In May 2024, the launch of England’s Pharmacy First service was hailed as a “big win” by the then pharmacy minister Andrea Leadsom in an interview with The Pharmaceutical Journal. “It is a win for patients, a win for GP access and a win for the sustainability of pharmacies,” she said.
However, the first five months of claims data on Pharmacy First clinical pathway consultations, the most recent of which was published by the NHS Business Services Authority on 25 September 2024, reveal patchy implementation across the country. It is clear that patients — and pharmacies — in some areas of England are benefitting from the service more than others.
Under Pharmacy First, which launched on 31 January 2024, patients can gain access to specific treatments for seven common conditions: sinusitis; sore throat; infected insect bites; impetigo; shingles; uncomplicated urinary tract infections (UTIs) in women; and acute otitis media. The service aims to relieve pressure on overstretched GPs.
Between February and June 2024 — the latest data available at the time of writing — 10,188 pharmacies claimed for more than 750,000 consultations across the seven conditions (see Figure 1).
However, although the service got off to a flying start, with 125,275 consultations in the first month, rising to 144,389 in the second month, the upwards trend has started to dwindle. The diminishing number of consultations in June 2024 is likely partly down to the seasonality of some of the services (see Figure 2) and a slightly shorter month, but pharmacy organisations have attributed low consultation numbers in general to a lack of referrals from GPs, as well as insufficient advertising of the service.
Most used pathways
Some of the seven clinical pathways in the Pharmacy First service have proven more popular than others during the first five months, with the most used being acute sore throat and uncomplicated urinary tract infection, which accounted for 35% and 26% of all consultations, respectively (see Figure 2).
Commenting on Pharmacy First activity, Paul Rees, chief executive of the National Pharmacy Association (NPA), told The Pharmaceutical Journal in September 2024: “Pharmacy First is a great idea, with potential to do so much more, but it was always going to take time to expand, particularly during the summer when people are away and sore throats are less of an issue.”
Malcolm Harrison, chief executive of the Company Chemists’ Association (CCA), says the data indicate Pharmacy First is a service strongly tied to seasonality.
Indeed, the claims data show that consultations for otitis media, sore throat and sinusitis fell in June 2024 compared with May 2024, while consultations for infected insect bites increased.
“As the cold and flu season begins this autumn, we expect the overall volumes of consultations to rise,” says Harrison.
However, he adds “variation in volumes regionally between ICBs remains a concern”, as highlighted by an analysis of CCA members published in May 2024.
Variable implementation
The latest data confirm that the number of consultations being claimed for by pharmacies varies hugely between integrated care boards (ICBs), with pharmacies in some ICBs claiming for almost ten times as many consultations as those in others. For example, pharmacies in North East and North Cumbria ICB claimed for 49,468 consultations between February 2024 and June 2024, whereas pharmacies in Cornwall and the Isles of Scilly claimed for 5,633 consultations.
When taking ICB populations into account, there is still a gap, with pharmacies in North East and North Cumbria ICB claiming for 1,565 consultations per 100,000 population between February 2024 and June 2024, and pharmacies in Cornwall and the Isles of Scilly ICB claiming for 926 consultations per 100,000 population (see Figure 3).
Higher use in deprived areas
The analysis also reveals that people living in areas of highest deprivation use Pharmacy First more than those living in areas of least deprivation, with 27% of consultations in June 2024 taking place in the 20% most deprived areas of England, while 14% were undertaken in the 20% least deprived neighbourhoods (see Figure 4).
These figures tally with a previous analysis of data from CCA members looking at the first month of the Pharmacy First service, which revealed that 30% of consultations were provided in the 20% most deprived communities. They also fit with an investigation carried out by The Pharmaceutical Journal in January 2023, which revealed that pharmacies in areas of high deprivation provide 50% more NHS services to their local populations overall.
A national evaluation of pharmacy funding and the size, role-mix and distribution of the pharmacy workforce is necessary to improve planning of pharmacy services
Louise Ansari, chief executive of Healthwatch England
Louise Ansari, chief executive of Healthwatch England, a patient advocacy committee within the Care Quality Commission, says that people living in deprived areas find it harder to get a GP appointment. “So it’s welcome that Pharmacy First services are being used in areas of higher deprivation. However, we know that capacity challenges, such as staff shortages, are leading to permanent and temporary pharmacy closures,” she said.
“This calls into question the future availability of pharmacy services. We hear from many people who can’t get the advice, care and medications they need, when they need them.
“A national evaluation of pharmacy funding and the size, role-mix and distribution of the pharmacy workforce is necessary to improve planning of pharmacy services. In the meantime, better real-time information on when pharmacies will be closed would go some way to improving patient experience.”
Generally, the seven clinical pathways were used consistently across the most and least deprived areas, except for acute sore throat, which accounted for a higher proportion of consultations in more deprived areas, and infected insect bite, which made up a higher proportion of consultations in less deprived areas.
In June 2024, 35% of Pharmacy First consultations related to acute sore throat in the 20% most deprived neighbourhoods, compared with 28% in the 20% least deprived areas (see Figure 5). The infected insect bite pathway accounted for 15% of consultations in the most deprived areas compared with 19% in the least deprived areas.
