Classification: Official
Publication reference: PRN01108

To:

• Community pharmacy contractors and commissioners
• General practice contractors and commissioners
• Primary care network clinical directors

cc. 

• Integrated care boards:
  • chief executives
  • clinical directors
• NHS England regional directors of primary care

Dear colleagues,

Launch of NHS Pharmacy First advanced service

This letter confirms that the new NHS Pharmacy First advanced service will launch on Wednesday 31 January 2024, as announced in November 2023. We would like to thank the more than 10,000 pharmacies who have registered to deliver the service to date.

The new Pharmacy First Service will enable community pharmacists to complete episodes of care for patients without the need for the patient to visit their general practice. This, alongside expansions to the pharmacy blood pressure checking and contraception services, will save up to 10 million general practice team appointments a year and help patients access quicker and more convenient care, including the supply of appropriate medicines for minor illness.

The Pharmacy First Service builds on the previous Community Pharmacist Consultation Service (CPCS) by enabling community pharmacies to manage patients for seven common conditions, following specific clinical pathways. The overall service consists of three core elements:

• Pharmacy First (clinical pathways) – new element
• Pharmacy First (urgent repeat medicine supply) – previously commissioned as the CPCS.
• Pharmacy First (NHS referrals for minor illness) – previously commissioned as the CPCS.

The seven conditions are:

* Distance Selling Pharmacies will not complete consultations for Acute Otitis Media.

The clinical pathways were carefully developed with input from a group of multi professional experts, including practising clinicians, antimicrobial resistance specialists, and representatives from national organisations. They have been approved by the National Medical Director at NHS England and the Chief Medical Officer for England.

Pharmacies have been working on antimicrobial stewardship for a number of years and we encourage them to use RCGP TARGET tools with patients. The pathways include self-care and safety-netting advice, and, when appropriate, pharmacists can supply a restricted set of prescription only medicines via patient group directions and/or over-the-counter medicines via clinical protocol.

Reporting of community pharmacy consultation outcomes will enable surveillance of antimicrobial supply through Pharmacy First. The NHS Business Services Authority will make this data available in much the same way as prescribing data via the ePACT2 dashboard.

Patients will access the new clinical pathway element by walking into the pharmacy directly or where appropriate, by contacting them by video consultation. In addition, patients will access the service via referrals from:

• NHS 111 (online, telephone and NHS App)
• integrated urgent care clinical assessment services
• urgent treatment centres
• emergency departments
• 999
• general practice (GPs cannot make a referral for urgent repeat medicine supply)

We expect activity for this service to increase gradually following the launch.

The National Institute for Health Care Research is leading an evaluation of this service that will include any implications on antimicrobial resistance.

The service specification, clinical pathways and patient group directions/clinical protocol for this service are all available on the dedicated NHS England website. See Appendix 1 for frequently asked questions about the Pharmacy First service.

Information for community pharmacy contractors

Pharmacy contractors who have not yet registered to deliver the service are encouraged to do so by registering via the Manage Your Service platform. Pharmacy contractors who register to deliver Pharmacy First by 23:59 on Tuesday 30 January 2024 will qualify for the one-off initial fixed payment of £2,000.

To prepare for the service, pharmacy contractors should:

• ensure staff review the CPPE Pharmacy First self-assessment framework to assess their competence to provide all elements of the service
• ensure they comply with the service specification
• understand the requirements associated with service payments in the drug tariff
• order an otoscope (this does not apply to distance selling pharmacies); guidance on selecting a suitable otoscope is available in Annex C of the service specification
  • pharmacies may start to deliver the Pharmacy First service without being able to provide the otitis media clinical pathway, if they have evidence that they have ordered an otoscope and are awaiting delivery
  • from 1 April 2024 an otoscope must be available, and all clinical pathways must be provided

All four approved IT system suppliers are upgrading their systems ready for Wednesday 31 January 2024, so their community pharmacy customers automatically have the Pharmacy First screens to support the clinical pathways and send data for payments and monitoring to NHS BSA. Each supplier is supporting customers and making more information available directly:

• Cegedim
• Emis Pinnacle
• Positive Solutions
• Sonar

The Urgent and Emergency Care (UEC) Directory of Services will include pharmacies providing Pharmacy First. Health professionals (including those employed by 111 services) can access this information via NHS Service Finder or via their GP system where GP systems support this.

Pharmacy contractors should review their information in NHS Profile Manager, to ensure information such as opening times and contact details are up to date. Pharmacies will not need to update Profile Manager to indicate they provide Pharmacy First as it is not listed as a specific service in the Profile Manager list of services.

Community Pharmacy Consultation Service (CPCS)

Pharmacy First will incorporate the existing CPCS which will cease to be commissioned from 23.59 on 30 January 2024. The existing CPCS service specification will be available on the NHS England website until this time.

IT system suppliers will continue to make the current CPCS consultation record available to Tuesday 30 April 2024 to enable pharmacy contractors to submit claims for consultations delivered up to and including the Tuesday 30 January 2024 as a contractor is allowed a grace period of up to three months to claim for any consultations after the date of that consultation.

Information for general practice

To streamline and improve workflow, we have redesigned the way that pharmacy consultation outcomes can be captured in the patient record. This will roll out throughout February 2024 and will mean that practice staff can review consultation information and add the data to the patient record with one click of a button.

Until this functionality is rolled out, practices will continue to receive information through NHSMail in line with existing processes.

NHS England are drafting a separate operational note to further support general practice and primary care networks. This will be available before the launch of this service.

Many practices are already making referrals into CPCS and we appreciate your continued support. These practices should continue to use their established CPCS process to refer to the Pharmacy First service and should begin referring for the seven new conditions from Wednesday 31 January 2024.

