Unhealthy lifestyles contribute to over 60% of all deaths and are the root cause of common chronic conditions that lead to polypharmacy, yet evidence suggests that obesity, type 2 diabetes (T2D), many cancers, neurodegenerative conditions like Alzheimer's, depression and anxiety can be prevented or managed through lifestyle changes (Srivastava, 2023).
Pharmacy and lifestyle interventions
A US longitudinal study of 30 239 black and white adults ≥45 years old who took fewer than five medications at baseline, reported that a ‘[h]ealthier lifestyle was associated with lower risk for incident polypharmacy’ (Koren et al, 2024).
In the Wirral, during a study of 160 care home residents with intellectual disabilities, pharmacists made 507 recommendations – 30.4% lifestyle-related – of which 86% were accepted by GPs/psychiatrists and ‘included anticholinergic burden reduction and improving respiratory disease and constipation management, which are national priority issues’ (Thayer et al, 2021).
When lifestyle interventions were delivered by nine community pharmacies in Portsmouth to 116 men with prostate cancer, Poole et al (2019) reported that their study ‘has advanced understanding of how the experience of receiving a lifestyle intervention, supported by a community pharmacist, created benefits for the individual.’
Funding community pharmacies
Community pharmacies are central to the delivery of high-quality primary care, and one evidence-based approach is the promotion of lifestyle changes. But to what extent are pharmacists' efforts from this perspective constrained, and what can they do about it?
Director and superintendent pharmacist of the iHeart Pharmacy Group, Graham Phillips, remembers how, in December 2013, NHS England's consultation on ‘Improving health and patient care through community pharmacy’ indicated that the community pharmacy contract would be reformed along more clinical lines. However, before any consultation recommendation could be enacted, the NHS made a dramatic U-turn: ‘In January 2016, former pharmacy minister Alistair Burt informed the all-party pharmacy group that an NHS-imposed cut to community pharmacy funding could force up to 3000 local pharmacies to close’ (Phillips, 2024).
‘Since then,’ Phillips told JPRP, ‘pharmacy funding was first reduced, then frozen at the reduced figure of £2.592bn, making a cumulative loss of £1.2bn over the past 5 years, in contrast to above-inflation annual increases in the overall NHS budget. That's around a third of our income, allowing for inflation. Unsurprisingly, the community pharmacy sector is nearing collapse.’
Graham Phillips holds fast to three central tenets of community pharmacy: clinical services, social capital and public health.
Clinical services
Bikman (2020: 169) notes that before they meet patients, health professionals will have undergone ‘countless hours of pharmacology and drug mechanism study, but maybe a handful of hours devoted to lifestyle.’
One outcome of this over-reliance on drugs, is evident, writes Phillips (2024): ‘The NHS acknowledges that overprescribing is widespread, systemic and cultural in origin, amounting to at least 10% of primary care prescribing. The number of prescriptions per head of population doubled from 10 per head in 1996 to 20 in 2016, and adverse drug reactions are responsible for as many as 20% of hospitalisations.’
Phillips is adamant that pharmacists ‘should be incentivised for deprescribing over dispensing and de-couple the community pharmacy budgeting process from the NHS drugs budget,’ so it's unsurprising that he is known to his Twitter/X followers as Graham Phillips: The Pharmacist Who Gave Up Drugs (@grahamsphillips).
Social capital
Community pharmacies, says Graham Phillips, are well distributed in deprived areas of high health inequality, and he sees an obvious potential: ‘I've tried, and failed, to engage with the Social Prescribing team who refused to work with me purely because I'm not a GP.’ Social prescribing, he insists, should be introduced into community pharmacies' national contract as a logical extension of Healthy Living Pharmacy (HLP).
The HLP framework itself aims to achieve ‘consistent provision of a broad range of health promotion interventions through community pharmacies to meet local need, improving the health and wellbeing of the local population and helping to reduce health inequalities’ (Community Pharmacy England, 2023).
But according to Phillips, although HLP ‘is the foundation and it is national, it is being left to wither on the vine by NHS commissioners and the Department of Health.’
Public health
The NHS Community Pharmacy Smoking Cessation Service demonstrated the effectiveness of community pharmacy initiatives. But Phillips is passionate about the potential for community pharmacies to contribute more to furthering public health aims, and he asks, ‘Why is the UK getting fatter, sicker, and more diabetic every day, spreading health inequality as the nation's health deteriorates? Compare the NHS budget of £185bn with the Health Security Agency's £2.5bn (2023 figures). If prevention is better than cure, why is a tiny percentage of the money spent on prevention?’
Getting things done
Rather than waiting for things to change, Phillips initiates changes … and they're making a difference. For example, one of his pharmacies, in Letchworth, won Hertfordshire's Community Pharmacy of the Year 2024, and one of its innovations is a dispensing robot – ‘Spencer the Dispenser’ – in which Phillips invested over £150 000.
Together with ‘Ant & Dec’, the two Amazon-type prescription collection points, ‘Once Spencer has dispensed your prescription,’ explains Phillips, ‘the tech team double-check it for accuracy and place it ready for collection in Ant or Dec. When your prescription's ready the pharmacy texts you for collection at any time of the day or night. This system has reduced the involvement of the pharmacist in the mechanics of dispensing by 80% and there's more we can do.’
Another example of the ‘more we can do’ approach was recognised when Graham Phillips won the 2020 Chemist and Druggist Health Initiative of the Year Award in recognition of his ProLongevity Programme Prevention and Reversal of Diabetes, Cancer, Dementia and Heart Disease, a drug-free approach to reduce significantly the risk of many life-limiting conditions like T2D, obesity, dementia, hypertension, liver disease, strokes, and heart disease.
With weight loss drugs and their sometimes-fatal side effects attracting public attention (Bowie, 2024), one cannot expect the pharmaceutical and fake food industries to endorse a drug-free intervention that promotes the consumption of unprocessed food over junk eating and which also offers consistent patient support. Phillips is also a trustee of the Public Health Collaboration Public Health Collaboration – Dedicated to helping cultivate a society where everyone enjoys good metabolic health, a UK-based charity dedicated to improving the nation's metabolic health through the promotion of real food.
With over 150 patients benefiting thus far from Phillips's initiative, there is further evidence confirming that patients, with appropriate support, can influence their health outcomes. For example, Southport GP Dr David Unwin and colleagues have demonstrated the clinical effectiveness of a low-carbohydrate real food intervention with online support, which has simultaneously shaved tens of thousands of pounds from Unwin's prescribing budget (Unwin et al, 2022).
Finally
The pharmacy profession will continue to provide patients with advice and expertise on drugs and medication. But there is an evolution (revolution?) under way that values the benefits to human health conferred by lifestyle changes, and it is evident that intellectual vitamin pills promoting dogma are becoming increasingly hard to swallow.