As community pharmacies were this week briefed on how they can opt in to prescribe for seven common conditions – and the contraceptive pill – Anna Colivicchi looks into the detail of the scheme.
One of the first tasks of the new health secretary Victoria Atkins was overseeing the rollout of the ‘Pharmacy First’ scheme.
The £645m scheme scheme was hailed in the primary care recovery plan. The biggest change will see a shift of workload to pharmacies, chiefly prescribing for seven common conditions: sinusitis; sore throat; earache; infected insect bite; impetigo; shingles; and uncomplicated urinary tract infections in women.
Under the new plans, from 31 January, pharmacists will be able to hold consultations with patients to treat these conditions without the need for patients to visit a GP, and supply prescription-only medicines including antibiotics and antivirals.
On top of this, the NHS has announced an expansion of the scheme allowing pharmacies to initiate the prescribing of contraception, an expansion of the hypertension case-finding programme and giving pharmacists greater powers to change a patient’s GP record.
These changes are intended to support a general practice service in crisis.
But there are concerns, too. When it was first revealed that the Government – under short-lived health secretary Thérèse Coffey – was looking at allowing community pharmacies to hand out antibiotic prescriptions, there was some outrage from experts warning it would hamper antibiotic stewardship efforts. The BMA argued that making it easier to access antibiotics wouldn’t be good for the patients nor would it reduce pressures on GPs, and it could lead to ‘overusing antibiotics’, making them less effective.
Furthermore, many GPs believe that the money would be better off spent in general practice.
Under the plans, A&E, urgent care centres and NHS 111 should begin to refer patients that would have otherwise been sent to their GP to participating pharmacies instead.
Pharmacies can claim an initial fixed payment of £2,000 from December up to the launch of the Pharmacy First service in January. The NHS will reclaim this money if pharmacy owners do not provide five clinical pathways consultations by the end of March next year.
As part of the service, pharmacies will also be paid £15 per consultation.
Seven different Patient Group Directions (PGDs) allow medicines to be supplied to patients who meet certain criteria after having a consultation with their pharmacist. There will be seven PGDs in total, one for each condition, which have been signed off by the Chief Medical Officer but not published yet.
Community Pharmacy England (CPE), which has negotiated the PGDs, said these allow community pharmacists to supply antimicrobials ‘only where clinically appropriate’ without ‘increasing the risks of antimicrobial resistance’.
But GPs have expressed concern, especially around the cost of the scheme.
Doctors’ Association UK GP spokesperson Dr Steve Taylor says: ‘Could similar funding have been provided to GP practices? A lot of the need wouldn’t have been there in the first place, if it had.’
Dr Emma Nash, a GP in Hampshire and mental health lead at Southampton, Hampshire & Isle of Wight ICB, agrees that the funding attached to the scheme was ‘somewhat disappointing for primary care, given what we deliver for much less’, but adds that it won’t particularly help GPs – and could cause issues around patient safety. ‘I don’t know if they’ll be audited on antibiotic prescribing or referrals back to GPs, but some metric on primary care workload is advisable.
‘I think what would be more helpful is the permission for pharmacists to change medications based on availability. This takes much more time and would be a better investment of time and funding, and more within their skill set.’
She added that the theory behind giving pharmacists more powers is ‘good’, but the experience of the community pharmacy referral scheme locally ‘has made her cautious’.
‘Misdiagnosis is easy, especially for things like insect bites which can be inflamed but not infected, and I do wonder about antimicrobial stewardship,’ she said.
‘It’s more differentiated than previously, so hopefully less will be bounced back to us, but we’ll still have to review the notes to ensure context, such as for recurrent UTIs.
‘It may be quicker, in these instances, to do it ourselves, especially given the availability of electronic proforma which collect much of the information for us already.’
RCGP chair Professor Kamila Hawthorne said that while ‘it is right that pharmacies are given the support they need to help patients most effectively’, pharmacists and GPs ‘are distinct health professionals’, and neither should be seen as a substitute for the other.
‘While we are keen to see initiatives that will ease the pressure on our struggling family doctor service, patients will in many cases, need the expert diagnostic skills and expertise of a GP,’ she added.
But Doncaster LMC chief executive Dr Dean Eggitt strikes a more positive tone: ‘This is the dawn of a new era which will be expanded upon. Difficult – yes. Worth it – yes.’
Initiating oral contraception
Currently, community pharmacies manage ongoing monitoring and supply of repeat oral contraception that has already been initiated by a GP or sexual health service under a pilot scheme that has been running since April and including around 100 outlets.
Now, under the second phase of the pharmacy contraception service, community pharmacies will be allowed to initiate contraceptive prescriptions, starting 1 December. This next stage of the service had been due to launch in September but was delayed.
