Royal Commission on the NHS Chapter 8

  Pharmaceutical, Ophthalmic and Chiropody Services

8.1 In this chapter we deal with the general pharmaceutical and general ophthalmic services, and have a brief look at chiropody services. Although chiropody is not provided on the same basis as the “contractor” services, and most chiropodists work in private practice, we include them here because their relationship to patients is similar in many ways to the relationship between the members of the contractor professions and their clients.

8.2 Apart from the evidence we have received about these services, we have had available to us the results of a study on access to primary health services commissioned by the DHSS and undertaken by the Office of Population Censuses and Surveys (OPCS). We ourselves commissioned jointly with the National Consumer Council (NCC) a study which complemented the OPCS survey. We have drawn on these studies in this chapter.

Pharmaceutical Services

8.3     The evidence we received about the general pharmaceutical services concentrated on two distinct but linked aspects – access to pharmaceutical services and the role of the pharmacist in the community.


8.4    Most of those who submitted evidence about pharmacists were con­cerned with the reduction in the number of pharmacies which has occurred in recent years. Although numbers of trained pharmacists and those in training have been rising, the number of pharmacies in the community has fallen by more than a quarter since 1963. Most of the closures have been in urban areas but their effect has been felt particularly in rural areas, and was the subject of comment by a number of community health councils. Bath CHC told us:

“the increasing trend for small pharmacies to close is giving more and more cause for concern particularly in the small and rural communities where the alternative service may be some distance away.”

8.5    However, this experience does not appear to be general and both surveys of access to primary care showed that relatively few patients experienced difficulties in getting a prescription dispensed. Nine out of ten people interviewed in the OPCS study said that they found it very or fairly easy to get to a chemist from where they lived, and about the same proportion usually went to one which was less than one mile from their home or from the doctor’s surgery. Difficulties were greater in rural areas, where the OPCS survey reported that 15% of people living in these areas found it fairly or very difficult to get to a chemist, particularly the elderly disabled and those who did not own cars.

8.6    Nevertheless, numbers of pharmacies have been declining in all parts of the UK, and if the trend continues the difficulties that some people are now experiencing in getting to a pharmacist are likely to become more widespread. The main reason for the decline in numbers seems to be that many pharmacies are simply not profitable. The Pharmaceutical Services Negotiating Committee (PSNC) told us:

“Because of the system of reimbursement, over 4,000 pharmacies in England and Wales, i.e. those dispensing up to 23,399 prescriptions per annum … are estimated not to recover their costs. These pharmacies can be sustained if they have a substantial volume of retail trade but figures show that pharmacies are experiencing a 10% drop in volume sales over the counter.”

8.7 An important influence on the distribution of pharmacies is the distribution of GPs. Patients find it convenient to visit a pharmacy close to GPs’ premises to have their prescriptions dispensed. The OPCS survey found that 51% of the people who had taken at least one prescription to be dispensed during the previous year said that their “usual” chemist was near (i.e. within one mile) to the doctor’s surgery. The concentration of GPs in group practices has led, in some places, to a process of leapfrogging in which pharmacies try to move nearer to practice premises. Pharmacists complain about the dispensing of drugs by GPs in certain rural areas, though there has been only a small increase in numbers of dispensing doctors in recent years.

8.8 The falling numbers of pharmacies may mean that patients have to travel further to get their prescriptions dispensed. In rural areas many patients will be quite happy to collect their medicine at the doctor’s surgery, usually after a consultation, or to have it brought when the doctor visits, or collected by relatives or neighbours. In urban areas concentration of pharmaceutical services in fewer, larger shops may enable better and less costly services to be It is not clear how far, if at all, small pharmacies should be preserved from the effects of competition. A differential system of payment for dispensing NHS prescriptions has recently been introduced in England and Wales which will benefit smaller pharmacies at the expense of larger ones. In the short term some £5m will be provided by the taxpayer to phase the scheme in. It remains to be seen what effect the new system will have.

8.9 We had available to us the report of a committee on dispensing in rural areas, which was chaired by one of our members. The Clothier Committee recommended that a new independent statutory body be set up to regulate significant changes in dispensing arrangements in rural areas. The proposals of the Committee have been accepted by the medical and pharma­ceutical professions and are at present under consideration by the DHSS.

