The notion of a ‘Pharmacy First’ service in England is becoming something of a buzz phrase for government ministers.
Most recently, pharmacy minister Maria Caulfield told the House of Commons on 12 January 2022 that the government is “looking towards” introducing the model in England to enable patients to access treatments for minor ailments from pharmacists “without necessarily going first to the GP, opening up primary care and making it much more accessible” (see Box).
Bringing the model to England was first mooted by health secretary Sajid Javid in October 2021 when said he was “asking my department to work with the NHS and look at a ‘Pharmacy First’ scheme for England” as part of the government’s answer to the massive release of pent-up demand on primary care services that had accumulated during the initial stages of the COVID-19 pandemic.
Since then, although official talks are yet to start, the implementation of a national minor ailments scheme has been hotly anticipated by the sector, but what will it mean for England?
What is a ‘Pharmacy First’ service?
The term ‘Pharmacy First’ means slightly different things depending on where you live.
In Scotland, the ‘NHS Pharmacy First’ service launched in July 2020, offering anyone living in Scotland the opportunity to visit a pharmacist as their first port of call for minor illnesses, such as urinary tract infections, impetigo and acne.
Through the service, patients can access assessment, referral and free treatment for their ailment. Pharmacies receive a base payment of £1,250 each month and an activity payment from a funding pot of £785,000 if they provide a minimum of 100 consultations per month.
As of November 2021, more than 2 million consultations had been carried out through the service since its launch and, according to Public Health Scotland 2021 contract activity data, nearly 1.9 million of these occurred in the first nine months of 2021, earning pharmacies of total of £23.3m.
The number of these consultations look set to grow as Alison Strath, chief pharmaceutical officer for Scotland, on 5 November 2021 .
Meanwhile, in England, there are some local minor ailments services being run, some of which are using the term ‘Pharmacy First’.
According to a database maintained by the Pharmaceutical Services Negotiating Committee (PSNC), as of 17 September 2021, there were 22 such services ongoing in specific areas, 9 of which are commissioned by NHS England and the rest by individual clinical commissioning groups.
The treatments offered through these local services vary by area, with some only offering to treat walk-in patients with uncomplicated urinary tract infections. Others, including the ‘Pharmacy First’ service in Liverpool that launched in January 2022, enable pharmacists to treat a range of services, such as a newly launched point-of-care test and treat service for acute cough.
How do pharmacists supply medicines through these schemes?
There are two ways that pharmacists can provide treatment through minor ailment schemes.
Both the Scottish NHS Pharmacy First service and the locally commissioned services in England use patient group directions (PGDs) to supply prescription-only medicines.
PGDs provide a legal framework to allow pharmacists to supply and administer certain agreed treatments to pre-defined groups of patients without a prescription or needing to be a prescriber. Each PGD is developed locally by multidisciplinary working groups and authorised by one of five types of organisations, including clinical commissioning groups and NHS England. Therefore, under ‘Pharmacy First’ services, medicines are supplied rather than prescribed.
According to the , which supports medicines optimisation across the health service, NHS prescription charges apply to all eligible patients receiving a supply of medicines under a PGD, unless the medicines are administered by a healthcare professional under a PGD.
Prescription charges in England — currently £9.35 per item — do not apply when the medicines supplied relate to: the treatment of a sexually transmissible infection; the treatment of tuberculosis; the supply of contraceptives; or are treating a mental disorder supplied to a person subject to a supervised community treatment order.
However, in Wales, the independent prescribing service — which has been running in various forms since 2016 —allows pharmacists to prescribe from the formulary set by the local health board for a range of listed conditions, such as hay fever, athlete’s foot and eye infections. This service was rolled out from November 2021 across Wales so that health boards could start commissioning any eligible pharmacy to provide it.
In Scotland, the extended ‘Pharmacy First Plus’, which launched in September 2020, does include an element of independent prescribing. This allows pharmacist independent prescribers to manage the treatment of patients with common clinical conditions that may otherwise have needed referral to another healthcare provider, including allergies and eye infections.
The ‘Pharmacy First’ model could become an attractive option as the number of independent prescribers in England is set to increase. From 2026, all new pharmacists will be able to start prescribing at the point of registration and, in the meantime, the NHS has committed £16m to provide fully-funded training for existing community pharmacists — including independent prescriber training, March327 applicants to the training programmes.
Why are minor ailment services only commissioned in certain places in England?
The government’s latest push for a minor ailment scheme for community pharmacy is anything but new.
In April 2008, the then Department of Health published the white paper ‘, which included plans for minor ailment schemes in all pharmacies in England.
At the time, the government said: “Pharmacy’s ready availability in more deprived areas offers enormous potential on which to capitalise and expand access to healthcare services for more disadvantaged groups or those who do not regularly use other health services.”
The expectation was that these services would be commissioned across England by April 2018.
However, in 2017, Keith Ridge, chief pharmaceutical officer for England, said clinical commissioning groups (CCGs) were beginning to decommission the minor ailments services as things had “moved on”.
Then, in October 2018, The Pharmaceutical Journal revealed that 23 of the 104 pharmacy minor ailment schemes in England had been decommissioned over the previous three years.
Some CCGs have held on to their minor ailment services, with such services still running in 22 areas of England. One local pharmaceutical committee chief officer in Liverpool has said that his local service helps “to reduce demand on the wider NHS”.
