CPCS SOS: How the service could still be improved

Three years on from its launch, how is the Community Pharmacist Consultation Service (CPCS) being received by patients, GPs and pharmacists?

The CPCS launched as an Advanced Service in October 2019, replacing the NUMSAS and DMIRS pilots and connecting patients with a minor illness or who need an urgent supply of a medicine or appliance with a community pharmacy.

It was created with the lofty aim of relieving pressure on the wider NHS by connecting patients with pharmacy as their first port of call, and also gives community pharmacy the opportunity to play a bigger role than ever within the urgent care system, and an additional income stream – with pharmacies paid £14 for every phone or face-to-face consultation completed.

But use of the CPCS service is not expanding as rapidly as many would like – and questions remain over its efficiency and whether it is reducing workload for all GPs.

Does the CPCS need to grow faster? 

The CPCS referral pathways have expanded further since launch. From 1 November 2020, general practices have been able to refer patients for a minor illness consultation via CPCS, and on 14 January 2022, NHS England increased the range of referrals possible from NHS 111 following a review of the NHS Pathways algorithms, adding three new condition types (scratches and grazes, teething, sinusitis) and general health information requests to the existing list.

In a recent statement, England's chief pharmaceutical officer David Webb said around 7,000 CPCS referrals were being dealt with by community pharmacies every week. Yet this remains only a small proportion of the more than 1.2m consultations a week – or 65m a year – that are now being carried out by community pharmacy teams in England, according to PSNC’s 2022 Pharmacy Advice Audit.

The PSNC audit of over 4,000 community pharmacies recorded 82,872 informal patient consultations, with the average pharmacy completing 19 consultations per day. This, says PSNC, suggests that ‘more than 1.2m informal consultations are taking place in community pharmacies in England every week’.

The audit also helped quantify the number of informal referrals being made to pharmacies by GPs and NHS 111, with 7,774 informal patient referrals into pharmacy coming from these routes. Grossed up to a national level that means 117,000 cases per week, which PSNC says are all referrals that ‘could and should have been made by the NHS Community Pharmacist Consultation Service’.

Extrapolating the results of the audit to show that community pharmacies save roughly 32.2m GP appointments per year, PSNC chief executive Janet Morrison says: ‘It is worrying to see GP and NHS 111 referrals coming through outside of the CPCS, and we’ll continue to try to address this through our negotiations.’

In its recent report – What the NHSEI package means for general practice – BMA England suggested another way to make best use of community pharmacy CPCS, saying: ‘While CPCS may bring some benefits of referring patients to pharmacies, the impact for patients and practices would be much greater if patients could self-refer, removing the [GP] practice from the process entirely.’

The service can work very well for GP practices 

At this stage of the service there are proponents and critics of CPCS in all camps, with views seemingly dependent on what kind of socioeconomic area the healthcare professionals are based in, as well as how much training GP surgery reception staff – or ‘care navigators’, as some call them – have done around how to refer into pharmacy via CPCS.

Farzana Hussain – GP principal at The Project Surgery in Plaistow (list size 5,000), and clinical director of Newham Central 1 Primary Care Network – is a fan. ‘CPCS is working well at my practice and we have rolled it out to the PCN of 67,000 residents and seven practices,’ she says. ‘We use it daily and on average send 10-15 patients a week to pharmacy, which is a huge benefit for us and for patients, since 15 patients seen is the equivalent to one whole GP clinic a week.’

Dr Hussain says the driver to get going with CPCS in her practice came from ‘GP need rather than from community pharmacy being the first to initiate it, but we certainly had community pharmacist colleagues – such as Jignesh Patel at nearby Rohpharm Pharmacy – who were keen to do it with us, so it made absolute sense that if they were involved we would want to refer patients to them.’

Acknowledging that ‘the success of CPCS relies on your reception team’, Dr Hussain credits her practice manager with the smooth set-up of the service following a three-hour training session for staff to learn the computer system, adding ‘the actual guidelines are fantastic as they fit on one A4 sheet of paper on our reception noticeboard that covers what can be referred, and exclusions, and are easy to understand’.