8.10 A number of suggestions were put to us to improve the distribution of pharmacies.  One was that there should be a system of classification of areas, on the pattern of the control of general medical practice exercised by the Medical Practices Committees (discussed in Chapter 7) to prevent pharmacists opening businesses in areas which were already well or over-provided. In rural areas this proposal has been largely met by the recommendations of the Clothier Committee. Another suggestion was that the NHS should run the service directly in some places and pay pharmacists’ salaries, in the same way as those employed in hospitals are salaried, so that they would not be dependent on making a profit from their businesses. In some isolated communities a pick-up and delivery service for prescriptions has been developed.

8.11 We are not convinced that there is sufficient difficulty in getting NHS prescriptions dispensed to warrant the introduction of a national system for controlling the location of pharmacies. This is not to deny that there are local problems in some rural areas or for some groups of patients, but we doubt whether there is one solution which will meet all circumstances. We think that, as for the salaried GP and dentist, there may well be a place for a salaried pharmacist, perhaps employed by the health authority in some places and possibly located in a health centre. We hope that the health departments will support experiments in this field. A flexible approach and a balancing of the needs of people living in rural areas, who seem to be those most likely to be inconvenienced by closures of pharmacies, with the costs of any changes should permit the development of local solutions suited to local conditions.

Role of the pharmacist

8.12 Traditionally it is the function of a pharmacist to dispense medicine to the prescription of doctors. In the past the bulk of medicines had to be made up, but this skilled task has increasingly been taken over by the pharmaceutical companies and many medicines now need no preparation by the pharmacists. Perhaps for this reason much of the evidence we received from the profession was concerned with developing a new role for pharmacists to make fuller use of their extensive training. Since 1970 pharmacists have had to take a three year degree course followed by a pre-registration year in a recognised pharmacy.

8.13 It was suggested to us that pharmacists might develop their role of giving advice to the public. The PSNC said:

“The training and experience of the general practice pharmacist allows the public access to responsible advice on the actions and uses of medicines wherever a pharmacy is situated. With the growing concentration of medical practitioners serving a wide area in health centres, it will be even more important in the future to ensure that members of the public have convenient and ready access to advice about matters and information about medicines.”

The Pharmaceutical Society of Great Britain pointed out that “the general practice pharmacist is regarded as one of the main sources of advice in relation to minor ailments”. This is substantiated by both the OPCS and NCC surveys referred to and by previous studies. In the OPCS survey 15% of the people interviewed said that they had gone to a chemist for advice instead of to their doctor during the preceding year. Over two-fifths of them had gone with various respiratory conditions and with stomach or skin complaints.

8.14 This seems to us to be an important and useful service, and one which should contribute towards keeping down demands on other parts of the NHS. If a pharmacist is able to provide his clients with remedies for their aches and pains he is likely to be saving his medical colleagues’ time and possibly the cost of an NHS prescription. In the OPCS study nearly a fifth of those who had gone to the chemist instead of their doctor had been told to consult their GP by the pharmacist. In Chapter 5 we emphasised the importance of patients caring for their own health, and the pharmacist may be well placed to help them do so though it must be remembered that he is not trained in diagnosis. He can and should respond helpfully to people who ask his advice, but we do not see him as a quasi-doctor.

8.15 One way of making better use of the present under-used skills of the pharmacist is the establishment of pharmacies in health centres. This would enable the pharmacist to provide a better service to patients, foster good working relationships with his medical colleagues and might lead to collabor­ation to improve the accuracy of prescribing. We recommend that it should be The possibility of pharmacists being used to advise on the safe keeping and administration of drugs in nursing homes, and establishments for the handicapped and elderly, and to monitor repeat prescriptions also deserves consideration.