Gaps in provision
While 3.5% of pharmacies in England — approximately 370 pharmacies — have not signed up to provide Pharmacy First, according to Community Pharmacy England (CPE), our analysis reveals that 1,455 pharmacies — 15% of pharmacies submitting claims to NHSBSA — did not claim for any consultations in June 2024 (see Figure 6).
The areas with the highest proportions of pharmacies not making any claims were North West London ICB and Cornwall and the Isles of Scilly ICB, both with 24% of pharmacies (115 and 24 pharmacies, respectively), and the area with the lowest proportion was Gloucestershire ICB, with 5% (5 pharmacies).
In addition to the £15 consultation fee contractors are paid for offering Pharmacy First, a monthly fixed payment of £1,000 is also paid to pharmacy owners who complete a minimum number of consultations that pass a ‘gateway’ point for payment. When Pharmacy First was introduced, this threshold started at one consultation per month, but it rose over time to 10 consultations in June 2024, increasing to 20 consultations per month in September and October 2024.
In its updated ‘Delivery plan for recovering access to primary care’, published on 9 April 2024, NHS England set an ambitious target of 320,000 Pharmacy First consultations per month by March 2025.
However, The Pharmaceutical Journal revealed in September 2024 that pharmacies had missed out on £9.6m in funding between February and May 2024 because they did not reach the monthly consultation threshold.
The latest data show that 2,185 pharmacies that made at least one claim in June 2024 did not reach the ten-consultation threshold (see Figure 7). Combined with those that did not make a claim at all, this amounts to an additional £3.6m in missed payments in June 2024, bringing the total in lost funding for the first five months of the service to £13.2m.
The area with the highest proportion of pharmacies not meeting the threshold for payment in June 2024 was Cornwall and the Isles of Scilly ICB, with 51% of pharmacies (51 pharmacies) claiming between 0 and 9 consultations. The areas with the lowest proportion were Bedfordshire, Luton and Milton Keynes ICB and Bristol, North Somerset and South Gloucestershire ICB, both with 25% of pharmacies (39 pharmacies in each ICB) missing the threshold.
In September 2024, Rees said that the NPA had been warning about issues with Pharmacy First thresholds for months.
“Ministers need to support the rollout of Pharmacy First and acknowledge the huge amount of work pharmacies do to ease pressure on the NHS by giving advice and support, mostly for free.
“We need to move to a system where pharmacies are properly paid for the vital support they give to their communities, not subject to the ebb and flow of demand with the seasons.”
A survey of 4,589 pharmacy premises conducted in September 2024 by CPE found that more than 60% were “not at all confident” about meeting the thresholds in September and October 2024. The vast majority of respondents (87%) stated “low number or no GP referrals” as a factor in being unable to meet the increasing thresholds, with 81% citing insufficient advertising of the service and 77% blaming low public awareness of the service. Over two-thirds of respondents (68%) said that the gateway points in the clinical pathway are too restrictive.
While we would not dispute claims that problems are affecting the roll out of Pharmacy First, we have seen no evidence that family doctors are refusing to take part
David Wrigley, deputy chair of the British Medical Association’s General Practitioners Committee England
David Wrigley, deputy chair of General Practitioners Committee England at the British Medical Association, acknowledges that GPs have been subject to criticism that they are not sending patients to pharmacies under the scheme and that some practices are refusing to participate altogether.
“While we would not dispute claims that problems are affecting the roll out of Pharmacy First, we have seen no evidence that family doctors are refusing to take part.
“We are aware of GPs raising concerns that this scheme is being rolled out too quickly, and is relying on inadequate IT infrastructure, which is ultimately increasing the burden on practices — putting further pressure on a system already close to breaking point. To be clear, we want community pharmacists and GPs to work together to ensure patients receive safe and effective care.”
GP access
Analysis of the Pharmacy First data did not suggest a correlation between the number of patients per GP in each ICB (a proxy for GP access) and the number of Pharmacy First consultations claimed in that area (see Figure 8). Cornwall and the Isles of Scilly ICB, which made the lowest number of Pharmacy First claims in June 2024, has 1,589 patients per GP, while North East and North Cumbria ICB, which carried out the highest number of consultations in June 2024, has 1,587 patients per GP.
The CCA believes that some of the success of Pharmacy First in North East and North Cumbria ICB could be attributed to a pilot scheme to treat uncomplicated UTIs that began in community pharmacies within the ICB in July 2022, which has provoked behaviour change among patients and GPs. “The success of this pilot has likely provided a very strong base for Pharmacy First in that locality,” a CCA report published in May 2024 said.
Data from Scotland’s Pharmacy First scheme, which began in July 2020, show the number of consultations has increased by 60% in the first three full years since it launched, going from 2.6 million consultations in 2021 to 4.2 million consultations in 2023.
According to Janet Morrison, chief executive of CPE, whether England will be able to grow its Pharmacy First service will depend on NHS England “consistently and effectively marketing the service to the public, as well as driving up referrals to it”. It will also be reliant on curbing pharmacy closures through proper contract funding and workforce planning.
