By Arthur Walsh

Community pharmacies throughout England have spent the past months readying themselves for the launch of the Community Pharmacist Consultation Service – almost three-quarters (8,649) had signed up by the launch date of October 29.

The CPCS brings urgent medicines requests and minor ailments queries to pharmacies via NHS 111. The service was one of the flagship announcements in the new contractual framework and sector leaders have been seemingly unanimous on the subject of its importance.

This is a crucial first step to helping pharmacists demonstrate their value through the provision of clinical services, it has been argued.

The CPCS “provides the opportunity for community pharmacy to play a bigger role than ever within the urgent care system,” said PSNC. The service is based on the NUMSAS and DMIRS pilots that it replaces.

Get basics right

According to pharmacist and NHS England network chair Andre Yeung, the CPCS will in some respects be “business as usual” for pharmacists, most of whom provide quality clinical care as a matter of course and will be used to treating minor ailments and making urgent medicine supplies.

Yeung, one of the architects of the DMIRS pilot that informs the minor ailments side of the CPCS, told Pharmacy Magazine that in linking this clinical offering to NHS 111 the service “formalises” community pharmacists’ work.

There may be boxes to be ticked – technology must be sourced (NHS England will reimburse all CPCS-related IT expenses for the first 18 months of the service) and SCR access and a private consultation room will be absolute requirements – but fundamentally it is about getting the basics right, Yeung says. “What we need to focus on is the delivery of high quality, confidential, timely consultations.”

Clinical assessments

Pharmacists need to have confidence in their decision-making abilities, Yeung told Pharmacy Magazine. “It is about your clinical assessment. This service is not about NHS 111 just sending patients that are always going to be appropriate.

“After all, that is what GPs do, isn’t it? They make a judgement call based on their clinical assessment and decide what happens next. It is for pharmacists to understand the importance of that clinical assessment.”

Clinical assessments “need to be robust”, he said. Pharmacists “need enough information to make the right clinical decision”, whether that involves offering simple advice or, more rarely, referring the patient to another healthcare provider such as their GP.

Yeung also stressed the importance of ‘safety netting’ all patients referred to the pharmacy. A basic safety net might involve telling a patient to come back or see another clinician if their symptoms don’t improve, he said, while a more advanced safety net would see the pharmacist give specific advice.

It's about your clinical assessment – NHS 111 won't always refer appropriate patients

Referrals

As with all things to do with the contract, the enthusiasm of sector leaders does not always chime with the feelings of pharmacists on the ground – some of whom have been rather more sceptical. In particular, some pharmacists were disappointed to find in the early weeks of the service referrals were few to non-existent.

NHS England had given some warning predicting that, to begin with, pharmacies might receive one or two referrals a week (which the early data suggested was exactly the case). This is perhaps partly because the CPCS is not being advertised to the public, with the health body hoping that rather than inundate call handlers and pharmacies from day one, referral rates will build as winter health awareness campaigns get fully into gear.

Nonetheless, one pharmacist told Pharmacy Magazine that, after all the fanfare, expectations were “certainly not aligned to a one-or-two-aweek mindset”. The pharmacist spoke of others who had “set themselves up as mini A&E clinics” only to find they were not receiving any referrals.

It may not do to be too pessimistic, however. While NHS England is not planning to publish official figures before the end of December, a source with access to PharmOutcomes and Sonar data two weeks into the service told us that just under 17,500 referrals had been made, with more urgent medicine referrals than minor ailment consultations, and activity spikes over the first two weekends.

In an (admittedly unscientific) Twitter poll by Pharmacy Network News on November 12-13, a majority said they had received between one and 10 referrals, while close to half had not received any. One reported having received more than 10 referrals, and one more than 20.

Some pharmacists have been disappointed with low referral rates in the early weeks

Clunky service spec?

Criticism has also been levelled at the service specification, with some describing it as ‘clunky’. There have been complaints of patients not being triaged properly by NHS 111, as well as concerns around how a complex service involving several steps can be made to align with the daily workings of a busy pharmacy. One pharmacist told PM the CPCS “feels like a big research project” rather than the game changer it has been made out to be.

Again, those behind the service hope that time will assuage these concerns as working practices become fully embedded. Andre Yeung defended the minor illness side of the service specification, saying it had been built on the experience of the pilot. “The specification is just to inform us of what the service is and how to deliver it – it is not something you’ll need to refer to every day,” he said.

He acknowledged that for overstretched pharmacies the CPCS would not always be easy to deliver, but said it was worth it. “It is a recognition of those clinical skills that pharmacists are using on a daily basis, but this time with patients that have been referred in.”

Demonstrating value

Some contractors have asked whether the CPCS will make up for monies lost once MURs and establishment fees are scrapped entirely. Others responded that this does not come anywhere near to formulating the right question – for one thing, it does not account for the transitional payments built into the funding settlement.

It does seem fair to say that at £14 a consultation, the service is unlikely to be a gravy train for anyone. Its principal value appears to lie in its potential to demonstrate to both patients and policymakers that community pharmacists are highly skilled professionals who can be relied on to deliver clinical services.

The data suggests this ambition is not so far fetched. NHS England surveys of the DMIRS pilot showed that over 80 per cent of patients were satisfied with the service they received, while over 90 per cent of pharmacists delivering the service had confidence in it.

In Andre Yeung’s view, “the more patients see a pharmacist for minor illnesses as a result of a NHS referral, the more their impression and understanding will change as they have positive consultation experiences with community pharmacists.”