8.16 There are nearly 3,000 pharmacists employed in the hospital and community health service in the UK. There are recruitment difficulties in the basic grades (one out of every six posts is currently vacant), but there appears to be no difficulty in attracting new entrants into the profession as a whole, and the shortage may have arisen as the result of a discrepancy between earnings in the public and private sectors. Hospital pharmacists can play an important part with their medical colleagues in improving prescribing and in restraining drug costs. Local drug information centres, staffed by salaried NHS pharmacists, can also help to improve the quality of prescribing in general practice by providing information perhaps in the form of a newsletter, on new drugs and on drug interactions. We welcome recent developments along these lines.

General Ophthalmic Services

8.17 Eye problems may be dealt with under the NHS by hospitals or in the general ophthalmic services (GOS). The GOS provides sight-testing and the supply, replacement and repair of spectacles. Opticians, like pharmacists, derive part of their income from NHS work, but perhaps three-quarters of their gross profit comes from other activities, including private practice, and the sale of sunglasses, etc, which are not obtainable under the NHS. There are about 6,500 opticians’ establishments in the UK.

8.18 Two-thirds of the people interviewed in the OPCS survey said that they had had glasses or lenses prescribed through the GOS. Considering the high proportion of spectacle wearers in the population we received surprisingly few complaints from patients about the service. The principal complaint was that NHS spectacle frames were often not displayed and non-NHS frames did not carry prices so that patients were encouraged to buy relatively expensive private frames. We also had some complaints about the poor range of NHS Both the level of NHS charges and confusion over eligibility for exemption, emerged as problems from the NCC study, though the OPCS study found no clear evidence that charges put people off going for sight tests if they did not already wear spectacles.

8.19 We had representations from the profession about insufficient rewards for NHS work, the restrictions on what could be prescribed, and the lack of a fee for a domiciliary visit to patients who were confined to their homes or who lived in local authority residential homes.

8.20 So far as patients’ complaints are concerned, we understand that the health departments are discussing with the profession a requirement for NHS opticians to display the full range of NHS spectacle frames. If agreement on this can be reached, it will meet one of the frequent criticisms of existing The gradual extinction of NHS charges, proposed in Chapter 21, would reduce confusion amongst patients about prices and charges. Until that time we recommend that charges for NHS and non-NHS items and details of eligibility should be prominently displayed and publicised. It would be difficult to show that the existing range of NHS frames was unsatisfactory so far as patients’ vision was concerned, and fashions in spectacle frames may change. A larger range of frames is likely to mean greater cost and should not be given much priority.

8.21 In general the GOS is likely to provide a cheaper service than hospitals, as well as being more convenient for most patients, and we recommend that serious consideration be given to widening the range of items, such as magnifying glasses for the partially sighted, which can be prescribed and dispensed under the GOS. Our evidence does not suggest that many people require domiciliary consultations with an optician, but there will be some, particularly the elderly and the handicapped, and those in residential accom­modation, and it is important that they should be provided for.


8.22    Chiropodists, like pharmacists and opticians, engage partly in private practice and partly in NHS work. Access to chiropody is not normally via referral from a doctor. However, while the NHS aims to provide pharmaceut­ical and ophthalmic services to all who need them, chiropody on the NHS is currently restricted to certain priority classes – the elderly, the handicapped, expectant mothers, school children and some hospital patients. Anyone else needing chiropody has to pay for it themselves. Health authorities have no powers to charge for chiropody treatment.

8.23 In 1977 about six and a half million NHS chiropody treatments were provided to just over one and a half million people in Great Britain. This represents an increase of 19% on the number of treatments provided three years earlier. Over 90% of patients receiving these treatments were aged 65 or over. Treatments are mainly provided in clinics, but about one-quarter take place in the patient’s home, and a further one-eighth in the chiropodist’s own surgery. Chiropody is an extremely important service for the eight million aged 65 and over in the UK. The Elderly Invalids Fund pointed out to us that:

“Painful feet can mean that people do not go out to shop or to lunch clubs and can easily become isolated and possibly undernourished. They become less mobile indoors, sit still for longer periods and so become cold, may take to their bed for warmth, become weaker and possibly bedfast.”

Providing chiropody may well be an alternative to providing other, more costly community services.

