-payment scheme, it's not an insurance-based theme that works through these business managers that you have in the United States, it's a very different setup. But the parallel in the United States, the parallel across the world actually, and certainly the developed countries, is very similar. It's a price down, we want more for less.
Alana Hippensteele: Right. Are you aware of any differences in the authorities pharmacists have in the US versus UK in relation to being able to provide direct care to patients in the form of health care services? We've talked about this a little, but just in terms of specifically calling out some of the differences.
So, for example, right now, there's a Supreme Court case that's trying to get reimbursement coverage for pharmacists in delivering some of the services that I mentioned regarding medication management, management of chronic conditions, point-of-care testing.
Before that, Medicare, which is a federal insurance program, it wouldn't reimburse pharmacists for delivering these services. So, issues in relation to that in the US are rather complicated in this regard because it can change state to state, but generally speaking, do you have a sense of what some differences might be?
Michael Holden: Yeah, I guess again, it goes back to the way the funding streams come down with no co-payments and no insurance schemes to do so. So, those who have money can buy services or product, and those who don't tend to go to the NHS, and they have more limited choice in that respect.
But because of the culture that we have around the NHS being free at point of care, and the NHS badges on our pharmacy, and then something like 90% of most pharmacies business is with the NHS, as opposed to the direct customer, the challenge we have then is that people expect to get that free when they walk in.
That's starting to change, and pharmacists have to value themselves first before they start asking people to value them, and sometimes we don't value our own time as health care professionals.
We go into the profession like everybody in the world to provide care. That's why we do it. Therefore, some people will find it hard to say well that's going to cost because it's a caring profession.
But we have to be real. Particularly in the circumstances I've just alluded to around the financial sustainability of pharmacy, we have to be real about saying this has a value to the individual, to the state, and to the country and the NHS.
So, we need to be saying we're not doing it for free. We need to be saying we're doing it as a charge, and if we don't get a payment for it, we may not do it or won't do it. So, there's a little bit of cultural shift there as well as balancing professional and business, which is always a challenge for everybody.
Bearing in mind something like 55% or 60% of the pharmacies are owned by large corporates in UK, then they make the decision around whether this is an added value service that they don't charge for, it's a service they do charge for, and if they're doing it for free then it makes it difficult for somebody else to charge.
So, we're not always joined up as we might be around that that cultural shift that will then educate the patient that there's a value to this service, and therefore you have to pay for it. But there are people who are leading that change and making a big difference, and we're sort of shifting pharmacy from being a supplier of medicines to being a walk-in clinic.
Alana Hippensteele: Yeah, interesting. So, there's a similar kind of shift that's happening in the United States around the role of the pharmacist. And in the US, some of that shift has really taken place during the COVID-19 pandemic, where there's been a greater emergence of the importance of the role of the pharmacist, specifically, like you've been talking about, just keeping their doors open during the pandemic, and the critical role that had for a lot of patients seeking care and services.
So, this kind of change in awareness in the US, how would you say that's—you've mentioned that's happening a bit in the UK—how is that kind of playing out in the UK, and would you say the US is on a similar kind of awareness level in relation to that of the UK or would it be a bit different?
Michael Holden: I think it will be a little different because the cultures are different. We're very different, and you haven't got the NHS, and we have—so I know I keep repeating that, but the NHS is 80 years old coming up, it's over 75 anyway, because we had a 75th birthday of the NHS not too long ago, and therefore it's very embedded in the culture of health care in the UK.
But there's loads of private providers out there, and not just pharmacists. You've got various organizations, some of whom have come from the United States as private providers and launched themselves here.
So that cultural shift, and then the point I made around valuing ourselves and time we give, it's not about selling a product, it's about providing a service, and the micro products associated with that service. That's a very significant shift for us in mindset terms from being one of a supplier of medicines, whether they be bought over the counter or whether they be provided on the prescription to one of which is a service provider who happens to provide medicines at the same time.
We don't want to lose the medicines because that gives us the footfall and the safety and everything else that goes with that, but we have to change that. It's like converting the pyramid and getting us to a mindset where we are a provider of services, health care services, whether they be private or NHS—doesn't matter in the way we operate because it'll be done on a safe basis.
But we have to have the skills to do that. We have to have the business now, as well as the clinical skills, and we have to have the leadership skills to change what we do and how we go about it and take our team with us.
Alana Hippensteele: Absolutely, yeah. I think that's really interesting, and I would say there's also, just even in terms of kind of developments in care, there's been also a push that has been accelerated to some extent during the pandemic around personalized medicine, which pharmacy would be the ideal location for, in terms of providing that at scale in environments where pharmacists know their community members. So, that's another interesting kind of push that I think aligns with the role of the pharmacist truly just expanding and potentially just growing into the future.
So, how has the COVID-19 pandemic, in your perspective changed how the world views the role of the pharmacist in health care in general? So, that's very hard to say because you don't have to speak for the entire world, but just in terms of beyond just the UK and the US, do you think that this is something that's really changing on a global scale, or is that something that you feel comfortable speaking to?
Michael Holden: Yeah, and there are different starting points in different parts of the world. If you're living in Italy, for example, you wouldn't dream of going to the doctor unless you're really, really ill because it's going to cost you, I don't know, 25 euros or something to go and see them. But you can walk into the pharmacy, and the pharmacies are empowered to do much more personalized care and initiate and supply medicines which are there.
In the UK, we wouldn't be allowed to at this stage, but the culture is pharmacy first and talk to them about your ailment and everything else, and we're getting towards that now, and I think the US is getting towards that pharmacy first approach as well.
