Pharmacy First: A year of the service in England

In the run up to the service launch on 31 January, The Pharmacist spoke to under-pressure community pharmacists who were torn between welcoming the opportunity of Pharmacy First and wondering whether patient demand will exceed its capacity.

Before the scheme began (and in the months that followed) it was stressed that the ‘success and full benefit’ of Pharmacy First was reliant on strong relationships between community pharmacy and general practice.

And among the teething issues of the service were reports of pharmacy owners struggling to get hold of otoscopes ahead of the launch date. NHS England then confirmed that those who had ordered but not yet received one were allowed to begin offering Pharmacy First from 31 January without the otitis media clinical pathway.

Then it was launch day. A total of 10,265 community pharmacies in England signed up ready for the start date – marking what was been described as a ‘step-change’ for pharmacies, patients and the public.

Among leaders welcoming the new service was then Prime Minister Rishi Sunak who said that with the launch of Pharmacy First the government was ‘determined to go further’ and unlock the ‘full potential’ of community pharmacies to deliver routine care.

The service sees pharmacists funded to provide advice and treatment where necessary for seven major conditions: acute otitis media in children, impetigo, infected insect bites, sinusitis in over 12s, sore throat in over fives, shingles in adults and uncomplicated urinary tract infections (UTIs) in women aged between 16 and 64.

It also encompasses referrals from GPs and 111 for other minor ailments, previously known as the Community Pharmacist Consultation Service (CPCS), as well as referrals for urgent repeat medicines supply.

Within the first week it was revealed that around 3,000 consultations had taken place during the first three days of Pharmacy First.

At the time, Janet Morrison, chief executive of Community Pharmacy England (CPE), said: ‘Pharmacy First has got off to a fantastic start, with thousands of consultations taking place in the first few days of the service.

‘This is a clear sign of support from the huge number of people who know the best route into healthcare is often to visit their pharmacy first.’

This volume of consultations has happened even before NHS PR campaign begun – which finally came nearly three weeks later.

The campaign featured ‘temporarily rebranded’ pharmacy signs, bearing names such as ‘It Burns When I Pee Pharmacy’, ‘He’s Got an Itchy Rash Pharmacy’, ‘I’m So Bunged Up Pharmacy’, ‘This Earache Is Getting Worse Pharmacy’ and ‘Get Well Sooner Pharmacy’.

But concerns were raised that it didn’t go far enough – and the same was said about a tweaked version launched later in the year.

Later in February, NHS England confirmed that the functionality that would allow community pharmacies to update GP patient records with Pharmacy First consultations was in the ‘process of getting ready to go live’.

When the service was launched, pharmacies were having to send details of patient consultations to GPs via existing processes previously used for Community Pharmacy Consultation Scheme (CPCS) appointments.

While Pharmacy First funding had included an allocation to develop ‘interoperable’ patient record systems between community pharmacy and general practice, the GP side of the system was not ready for the system’s launch.

It wasn’t until nearly the end of March that the IT functionality started to be rolled out in a ‘phased’ manner. At the time of publishing, one pharmacy IT provider had confirmed to The Pharmacist that it would go live with the update during the last week of the month.

Other IT issues in March also saw an extension for pharmacy contractors submitting their Pharmacy First payment claims for services delivered in February.

CPE had said a ‘backlog of unresolved issues’ with Pharmacy First IT systems have had an ‘unacceptable impact’ on pharmacy owners and teams and caused concerns about the impact on patients.

In April, concerns were raised that many Pharmacy First consultations were not passing the gateway point for a service payment.

The chief executive of the Independent Pharmacies Association (named Association of Independent Multiple Pharmacies at the time) raised concerns that the level of funding provided for the service ‘does not reflect fairly on the level of work pharmacy teams need to put in to deliver the service’.

This was because an IPA survey found that six in 10 (59.5%) survey respondents said that ‘less than 50%’ of initial Pharmacy First consultations passed the gateway point for a claimable Pharmacy First consultation.

And in more IT news, on 26 April we reported that just one IT provider was believed to have rolled out updates to allow pharmacies to send structured records of Pharmacy First consultations to GP practices – almost three months into the service.

It was in May when the Health and Social Care Committee stepped in and asked the government to set out what progress has been made on rolling out ‘the full digital product’ for the documentation of Pharmacy First consultations.

Meanwhile, NHS England confirmed in the same month that, at that time, it had no plans to replace the referral requirement of Pharmacy First with a walk-in approach – despite concerns from the sector.

The month began with confirmation that changes to allow pharmacy technicians to supply medicines will not apply immediately and will not affect Pharmacy First.

The Human Medicines Regulations were amended to enable registered pharmacy technicians to supply medicines under patient group directions (PGDs).

But CPE confirmed that the legislative changes will not mean that pharmacy technicians will be able to conduct Pharmacy First consultations, as this service was negotiated on the basis of a pharmacist providing the service, as is referenced throughout the service specification.

