Scotland’s CPhO on ‘messy’ temporary pharmacy closures and building on COVID-19’s legacy
Reflecting on her first 18 months as CPhO, Alison Strath reveals her vision for the sector in Scotland, her plans for new women’s health services and her thoughts on the “messy” temporary pharmacy closures situation
Never has the role of chief pharmaceutical officer (CPhO) been under such scrutiny than in the past two years. Thrust into the spotlight as Scotland’s new CPhO 18 months ago, Professor Strath has played a central role in directing the twists and turns of Scottish pharmacy’s response to the pandemic, emerging throughout this crisis as a steady voice of reason.
With the nation on high alert once again as the number of COVID-19 cases remains strong, her hands are firmly on the wheel.
While Scotland is widely seen to be leading the way in the evolution of community pharmacy, Professor Strath is modest. “I’ve got to be honest, part of the issue,” she says laughing, is that “we’re the size of a health authority in England, so even though the geography is horrendous, we do have quite short lines of communication”.
“This makes it a little bit easier, I think, to make progress on things.”
“Nobody voted for me to make difficult decisions”
So, who is the woman who has such influence over the Scottish pharmacy sector? A key figure in the Scottish government since 2002 – initially appointed principal pharmaceutical officer – she has also held roles at the National Pharmacy Association, McPherson Pharmacy and her alma mater, Robert Gordon University, where she served as professor of community pharmacy practice.
2020-2021: Between October and August, she served as interim chief pharmaceutical officer, taking the lead for NHS pharmaceutical care and medicines policy in Scotland and providing advice to the first minister, the health secretary and wider ministerial team.
2002-2020: As principal pharmaceutical officer for the Scottish government, she led on developments in pharmaceutical education and supported the implementation of Achieving Excellence in Pharmaceutical Care.
2008-2018: A professor of community pharmacy practice at Robert Gordon University, her research interests included interprofessional education; the management of long-term conditions and person-centred care; models of community pharmacy remuneration and the technological developments underpinning pharmacy practice.
1996-2018: In her two decades at McPherson Pharmacy in Dundee, she served as director.
1995-1999: Professor Strath held the role of community pharmacy development co-ordinator at the National Pharmacy Association.
Her hobbies? Seemingly collecting titles. Appointed a fellow of the Royal Pharmaceutical Society (RPS) in 2010, she was also made an emeritus professor at the School of Pharmacy and Life Sciences at Robert Gordon University in 2018.
In March 2020, Rose Marie Parr announced she was stepping down as CPhO. Professor Strath, having proven herself as interim CPhO during the pandemic, was the top choice for the job and took over officially in August 2021.
“I'm always very mindful of the fact that nobody voted for me to make difficult decisions or even easy decisions. That’s really what the ministers are there to do,” she tells C+D via Zoom.
Professor Strath may be a qualified pharmacist, but it’s hard to come away from a chat with one of the Scottish government’s most senior medical advisers without thinking there's also something of a seasoned diplomat about her.
“I have to say, across all the years I've worked in government, either as principal pharmaceutical officer and now in my role as chief pharmaceutical officer, I've always had a great working relationship with our ministers. They’re always really keen to learn about the profession,” she adds.
"Don't come with problems, come with solutions, because ministers don't need to hear about your problems"
“I think that also [comes] down to how the pharmacy profession has presented itself to ministers. What I've always said to colleagues in Community Pharmacy Scotland (CPS) and the RPS and others is, don't come with problems, come with solutions, because ministers don't need to hear about your problems. What they want to understand is what can we do about it to make it better,” she adds.
“I think the profession has always come forward pretty much with a united voice in Scotland – I’m glad to say – and has been able to talk about what the problems are and how they can actually offer a solution to that.”
Relationship with other CPhOs
But what about her relationship with the CPhOs of the UK’s other three countries?
