Prescribing pathways – what a load of ARRS

Exploring the detail in an email from his ICB, our anonymous correspondent wonders if someone is robbing Peter to pay Paul?

This column goes to press without any further detail on contractual framework updates (no surprise). Neither is there any news of the substance behind the Not-A-Minor- Ailments Service, in which our key interest is in how much of the headline £645 million promised over two years actually makes it to the proverbial coalface.

There was, shortly after I submitted Augusts’s column to the The Editor, a minor faff about the ‘flu vaccination service start dates. But like all good teases, I’m going to leave seasonal vaccinations for a month or two. I’ll also skip over the recent football tournament, beyond saying how enjoyable it was especially to see my local team’s flag flying in Stadium Australia for the final. 

With a lack of news in our inboxes about contractual arrangements or how to get at some of those £645 millions, I was intrigued by some emails talking about expressing interest in the rather awkwardly titled Community Pharmacy Independent Prescribing ‘Pathfinder’ Programme. 

Expressions of interest will be invited. Soon. Which sounds terribly exciting. ‘Prescribing’ and ‘Pharmacy’ have been talked about, intimated – even promised – a lot over the last few years, so adding ‘Pathfinder’ into the mix makes it seem really exciting (really?).

I read on. This is a programme where Integrated Care Boards (ICBs) have submitted bids to develop test sites where PCN-employed pharmacists will be made available to community pharmacies to provide a Local Enhanced Service that requires some pharmacist prescribing. Community pharmacies will pay their PCN £198 per four-hour session for the privilege. Six sessions per week for 39 weeks. Cough. Splutter. 

There is a lot going on here, and an awful lot that is unsaid, unclear or quite probably nowhere near being decided. What we do know is that there is £12m for this programme – likely from the Pharmacy Integration Fund monies that used to be ours. We know the £198 bit and the aspiration to provide this from all 42 ICBs. There will be an average of five or six sites per ICB able to provide this service, based on the minimum funding per site and the £12m available.

What we have no idea about is what the services might be, how the finances might work or what its impact will be. We should give it some thought though.

It’s difficult to see a pharmacy owner not being interested in offering a prescribing service. We’ve been clamouring for it for decades. If you make six per cent net margin on a prescription worth £9, the prescriber would have to generate a lot of items per hour to pay their way. And the Government has been clear for more than eight years that there is no money in dispensing.

What services would these pharmacist prescribers be able to offer for £49.50 an hour? To be clear, they don’t exist now – otherwise we would already be offering them. The purpose of the pathfinder is to flush out services that from 2026 – when every newly minted pharmacist will be a prescriber – can be commissioned from community pharmacies as opposed to alternative primary care premises.

Yet there we hit upon a stumbling block. Community pharmacies cannot provide ‘Care’. The provision of Care – as in healthcare – is protected. Only providers registered with the Care Quality Commission can provide Care, and pharmacy definitely doesn’t provide Care. How can we be so sure? Because we (or PSNC) actively negotiated this.

This means that pharmacy is impaired in the services it might offer under this pathfinder programme. Think about a prescribing pathway that involves a blood test – finger prick or otherwise. If you need to use an off-site lab to inform a clinical decision, it is registered Care. 

What you have then are ICBs searching for services to push into community pharmacies that need prescribing, but not too much. Slightly souped-up versions of existing local and national services. And the majority of those services don’t pay very well – certainly not enough to cover six £198 hour sessions a week. Not any more. There was once one though.

It used to take 10-15 minutes and at that rate paid about £100-120 an hour. Patients really liked it and there was demand. The one thing it lacked was a prescribing element to solve the problems it found. Then it was cancelled, and the monies diverted into other things. Two of these were the Additional Roles Reimbursement Scheme (ARRS), which funded the recruitment of PCN-employed pharmacists, and the Pharmacy Integration Fund.

That expression of interest your ICB is sending you? It’s not just robbing Peter to pay Paul. It’s the MUR money they took off you, to recruit a colleague away from you, to then pay you to pay them to come back and provide the same service they took away from you in the first place.

Conspiracy theory? Only if it doesn’t happen.

Outsider is a community pharmacist