Analysis: How do pharmacy first schemes compare across the UK?

Sarah Scott, a community pharmacist and independent prescriber in East Lothian, has been involved with NHS Pharmacy First Scotland since it began in 2020, building on an existing but more restrictive minor ailments scheme.

There is a long list of conditions where pharmacies can provide approved products as part of the service. A handful of PGDs also enables pharmacists to supply medication for conditions like urinary tract infections, impetigo, cellulitis and, more recently, hay fever.

“It is open to any resident in Scotland – you don’t need to be registered with a GP – so it is very inclusive. It was launched at the start of the pandemic and the idea was that it would help remove barriers to accessing healthcare at a time when people weren’t sure what was going on,” Sarah explains.

“It covers all the common conditions you would expect, so anything from head lice to thrush to headaches and colds. Patients have a consultation where they might just get advice, which happens quite commonly, or if treatment is required we can give something off the approved list. The other option is onward referral.”

It is all recorded onto the patient record so if any follow-up is needed, it is clear what has already been offered, she says. Last year the scheme passed 5 million consultations. 

In Sarah’s experience, most of the time patients are opting to come to the pharmacy but healthcare professionals or GP receptionists can also refer. 

Moving from minor ailments to Pharmacy First felt “very natural” but there was still work needed to raise awareness, she adds. “In terms of communication between other healthcare professionals and the pharmacy, that has definitely built over time.” 

Pharmacies get a baseline payment for the first 100 consultations. After that, funding is paid from an activity pool based on national monthly data and divided up. “It is more work, but the key is to have a skilled team around you.”

Currently about a quarter of pharmacies in Scotland offer Pharmacy First Plus, which means they can use a pharmacist independent prescriber to deliver care for conditions within their expertise such as dermatology or ENT.

Ali Sparkes is owner of the Health Dispensary, a pharmacy with two branches in Neath. Wales first launched a trial of Choose Pharmacy – a national common ailments scheme – in 2013. Based around a digital capability to allow pharmacy access to patient records, it went national in 2016. 

Under the scheme, free treatment and advice can be offered for 27 common conditions. Data from March suggests it freed up almost 26,000 GP appointments that month alone. A sore throat test and treat service was added in 2018 after a pilot in two health boards.

“There are two versions of common ailments services in Wales: the main conditions can be seen by any pharmacist and it can be a walk-in service,” says Ali. As an independent prescriber, she offers an additional service at her pharmacies by appointment and has more options around what she can provide. “It doesn’t give you free rein, but I’m not as limited by, say, age or product choice. I really enjoy that part and I’m trying to specialise more in skin problems.”

Despite the whole concept being based on the Choose Pharmacy IT system that provides the  access to patient records, logging onto the system can cause stress for her team because it can be “very slow”, she says.

Awareness among the general public about what the pharmacy can offer has really grown, she adds, “especially now as GP appointments are harder to come across. We do a lot of marketing and social media, and we have a website, so we get a lot more people coming in one way or another. There is also the cost of living impact with people not being able to afford medicines.”

Her pharmacies are also seeing more GP referrals but they are not always appropriate, which relates to a lack of awareness about the criteria they have to follow. “In fairness to them, it can be a bit confusing because it depends on your scope of competence. In some ways, with England coming on board, that is going to be made worse because English pharmacies can provide things we can’t, say for shingles or ear infections, unless we have an independent prescriber in place.”

Ade Williams, superintendent pharmacist at Bedminster Pharmacy in Bristol believes Pharmacy First is a positive change but will take time to settle in. His pharmacy was one of the pilot sites, so is further ahead than most.

The scheme in England is limited to seven conditions with the focus on the provision of POMs via PGDs if patients meet certain criteria.

“The groups that have been really quite elated by this are parents of young children but also people that have busy lives and are working. For me, this has been less about offering treatment and more about reinforcing self-care advice.”

As has also been seen to some extent in Wales and Scotland, there has been confusion about what GPs can refer for, or whether they can refer at all, and that relates to how the service has been set up, says Ade, which does impact payment. “Pharmacies are doing more consultations than they are being reimbursed for and that is one of those unintended consequences. The GP referral element is a work in progress.”

He hopes this is just the beginning for the scheme. “The question is whether it is ambitious enough, with these seven conditions. That is one of the frustrations we hear from patients. There are conversations about how we can look at Scotland and consider what we should offer.”

The goal should be to shift behaviour and encourage patients to do more self-management, he says. “If we are really going to shift that dial, then at the moment [the current scheme] is simply not enough.”