Nurse practitioners in pharmacies: a potential solution to the NHS crisis

UK pharmacies have long aspired to be further recognised as accessible walk-in centres for less serious acute medical problems and chronic disease prevention and care. Since 2013, NHS England and its predecessor (NHS Commissioning Board) have been closing walk-in centres to save money. But in the United States, President Obama’s healthcare reforms are generating a new wave of retail clinics, including pharmacy-based walk-in centres, providing a lower-cost alternative to conventional community medical care and hospital emergency rooms through services delivered by nurse practitioners.

Community pharmacy collaborating with on-site nurses could facilitate the evolution of the community sector in the UK, and thereby help the NHS transfer more hospital-based care into settings closer to patients’ homes.

Struggle for the NHS

The NHS is currently facing severe challenges in meeting the need for urgent and emergency care. Demand is rising, partly as a consequence of the increasing number of older people who have multiple chronic conditions, but a number of supply side factors are simultaneously shrinking the capacity of primary and urgent care services. There are GP shortages in some areas, difficulties with recruitment and low take-up of GP training places. Some clinical commissioning groups (CCGs) have resorted to offering Master of Business Administration funding and overseas placements to recruit more GPs^[1]
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In 2012, only one in five patients was able to get a same-day GP appointment^[2]
. The number of district nurses almost halved in the decade to 2013, and only one-third of their time is now spent on direct patient care^[3]
. Meanwhile, 230 NHS walk-in centres opened between 2000 and 2010, which were set up to improve patients’ access to primary care, modernise the NHS to be more responsive to patients’ busy lifestyles, and offer patients more choice, but more than 50 of them had closed by 2014. Most of that lost capacity has not been replaced^[4]
. The closure of NHS Direct and its replacement by NHS 111 caused disruption to the urgent care system and removed clinically trained advisers from the national telephone advice service in England. NHS 111 advises more patients to go to accident and emergency (A&E) than NHS Direct did, and the Royal College of Emergency Medicine has claimed this accounts for nearly all the additional patients now attending A&E^[5]
.

Over the life of the 2010–2015 Westminster parliament, while NHS funding has, to some extent, been protected (although with rising demand and costs, level funding amounts to a real-terms reduction), local authority funding has been cut by £20bn (40% in real terms)^[6]
. The impact has been seen in reduced availability of domiciliary, day and respite care and restricted funding for care home places for vulnerable older people. This makes it harder for hospitals to discharge these patients promptly because the necessary support may not be available in the community.

At the same time, community pharmacy remains frustratingly under-recognised and under-used by the public as a convenient, accessible source of advice on minor, self-limiting illnesses.

Pharmacy walk-in clinics

A novel type of service in the United States could be adopted in the UK to help address the crisis in urgent care, and establish community pharmacy clinical services sustainably and at scale. For example, the US pharmacy chain CVS Caremark has over 800 branches that have walk-in ‘MinuteClinics’, which are open seven days a week, including evenings. The clinics are staffed by nurse practitioners who provide treatment for common family illnesses and wellness and prevention services, including health-condition monitoring for patients with chronic diseases.

Integration is an important feature of this initiative. In 2014, CVS announced new clinical affiliations with four major regional US health systems. CVS will provide prescription and visit information to those health systems through the integration of secured electronic medical record systems, including data on interventions conducted by CVS pharmacists to improve medicines adherence for their patients. Physicians affiliated with the participating health systems will collaborate with MinuteClinic nurse practitioners on joint clinical programmes and care coordination.

CVS, its rival Walgreens and others have faced criticism that they are taking the place of doctors. But those championing these facilities say walk-in clinics may relieve pressure on the system amid a shortage of primary care physicians in the United States that is only set to worsen^[7]
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Potential for centres in the UK

A UK pharmacy walk-in clinic (PWIC) could have two arms: a walk-in service for minor ailments and minor injuries, and management of long-term conditions for registered patients. Both arms would be delivered jointly from suitable pharmacy premises by nurse practitioners and pharmacists.

Pharmacists’ and nurse practitioners’ skills and expertise should be complementary: PWICs would bring together pharmacists’ expertise in prescribed medicines and over-the-counter medicines for minor acute conditions with nurses’ skills in holistic patient assessment and treatment of minor injuries and long-term conditions. The basic infrastructure for PWICs already exists in the form of modernised pharmacy premises with consultation rooms, although not all pharmacies would be suitable. Larger pharmacies with space for a second consultation room would be best placed to participate in a pilot scheme.

