GP surgeries have now joined the NHS 111 service in being able to refer patients with what NHS England calls ‘lower acuity conditions’ to their local community pharmacy for a face-to-face or remote consultation with a pharmacist.
According to the Pharmaceutical Services Negotiating Committee (PSNC), pharmacies already registered to provide CPCS do not need to re-register to receive referrals from GPs, as this is an extension to the existing Advanced Service. Contractors who are not registered can still do so via the NHS Business Services Agency’s Manage Your Service (MYS) portal.
General practices can also choose whether they want to get involved, but before GPs can make referrals, there must be local discussions with pharmacy contractors, the primary care network (PCN) and its member general practices, the NHS and local pharmaceutical committees (LPCs) to agree how this will work.
“We expect this addition to the CPCS to become a community pharmacy service offering which is highly valued by patients and general practice alike,” says Alastair Buxton, director of NHS services at PSNC. He acknowledges that “the successful roll out will rely on team working, with NHS England & Improvement regional teams providing local leadership and support, with assistance from others, including LPCs”.
Mr Buxton stresses that the NHS has “a significant task in supporting general practices to engage with the CPCS”. He says discussions between community pharmacy and general practice within PCNs will also be “critical to achieving a successful local roll out”, adding: “in some cases this may be the first time the two professions have had such discussions”.
PSNC says the service aims to alleviate pressure on GP appointments and emergency departments, in addition to harnessing the skills and medicines knowledge of pharmacists. It is also a welcome boost for community pharmacy’s finances, with £14 for every completed referral and no upper limit on the number of CPCS consultations pharmacists can carry out.
Nonetheless, some contractors have concerns that any potential lack of understanding from practice care navigators about what pharmacies can and cannot do may have detrimental effects on patient expectations, and satisfaction. Sanjay Patel, owner of Sutton Pharmacy and committee member at Merton, Sutton and Wandsworth LPC, says one of his students has worked at an NHS 111 call centre and seen first-hand that some operators are unfamiliar with the scope of community pharmacy.
“She told me that the first page of computer triage is always pharmacy, but everyone presses ‘escape’ because staff working there don’t know what pharmacy does,” says Mr Patel. “So I asked her what the trainers had taught them to do, and she said the trainers don’t know what pharmacy does either. I’ve mentioned this at the LPC because if this is happening with 111 training then we need to make sure it’s not going to happen with GP surgery training as well. When we knock on GPs’ doors they already say they’ve got enough to do with Covid, so these training packages have to make sure the pharmacy referrals work properly.”
everyone presses ‘escape’ because staff working there don’t know what pharmacy does
Boots pharmacist and Royal Pharmaceutical Society (RPS) and Pharmacist Support ambassador Paolo Cavallo is one of the team delivering free CPCS training funded by NHS Health Education England. This is run by the RPS in partnership with the Royal College of GPs and the Centre for Pharmacy Postgraduate Education. He says another concern contractors have expressed to him is that with GP surgeries still closed to many patients, pharmacists will end up with even more people to see, as well as more paperwork to do.
“Some of my colleagues have said they are concerned that pharmacists are already under pressure from receiving referrals on a daily basis during the pandemic from GPs working behind closed doors, and they are wondering how much the GP CPCS referral will increase the customers they get into the pharmacy face-to-face or over the phone,” he says. “This will also be a massive job in terms of paperwork, and 80-90 per cent of my colleagues are not 100 per cent happy, although everyone knows we need to do this service to the best of our ability.”
There is also concern that GPs will just tell patients to go to the pharmacy, and without the digital trail, pharmacists won’t get paid.
From the patient’s point of view, in the case of GP referrals, the ‘practice care navigator’ will send a digital referral to a convenient pharmacy, where the patient can receive pharmacist advice and treatment for a range of common conditions, or an urgent supply of a previously prescribed medicine. Unlike with the NHS 111 arm of the service, which has been running since October last year, GPs will not be able to refer patients for an urgent supply of a new medicine or appliance. Should the patient need to be escalated or referred to an alternative service, the pharmacist can arrange this.
In spite of all that, the sector has high hopes for this second strand of CPCS, and it may be more practical to see these issues as inevitable at the start.
The pilot has run in 12 regions since last year, with plenty of positive reports coming out of it so far. For example, Bristol, North Somerset and South Gloucestershire started piloting the GP referral to CPCS in July 2019 and says it had “an excellent response from practices willing to participate in the pilot” with this interest “continuing to grow”. Feedback from patients who had a consultation with a pharmacist has also been “very positive”, and the pilot has reportedly “developed and supported maturing relationships between community pharmacists and GP practices”.
Dr James Case, GP at Concord Medical Centre in Little Stoke, Avon, says the training his reception team received has meant the referrals they have made to pharmacy have seen “70-80 per cent of the issues resolved” by the pharmacist.
This is a hugely important clinical service for community pharmacy and we have to implement it well
Richard Brown, chief officer of Avon LPC, says heavily supporting both GP practices and community pharmacies in the region was key to the success of the pilot programme, but stresses that the learning must not stop there. “The point of a pilot is to see what didn’t go well so others can avoid that, so I’m talking to all LPCs to share our learnings so each local system can take these and evolve them to meet their local needs. Just because the national roll-out went live on 1 November doesn’t mean that every GP practice had to be live from that date,” he says.
“This is a hugely important clinical service for community pharmacy and we have to implement it well, which means not moving slowly, but doing it right. The most important point is that it’s a seamless pathway from surgery to pharmacy – and it has to be seamless even for the 10 per cent of patients we find we need to refer back to the surgery. Once you’ve got your GP advocates it mushrooms, and if we can manage our patients seamlessly across primary care, then it will be a huge success.”
Mr Brown says that patient feedback so far has been “excellent”, adding: “If they are saying that to the GPs, that will also be good. It’s about primary care seeing patients in the right place at the right time, so we have to do it right and do it well. There’s still too much noise that this needs to be up and out and running all at once now, but in a year’s time it will still be new, so let’s not over-complicate it right from the start.”
The Company Chemists’ Association is also pleased with progress so far, with chief executive Malcolm Harrison, saying: “We see this as an excellent opportunity to continue our close working with our colleagues in the wider healthcare sector, and a key part of transforming community pharmacy and patient care – and we would like to thank LPCs for their hard work in supporting these relationships so far.”
Recognising that the initiative is “in its early stages”, he adds: “We hope it can build on the initial success seen in some of the local pilots, and we are keen to engage with local and regional NHS teams to make GP CPCS a success and progress it in other geographies.”
At a time when uncertainty seems to be the only thing that is certain, maintaining a balanced perspective is not always easy, but steering a steady course is a good place to start.
As Mr Buxton says: “While there may be challenges to overcome, this referral pathway should create a new foundation of collaboration between general practices and pharmacies, which can be built on in the years ahead.”