Bristol, North Somerset and South Gloucestershire (BNSSG) started piloting the General Practice referral to NHS Community Pharmacist Consultation Service (GP referral to CPCS) in July 2019, as part of the NHS England and NHS Improvement Pharmacy Integration Fund Programme.
The aim of the service is to improve access to primary care by referring patients requiring advice and treatment for certain minor illness conditions, from a GP practice to a community pharmacist, ensuring that patients have access to the same levels of care, close to home and with an emphasis on self-care. Patients need to be supported and feel confident that they are being provided with the right care by the right person for them, at the right time. The GP referral pathway to CPCS aims to integrate community pharmacy into local NHS urgent care pathways.
Key benefits and outcomes
- 4,028 consultations have been completed in the BNSSG area to date. 71% of patients received advice or advice and an over the counter product to manage their concern. In 12% of cases, the pharmacist identified that the patient required an urgent GP appointment which they were able to help arrange, and 17% of patients that consulted with the pharmacist were signposted to another health care professional, or back to the GP for a non-urgent appointment;
- patient feedback for those who have had a consultation with a pharmacist has been very positive;
- there has been an excellent response from practices willing to participate in the pilot and this interest is continuing to grow. This has been supported by having strong advocates of the service in GP practices;
- the pilot has developed and supported maturing relationships between community pharmacists and GP practices, ensuring that the patients in the local community are cared for jointly and practice teams better understand the role of the community pharmacist; and
- community pharmacists alert GP practices when they direct a patient back to the practice or on to other care settings, or where they believe there are other underlying issues that the practice should be aware of, building trust and the understanding that both have a responsibility for the care of patients.
Fiona Davenport, GP Forward View Transformation Lead at NHS England and NHS Innovation, South West Region, describes how the pilots have been working across the region:
“The service across BNSSG has developed very successfully with practices keen to get involved and currently includes 35 GP practices and 104 pharmacies with another 10 practices coming onboard by mid-September. The collaboration and close working between NHS England and NHS Improvement, the CCG and Local Pharmaceutical Committee has really supported the widespread roll-out and success of the pilot in our region.
“Although patients and the general public already access community pharmacies for self-care advice and to purchase over the counter medicines, they sometimes find it difficult to know when it’s appropriate to access minor illness advice and care from different healthcare settings, for example whether to visit the GP practice or a community pharmacy instead.”
In the BNSSG pilot, the reception team at the GP practice advises patients with minor illnesses, who have called to request a GP appointment, that they should attend a local community pharmacy for a consultation with a pharmacist and that if they agree, personal data, including a short description of their presenting condition, will be transferred to the pharmacist.
The patient is asked which community pharmacy they would like to attend and secure electronic transfer of data to support the referral, is sent from the practice to the community pharmacist.
When the patient arrives, the pharmacist carries out a clinical consultation, which will include viewing their summary care records and use of NICE Clinical Knowledge Summaries to identify any red flags, such as sepsis and the pharmacist will either then provide relevant clinical advice and support if there are no red flags, or will refer/escalate the patient to another service or healthcare professional, where appropriate.
All GP practices in BNSSG use the same EMIS clinical system and referrals are currently being made by several different methods including the use of a form embedded within EMIS, which pre-populates patient and referral data. The record is then saved in the patient notes and the template is copied and pasted into an nhs.net email account and sent to the patient’s choice of pharmacy. A small number of GP practices are trialling PharmRefer, a standalone system which sits alongside the clinical system, providing an alternative way to send referrals.
Pre COVID-19, the GP practices provided the details of the selected pharmacy to the patient, advising them to attend the pharmacy within 12 hours. If the patient didn’t attend after 12 hours, the pharmacist would attempt to contact the patient a number of times and this data would be captured. Post COVID-19, the process has been changed slightly and practices now inform the patient that the pharmacist will contact them once they have received the referral and will decide whether to conduct the consultation over the phone or whether they need to invite the patient to attend the pharmacy.
Results and outcomes
Dr James Case, GP, Concord Medical Centre, explains why his practice became involved with the pilot: “We see constant requests throughout the week from patients wanting to see their GP, many with minor illnesses, which are more suitably addressed by a community pharmacist. We estimated between 5-10% of those patients would be better signposted to a community pharmacy for help instead.
“With training, our reception team was able to pick up on the sorts of illnesses that can more suitably dealt with by a community pharmacist. We have a good process in place for referring patients to see the pharmacist and 70-80% of the issues are resolved by them. If during the consultation, the pharmacist identifies that the patient has a more complex problem, we will arrange to see them at the practice.
“The Community Pharmacist Consultation Service has a real opportunity to help GP practices reduce our daily demand and manage our more complex patients, which is very valuable for us.”
The outcomes in the BNSSG pilot area are that access to GPs for patients who really need a GP consultation has improved, by diverting those with minor illnesses to community pharmacists in a way that is convenient, safe and effective and enables those patients to be seen by an appropriate healthcare professional on the same day.
The pilot is helping relieve pressure on GP appointments and create some additional capacity for the practices.
Richard Brown, Chief Officer of Avon Local Pharmaceutical Committee adds: “Heavily supporting both the GP Practices and Community Pharmacies in the region, has been key to the success of the pilot programme to date. We have seen how it is helping individual patients manage their own health more effectively with the support of community pharmacists, who are recommending solutions that could encourage self-care and/or the use of pharmacy as a first point of contact for minor illness symptoms in the future.”
Tom Gregory, Clinical Pharmacist, 168 Medical Group Practice says: “It’s been beneficial to have a formal referral route to community pharmacists and it’s really helped the work I’ve been doing within the practice to promote self-care. I hope that patients will consider visiting a pharmacy first in future – many patients don’t realise the range of conditions that pharmacies can manage, whether they need just need advice, or an over-the-counter medicine.”
Debra Spencer, Practice Manager, Birchwood Medical Practice, adds: “When we refer our patients to a pharmacist, we provide as much information as possible to help them and we find that we get just as much information back from the pharmacist after they have seen the patient. The pharmacist can also pick up on emergency situations and arrange the appropriate care.
“The pilot is working really well for us and means a great deal to our surgery team, freeing up appointments to enable our GPs to focus on more complex cases. It is also great that the patient has had the education of right healthcare professional at the right time and that self-care and their local pharmacist is where they look first, before they come to their general practice.”
Care navigation training has been provided to practice staff across the BNSSG pilot area, so they fully understand the benefits of the service to their practice and to patients. Prior contact with pharmacies before ‘going live’ with the pilot has built confidence and understanding in the service amongst reception teams and pharmacists alike and ensures that the service they deliver is of the highest standards.
This training for receptionists also includes advice on how they can explain the service to patients who do not understand that a community pharmacist can clinically assess their minor illnesses.
Greg Dziedzicki, Pharmacist, Boots Bristol Brislington, says: “We are seeing about 3-4 patients daily on average being signposted from their surgery. Patients are really enjoying interacting with a pharmacist, they treat us seriously and can see how professional the service is that we are providing. Patients are very grateful for the advice they are receiving and are relieved they can be seen on the same day and don’t have to wait for a GP appointment.”
Take away tips
- A collaborative approach involving all local partners, including the CCG and Local Pharmaceutical Committee, helps support widespread roll-out and successful implementation;
- invest time in building strong relationships between community pharmacists and GP practices in the area;
- ensure a common understanding of the service and how the benefits support both professions and patients;
- ensure both GP practices and community pharmacists understand the patient journey;
- build trust and confidence within GP reception teams and spend time ensuring they are trained and understand the benefits to the practice and to patients; and
- ensure the referral method from GP practice to the pharmacist is simple and quick.