Pharmacy support staff and healthcare assistants could also be involved. As well as face-to-face services, advice could be offered via telephone, email and Skype, which could be particularly valuable to the ever-growing population of housebound older people who cannot get to pharmacies.

PWIC services could be commissioned by the NHS and could also be available on a private basis, for example, to overseas visitors, who would have to pay to access NHS services.

Nurse practitioner-led walk-in centres and minor injury units are a well established model in the UK and United States, delivering care safely, quickly and appropriately to large numbers of patients (up to 50,000 patients per annum in the UK) and achieving high levels of patient satisfaction^[8]
.

Making it happen

Many pockets of new and innovative clinical practice have emerged in community pharmacy, most led by independent contractors, but the challenge has been achieving sufficient scale and sustainability to change the landscape for the community sector permanently in a comparable way to the advances achieved in hospital pharmacy roles over the past 15 years. One potential route to scale would be a pilot scheme by one of the larger pharmacy chains in a number of branches, which would then be evaluated and modified as necessary and, if successful, rolled out. Once a service had proved its worth in multiple locations, a case could be built for a nationally commissioned service.

PWICs would build on existing clinical services in England, such as the new medicine service introduced in October 2011, which has been delivered by over 90% of pharmacies^[9]
, and the healthy living pharmacy framework. The PWIC model could be a way of achieving new synergies and efficiencies in urgent care. It could provide convenient access for patients at a lower cost to commissioners than the current high level of attendances at hospital A&E departments for non-emergencies — an additional 400,000 visits in 2014^[10]
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Clinical staff working in PWICs would need access to patients’ summary care records (community pharmacists in England will soon get access to these), at a minimum, to provide safe, effective and integrated care. A record of the care provided by PWICs would also need to be communicated to the GP and other healthcare providers involved in the patient’s care^[11]
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A 2009 review of after-hours care provided in walk-in centres and other settings in seven countries, including the UK, identified the enablers of successful services as: integration with other health services (e.g. via patient information flows); proximity to a hospital emergency department; a non-appointment system; short waiting times; financial incentives to establish the service; services led by qualified prescribers able to make specialist medical referrals; and effective campaigns to raise public awareness and that of other healthcare professionals, driving sufficient patient flows and referrals from and to other providers to make the service sustainable^[8]
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Possible barriers

Low public expectations of what pharmacies and pharmacists can provide remain a significant barrier to PWICs. In a 2007 study, 12% of respondents used pharmacies for health advice but only 1% sought urgent advice from a pharmacy^[12]
. A 2013 survey for Monitor, the health sector regulator, found that only 5% of patients attending NHS walk-in centres would have gone to a pharmacy instead if the walk-in centre had not been available^[13]
.

Workforce supply constraints could also be a barrier to PWICs. The Royal College of Nursing has drawn attention to the overall shortage of nurses across the NHS and independent sector, including: increased use of agency staff; the ageing nursing workforce; changes to immigration rules that may force non-EU nurses to leave the UK; a lack of workforce planning; and cuts to nurse training places^[14]
. However, PWICs could still attract nurses by offering them more autonomous roles than those of practice nurses in GP surgeries, and could provide an attractive alternative to district nursing.

Professional rivalries could be another barrier, particularly between pharmacists and doctors. Commenting on a report about the future of urgent care in England, an article published in The BMJ
^[15] said: “Caution is needed regarding the suggestion of additional community-based resources — for example, pharmacists trained to deal with minor illness — because new services often increase use.”

An achievable solution

At this time of apparent crisis in urgent care, with seemingly unsustainable pressure on GPs and hospital A&E departments, PWICs could usefully supplement other in-hours and out-of-hours primary care services. Pharmacists would not have to deliver walk-in services by themselves; involving nurse practitioners would broaden the service offering considerably, and could help to build greater public and professional trust in clinical community pharmacy services. PWICs could thereby offer a bridge to the clinical roles that community pharmacy aspires to.

A fresh approach is needed to accelerate the shift from a medicines supply-dominated function to clinical roles in community pharmacy. The advent of a new UK parliament offers an opportunity for community pharmacy to restate its ambitions and offer a different vision of community-based urgent care and long-term management of conditions.