With the latest data from PSNC showing that consultations for minor ailments are less expensive when provided through community pharmacy, and evidence suggesting that a pharmacy-based service provides a suitable alternative to GP consultations, why is the service still not being fully funded in England?

Pharmacy-based services were introduced locally across the UK more than 14 years ago to treat selflimiting common ailments and reduce the burden of minor ailments on higher cost settings, such as general practice and the A&E departments of hospitals.

An NHS minor ailments service (MAS) is currently available at pharmacies in Scotland and Northern Ireland, but is yet to be rolled out nationally in England and Wales.1 This is despite an NHS England report on the urgent care review, published in June 2013, concluding that ‘community pharmacy services can play an important role in enabling self-care, particularly amongst patients with minor ailments and long-term conditions’.

According to figures from the Personal Social Services Research Unit – an organisation that combines data analysis from three UK universities, including the London School of Economics – community pharmacy offers the most cost-effective provision of treatment of minor ailments, with treatment in A&E costing between £58 and £112 for each presentation, each visit to a walk-in-centre or similar service costing the NHS from £63 upwards, and a GP consultation typically at £43.2

So if NHS-funded community pharmacy can offer potential solutions for the UK’s urgent care challenges, why isn’t MAS being rolled out further across England and Wales?

Potential for change

A year on from its ‘Now or never: shaping pharmacy for the future’ report into the pharmacy profession’s role in the reformed NHS in England, the Royal Pharmaceutical Society commissioned the Nuffield Trust to undertake a further independent assessment of progress made in implementing the recommendations made in ‘Now or Never’.

The follow-up – published this December as ‘Now more than ever: why pharmacy needs to act’ – shows that while pharmacists at a local level continue to work to persuade local commissioners to fund innovative services to support health and social care, such progress ‘remains patchy and lacks scale’. The report also claims that at a national level there has been ‘disappointingly little progress over the last year in shifting the balance of funding and commissioning away from the dispensing and supply of medicines toward the delivery of direct patient services; perhaps reflecting the complex and often fractured nature of pharmacy leadership in England’.

The report’s authors recommend national funding and coordination to enable pharmacists to assume a wider care-giving role in areas such as common ailments, within urgent care networks, which it suggests will show that NHS policy-makers ‘mean business’ about pharmacists assuming this wider role. But, adds the Nuffield Trust, ‘such backing needs to come through changes to the national community pharmacy contract, and/or the new payment mechanisms being put in place to support the Five Year Forward View’.

Although NHS England is responsible for the framework of the community pharmacy contract, it is the Department of Health which looks after remuneration for medicines and making changes to the regulations that support the framework, and the latest community pharmacy contract for 2014/15 featured no significant shift in the balance of funding, with the largest proportion of the global sum negotiated for community pharmacy still linked to the volume of prescriptions dispensed.

PSNC is working hard to promote the benefits of a national minor ailments service as outlined in its ‘Vision’, and the recently launched ‘Community Pharmacy Manifesto’ – developed with Pharmacy Voice and the Independent Pharmacy Federation – provides an opportunity to raise the importance of utilising community pharmacy through the commissioning of national services, such as one for minor ailments.

‘NHS England is in a strong position to review the roles of the different primary care providers and we believe that should include another examination of the opportunities presented by a national MAS,’ says Alastair Buxton, PSNC’s head of NHS services. ‘Historically one of the main reasons that national commissioning was rejected by the Department of Health was the difficulty of changing general practice funding, so GPs are not funded to provide management of minor ailments at the same time as community pharmacy, [but] in the meantime it is reassuring to see that many CCGs are commissioning MAS at a local level.’

Welsh progress

In Wales, an NHS Wales Common Ailments service is being delivered in two Pathfinder areas of urban Cynon Valley in South Wales and rural Gwynedd in North Wales. The service is available at 13 pharmacies in Cynon Valley and 19 in Gwynedd covering 26 common ailments including indigestion, constipation, hayfever, head lice, acne and back pain, and is branded by the two health boards involved as ‘Choose Pharmacy’.

A spokesperson for Community Pharmacy Wales says: ‘We think this is exactly right as it emphasises the value of patients choosing pharmacy for the 26 common ailments covered and so freeing up GP time. The experience of these 32 pathfinder pharmacies will be crucial to the evaluation of the service prior to it being rolled out as a Welsh national service.’

Scotland’s service

Scotland’s Minor Ailment Service is ‘business as usual’, according to Matt Barclay, pharmacist at Community Pharmacy Scotland, who says that the service has been ‘well accessed by a large number of eligible patients’ since it was established nationally in 2006. But lessons from running the scheme could result in a few changes, such as a new name. ‘It should be supporting the aims of patients accessing the right service, at the right time, from the right healthcare professional when appropriate, so we are raising points with the Scottish government for them to consider in terms of future development, including rebranding of MAS to Common Clinical Conditions, removing exemption criteria (which currently remains with MAS so it’s not open to all) and utilising PGDs to provide treatment for UTIs, impetigo and so on.’

Hull’s example

In England, Hull has had a Minor Ailments Service in its pharmacies for four or five years, which ‘works very well’, according to Ray Hall, pharmacist and owner of the city’s Raymond C Hall Pharmacy.

However, Mr Hall is not so sure that the government’s recent advertising campaign advising the over-60s to go to the pharmacy for minor ailments will have the desired effect without a scheme in place. He says: ‘The problem is that with no national MAS scheme a lot of that effort is wasted because people still associate going into pharmacy as having to pay for something, while going to the doctor means getting it for free.’

And while he’s careful to point out that MAS is not ‘a free-for-all on freebies’, he emphasises that if someone comes in ‘we try to look after them and if we see they need something then we make sure they get it or refer them on to A&E or to their GP.’

The service is generally successful, he says. ‘It’s not a “remote” service and we’ll only do it if people come into the shop, but we have a system here that works very successfully where we can refer people directly to the doctor; they can get an appointment and come back to us with a prescription on the same day – which saves them having to wait for days to see their GP.’

For Mr Hall, MAS is ‘the perfect filter’ because patients seem to fall into two camps. He says: ‘Either they don’t want to bother their doctor at all, or they’re in there all the time because they get free prescriptions and don’t want to spend their money on medications. So the MAS covers all those people – although we have the same problem getting through to the doctor as the patients do, and I do have a concern that we don’t have a hotline to the surgeries.’

In terms of what’s stopping the scheme being rolled out nationally, Mr Hall says: ‘I don’t know for sure, but it must be down to finance at the end of the day. It was negotiated by the early PCTs – when they were around – and I suppose Hull just got lucky. Because we got it early we’ve managed to keep it, but other areas are struggling to get it commissioned. I’ve never seen anyone do any costings on it, but I always think that if I’m giving someone some paracetamol and saving them going into the doctor then it’s saving them time and the doctor more inconvenience and the NHS some money.

‘We’ve got a lot of paperwork to do to get our fee, but I still think MAS is a great thing. Pharmacies are “the gateway to the health service” and our customers like the reassurance from the minor ailments service that they don’t need to go to the doctor at the moment. True, it’s not for treating serious injuries or illnesses but pharmacy is the perfect place for people with minor ailments to start off and I think it will be funded nationally eventually as it is undoubtedly a successful scheme,’ concludes Mr Hall.

References

1. Paudyal V, et al. Are pharmacy based minor ailment schemes a substitute for other service providers? Br J Gen Pract 2013; 63 (612), July 2013: 472-481

2. Unit costs of health and social care. 2012. Personal Social Services Research Unit