Since the community pharmacist consultation service (CPCS) launched last October, the benefits have been unsurprising but there have been some unexpected challenges as Sasa Jankovic discovers...
Pharmacies in England have seen over 100,000 patients referred through the community pharmacist consultation service (CPCS) in the first 10 weeks since its launch in October last year.
The latest government report on the initiative – introduced as part of the five-year funding contract in England with the aim of establishing community pharmacy as the ‘first port of call’ for low acuity conditions and supporting the integration of community pharmacy into the urgent care system – says the 10,610 pharmacies currently registered with the CPCS have received 114,275 patients since the scheme began.
Dr Bruce Warner, deputy chief pharmaceutical officer for NHS England and NHS Improvement, says the number of referrals from NHS 111 in the first two months alone “shows how well [CPCS] is working”, with NPA chief executive Mark Lyonette stressing that his organisation is “committed to working with the NHS to ensure that implementation is widespread and effective”.
All of this is a much-needed boost for community pharmacy’s coffers, with pharmacists receiving £14 for every completed referral and, unlike MURs – which are being phased out – no upper limit on the number of CPCS consultations they can carry out.
However, as with any new initiative, the accompanying challenges and hurdles are often not apparent until the scheme gets rolling. So how are independents finding the service?
Promoting the service
Graham Thoms, chief executive officer of pharmacist PGD supplier PharmaDoctor+, says pharmacists are sharing their frustrations about not being permitted to promote the service to patients.
“It’s early days but the feedback is that the biggest challenge is communication,” he says.
“Call handlers are still getting to grips with how best to make it clear to patients they have to tell the pharmacist they have been referred, and on the other side pharmacists are frustrated they are not allowed to actively promote the service, as this is counter to the conditions.”
However, not all contractors might follow this to the letter. Siddiqur Rahman, a general practice pharmacist prescriber, managing director of PharmaSid Ltd and board member of The Pharmacist Cooperative, posits that “If patients are turning up at pharmacies requesting emergency supplies and it is not their usual pharmacy, the pharmacy will tell the patient to contact 111 in the pharmacy to get a CPCS referral so [they] will get still paid for the service and won’t inconvenience the patient as they get the urgent medication they require, providing all the legalities of the supply and clinical judgement are applied by the RP.
“However, this might be frowned upon in the specs as you are not allowed to ‘advertise’ the service to the general public, but pharmacies that require extra funding will do this regardless since the number of MURs have been dramatically reduced this year and will eventually cease.”
Training and treatment lag
Training is another hurdle, according to Mr Thoms. “A lot of pharmacists still aren’t trained in the clinical skills needed to deliver the service”, he says. “For example, I know in Greater Manchester they have a training tender out which won’t be filled till February, and some of the LPCs want to provide training centrally but this is also not quite there yet.”
The problem this causes, according to Mr Thoms, is that “if, for example, someone is referred to the pharmacy with earache but the pharmacist is not trained to use an otoscope, which is necessary to conclude the patient has an ear infection, then the service is fairly limited because they can only give an OTC treatment which just won’t cut it.
“Even if the pharmacist can diagnose an ear infection, the patient needs a POM and – unless the pharmacist has a PGD that supports them to properly treat the patient – at the moment the CPCS doesn’t allow for that so they have to go back to their GP for prescription.
“If you think about it from the patient’s point of view, 111 sends you to the pharmacist who then say ‘yes you’ve got an ear infection but I can only give you paracetamol so you need to make an appointment to see your GP,’ so you’re going to feel a bit short-changed and wondering why you didn’t get sent to the doctor in the first place.”
Similarly, sometimes patients won’t tell pharmacy staff that they have been referred by NHS 111, despite being asked to by the NHS 111 call advisers, which means the pharmacist doesn’t get the consultation fee.
And there can also be issues within the scope of the referrals themselves. According to Mr Rahman, another problem is “CPCS referrals asking for pharmacies to issue emergency supplies on Schedule 2 & 3 Controlled Drugs which is against the Misuse of Drugs Act 1971. The pharmacist has to then contact out-of-hours to explain this to [the patient] as they cannot just refuse and let the patient call 111 again, which prolongs the consultation time.
“Then there are the 111 call handlers advising patients that community pharmacists can prescribe antibiotics or any other POM as part of the CPCS service, which is not part of the minor illness agenda, or inappropriate minor illness referrals where call handlers use the community pharmacy as a triage for patients and refer those already describing red flag symptoms to go to the pharmacy, who then have to spend extra time calling the OOH team or refer patients straight to A&E if urgent, which could’ve been avoided at the original 111 call handling.”
Mr Rahman says a “lack of understanding from the 111 call handlers about what pharmacies can and cannot do” could actually create a “breakdown in pharmacy-patient relations as the general public tend to side more with the 111 non-clinician call handlers than the pharmacist.”
Pharmacists are also concerned about whether GPs refer patients digitally or just tell them to go to the pharmacy, because if GPs do the latter there's no evidence base and, again, pharmacists won't get paid.
Ade Williams from Bedminster Pharmacy in Bristol says although he has had a “fair amount” of referrals because his pharmacy is also part of the GP referral pilot scheme, there have been some problems.
“Some GP surgeries are still struggling to do the administrative precursor to the consultation, forgetting to do the referral paperwork or to tell the patients what they are doing,” he says.
“Patients need to understand what the service is, and GPs must ask them to mention it at the pharmacy, because it can be an uneasy way to introduce a consultation if we have to ask them why they have been referred.
“Encouraging patients to mention CPCS also gives them a sense of purpose because they know the pharmacist has been expecting them.”
In a November 26 briefing on the service, PSNC gave some advice around managing referrals and identifying referred patients.
It suggests checking your CPCS IT system and NHSmail for referrals throughout the day, rather than waiting for patients to arrive or call the pharmacy.
Similarly, if the patient has not telephoned or arrived in the pharmacy within two hours (urgent supply) or 12 hours (Minor Illness), the pharmacist should attempt to contact them.
Some pharmacies are now asking patients who ask for advice on the management of a minor illness (as opposed to those just asking to buy a specific OTC medicine) whether they have been referred by NHS 111.
Some pharmacies are also displaying a notice asking patients that have been referred by NHS 111 to mention this to pharmacy staff.
The PSNC says that pharmacists with a clinical concern about a referral should complete the incident report form within the CPCS IT system and adds it is also keen to hear about good practice and case studies where the service has made a real difference to a patient.
Mr Williams says he hopes NHSE is capturing details of patients who are turning down the referral.
“It’s great that people are using the service but we need to know who is saying no and why. It could be that the people who are coming via the CPCS are those who would have come into the pharmacy anyway, so it’s useful to know who we are missing.”
For the ones that he does see via the service, Mr Williams has designed an exit questionnaire which he says has shown some useful feedback.
“On the plus side, patients have told us they value the service because they didn’t think some of the issues they were presenting with at the GP were in the scope of community pharmacy, so they were surprised to be sent to us.
“On the other hand, some are surprised they had to pay for the products after seeing us and others have asked the obvious question of ‘why can’t I come in to speak to you directly and have access to this service?’
“We explain that the service is designed to help reduce pressure in general practice and A&E, which is why we hope it will get even easier for patients to access over time.
“If we are able to gather more of evidence of how this is working – including how it has gone for the patient if they are referred on after the consultation – CPCS will be more of a success and could be a real game changer for community pharmacy.”
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