‘The devil’s in the detail’: What will England’s national Pharmacy First service mean locally?

NHS England has recently announced a £645m investment in community pharmacy, some of which will be allocated to a new national Pharmacy First service for England – allowing pharmacists across England to treat seven common conditions – sinusitis, sore throat, earache, infected insect bite, impetigo, shingles, and uncomplicated urinary tract infections in women – under patient group directions (PGDs) from winter 2023.

But in many parts of England, some form of walk-in, minor ailments or PGD-based service has already been running or is being developed. And with the details of a national specification still to be worked out, some Local Pharmaceutical Committee (LPC) leaders are unsure about what impact a national service for England will have on local commissioning.

If a national service were to replace locally commissioned services, would patient provision risk going backwards in areas where local pharmacies are already offering a more comprehensive service? And could patients become confused about what’s available to them?

We spoke to three LPC leaders to explore what a new national service needs to consider to work well at a local level.

Locally-commissioned services could be a tailored ‘add-on’ to a national specification

‘Services developed under the national community pharmacy contract can of course be developed further for local neighbourhoods to meet ICB population health needs,’ chief pharmaceutical officer (CPhO) for England David Webb told delegates at the Clinical Pharmacy Congress earlier this month.

And Amit Patel, CEO of Merton, Sutton and Wandsworth and Croydon LPCs, says that securing funding for commissioned services is crucial to kickstart investment and development.

When services are commissioned, it affects ‘the workforce development, the infrastructure’, and ‘most importantly’ gives pharmacists ‘the ability to have recognised pathways that can then be fed back. And what we really need to be having is pathways of care that follow the patient’, he says.

He points to a locally commissioned Winter Fit Service as ‘a really great example of that’.

It was developed by community pharmacies and local partners in response to their awareness of an underserved aging population, and financed by an innovation fund bid.

Through the Winter Fit Service, commissioned pharmacies speak to people over the age of 65 around staying warm in the winter, eating well and living well, and are able to link in with other services such as local social prescribers, government advice on pension credits, and GP referrals where necessary.

‘People felt a lot more looked after’, says Mr Patel.

‘When commissioned we always deliver. But the ability to deliver is taking up that infrastructure and resource behind that’, he adds.

Services aren’t deliverable without local investment

Local commissioners are starting to understand how they can support the implementation of national services on a local level, says Mr Patel.

‘Nationally commissioned services are supported by LPCs with no additional resource – actually very, very little resource – to embed them. And unless we have our ICBs or our place-based systems supporting the delivery of national services, they become impossible’, he says.

In his area of South West London, the local Integrated Care Board (ICB) supports general practices and pharmacies to deliver the Community Pharmacy Consultation Service (CPCS) and the Hypertension Case-Finding Service, as well as funding infrastructure to support the Discharge Medicines Service (DMS) alongside a DMS working group.

‘That local support becomes the foundation of the delivery of service – whether it's locally or nationally commissioned, that additional resource has to be there otherwise services just aren’t deliverable’, says Mr Patel.

Ash Soni, president of the National Association of Primary Care (NAPC) agrees.

‘There is a slight fear that because of this announcement, the £645m for community pharmacy, the perception is, oh, we don't need to worry about community pharmacy now’, he explains.

Instead, national investment should be ‘a bit of a guide as to what the opportunity could be at an ICB level’.

‘National [funding] has provided a stimulus, the opportunity is, how do ICBs take that and develop it further?’

Prolonged uncertainty could discourage investment

Nick Hunter, chair of Nottinghamshire LPC, thinks that national funding was needed to create an environment in which both contractors and commissioners would want to invest in community pharmacy. for investment’.

‘Contractors will invest if they believe they'll have confidence that they can return on that investment’, he explains.

But he says that over the past few years, national funding cuts triggered a ‘downward spiral’ of contractors needing to cut back on investment in premises, workforce development and recruitment.