8.24 NHS chiropody is essentially a community service provided for the elderly. The complaints made about it, mainly in evidence to us from community health councils, were for the most part that more and better distributed services were needed. Perhaps surprisingly the issue of whether a chiropody service should be provided by the NHS for the whole population was barely touched on. The main problem seems to be a shortage of chiropodists to undertake NHS work and consequent delays in getting treatment. Some of this treatment is of a very simple kind, such as cutting toe nails, which a more active person would be able to undertake for himself and which could be performed by an assistant with relatively little training; but some of it is more complicated and may, for example, involve giving injections. At present the demand for NHS chiropody outstrips the supply. The OPCS survey found that 13% of the over-65s who had had chiropody treatment during the past two years had used private chiropody services, though the numbers of treatments provided by the NHS has been rising.

8.25 Chiropodists employed in the NHS must be state registered. The normal qualification for registration involves a three year course of training to the syllabus if the Society of Chiropodists. At least five “O” levels or their equivalent are needed to start training. There are about 5,000 chiropodists on the register but only about two-thirds of those work for the NHS (figures are imprecise because much of the treatment provided by the NHS is paid for on an item of service basis). There are, therefore, a substantial number of chiropodists who would be eligible for NHS employment but who work only in private practice. In addition, there is an unknown number, possibly amounting to several thousands, of people who practise some chiropody, perhaps on a part-time basis, and are not registered. The NHS is competing for registered chiropodists with the attractions of independent private practice.

8.26 About £15m per annum is spent on chiropody in the NHS at present, and the DHSS Priorities Documents propose that chiropody services should be increased by more than 3% per annum. The ability of health authorities to meet this objective depends on their success in attracting staff as well as finding the money to pay them. At present numbers of registered chiropodists are increasing at under 1% per annum, and existing training schools are doing little more than keeping up with natural wastage. There are proposals to open new schools but, under the provisions of the 1960 Professions Supplementary to Medicine Act, the approval of the Chiropodists Board is required. The Board is at present reluctant to approve any further schools, than one in Belfast, on the grounds that there would be difficulties in staffing new schools. This does not seem to us to be an insurmountable problem, and we recommend that more training places should be provided and that services to the elderly in the community should be increased.

8.27 We support the suggestion put to us by the Association of Chief Chiropody Officers for the introduction of more foot hygienists who undertake, under the direction of a registered chiropodist, “nail cutting and such simple foot-care and hygiene as a fit person should normally carry out for himself.

8.28 While accurate assessment of need is not available, our evidence suggests that there is plenty of work amongst the existing priority groups for all the chiropodists likely to be employed by the NHS in the foreseeable future. In the circumstances, we do not think that it would be sensible to attempt to extend the service to the rest of the population.

Conclusions and recommendations

8.29 The main problems in the pharmaceutical services appear to be falling numbers of pharmacies and the erosion of the pharmacist’s traditional role with the development of modern packaging of medicines. While surveys suggest that access to a pharmacy is not yet a serious problem for many people, it may well become so in the future. Pharmacists will continue to have an important role since the use of potent drugs in medicine has increased substantially. We do not consider, however, that they should develop a quasi-medical role, and we think their expertise can most usefully be employed in advising doctors on prescribing matters and the public on self-medication.

8.30 The complaints about the general ophthalmic services were mainly lack of information about NHS treatment and spectacle frames. The optician has a financial interest in encouraging patients to buy non-NHS frames, but we see no reason why he should not be required also to display NHS frames and the prices of both NHS and non-NHS items.

8.31 The NHS does not attempt to provide a comprehensive chiropody service. Within the NHS chiropody is mainly provided to the elderly, and there are shortages of qualified chiropodists prepared to undertake the work. One reason for this is a shortage of training facilities for chiropodists; another is the attractions of the private sector in which most chiropodists work at The health departments should promote the introduction of foot hygienists.

8.32 We recommend that:

  • the establishment of pharmacies in health centres should be encouraged (paragraph 8.15);
  • charges for NHS and non-NHS items and details of eligibility should be prominently displayed and publicised by opticians (paragraph 8.20);
  • serious consideration should be given to widening the range of items which can be prescribed and dispensed under the general ophthalmic services (paragraph 8.21);
  • more chiropody training places should be provided and services to the elderly in the community increased (paragraph 8.26).