In the middle of June, the pharmacy negotiator clarified that pharmacies can be paid for a Pharmacy First consultation for any minor illness that is referred from a GP surgery, even if this is not covered by the seven common conditions listed in the service specification.

In July, the NHS Business Service Authority (NHSBSA) revealed that 423,310 Pharmacy First consultations had been delivered in the first three months of the service.

A total of 9,976 community pharmacies claimed payments for the service, although the number of those claiming on a monthly basis in February, March and April appears to be lower than this.

On average, community pharmacies delivered between 14 and 17 consultations per month – well above the targets of one consultation for the first month and five by April 2024.

However, the average figures do not detail the variation between contractors, meaning that some community pharmacies could have been delivering more and less than this amount in each month.

In the summer, GPs voted in favour of taking working-to-rule collective action, amid funding concerns.

And as part of this, almost two-thirds (61%) of GPs said their practice had turned off the Update Record functionality that allows community pharmacies to send Pharmacy First consultation information in a format that can easily be added to patient records.

The snapshot survey, carried out by our sister title Pulse, saw a further 16% of respondents report that they were still considering whether to turn off the functionality in the future. Just 12% said they were not planning to take this action.

In September, NHS England confirmed it was reviewing its projected trajectory of how many Pharmacy First, blood pressure and contraception service consultations will be delivered by community pharmacies in 2024/25.

And that same month, The Pharmacist published an exclusive Pharmacy First roundtable – which brought together representatives from both community pharmacy and general practice to discuss how the first six months of the service had been.

Local relationships between general practice and community pharmacies have been identified as ‘key’ to the success of the service, as was evidenced by our discussion around referrals to pharmacies and patients being sent back to their GP.

Funding and workload pressures on both sectors underpin many of the challenges facing the service. Our attendees agreed that Pharmacy First is not a solution to GP access pressures nor to the community pharmacy funding crisis.

Throughout the discussion, some clear points emerged on clinical issues and patient experience. Attendees shared examples of initiatives that had worked in their local areas to improve the service.

And suggestions were made as to how the service – including what clinical pathways were included – could be refined and expanded in the future.

Most strongly, there were clear calls to make Pharmacy First accessible to walk-in patients for all minor ailments.

October saw the government introduce caps on the maximum number of Pharmacy First clinical pathway consultations that each pharmacy can claim payment for.

The caps are based on each pharmacy’s monthly average earlier in the year, and will be in place from October to December this year. We created an interactive tool so you can find out your cap, and how your clinical pathway consultations compare to other pharmacies.

Unsurprisingly, Pharmacy First was a big topic at the Pharmacy Show in Birmingham in the middle of October.

It was announced that thresholds for the monthly Pharmacy First payments had been lowered until March 2025.

NHS England’s director of pharmacy, optometry and dentistry, Ali Sparke, said the thresholds for clinical pathway consultations would be ‘revised downward’ in recognition of the ‘levels of pain going on in the sector’.

And at the same event, CPE suggested the government intends to expand Pharmacy First to create the community pharmacy prescribing service promised in its pre-election manifesto.

In November, a national newspaper changed its headline about obtaining antibiotics through Pharmacy First following concerns raised by the sector’s negotiator.

And an exclusive survey by The Pharmacist suggested Pharmacy First won’t tempt practice pharmacists back into community services just yet.

NHS England also relaunched its Pharmacy First advertising campaign with minor tweaks – but sector leaders warned it needed to be part of a ‘much bigger, ongoing public awareness campaign to ensure the service has maximum impact’.

It cannot be missed that in a perhaps unprecedented move in November, pharmacy owners in England, Wales and Northern Ireland voted in favour of taking collective action, according to a ballot carried out by the National Pharmacy Association (NPA).

The vote saw some 99% of participating pharmacy owners say they were willing to limit their services unless funding is improved.

New Pharmacy First analysis in December suggested pharmacists are treating antimicrobial stewardship with ‘utmost importance’ and only supplying antibiotics ‘when appropriate’.

On average, two-thirds (66%) of patients attending pharmacies for earaches, bladder infections, sore throats, sinusitis, infected insect bites or impetigo are provided antibiotics, according to the report by the Company Chemists’ Association (CCA).

This was particularly welcomed following some outside concern raised the initial roll-out of the service.

The Pharmacy First scheme has been up and running for almost a year now, and for the majority of that time, contractors have been working under the terms of a contractual framework agreed in 2019, that expired in March this year.

A new contract was due to begin in April but was delayed as negotiations because of the general election. But on 17 December, pharmacy minister Stephen Kinnock said he was ‘confident’ negotiations for the community pharmacy contract in England will begin in the new year.

And in the same week, health and social care secretary Wes Streeting said he was working on a funding package to stabilise community pharmacy.