Pharmacy First: Are the floodgates about to open?

EXCLUSIVE: With the launch of Pharmacy First in England just days away, an under-pressure community pharmacy sector is torn between welcoming the opportunity and wondering whether patient demand will exceed its capacity.

From 31 January, the launch of the highly anticipated service will see patients able to access advice and treatment for seven common conditions – sinusitis, sore throat, earache, infected insect bite, impetigo, shingles, and uncomplicated urinary tract infections in women – all from their local community pharmacy.

Abbas Esmail, a pharmacist independent prescriber and contractor in Birmingham, thinks the launch of Pharmacy First could close the loop for enquiries that pharmacies are already getting from patients.

At the moment, without a patient group direction (PGD) or prescribing skills to enable medicines supply, ‘the only thing we can say is, please ring the surgery’. ‘Not anymore,’ he says.

Abbas welcomes the autonomy that the new service will bring to pharmacies.

‘It almost turns into a one stop shop,’ he says.

In Birmingham and Solihull, community pharmacies already operate under several locally commissioned PGDs similar to the national service that will be introduced at the end of the month.

They’ve been well-received by other local healthcare partners: ‘Where we have managed to convince GP practices and where they have seen case after case workload taken off, they have really bought into the service,’ Abbas says.

He thinks the experience of running a similar service will stand pharmacies like his in good stead to begin the national service.

But transitioning to running more clinical services ‘takes a lot of adjustments to your day-to-day work’, he warns others.

Anticipating an increase in GP referrals and patient walk-ins once Pharmacy First is launched nationally, he advises participating community pharmacies to work out their upper capacity, and ‘not to bite on more than what you can chew’.

‘More funding would have enabled us to do more’

Olivier Picard, who owns Newdays Pharmacy group in Berkshire, says the funding for the service has limited the investment he’s been able to make – and consequently will limit the service that pharmacies can provide to patients.

‘As a contractor, I’m living within my means,’ he says. ‘I could have done things better if the NHS offered more upfront payments – not just front loaded, but ongoing.’

As part of the funding promised by NHS England for the service, participating pharmacies will receive an initial fixed payment of £2,000, and a further £1,000 per month, subject to delivering a minimum number of consultations.

But the upfront payment is ‘not enough’ to cover pharmacist training time, Olivier says, which he is funding and freeing up his staff to do within work hours.

Meanwhile, the £1,000 given each month will not be enough to cover the second pharmacist he suspects will be needed during busy times for the service, he adds.

And in one branch, where services already fully book out his consultation room, he’s installed a second consultation room at a cost of almost £14,000. His other branches will have to make do with the room they already have.

‘That means we will be more limited as to what we can offer as a result.’

‘As always, what is happening is the NHS has given us something which is not a bad deal. But it means that we have to live within our means, rather than say: "OK, let's go for this”.’

‘The demand is there’

Beran Patel, from Brigstock Road Pharmacy in Greater London, will also begin the service with just one already overwhelmed consultation room.

‘The closest analogy would be Gatwick airport with one landing strip and five planes trying to land,’ he tells The Pharmacist.

His pharmacy is sandwiched between two medical centres, and already takes GP referrals through the Community Pharmacy Consultation Scheme (CPCS) in addition to running a private clinic, independent prescribing, travel vaccinations, the discharge medicines service, hypertension screening, chlamydia screening and treatments.

He says his sole consultation room ‘is in constant demand’ from the two pharmacists managing these services.

‘We are going to have to lose floor space to create another consulting room so that we build capacity,’ he adds.

However, he’s not sure whether swapping retail space for service capacity will be worth the financial investment.

‘If those services are lucrative enough to justify that space being taken off, fair enough,’ he says.

But he’s concerned that the labour cost of an experienced pharmacist delivering services will ‘eat into’ the payments offered by the government.

‘We are effectively being paid a very minimal amount for quite an important service,’ Beran says.

And he worries that the sector ‘may get swamped’ by patient expectation for a service that they cannot deliver.

‘The demand for the service is there, the doctors are desperate for me to do more work, because it takes a whole lot of pressure off them. But how do I manage expectations? Can I afford to manage those expectations?’