This is also an opt-in service for pharmacies. The service specification for tier 2 of the service, which begins next months, has yet to be published but pharmacies taking part under tier 1 received:
- A set-up fee of £900 per pharmacy, paid in instalments as follows:
- £400 paid on signing up to deliver the service via the NHSBSA MYS portal;
- £250 paid after claiming the first 5 consultations; and
- £250 paid after claiming a further 5 consultations (i.e. 10 consultations completed).
- A fee for each consultation of £18.
The Government said it expects around half a million women would be able to make use of the scheme when it starts and as more pharmacies sign up, women will be able to search on the NHS website for the nearest participating branch.
While women do not need a GP referral to access pharmacy-provided contraceptive pills, GPs and sexual health clinics will be able to refer women, the Government has said.
The pharmacist will then offer a consultation and reach a decision with the person about their first supply of the pill, or the ongoing supply of their current oral contraception, and its supply will be free.
A BMI and blood pressure measurement will need to be taken as part of the consultation or can also be self-reported by the patient. Any self-reported measurements will need to be recorded as such, the document added.
Dr Nash agreed that this second phase of the service could help reducing GP workload.
‘That’s better in terms of workload reduction, provided robust safety processes are in place,’ she says.
Hypertension case-finder service expanded
An expansion of the pharmacy hypertension case-finder service was also announced yesterday, with more money and ‘a better use of the skill mix’ within community pharmacies from next month.
CPE said that new guidance on the expansion is expected to be available ‘shortly’.
The scheme initially launched in 2021 to identify eligible patients with high blood pressure and ‘refer them to general practice to confirm diagnosis and for appropriate management’, and on top of this, all pharmacies in England can offer targeted cardiovascular (CVD) screening to patients aged over 40 as part of the service.
CPE said the service will be relaunched ‘to make better use of skill mix’ and ‘increase provision’ of ambulatory blood pressure monitoring (ABPM) – currently the screening can only be carried out by pharmacists and pharmacy technicians, so an expansion of the roles that can provide the service could be in the works.
Participating pharmacies receive:
- A set-up fee of £440;
- A fee for each clinic check of £15; and
- A fee for each ambulatory monitoring of £45.
They can also receive a £1,000 incentive payment if they achieve 20 ABPM checks in 2023/24.
Pulse’s sister title The Pharmacist has learned that the hypertension service is ‘not changing significantly’ upon the relaunch, except for the addition of skill mix, which will allow any pharmacy team member to deliver the service as long as they are appropriately trained.
The service was launched, GPs expressed concerns that this would lead to unofficial screening.
Pharmacists to access and add to GP records
The shift to pharmacy consultation and prescribing will also require a change to how patient records are managed. While the full details are not yet outlined, community pharmacies will need to be able to access and add to patient records.
Pharmacists will have access to more parts of the GP record, including medications, observations and investigations, and will use the new Pharmacy First consultation record to capture consultations, which will then send automatic updates to the GP record and to the NHSBSA to support payments and reporting on the service.
CPE has stressed that updates to supporting IT infrastructure are essential to the roll-out of the services.
Pharmacies will be given access to patient records using GP Connect that will enable them to view relevant information without needing to open new records. This is unlikely to be ready by December, but is expected to be in place by the end of January.
An update to allow community pharmacies to write into the GP patient record for the first time is also being developed, building on the existing functionality in place for sending information about flu vaccinations and medicines under the existing Community Pharmacist Consultation Service (CPCS) to GPs.
The development of a clinical triage system will also be implemented to send electronic referrals from NHS 111 and urgent and emergency care settings to community pharmacy that may otherwise go to a GP practice, for the seven common conditions targeted.
Sheffield GP Dr Ben Allen says the schemes present ‘potentially lots of good changes, adding: ‘We do need ways for pharmacists to use their knowledge and capabilities. We also need medical record connectivity and the protection for pharmacist to use clinical judgement.’
But Dr Neil Bhatia, a GP and records access lead at his practice in Hampshire, tells Pulse that it is important that any information from a pharmacy ‘comes into a document inbox, identical to hospital letters, and can be read first,’ then filed in the GP record.
‘GPs would be unhappy if letters or blood pressure readings from the pharmacy were automatically filed in the GP record,’ he adds.
‘It is singularly important as patients now have access to the GP record and, rarely, we might need to hide communication from the pharmacy from online access, either to the patient or a proxy.’
The RCGP has highlighted the importance of maintaining patient confidentiality when the changes take place, arguing that ‘patient safety and confidentiality must continue to be a priority’.
These measures taken together may well have an effect on GP workload. But as of now, it is unclear whether they will be the intended effects.