Why were the services decommissioned?
Ridge said in 2017 that minor ailment services were being decommissioned partly owing to the rollout of the ‘NHS urgent medicine supply advanced service’ (NUMSAS) in September 2016, which enabled pharmacies to provide out-of-hours emergency prescriptions to patients for any prescription-only medicine, excluding schedule 1, 2 or 3 controlled drugs.
However, NUMSAS was later subsumed into the ‘Community pharmacist consultation service’ (CPCS) in 2019 along with the ‘Digital minor illness referral service’ — providing one referral route for patients to access care from community pharmacies.
He also attributed the cuts to the NHS’s plans announced in 2018 to reduce the prescribing of common over-the-counter (OTC) products, such as paracetamol for back pain, and ‘low value’ medicines, such as liothyronine, which may otherwise have be supplied through minor ailment services.
He was referring to NHS England’s guidance for CCGs on limiting prescriptions for OTC items, which it expected to save “almost £100m for front-line care each year”. However, as of January 2019, the change in guidance had only saved £25.9m.
With this in mind, despite comparisons with the ‘Pharmacy First’ scheme in Scotland, it seems unlikely that pharmacies will revert back to providing paracetamol on the NHS.
How would an English ‘Pharmacy First’ service fit in with the ‘Community pharmacist consultation service’?
It is not yet clear how a ‘Pharmacy First’ service would sit alongside the CPCS.
Currently, under the CPCS — which launched in October 2019 — NHS 111 and general practice can refer patients with minor illnesses to a community pharmacy for free advice or referral. However, any OTC medicine recommended must be paid for by the patient and prescription-only treatments are not available from a pharmacy through this service.
Data published in June 2021 showed that 353,000 patients had been referred to community pharmacies through the CPCS since the service began; however, pharmacists are unable to claim funding for similar consultations carried out with walk-in patients who were not referred into the service.
Nevertheless, the PSNC launched a third ‘Pharmacy Advice Audit’ during the week commencing 31 January 2022 to build a case for funding pharmacist consultations with walk-in patients.
Doing so would be a major step towards providing a service similar to what is already offered in Scotland and parts of England, which do not rely on referrals from other providers.
A previous advice audit, held in January and February 2021, suggested that pharmacy staff conduct 58 million unfunded patient consultations each year — which could generate £812m in funding if remunerated at £14 per consultation, according to a calculation by The Pharmaceutical Journal.
Would GPs support a pharmacy minor ailments service?
According to their representative body the Royal College of GPs (RCGP), GPs are in support of a national minor ailments scheme rollout.
A joint report, published by the RCGP and the Royal Pharmaceutical Society (RPS) in November 2021, called on the government to develop an independent prescribing service for community pharmacists in England. It appealed for their role to be expanded to manage minor illnesses, resembling the ‘Pharmacy First’ and ‘Pharmacy First Plus’ services in Scotland.
The report said setting up such a service in England would resolve one of the main barriers to GP participation in the CPCS — namely an inability for pharmacies to ‘close’ some CPCS consultations because the patient required a prescription-only medicine (POM), along with advice.
Instead, pharmacists are required to refer patients back to general practice for an appointment with a physician who can prescribe the necessary medicine.
“This was seen to produce extra workload on general practice, taking up additional appointment slots, delaying care for the patients, and potentially widening health inequalities, despite community pharmacists being more than capable of completing the episode of care and supplying a medicine,” the report said.
“While the CPCS has the offering to be extremely helpful, a more advanced service, which included the supply or prescribing of POMs by community pharmacist for minor ailments, would help general practice and patients even further.”
How far have discussions progressed in implementing a national minor ailments scheme in England?
Discussions between the Department of Health and Social Care (DHSC) and the PSNC on implementing a national minor ailments scheme have not yet officially started.
A spokesperson for the PSNC told The Pharmaceutical Journal on 31 January 2022 that it does plan to bring a case for funding a walk-in advice service to the next round of contract negotiations, which at the time of publication was expected to begin shortly.
However, they said informal discussions with the government have been ongoing, including seeking DHSC input to the latest advice audit.
The DHSC also appears to have been discussing this internally. Sent on 20 January 2022, its response to areedom of information request — in which The Pharmaceutical Journal asked for more information relating to the launch of a national minor ailments service — inferred that policy development is already underway in this area.
Box: Key quotes
Maria Caulfield, pharmacy minister, January 2022: “We are looking towards a more pharmacy-first model as in Scotland and Wales, where patients can go direct to pharmacists without necessarily going first to the GP, opening up primary care and making it much more accessible.”
Martin Marshall, chair of the Royal College of GPs, November 2021: “Pharmacists are highly trained and highly trusted healthcare professionals, who can play a vital role in supporting people with a range of minor ailments, freeing up GPs’ time for patients with complex health needs.”
Alastair Buxton, director of NHS Services at the Pharmaceutical Services Negotiating Committee, November 2021: “The PSNC wants the walk-in advice that pharmacies are now providing to be fully funded, and we were pleased to hear the secretary of state supporting an extended role for pharmacists in supporting people with minor conditions.”
Sajid Javid, health secretary, October 2021: “I’m asking my department to work with the NHS and look at a ‘Pharmacy First’ scheme for England, so pharmacists can provide treatment for specific conditions such as sore throats, without patients having to go to their GP — building on pilot schemes in England and much as they already do in Scotland.”