The phorce is with us

Community pharmacy is finally getting new clinically based services

Community pharmacists are highly trained healthcare professionals, with a core expertise in medicines, and have for generations counter-prescribed medicines for common ailments.

However, there has been a view that community pharmacists’ skills, knowledge and clinical experience have been underutilised, even to the extent that universities have been accused of preparing students for jobs that do not yet exist.

Pharmacy has been, as the oft used cliché says, ‘at a crossroads’.

This is now changing, and over the past few years we have seen a new form of community pharmacy emerge from a chrysalis, dry its wings and take flight to provide new services to patients in primary care.

Pharmacy First is a key element of that transformation – the ‘phorce’ we can believe in.

Pharmacy First was launched on the 31st of January 2024 and enables community pharmacists to provide treatment to patients for seven common conditions directly – including antibiotics and antivirals.

The conditions include impetigo, acute otitis media (earache), infected insect bites, shingles, sinusitis, sore throat and uncomplicated urinary tract infections.

The age ranges for the clinical pathways vary. For example, sinusitis covers those 12 and above, and acute otitis media is only for those from one to 17 years of age.

Patients do not need to go to their GP, or obtain a prescription, and in a primary care health system struggling to meet demand for GP services, being able to walk into a pharmacy to obtain treatment is a huge convenience.

Pharmacists are easily accessible in the community. While some are arguing for the concept of 15 minutes cities, where the daily necessities of life are reached by a 15 minute walk, cycle, or public transport, four out of five people already live within 20 minutes walk of a community pharmacy.

The use of pharmacies as a health resource is an easy sell. Pharmacists are often the first port of call for the public with health-related issues already, and expansion into areas such as vaccination and travel medicine has heightened public awareness.

Pharmacists are already highly trusted members of the healthcare team, who played a key role throughout the pandemic in delivering healthcare, and even in the COVID-19 vaccination programme.

Pharmacists have taken the initiative. Over 90% have signed up to Pharmacy First and in the first three days of the Pharmacy First scheme over 3,000 patients made use of it.

Yet, an underlying fragility exists. The community pharmacy network has been under immense strain, both businesses and the workforce within it.

Funding has fallen 40% in real terms over the past ten years, with the majority of pharmacies operating under a deficit.

Eight pharmacies are closing a week, with some major players dropping out of the sector entirely. Pharmacies have provided essentially unfunded, unsustainable, clinical services for years, as well as free delivery of dispensed NHS medicines and the provision of blister packs.

Community pharmacists themselves are under personal pressure, with no protected learning time for upskilling, major staffing shortages and having to squeeze new services into an already highly pressured working day.

There have also been concerns about the implementation of Pharmacy First, with the inevitable IT teething problems, a very short planning phase, and some concerns from GPs around expertise and capacity in community pharmacy - even reports of extra referrals to GPs coming from Pharmacy First.

Other concerns have been raised about the heightened opportunity for antibiotic microbial resistance (AMR), although this has not been seen in Scotland or Wales who pioneered such services.

Pharmacists are well educated on AMR and many pharmacists are involved in attempts to reduce AMR, including national advocacy and policy. Yet, if the shift to a more clinically focused arm of pharmacy works – aligning them with their hospital and general practice colleagues - then it could have major benefits for patients.

Pharmacy First was born of the COVID-19 pandemic, the strains of which, along with increasing demographic pressures of an ageing population, have put crushing pressures on general practice services - as anyone trying to obtain an appointment will have found.

The government’s recovery plan for the NHS tried to holistically look at all the primary care services, and one proposed solution focused on changing pharmacy’s contractual framework to widen the scope of services available to the public.

The Pharmacy First scheme is also part of a vision to empower patients to do more for themselves, other aspects being use of improved NHS information (e.g. an improved NHS app) and self-directed care through self-referral to services or home monitoring.

Pharmacists have also been delivering blood pressure checks as part of an advanced service since 2021, with expanded funding now available for this service.

The oral contraceptive services in community pharmacy started in April 2023, and were further expanded in December 2023 - with an expectation that one in four women using oral contraception will do so through community pharmacy.

It is hoped this huge expansion in community pharmacy services will reduce some of the demands on general practice, but there is further opportunity to expand the influence and responsibilities of community pharmacists.

Educational transformation has been happening for the past two decades, with a shift from a largely scientific based education, to a tightly focused clinical vocational qualification.

This has continued with new educational standards in 2021 with a focus on diagnostic, clinical assessment and prescribing skills.

NHS England has also offered 3,000 training places for independent prescribing to community pharmacists and from 2026 all newly registered pharmacists will be qualified prescribers.

The Pharmacy Integration Programme has also provided clinical examination skills training for community pharmacists to prepare pharmacists for prescribing and to extend the scope of existing practice.

This new cohort of prescribing community pharmacists, combined with improved digital capabilities, could create an exciting professional future in which community pharmacy and general practice works as one in a new model of primary care.

A beneficial side effect may be reduced pressure on general practice, as well as potentially reducing inappropriate use of accident and emergency.

There is also the potential to reduce medicine issues across the primary-secondary care interface and joined-up services between hospitals and community pharmacists relying on more integrated NHS IT services.

Pharmacy representative bodies are invested in this model, with a #votepharmacy manifesto for the next election designed to ‘unleash the potential of community pharmacy’.

This includes plans for an enhanced Pharmacy First offering, building on the already successful advanced services in Scotland and Wales.

NHS England is also developing pathfinder sites across integrated care systems to enable community pharmacist prescribers to support primary care clinical services.

While it is not clear what those will look like, independent prescribing, a public health role and additional support for the community pharmacy workforce – including a sustainable funding model should help build a new future for community pharmacists and the patients they serve.

Professor Anthony R Cox is based at the University of Birmingham and is co-founder of CliniSkills.
Go to birmingham.ac.uk