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What does a ‘realist’ evaluation of the prescribing pathfinder initiative tell us about the investment needed to make the IP model work? Leela Barham considers

I have looked at what the University of Manchester’s Realist Evaluation of Independent Prescribing Pathfinders found from an economic point of view. Spoiler alert and no surprise: independent prescribing needs more money.

The Evaluation

The University of Manchester was commissioned by NHS England (NHSE)to look at the independent prescribing (IP) pathfinder programme, backed with funding of £202,000. The pathfinders themselves came with £12m in funding, although not all of that went to the sites. 

The evaluation used a realist approach, which boiled down to 12 interviews with policymakers and decision-makers, analysis of 42 expressions of interest to take part from 42 integrated care boards (ICBs), interviews with 141 participants in the pathfinders and another 110 interviews with people working in ICBs. 

This all led to selecting 10 case studies which included more interviews with pharmacists, employers/owners and other pharmacy staff, plus other stakeholders and observing practice. 

One fact stood out as providing valuable context. There is around one IP for every five community pharmacies in England. At 42 pages, its brevity is welcome, so read it if you haven’t already, although the title of the file – FINAL-Report-agreed_version – signals how hard it may have been to have reached those 42 pages of content.

The findings

Two IP models were trialled: an acute minor illness model and a long-term conditions model. Both require five things to be in place to work: clinical governance, supervision and support, skill mix, digital infrastructure and funding.

The economic implications of the realist evaluation aren’t clearly set out but rest on both the obvious – the need for direct resources – but also the less obvious – indirect resources. Without doing the number crunching, IP needs more money if it’s to be done well and put on a sustainable footing for the future. 

The evaluation says pathfinder sites valued intensive ‘handholding’ support from ICBs. But are those indirect resources at the ICB level going to continue to be available? And for how long will they be needed, since help at the start makes sense, but what is the ongoing support needed from ICBs to keep IP working once established?

Similarly, the evaluation points to GP provision of clinical supervision to help build confidence among IPs. That time must surely be limited in availability and may well be needed less as experience among IPs increases. 

There was also an implicit call made for investment in an integrated IT system so that IPs could have read/write access to patient records. 

The evaluation also hints at a minimum viable number of patients to make IP worth it. That’s because there are upfront costs to allow IP to be offered, alongside marginal delivery costs. The evaluation talked about support within the pharmacy, noting that some sites used a two-pharmacist model or invested in support staff to free up the IP. 

It also highlighted getting indemnity insurance as an issue. These are some of the visible upfront costs which need to be paid for to make IP work. That’s the basic economics of community pharmacy; it costs to open the doors to patients before a patient is ever seen. And to deliver IP, probably more than the one-off £1,500 per branch fee that pathfinders were given. 

There’s also a missed opportunity driven by uncertainty, too. It’s hard to invest when confidence in a payoff is missing. That’s illustrated by Mike Hewitson, whose pharmacy was a pathfinder. Hewitson said on LinkedIn: “We could have done so much more to embed the pathfinder into local access pathways, but we had no security of longevity of the service.”

The evaluation also demonstrates the unquantified added value of IP. As of October 2025, 97 per cent of consultations were concluded without the need for patients to be seen by anyone else. That implies there was no delayed demand for GP appointments or other care from the NHS and that it was effectively redirected, potentially freeing up capacity within the NHS. 

With IP including services like lipid management, the payoff from better health for patients should also be borne in mind.

Recommendations

The evaluation came up with four recommendations. They included: 

At the national level: The need for a national governance framework. From an economic standpoint, it’s the need for the redesign of commissioning and funding models that are referenced within this recommendation that matters more; that sets out what’s feasible to deliver in practice.

At the ICB and Neighbourhood level: The need for local adaptation within the national framework, where the economics again relate to a need for funding.

For employers: The evaluation called for future preparation to use changes in legislation on supervision to free up pharmacist time. Optimisation of resources within pharmacies to deliver IP is seen as best dealt with by pharmacy business owners. That fits with a diverse sector that knows its cost base best

For individual pharmacists: The evaluation called for them to build trust within their own pharmacy teams. In economic terms, this builds on point three since it’s about optimising work within the context of the pharmacy team within each branch.

With £12m available for IP, there remain unanswered economic questions. Did that all get spent? What was the return on that investment? What investment is needed now to keep IP going, since some of the upfront work has been done? And just how many patients and at what fee does IP make sense?

There’s been encouragement from NHSE that ICBs keep pathfinders going. But with job cuts and unrelenting funding pressure will they?