Information for integrated care boards (ICBs)

We will launch a national marketing campaign from mid-February 2024, which will encourage the public to access advice and treatment from community pharmacy services for common conditions and run for six weeks. We are developing a communications toolkit for ICBs to use to share information across their channels.

NHS England will produce reports to monitor service implementation, versions of which will be distributed to ICB commissioners starting shortly after launch, to assist with assuring the safety and quality of service provision.

The success and full benefit of the service for patients and the NHS will be in the building and sustaining of local relationships between general practice and community pharmacy teams. We encourage ICBs to work collaboratively across their systems to support the implementation of this service.

Local implementation can be supported and driven by the community pharmacy clinical leads where available, with the support of the regional senior pharmacy integration leads.

The rollout of Pharmacy First is a significant moment for pharmacy, primary care and the wider NHS. The commitment to expand services in this way was a substantial commitment in our primary care access recovery plan and the NHS is delivering on our promise.

We are grateful for your continued dedication to the NHS as, together, we deliver innovative and new services for our patients and the public.

Yours sincerely,

Dr Amanda Doyle, National Director for Primary Care and Community Services, NHS England

Dr Claire Fuller, National Medical Director for Primary Care, NHS England

David Webb, Chief Pharmaceutical Officer for England, NHS England

Appendix 1: NHS Pharmacy First Service – frequently asked questions

1. Service development

1.1 Who helped design the Pharmacy First service?

In designing the Pharmacy First service, we collaborated with a team of experts to ensure that this service was developed with appropriate challenge, assurance, expert advice, and consensus at every stage of the development process. This group included practising doctors, pharmacists, and specialists in areas like prescribing, children’s health, allergies, and antimicrobial resistance.

We also sought valuable input from representatives of organisations such as National Institute for Health and Care Excellence (NICE), UK Health Security Agency (UKHSA), Royal College of General Practitioners (RCGP), and Community Pharmacy England (CPE). All decisions made by this group were consensus-driven and grounded in the latest evidence and national guidelines.

1.2 What measures have been implemented to foster inclusivity in this service?

NHS England is committed to ensuring the broad accessibility of this service to benefit as many patients as possible. In our commitment to inclusivity, we have consulted with subject matter experts.

The group reached a clear consensus that individuals who are pregnant, breastfeeding, immunosuppressed, have penicillin allergies, or are children under 18 will not be automatically excluded from the service, unless there is a valid clinical reason. People not registered with a GP can also access this service.

1.3 What measures will be in place to ensure antimicrobials are supplied appropriately?

All use of antimicrobials drives resistance, so it is important that they are used appropriately. NHS England takes the threat of antimicrobial resistance (AMR) very seriously. The NHS England AMR Board has been involved in service development and will continually scrutinise this service.

The role of community pharmacy in antimicrobial stewardship has been developed through the Pharmacy Quality Scheme, and pharmacy teams play a key role in advocating for appropriate use of antimicrobials.

For the Pharmacy First Service, pharmacists will be following defined clinical pathways which have been designed to incorporate the principles of antimicrobial stewardship and a shared decision-making approach. This approach provides patients with symptom management strategies, including allowing a self-limiting illness to run its course, as a viable alternative to antimicrobial treatment.

A fundamental principle involves offering non-antimicrobial treatment options, where available and in line with NICE guidelines. In cases where antibiotics are unnecessary for self-limiting conditions, pharmacists will guide patients in self-care utilising RCGP TARGET resources. Antimicrobials will only be offered if needed and supplied in accordance with NICE guidelines under the legal authority of patient group directions, which have been nationally approved by the National Medical Director, Chief Pharmaceutical Officer, and National Clinical Director for AMR.

2. Consultations

2.1 What happens during a consultation?

In a confidential consultation, the pharmacist will ask the patient questions about their health. This may include their previous medical history, any allergies, any medicines they are taking and the symptoms they are currently experiencing. The pharmacist may ask the patient for consent to check any patient record they can access.

For some conditions, the pharmacist may request to perform an examination, such as using an otoscope to examine the ear of patients presenting with acute otitis media symptoms. The pharmacist will be able to recommend the best course of action on an individual patient basis. A contemporaneous clinical consultation record will be made during the consultation and shared with GPs to add to the record.

2.2 Will diagnostic tests be used as part of the Pharmacy First Service?

No, pharmacists will not use diagnostic tests such as urine dipsticks or sore throat swabs as part of the service, as there is not enough evidence to support their use. We consulted our expert group, and came to this decision after a lengthy discussion, whilst taking into consideration national recommendations and current evidence.

For the urinary tract infection pathway, the national guidance from UK Health Security Agency currently does not recommend a dipstick test if the patient has two or three key urinary symptoms and no other excluding causes or warning signs.

For the sore throat pathway, we accepted the NICE recommendation that rapid tests for streptococcus are not recommended for routine adoption as their effect on improving antimicrobial prescribing and stewardship, and on patient outcomes, as compared with clinical scoring tools alone (such as FeverPAIN), is likely to be limited.

NHS England’s position on point of care tests will be reviewed should national guidance be updated or should the tests improve in diagnostic precision and clinical utility.

3. Monitoring and surveillance

3.1 What surveillance measures are in place for this service?

Surveillance of this service is a key priority. NHS England is working closely with colleagues at NHS Business Services Authority to capture data to allow for robust oversight of the new service and to monitor for any potential impact on antimicrobial resistance.

3.2 How will this service be evaluated?

Research has been commissioned by the National Institute for Health Research (NIHR), for a robust, wrap-around evaluation of the planned Pharmacy First service to understand the impact, safety, cost effectiveness and acceptability of these services, as well as any implications for antibiotic use and antimicrobial resistance.