In other countries in the world, where there is a charge to see the medic, then if you can walk into a pharmacy and only have to pay the equivalent of 5 dollars say, or 25 even, to have a conversation with a pharmacist, whereas it costs you 75 to go and see a physician, then why wouldn't you if you can get the same outcome?
There's a confidence, a trust in the capability, and the biggest thing there is the patient experience. If the patient experience is good, they'll come back. It's like going to a good restaurant—you get good food, you get great service, and you get great ambience.
So, if you get that same parallel in a pharmacy, with great clinical care, great experience, great premises that shows professionalism. Consultation rooms, which are equipped appropriately, and great IT systems.
Promoting what we do—that's one of the things we're really bad at, and I think that's a national thing, or an international thing. I don't think it's just UK. But in UK, we're particularly bad at it.
So, we're starting to gear that up now, so the patients understand what they can get from a pharmacy. It's not just a packet of pills, it's a package of care.
Alana Hippensteele: Right, absolutely. Yeah, that's very well said. That's, I think, absolutely the case in the US too—that problem around the awareness pharmacists have of their role in health care as well and that value they provide.
To kind of close things off here, what are your hopes for the future of pharmacy and pharmacists’ role in health care—let's say in the UK or even in the US, if you have any thoughts on that?
Michael Holden: I think we have to look at ourselves first. We do have a habit of having a chip on our shoulder sometimes, and forgive me for saying that, it doesn't come lightly when I say that we have a bit of a chip on our shoulder.
We have an expectation that we are provided for, and actually no, the market now is whatever it is. When you see other businesses in the world collapse from being significant because of the pandemic or because of the change in consumer behavior and expectations—they expect more, they expect better, they expect it faster, they expect it digitally, and we have to move into that arena, and nobody's going to do it for us—we have to do it ourselves, either collectively, but certainly individually—transformation and innovation starts at the bottom and doesn't start at the top.
Therefore, everybody has to see the common purpose, which is to elevate pharmacy to being firstly the point of contact for prevention, protection, and treatment to a level of our own competencies. If you break a leg, you wouldn't walk into a pharmacy. But if you can't manage your asthma, or you can't manage your blood pressure, maybe pharmacy is where you go first. Then, if the pharmacy triages, you decide you need to see a medic or a physician, and that could be in a hospital setting or in a primary care setting.
So, we need to get that whole triage thing set up with quality assurance associated with it, the clinical skills to support it, and the premises have to reflect that and the way we present ourselves to the market has to reflect that.
So, this is basic business, as well as health care. We established—3 of us, who are very experienced in leadership models, recently established a product or a brand called Pharmacy Cares, which is public facing, which we don't have in the UK—we don't have a public-facing campaign that says pharmacy does this, pharmacy does that for you, talk to your pharmacist about this.
As I said at the beginning when I introduced Pharmacy Complete, we upskill people on both business and professional skills, but also in consultation skills and leadership skills. So, it's about taking pharmacists who are not businessmen generally, they're clinicians, they're scientists by background, and therefore they're not necessarily good businessmen, they're not very good managers or leaders very often.
I'm not decrying that. It's a skill in its own right, and it doesn't naturally come to somebody who's a scientist who will be quite analytical and look at the evidence around what the decision-making process is rather than being, and you don't have to be a charismatic person to be an inspirational leader and an innovator, but you need to think differently, and therefore imparting those skills is something that we do, at the moment.
If you're going to work with what are currently competitors to collaborate together, to provide something in the community in which you work, where there may be 5, 10 pharmacies working in the community, but they're currently competing over prescriptions, and maybe they're over the counter business a bit. But around services, they could probably collaborate, so one provides one thing, one provides another, one becomes an expert hub for something. So that collaborative mindset is a cultural shift and requires those leadership skills to change. I'm kind of going around in circles a bit here, but you see where I'm coming from.
So, Pharmacy Cares was designed to be a brand that we say to the public, pharmacy does care, particularly during the pandemic, but you need to care for pharmacy as well as pharmacy caring for you during the pandemic, and not rush in and get angry because you had to wait a bit longer because of social distancing or whatever.
But also expanding on the range of things that pharmacists do—so one thing Deborah and I did way back in 2009 to 2010, I initiated a program called Healthy Living Pharmacy, which was intended to move pharmacy up the ladder in the prevention and protection scales, where health interventions that prevent illness or manage illness better around lifestyles were brought in. But actually, that was part of the agenda—part of the agenda was putting the skills in to change what we do and how we do it, and more importantly, why we do it.
If we look at our purpose, our purpose is to improve the health of our community. Yes, we have to make a living to do so, but that's an end product, that's an output, it's not an input. Why we do this is to improve the health of our communities. And you don't just do that by selling medicines or supplying meds on prescriptions, you do it by helping people have a healthier diet, reduce their alcohol consumption, stop smoking, or do more physical activity, and those are just some examples.
But also, vaccination, whether that be flu, pneumonia, shingles, chickenpox, or for travel purposes. So, the whole immunization agenda is a key part of that. So, when you think about that, if you think about Healthy Living Pharmacy as a model for developing the business with leadership and changing the skills of the team that you're working with, using automation and using digital technology to make yourselves more efficient, more effective, and safer, and then using the leadership skills to boost your business prowess in the community, understand what their market needs, and therefore develop your services towards that market, which will be different in one town compared to another city, or even one area of a city compared to another.
So, we tend to have a vanilla product at the moment, selling the same products, the same services to different people and different communities, and we can't do that—it needs to be integrated.
Alana Hippensteele:That's a really interesting perspective. Thank you so much for sharing that, and also thank you so much for taking the time today to speak with me today, Mike.
Michael Holden: Pleasure, Alana. Lovely to meet you.
Alana Hippensteele: Lovely to meet you as well.