Roundtable: Six months of Pharmacy First

Patient satisfaction

Pharmacy attendees at our roundtable shared high levels of patient satisfaction with the service.

Jonathan Cooper, who owns an independent pharmacy group in the North East of England, said his pharmacists reported that patients ‘really like the service and are more likely to come back and try it again if the need arises’.

‘I get nothing but positive feedback,’ agreed Sukhy Somal, head of Community Pharmacy Clinical Services at The Black Country Integrated Care System (ICS).

She highlighted that in her area, nine out of 10 patients surveyed after using Pharmacy First said they would return to a pharmacy to use the service.

Easing pressure on other parts of the NHS

When Pharmacy First was launched, the government and NHS England said it was designed to save up to 10 million general practice team appointments a year, alongside expansions to community pharmacy blood pressure and contraception services.

During our roundtable, Ms Somal suggested pharmacies were ‘generally’ able to deal with patients referred to the service by GPs, if those referrals came through correctly.

She said she thought that pharmacies were saving appointments in secondary care too, by avoiding patients attending A&E when general practice was closed – although she noted more work needed to be done to quantify this.

Utilising pharmacists’ expertise

Meanwhile, Shilpa Shah, chief executive of Community Pharmacy North East London, said she hoped Pharmacy First was the ‘start of a journey to educate patients’ on pharmacists’ expertise in medicines and minor conditions.

And she highlighted the opportunity to speak to patients and ‘make every contact count’ by offering other services such as smoking cessation or contraception. ‘It’s about giving that patient a total solution, and them knowing that they can get that in the pharmacy, and they can get it in their lunch hour,’ Ms Shah said.

Clinical note-taking

More than one roundtable attendee suggested that some community pharmacists struggled to know what information was most useful to write in the patient’s notes following a Pharmacy First consultation.

Ms Somal said that to overcome this, her ICB had run a webinar on what good note taking looks like, as well as developing a guide for pharmacists to know what sort of information was helpful to record for GP colleagues.

She also said the ICB had worked with local GP surgeries to understand what would help the practice code the information into its NHS payments system appropriately. ‘That collaborative piece of work has been really successful in making this work going forward.’

It was also noted during the roundtable that clinical record taking and consultation skills now form a core part of pharmacist training.

Ms Somal suggested that issues around communication between pharmacies and GP surgeries could be resolved once pharmacies had access to and could update patient notes.

Pharmacy First was intended to be underpinned by read/write access to patient records. But an update to GP Connect, which allows pharmacy systems to send consultation notes to general practice so that they can be added to patient records with ‘one click’, was not ready in time for the start of the service and was only rolled out to ‘most’ pharmacies by June 2024.

Allowing other clinicians access to GP records has also been met with opposition from some GPs, with nearly two-thirds of practices having turned off the functionality.

Alongside their own patient dispensing records, all community pharmacists can access patients’ Summary Care Records – usually via a separate portal, although some system providers have introduced a ‘one-click-integration’. In some areas pharmacists can access local Shared Care Records, also through a separate portal.

Training locum pharmacists

If the sole pharmacist working in a particular premises on any given day was not trained to offer Pharmacy First, patients would have to be turned away. To overcome this, Ms Somal said her ICB had run face-to-face training evenings and monthly webinars for locum pharmacists who would not have received training through an employer.

Driving patients to the service

Ms Somal also suggested that patients had been confused by the initial NHS England publicity campaign around the service, and called for more support for patient education.

Meanwhile, Mr Cooper flagged that local practice staff were not making formal referrals but rather signposting patients to the pharmacy.

Because pharmacies only receive a payment for minor ailments outside of the seven common conditions when a patient has been referred to the service by a GP or NHS 111, signposting patients rather than making a formal referral leaves pharmacies unpaid for any advice they give in those instances.

To help resolve this, Mr Cooper suggested that it could be made easier or incentivised for GPs to refer patients to Pharmacy First.

Also during the discussion Ms Shah shared how her integrated care board (ICB) had supported pharmacies and GP practices to deliver the service.

The ICB had funded a referral integration for general practice IT systems, which made it ‘really easy for the receptionist to press one button’ and refer patients to the service, she explained.

Every pharmacy in the area also has a ‘PharmAlarm’, funded by the ICB, that flashes when referrals come through to notify the pharmacy.

Ms Shah added that the most important intervention made by the ICB had been funding facilitators, managed by the Local Pharmaceutical Committee, ‘to go into every surgery and into every pharmacy to train the team’.

Ms Shah also said that ‘more could be done to send people to community pharmacy’ from NHS 111, suggesting that call handlers may be unsure about how the process worked.