Over three quarters of pharmacists surveyed recently by the Pharmacists’ Defence Association (PDA) shared concerns that patient expectations of the new service would not be met and that patients might become aggressive due to unrealistic expectations.

‘That's already happening now,’ Beran tells The Pharmacist.

But turning patients away is ‘not in our psyche’, he says. ‘Community pharmacy has never said no to anything.’

‘In my 30 years as a pharmacist, I've always tried to make sure that I look after my patients, no matter what. Even if it means I have to stay an extra hour at night, I'll do it.’

Beran says he’s 'really happy’ that he can ‘finally’ make use of his clinical skills.

He describes the new service as ‘something that we've been wishing for all these years’.

‘However, my concern is that the money that's being offered is so little, that you will be working harder and harder for less and less.’

And he stresses that community pharmacy core funding, ‘which is what keeps the whole system running’, needs to be addressed.

Weeks to prepare

It’s not just funding that will impact the roll-out of the service – current pressures and a tight timescale have made it difficult for pharmacy team to prepare for the launch of Pharmacy First.

With a busy winter period and flu and Covid vaccinations to administer, ‘nobody even looked at it until after Christmas,’ Beran says.

The earliest date he could book a training session with the Centre for Pharmacy Postgraduate Education (CPPE) for his team was for 4 February.

‘That's exactly three days after the service starts,’ he says.

And he adds that pharmacists not used to patient consultations need training and time to develop.

Though the payment structure for the service allows pharmacies to build up the number of patients that they are seeing gradually, Beran doesn’t think that expectations of a slow start to the service are realistic.

‘I know the proviso was to do a smaller amount and still not lose out and still get the money,’ he says.

‘But the problem is that if you open the doors from day one with advertising, you're going to get hit with so many people wanting the service. This is my issue: that the floodgates will open, and we [will have to] manage that capacity.’

Build relationships so GPs can refer with confidence

Raj Matharu, chief executive officer at Community Pharmacy South East London, has different concerns about the launch of Pharmacy First.

He thinks that community pharmacy will be able to meet the lower-level targets for Pharmacy First consultations in the early months following the launch and anticipates a slow start, similar to that of the blood pressure service.

That’s aligned with predictions from Healthwatch England, which recently suggested patients might be hesitant about the new service.

But Raj tells The Pharmacist that the 30 consultations per month expected by October and November ‘may prove challenging’.

‘Hopefully, by then we've established the trust and confidence between your local GP and your local pharmacy so that they're able to refer with confidence [that] this patient will be looked after by local pharmacists and be dealt with appropriately.’

Raj hopes to build relationships between settings through speaking to local practices and running regular in-person training hubs with community, practice and primary care network pharmacists across South East London.

And he stresses the importance of getting the whole pharmacy team upskilled to be able to deliver the services.

‘At some point, your pharmacist is going to be in the consultation room and the dispensing team are going to need to carry on with the dispensing element of it,’ he says.

In his own pharmacy, he’s looking at increasing dispensing staff by an extra 20-25 hours each week and is considering employing an administrative role akin to a practice manager, to ‘take the pressure off the pharmacists’.

‘If I could afford a robot, I’d put one in’

The government’s plans for pharmacy are predicated on technological advances delivering efficiencies and releasing staff time.

But Raj says that they’re not feasible for many contractors.

‘If I could afford a robot, I’d put one in,’ he says.

And changes to hub and spoke dispensing legislation are not yet in place to enable single independent pharmacies like his to take advantage of the process.

He also feels that dispensing and services should each be profitable in their own right.

‘I don't want to subsidise the clinical services to cover the dispensing costs,’ he says.

A representative from pharmacy chain Rowlands also expressed frustration over the current ‘glacial’ pace of regulatory change.

‘At a time when dispensing volumes are increasing, we need new ways of working,’ they tell The Pharmacist.

Regulatory reform, as well as ‘long-term sustainable funding’ and ‘a clear and shared strategy for future professional development’ is crucial to the success of the service, they say.

‘It has to be a complete package in order to work.’