“While we all go at a different pace,” she responds diplomatically, “we've all got similar ambitions around what we want to see happening, to develop our profession. Whether that be about how we develop hospital pharmacy services, whether that be about, the whole community pharmacy contract”.
Pre-pandemic, the teams would meet once a year, she explains. “Unfortunately, COVID-19 kind of put a halt on that. But we’re really keen to get that back up and running again.”
“We all come at it from a different skill set. Some of us have more community pharmacy background, some more hospital and it's that richness that lets us think about the whole picture,” she adds.
Temporary pharmacy closures “a messy area”
A topic that continues to unite all four nations, however, is workforce pressures.
A current source of controversy, the sector has been plagued by arguments from all sides on workforce shortages – or the lack of. Just last month, the Pharmacists’ Defence Association (PDA) hit back after the Company Chemists’ Association (CCA) accused the union of dismissing contractors’ workforce challenges.
Meanwhile, last August, CPS also called for a temporary halt in recruiting community pharmacists to general practice, warning that this could badly hobble the sector.
“My strapline on workforce is that pharmacy is an ecosystem. If you pinch one bit of it, you feel it in another bit of it”
So, does Professor Strath think pharmacist shortages are still an issue in Scotland?
“I think they're an issue everywhere,” she concedes. “I don't think there's any part of the UK where we don't have some challenges around this right now. But there are multifaceted reasons for it. So, I think in some cases, there are challenges in remote and rural areas that we’ve known about for a long time, in terms of attracting people to work in some of these areas,” she explains.
"My strapline on workforce is that pharmacy is an ecosystem. If you pinch one bit of it, you feel it in another bit of it.”
Indeed, as 2021 came to a close, the PDA also published a damning analysis of temporary pharmacy closures in Scotland, revealing that a “minimum of 574 closures” occurred across the country in just three months.
“I mean, some are inevitable, we can't stop them,” Professor Strath admits. “But in the main, if we can plan around it, and we're working between individual pharmacies or pharmacy groups and the health boards, we can manage some of that.
“I think we should be able to get our way through what feels like a messy area right now, to really try and understand what [is] causing it and therefore how we can work to effectively to address it,” she adds.
“I always feel that in Scotland, we have been fairly generous in our remuneration offer in terms of what we've tried to do to provide support to the network. But I do think sometimes we’re experiencing efficiency savings that are made on the back of where some of the remuneration offers may not have been so generous.”
“I do think sometimes we’re experiencing efficiency savings that are made on the back of where some of the remuneration offers may not have been so generous”
“I can see some real advantages for patients in that,” she admits. “It's really important that we do have those whole-system ways of working and thinking about how we integrate and transfer care between ourselves.”
Plans to tackle workforce issues
So, how can pharmacy employers continue to present community pharmacy as an attractive career path?
“One of the key things I want to achieve across the course of this year – and it will be a longer-term, ongoing piece of work – is to set up a workforce forum,” she explains. This involves “key stakeholders” including pharmacists, pharmacy technicians, locums, pharmacy support workers, to consider what the workforce should look like in a year, three years and five years’ time.
“It's probably difficult to go much beyond that right now,” she adds. Moving beyond pharmacy, it must also consider the part new technology and new medicines may play, “which might require us to deliver care slightly differently”, she says.
“New technologies, automation, artificial intelligence: how will they impact how we work? And [how will they] be different in the different settings?”
Women’s Health: “We have an ambitious agenda”
One area currently undergoing somewhat of a renaissance in Scottish pharmacy is women’s healthcare.
In August, in a bid to become a 'world leader' in women's health, the Scottish government published its ‘Women’s Health Plan’, becoming the first country in the UK to do so.
The plan, which was informed by women’s own testimonies, is described as “the first stage of a long-term commitment to reducing health inequalities for women”. The 68-page document also pledges to “provide and promote a 'Women's Health' Community Pharmacy service” within the next three years.