As in any organisation, asking staff to do something new is often perceived as asking them to do something ‘extra’, but Dr Hussain says her practice reception team were ‘keen from the start’. She says: ‘Patients were calling us in the first place because they wanted to see a medical professional for an appointment, and we can tell them that if they go to the pharmacy and the pharmacist thinks there is any issue at all they can refer them straight back to us. We keep one appointment a day free just for this and we probably only end up using one a week as our team are so good at referring appropriately.’

But there are criticisms

In contrast, Siddiqur Rahman – senior GP practice pharmacist prescriber at Court View Surgery in Strood, Kent – says CPCS ‘isn’t working well at all’ in his area.

‘We are located in a deprived area and patients who are being referred from a GP practice to a community pharmacy would like any OTC medicines, if indicated, to be made free similar to the previous “minor ailment scheme” which was sadly decommissioned nationwide a few years ago’, he says.

‘Although the service is intended to reduce appointments in GP practices, in reality, patients in our area do get referred back as they want medications on prescription so that they don't have to pay for them’, he adds, ‘and this is similar feedback I hear from other GP pharmacists around the country, especially in deprived areas or areas of low social-economic status.

‘Patients also get frustrated that they are unable to see their regular GPs and often see receptionists who want to refer them appropriately to community pharmacy as being difficult and “passing the buck” and making excuses for no GP appointments being available – despite a severe shortage of GPs in the Kent area.’

Nonetheless, from a personal perspective Mr Rahman says thinks CPCS ‘is good for community pharmacists’, but caveats: ‘Although, I do know they are already overstretched as it is and would like another pharmacist to be specifically doing the extra services whilst the other pharmacist is the Responsible Pharmacist and dealing with prescription checking.’

Krish Patel, GP pharmacist partner at Orchard Family Practice, pharmacist independent prescriber, and lead for development and support for primary care pharmacists in Medway and Swale, has another solution for extra workload challenges that CPCS throws up.

‘The CPCS should be offering a greater opportunity to work together as IPs’, he says. ‘It started off slowly in our area, mainly due to technical difficulties, but it has picked up and with mixed outcomes. We have had fast and efficient responses from independents rather than the multiples where locums change or are not there all the time, but it would be good if more community pharmacists in the area were upskilled as IPs.’

What's the community pharmacy view?

Tom Bisset is superintendent pharmacist at Ward Green Pharmacy in Barnsley, and secretary of Barnsley LPC, the smallest LPC, but biggest PCN in the country.

He agrees that having an IP annotation would make a lot of difference: ‘A slight frustration with the service at the moment, and one that frustrates patients more than anything, is that I might know what they need but I can’t supply it because either it’s a prescription-only medicine - and I’m not an IP so it would have to be private prescription, or I’m selling an OTC product which are mostly cheap enough that most patients can afford to pay for them, but some still feel or want to get it on prescription for free.

For example, at the start of September, I know I will get patients with infected insect bites as I see them every year, but I’ll have to send them back to the doctor for that.’

Despite this, Mr Bisset stresses: ‘Any time I’m talking about CPCS, I always say there’s no such thing as an inappropriate referral. The referral is based on what the patient has told the surgery, so even if they present at the pharmacy with something different, or tell us something completely different from what they have told the surgery, if the pharmacy picks something up that’s a win.

‘If we then need to send them back to the surgery, we can tell the GP what we think is wrong and what they need, and it may be that they still only need a follow up call from their doctor, or something can be prescribed based on what I’ve said.’

‘I think the scheme as a whole is excellent and long overdue’, he adds, ‘but it’s a national scheme being delivered a local level with no national direction; we don't have the tools to complete the job, and the IT infrastructure behind it is variable, but it’s a brilliant idea and the sort of thing that in different times with different priorities you could say is the foundation of how pharmacy should be in the future.’