She shared that she had visited one of the NHS 111 call centres to educate the team there about Pharmacy First on a drop-in basis but noted that ‘this needs to be done nationally and everywhere’.

A ‘fundamental’ issue with NHS 111 was that staff turnover is ‘really high’ and ‘they just don’t have capacity to release people for training’, she warned.

Improving GP confidence in Pharmacy First

Dr Sarah Jacques, a member of the Doctors’ Association UK GP Committee, shared GPs’ concerns that pharmacists may not have the expertise to identify patient issues outside of the seven clinical pathways, potentially risking patient safety.

And if patients were sent back to general practice because a pharmacist was unable to deal with their concern, Dr Jacques suggested that this ‘fragments care’; is frustrating for patients; does not solve workforce issues in general practice; and would not be cost-effective.

In response, Harry McQuillan, chairman at Numark and former chief executive of Community Pharmacy Scotland, highlighted that the PGD framework underpinning the service reduces the risk of missing a red flag.

And rather than care being fragmented between professionals, he suggested that patients having a regular community pharmacy would help pharmacists identify repeated issues.

Mr McQuillan also highlighted a report into the similar service in Scotland that found patient experiences were ‘very positive and not, as far as I’m aware, unsafe’, he said.

Pharmacy First is about giving patients access to ‘appropriate treatment in an appropriate place’ from a trained healthcare professional, he added.

If pharmacists had any concerns about the appropriateness of a treatment they would escalate the patient to a GP, he said.

Cost-effectiveness would also be improved as the service develops and more Pharmacy First consultations are delivered, Mr McQuillan suggested – as he said had happened in Scotland.

Meanwhile, Ms Shah noted that when patients attend a community pharmacy, pharmacists ‘don’t just look at that one thing that’s wrong’, but ask questions about symptoms and lifestyle, and refer to a GP or other clinicians like opticians or dentists where necessary.

‘Absolutely, we will be sending people back to GP surgery after they’ve visited us, but when it’s appropriate,’ she said.

Ms Shah said that in her area, 75% of patients seen under Pharmacy First so far had been seen appropriately in a community pharmacy with no need to be sent back to the GP.

And one local practice had been able to release a session of GP appointments each day, because of Pharmacy First.

But Ms Shah suggested that work still needed to be done ‘at both ends’ to match the success of the CPCS, which she said in her area had seen 99% of referrals dealt with appropriately in community pharmacy.

‘Inappropriate referrals’ from GPs that were outside the scope of the service needed to be improved, she said, while adding that there would be times when pharmacists ‘could have done more for the patient’.

‘It’s about learning. And it’s about working together,’ Ms Shah said.

To support patient satisfaction and care, Dr Selvaseelan Selvarajah, a GP partner in East London said his practice kept slots open so that they could offer a patient a same-day GP appointment if the pharmacist could not resolve their issue.

Strong concerns from GPs around patient experience and safety were further considered as the discussion looked towards the potential future direction of the service.

Could minor ailments be a walk-in service?

Several attendees suggested that the minor ailments part of the service should be made a walk-in service, as well as possibly the urgent medicines supply part.

Ms Somal suggested that pharmacists should be funded for the diagnoses, advice and treatment they have been giving to patients for free for many years.

And Dr Selvarajah commented that direct patient access to Pharmacy First ‘would really help’ both community pharmacy and general practice.

Mr McQuillan said: ‘It’s in the title’, adding that patients being able to come to pharmacies as a first port of call was ‘strategically’ right for the network.

Expanding or changing the scope of the service

Mr McQuillan suggested that in five years’ time, Pharmacy First could have evolved to be a prescribing service, as the number of independent prescribers in the community pharmacy workforce increases.

‘I think that the PGDs are a stepping stone to that,’ he said.

He also suggested that some elements of services in other UK nations could be replicated, such as antigen swab testing used in Wales to reduce antibiotics supply.

Expanding the service to make over-the-counter items available for free to eligible patients – as is already being done locally in some areas – would help reduce the need for patients to return to their GP if they were struggling with the cost of item, both Ms Shah and Dr Selvarajah suggested.

Dr Selvarajah also proposed that instead of otitis media in children, otitis externa in adults could have been considered for inclusion in the scheme.

Diagnosing and treating otitis externa ‘would have made much more sense’ for community pharmacies given that they already have a range of treatments available to patients.

Ms Somal agreed, saying that pharmacies often saw patients complaining of ear pain that turned out to be ‘something as simple as ear wax’, which could be treated by a micro suction service offered by many community pharmacies.

Dr Jacques also noted that the otitis media pathway was a concern for GPs.

‘Paediatric training and examining a child’s ear is quite a skill. We’re concerned about the safety aspects and how much training has been involved in that,’ she said.

