Finding the path or losing the plot? The rocky road towards community pharmacy prescribing

This month, The Pharmaceutical Journal’s health policy columnist evaluates NHS England’s primary care recovery plan and what it means for pharmacy prescribing.

The UK government’s new primary care recovery plan for the NHS in England, announced on 9 May 2023 to Parliament by Steve Barclay, health and social care secretary, includes various gimmicks that are not associated with pharmacy, such as a slug of new money for GPs to replace their phone systems (in the hyper-optimistic hope that this will avoid the 8am access lottery stampede).

However, the sector should not feel left out: ‘Pharmacy First’ was given its usual rhetorical nod, with pharmacy allowed to supply prescription-only medicines for seven common conditions under the NHS “by the end of 2023”.  

Not only this: the recovery plan will also “expand pharmacy oral contraception and blood pressure monitoring services this year, to increase access and convenience for millions of patients, subject to consultation”.

All of this could save 10 million appointments in general practice once scaled “subject to consultation”, Barclay has claimed.

Some may splutter at the recovery plan’s statement that “community pharmacies receive ~£2.6bn per year through the ‘Community Pharmacy Contractual Framework: 2019 to 2024‘, and we have expanded the services they offer as another step to strengthen the overall primary care offer”, given that this was in effect stand-still funding.

But another significant change has been under way. The drive by NHS England to have integrated care boards (ICBs) and systems trying to introduce local community pharmacy independent prescribing services presents the sector with a new set of opportunities — and, of course, risks.

NHS England seems to have no idea how much funding will be available, but Wasim Baqir, its senior pharmacist for the pharmacy integration fund, told the Clinical Pharmacy Congress in London on 12 May 2023 that “it was great to see every ICB in England — all 42 — came back with something”.

A permissive and locally-led approach from NHS England is novel, and broadly welcome, but there do seem to be some national issues that will arise

This enthusiasm to bid for funding may have something to do with the widespread financial distress in the ICB/systems sector, of course. The Health Service Journal has been reporting on the pressure that NHS England is putting on all systems to deliver a balanced budget forecast for 2023/2024.

A cynic may perceive a pattern of behaviour from NHS England dumping problems on ICBs without a clear plan (see also the NHS pay increase, solving health inequalities, cutting waits etc.)

Baqir added that ICBs submitted “15 different service types” in their expressions of interest, with those focusing on cardiovascular disease the most commonly proposed. Fans of NHS management jargon will be thrilled to know that the initiative is being described as ‘pathfinders’ as opposed to ‘pilots’. Yet, ‘pathfinders’ can be anything, such as hospitals.

The broad sense from all of NHS England’s presentations at Clinical Pharmacy Congress was that a permissive approach is being taken: to paraphrase: “It’s really up to you to navigate this; we want to learn from how you negotiate this locally.” A locally-led approach from NHS England is novel, and broadly welcome, but there do seem to be some national issues that will arise.

For one thing, there seems to be no equivalent of a ‘performers’ list’ for community pharmacy prescribers. Is this wise? Furthermore, if community pharmacies are to prescribe or deprescribe, how will these data be linked in with patients’ existing primary care records? How will the IT systems be linked up?

That seems an obvious clinical safety and governance issue that needs a national approach — as does dealing with the potential for conflicts of interest between prescribing and dispensing. There should, of course, be learning available from the management of prescribing and dispensing GP practices — but someone will have to marshal and spread it. At the moment, it’s not obvious that NHS England even have a model for this conflict of interest.

Some of the possible services would be around prescribing statins, but also anticoagulants and stopping antidepressants. These require significant levels of prescribing experience and skill: one wonders how those launching such services will be a) supported and b) monitored. There must be a way of doing this; after all, community pharmacist prescribing is already a reality in Wales and Scotland. But, again, someone will need to curate and disseminate the learning from them.

There is another important consideration: in the event of a prescribing error by a GP, the pharmacist checking prescriptions forms a last clinical safety line of defence before patient harm arises — and that is potentially removed in this model.

These are not insurmountable problems, but they are real. And many of them will require consistency of approach across England. Let’s hope the right lessons will be learned in good time.

Andy Cowper is the editor of Health Policy Insight and has written about health policy for 22 years

Last updated
The Pharmaceutical Journal, PJ, May 2023, Vol 310, No 7973;310(7973)::DOI:10.1211/PJ.2023.1.186369

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