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Pharmacists look back at the highs and lows of the service – and warn that better leadership is needed to fulfil its ambitions. By Saša Janković

Pharmacy First, built on the existing NHS Community Pharmacist Consultation Service that had run since October 2019, enables patients to be referred to community pharmacy for a minor illness or an urgent repeat medicine supply.

It launched on 31 January 2024 with the addition of consultations and treatment of seven common conditions following defined clinical pathways.

So what do pharmacists who have been running Pharmacy First for the past year think about how it is going? And what would they like to see change?

Building confidence and skills

John Bell & Croyden pharmacist Reshma Malde says one of the biggest positives from Pharmacy First so far is that it has demonstrated the breadth and depth of the skills that community pharmacists have.

“Pharmacy First gave community pharmacists a real doorway in to show our hidden skills that really hadn’t been utilised over the years,” she says. “This has also strengthened and focused our relationships with GPs and patients, especially coming out of the pandemic.”

On the downside, Malde says the reimbursement structure is a challenge. “If a patient doesn’t meet the gateway criteria, we have to tell them to go back to their GP, but we don’t get paid for that time or effort even though we still provide care,” she says.

“And it is also unhelpful that pharmacists cannot use PharmOutcomes to refer patients back to the GP when they don’t meet the gateway, and instead we have to tell the patient to find their own way back to their doctor.

"This worries me. How do I know if they have sought treatment and not just given up because they couldn’t get an appointment?”

For the coming year, she says: “Imagine if we had a pharmacist handling triage calls in GP practices — half those calls could be resolved straight away, saving time and resources – and I would love to see point-of-care testing introduced, such as cholesterol or health checks, to make it a more holistic service.”

Clinical freedom 

Michael Nicolson, pharmacist manager at Pharmacy+Health Knaresborough – part of a chain of 37 pharmacies across Yorkshire owned by the same team behind HubRx – says: “Pharmacy First has provided pharmacists with more clinical freedom – something which has been long promised, but slow to arrive.” 

A low point for Nicholson has been slow GP engagement in Pharmacy First, although he understands why: “For GP practices a referral to a pharmacy means more admin when they’re already overwhelmed and overstretched, but there’s been little investment and training offered to make the logistics work between GPs and pharmacies, and many GPs – as we’ve seen with the recent BMA vote about the hypertension case finding service – aren’t overly supportive of pharmacies taking a more active role in helping support primary care.”

His hopes for the coming year are: “Word of mouth grows so referrals aren’t reliant on GPs, and Pharmacy First can work well without adding more administration for them.

"I also hope to see the number conditions pharmacists can self-refer on expanded through Pharmacy First so that the targets are more realistically achievable. 

"I want to see Pharmacy First expand and the role of community pharmacy grow within clinical service delivery. But without the proper investment and support I can’t see how that’s going to be possible.” 

Ridiculous targets

Martin Bennett, superintendent Pharmacist of Wicker Pharmacy in Sheffield, also puts “funding, funding, funding” at the top of the list of his Pharmacy First concerns, alongside what he calls ‘the mistaken idea’ that some patients have that a consultation will always result in supply of an antibiotic. 

Targets are also a challenge, with Bennett calling them “ridiculous”. “We have exceeded them comfortably every month except September, when we were one short and so lost £1,000,” he recalls – an obstacle not helped by “the lack of referrals from GP practices”.

On the plus side, Bennett says the biggest benefit of Pharmacy First so far is being able to treat patients that previously we would have had to refer on.

“Provided there is adequate funding to cover ‘the day job’ then I would support an extension of the service,” he maintains.

GP engagement

Dane Stratton-Powell, independent prescribing pharmacist, director of Operations at RB Healthcare’s 15 pharmacies in the north west, and chair of Community Pharmacy Cheshire and Wirral, agrees that an increase in referrals from GP practices would “absolutely help”. 

“We’ve been engaging with GP surgeries to raise awareness of Pharmacy First, but it’s difficult to maintain consistency when there’s staff turnover or disengagement at the surgeries,” he says.

“We’re still finding prescriptions come through for patients who could have been signposted to a pharmacy first, but it’s hard to dictate surgery actions when GPs are also facing funding issues.”