It was clear from the discussion that both general practice and community pharmacy are facing inadequate funding for the overwhelming demand on their services.

Dr Jacques described Pharmacy First as a service ‘that very much supports community pharmacy’ rather than necessarily solving pressures in general practice.

‘These minor ailments are not what’s causing the overwhelming workload in general practice,’ she said.

‘We recognise you need support. We recognise that your funding has been taken away from you in the same way that it has for us… but a lot of us on the ground in general practice don’t feel that this service provides what people think it provides for general practice,’ she added.

Addressing GP concerns around cost and antibiotics

Dr Jacques also suggested that GPs would be more confident in supporting the scheme if they could see data around the cost-effectiveness of Pharmacy First and ‘proof that antibiotics are being prescribed appropriately’.

DAUK, of which Dr Jacques is a member of the GP committee, has previously suggested that the £1,000 monthly fee, awarded when pharmacies complete a certain number of clinical pathway consultations, plus £15 per Pharmacy First consultation, equates to pharmacies receiving £48 per consultation – more than double the £23 per consultation that GPs currently receive.

But Community Pharmacy England has responded to this concern by saying that the payments cannot be compared.

‘GP funding is largely based on capitation payments whilst community pharmacy owners only get paid when patients actively use their services. This means a lot of the overheads of running a pharmacy are not directly funded, unlike the GP model,’ CPE chief executive Janet Morrison noted at the time.

Meanwhile, initial analyses of Pharmacy First medicine supply have suggested that pharmacists are ‘closely following’ antibiotics guidance.

Pharmacies ‘not making money’ from Pharmacy First

Pharmacy roundtable attendees said that the service, as it stands, was not the solution to community pharmacy pressures either.

‘Although our patients that have used the system really like it, and it’s quite often saved them [going] a long way to see the GP, it’s not actually improving our financial situation at all at the moment,’ Mr Cooper shared.

He said that too few referrals from general practice, coupled with patients not knowing about the service and pharmacy teams being busy with high prescription volumes, meant that some pharmacies in his group were not conducting enough clinical pathway consultations to meet the monthly payment threshold.

Ms Somal agreed that community pharmacies ‘are not making money’ from Pharmacy First currently.

She said pharmacies in her area did not receive payment for around four in five patients seen by a pharmacist, as they were not referred to the pharmacy and did not meet the gateway criteria for walk-in consultations.

Pharmacy First is ‘not going to be the thing that saves the doors from closing or pays the bills or keeps the lights on’, she added.

Community pharmacy and general practice must ‘support each other’

Ms Somal suggested that rather than competing for the funding allocated to Pharmacy First, she would ‘much rather’ the service were ‘ a collective GP-pharmacist joint venture’.

‘That [would mean] that we all come out of this holding our heads up high and winning in terms of not just patient care, but actually financially, none of us are struggling going forward,’ she said.

Dr Selvarajan also advised caution against ‘artificial competition’ being created between the sectors. ‘There’s one pot of money for primary care. We divide that into general practice, pharmacy and other sectors, and we’re being kind of forced to compete with each other, and we’re all struggling.’

Each sector should be mindful of the ‘intense pressures’ both were facing, he added.

‘If general practice collapses, community pharmacy will struggle, likewise, the other way as well. So, I think it’s important we support each other,’ he said.

Opportunities for integrated working

Dr Selvarajan also highlighted that pharmacists having greater access to patient records would be ‘really helpful’ for integrated working.

And he suggested that the advent of pharmacist prescribing on a more widespread scale was an opportunity for both sectors to consider how they work together. ‘Things are changing, we need to look at how we work,’ he said.

Ms Shah also warned against an ‘us and them’ feeling between the two sectors.

‘I would just like to see integrated working,’ she said.

‘Our narrative needs to be the same to the patient: “come and see whichever healthcare professional you find it most easy to see for your specific condition, your lifestyle, your working career, etc, and we will help you. And if we’re not the right people, we will signpost you or get you help from the person that you’re meant to see”.

‘Because ultimately, we just want the public to have faith in primary care services. With that, everything else will just come together, won’t it? The funding and the accolades that the public will give us,’ she added.

Ms Shah also suggested that training placements for both pharmacists and GPs could take place across settings, helping to improve collaboration and mitigate concerns raised by GPs about reduced opportunities for trainees to see minor ailments in general practice if patients were attending Pharmacy First instead.

‘I do think that that is what is missing in primary care – that we don’t have enough cross sector working. We don’t have enough understanding of how things work in each other’s particular sectors,’ she said.

‘The way people access healthcare is changing, and it’s changing quicker than it’s ever changed before, so we need to start getting used to that and thinking, “what do we need to do differently to make sure it’s safe and efficient for the patient and the NHS?”’