“There may be some pharmacies that would want to really specialise in contraception”
In November last year, all community pharmacies in Scotland began offering a bridging contraception service, following a successful pilot.
“We have an ambitious agenda around women's health,” Professor Strath says. “The next step would be long-acting contraception. There's great potential around what we can do there.”
“In fact,” she explains, “I was speaking to one of the pharmaceutical companies who has an interest in women's health around what else could be done in terms of, for example, implants. I'm not saying every single community pharmacy would necessarily want to do that, but there may be some pharmacies that would want to really specialise in contraception.”
But her ambition extends far beyond contraception. “There's a great focus right now in terms of menopausal health and thinking about issues such as endometriosis. These are all areas that we're really keen to explore. What is it that pharmacists can do in that arena? And how can it add value?”
“Equally,” she adds, “I think there are areas and things like sexual health, over and above what we talked about in terms of contraception, but other things around access to treatments for sexually transmitted infections, for example, when logically pharmacy might be a good port of call around that.”
What’s next for Pharmacy First?
There is, however, one service that remains a landmark development in the offering of the Scottish community pharmacy sector. Since its launch in July 2021, the Pharmacy First service has seen more than two million consultations across 1,200 community pharmacies, taking on more than 200,000 appointments that would otherwise have gone to GP surgeries or hospital A&E departments.
The service caught the attention of health secretary Sajid Javid who confirmed in November last year that the government hopes to implement a “Pharmacy First” model in England, with the objective of encouraging patients with minor illnesses to visit their pharmacy, rather than seeing their GP.
“I want community pharmacies to be at the very heart of primary care, not just treating people, but preventing people from becoming patients in the first place,” he said at the time.
Professor Strath agrees. “The big thing for me,” she says, is “using patient group directions for some prescription medicines. What will be really nice to see is how we can actually start to move from Pharmacy First to our Pharmacy First Plus”, she adds.
“Some of our pharmacists who are independent prescribers obviously have a wider range of products available to them and we'd be keen to see that happening in all pharmacies,” she says.
“There’s lots of scope for us around that. We do need to think a little bit as we start to develop some of the parts of the service that we're delivering.”
In February, the RPS in Scotland unveiled its vision for pharmacy in 2030, in which it described how all pharmacists in a patient-facing role should be independent prescribers.
Scotland’s ambition for all pharmacists to be independent prescribers by 2023 “probably was a little bit early for the profession”
“It’s definitely a shared ambition, right across all of the stakeholder bodies in Scotland,” Professor Strath says. “We’d like to see community pharmacies, in particular, having access to an independent prescriber to allow them to extend the range of services they can provide.”
Scotland’s ambition for all pharmacists to be qualified as independent prescribers was initially put forward in its Prescription for Excellence strategy, published in 2013 – in which the government anticipated that all pharmacists would be required to hold the qualification by 2023.
“Now, that probably was a little bit early for the profession,” Professor Strath concedes. “But I think now that people can see how to use the skills, there is a real desire for that.”
Building on the legacy of the pandemic
Professor Strath may have had a baptism-of-fire welcome to her CPhO role and have plenty on her plate now to meet Scotland’s strong vision for community pharmacy, but she appears calm and determined to do this in C+D’s allocated interview time.
Ultimately, meeting the targets ahead will not be achievable without a personable figure at the helm and even via Zoom, Professor Strath emits warmth and friendliness – she tells C+D that she has to have a difficult conversation with someone immediately following the call, which she is “dreading”.
But, with the tasks of “stepping out of the pandemic”, developing Scotland’s women’s health strategy and building a workforce forum on the horizon, Professor Strath expects to take measured steps, learning from her experiences so far.
“I think one of the things that the pandemic has taught me is the importance of research and innovation, and thinking about how to do things differently and do things better,” she tells C+D.
“There's something around thinking quite carefully about how we build on some of the legacy [of the pandemic] and learning lessons about the things we did differently and understanding the benefits they brought.”