‘It's become a bit of a downward spiral because one thing leads to another – if you haven’t got workforce ability to deliver, you don't capitalise on the income opportunities. Therefore, you have less income, therefore you have less funding to invest in development for a more stable future’.

While the recently announced cash injection for community pharmacy was the ‘pump prime’ funding that the sector had been asking for, ‘the devil’s in the detail’, he says, echoing words from the Pharmaceutical Services Negotiating Committee (PSNC) as it entered negotiations on where and how the £645m would be allocated.

He also expressed concerns that uncertainty around the details of the national arrangement could hinder local investment – both on the part of commissioners and providers, such as pharmacies choosing whether or not to participate in the service, resource it, or to train their staff.

‘The problem at the moment is the uncertainty reduces investment’, he told The Pharmacist. ‘So, the longer the uncertainty, the more damage that gets done to some of these locally commissioned services.’

He said that he was currently involved in working up proposals for a local minor ailments service to replace one that was recently decommissioned when responsibility for community pharmacy commissioning moved to ICBs earlier this year.

The detail of the service, he said, ‘depends on what happens with this common ailments service nationally’.

‘It wouldn't make sense to be working up details of a locally commissioned service without knowing what's going to happen in terms of the national specification’, adding that ideally, ‘if anything’s being commissioned, it needs to join up with what's already existing’.

Local services could ‘complement’ national specification

In West Yorkshire, a scheme called ‘Pharmacy First’ runs across Leeds, which is focused on making a wider range of certain over-the-counter products available free of charge to eligible patients for low acuity conditions.

Similar schemes have been hailed as a solution to the increased pressure being put on GPs by patients asking for prescriptions when they cannot afford to pay for over-the-counter items, which pharmacists have reported as being on the rise since last autumn alongside escalating inflation and cost of living.

Nicola Goodberry Kenneally, CEO of the West Yorkshire Local Pharmacy Committee (LPC) hopes that despite the similar name commissioners will understand the separate value each service represents for patients and will continue to commission the local minor ailments service alongside the national PGD-based scheme proposed.

West Yorkshire is also home to a Walk-In Consultation Service (WICS) pilot, in which pharmacists receive a fee per consultation to assess whatever ailment a patient might present with, and which Ms Goodberry Kenneally says is ‘going really well’.

‘We've had really great feedback from the patients that have been really happy that they can walk in and see the pharmacists within a really short wait and go away with a solution that was right for them without having to wait for a GP appointment’, she says.

But she doesn’t yet know how the specification of this service would line up with a national Pharmacy First programme, and whether it would continue to be commissioned, or be replaced by the national specification.

It ‘would be a real shame’ if the WICS was discontinued and replaced by a national service limited to treating just seven minor ailment conditions, she says.

‘It would then make it quite narrow in terms of the breadth of what we can offer support with’, she suggested, adding that if the scope of the service were reduced, ‘patients would potentially miss out on some of those opportunities, and potentially then have to go back to either a GP or A&E or avoid accessing a treatment option’.

But if the seven PGD services proposed under national Pharmacy First plans could be added to the WICS, and other locally commissioned services that don’t currently involve a PGD, it would help to ‘complete the loop’ so that pharmacists could supply a prescription only medicine when necessary and appropriate.

And if a national service would fund the initial patient consultation – as the current local WICS does – ‘that would be brilliant’, she says.

Continuity needed for patients and pharmacists

Ms Goodberry Kenneally stresses the need to avoid a gap in service provision or patient expectation if local offerings were impacted by a national scheme.

‘We've put a lot of effort into getting patients into the mindset of pharmacy first’.

Pharmacists would also be keen to avoid a step backwards in the provision of clinical services.

The national Pharmacy First announcement has been heralded as a step on the journey towards community pharmacy delivering more clinical services supported by independent prescribing.

Ms Goodberry Kenneally agrees that it’s a ‘really positive’ step. ‘It gives pharmacists a lot of clinical skills and opportunities to use their clinical knowledge for the benefit of the patients. We do see it as complementing the other services rather than replacing,’ she says.