He also sees challenge around the gateway numbers. “I work in a pharmacy that is not next to a healthcare centre so we are reliant on passing footfall which makes it tough to meet the gateway for the £1,000 payment. We made it for the first four months, but since then, we haven’t hit it,” he says.

Nonetheless, Stratton-Powell calls Pharmacy First a “positive service”, but stresses that “for it to truly thrive, we need consistent referrals from GPs, better integration with other healthcare providers, and room to expand into areas.”

Improved patient access

Sunil Kochhar – independent prescriber (IP) and consultant pharmacist at Regent Pharmacies Ltd, Gravesend, Kent – welcomes Pharmacy First as “a good opportunity for pharmacists to have a different role that the public can access easily.”

However, he says that “poor marketing and unclear communication” have led patients to expect GP-level services at pharmacies, resulting in frustration when patients don’t meet the gateway for the service due to age or condition restrictions.

“People have already gone through the frustration of trying to book a GP appointment, then they’re told to come to the pharmacy where they queue up, only to hear we can’t help them,” he says. 

Indeed, rather than focusing on patient care, Kochhar says targets and barriers are pushing pharmacists towards looking at what’s commercially beneficial.

“The system would work much better if patients were referred through a digital platform and every consultation was paid for. That way we’d be dealing with efficiencies and delivering better care,” he believes.

Lack of support

Ade Williams is director and superintendent pharmacist of the M J Williams Pharmacy Group in Bristol, and says he feels “disappointment in the lack of a commitment from the government” about Pharmacy First. 

“There’s been no clear leadership or ambition for Pharmacy First in England compared to Scotland and Wales, where they’ve had a sense of direction and clarity about expanding services,” he says, adding that a national campaign for public awareness has been flat.

“Pharmacies are left to promote the service themselves, which is unkind given the sector is already under so much pressure.”

This, he says, has had a “demoralising impact on pharmacists who are not getting GP referrals and not meeting payment thresholds, with a lack of national answers to their concerns, and a failure on the part of NHS England and Community Pharmacy England to take ownership of the programme’s shortcomings and provide support.”

“When 30% of pharmacies aren’t meeting the payment thresholds, we need to ask if the rollout and design were flawed,” says Williams.

“It’s not that these pharmacies can’t deliver – it’s that they weren’t supported to succeed – but if the service fails the value-for-money test it could disappear, and that’s worrying for both the sector and the patients who rely on it.”

His hopes for Pharmacy First in the coming year are that the service is seen as “a big pilot that evolves with learning, with improvements to design, thresholds and funding to make it sustainable and impactful, alongside clarity, bold leadership and a commitment to expanding services, much like the success we’ve seen in other parts of the UK.”

Case study: Sepsis spotted just in time

Kostas Iliadis, pharmacist and branch manager at Pharmacy+Health Alwoodley in Leeds says the service inadvertently helped a patient presenting with a possible chest infection just before Christmas. “They’d come to us for help having heard about Pharmacy First,” says Iliadis.

“Of course, under Pharmacy First we can’t treat chest infections, but the symptoms worried me and I knew that the chances of the patient being able to get a GP appointment so close to Christmas was going to be near impossible.

"Fortunately, our normally fully booked prescriber had time that day to see the patient, and they quickly identified symptoms suggesting sepsis. An ambulance was called and the patient immediately went to hospital for treatment.

"The patient spent the next few days admitted to hospital, but it’s worrying to think what might have happened if they hadn’t been able to be treated that day.” 

Case study: UTI symptoms

Pharmacist Reshma Malde was working at John Bell & Croyden in London on a Sunday afternoon when a woman came in complaining of UTI symptoms.

“An immediate concern to me was that this patient said she was due to catch a flight to the United States in the evening, and that’s a pretty long flight”, says Malde.

“I took her straight in as a walk-in for Pharmacy First, and as she got through the gateway questions and I could help her with a course of antibiotics.

"I was pleased I was able to help her, but I was doubly relieved as when I asked her if she had travel insurance she said ‘no’, so if she’d got to the US and needed to access healthcare there it would have been difficult and costly to say the least.”