The community pharmacist consultation service could see the roll-out of more health checks through pharmacies, says Kathy Oxtoby...
Prevention is a key theme in the NHS Long Term Plan and providing greater access to diagnostic testing services through community pharmacy could go a long way to help support this.
“Early detection and treatment of long-term conditions can help patients live longer, healthier lives and, where individuals are identified with high risk conditions, appropriate preventative treatments can be offered sooner,” says Alastair Buxton, director of NHS services at the PSNC.
Helga Mangion, policy manager at the National Pharmacy Association (NPA), says the trusted position community pharmacies occupy at the heart of communities, including many deprived areas, means “they have an important role in preventative healthcare.”
She adds: “With any pharmacy service, including diagnostic tests, the advantage of having them in a local pharmacy is the greater level of support that is available. Patients are with a trained healthcare professional who is easily accessible and who can sit down and discuss their results in a holistic way to try and counteract any problems.”
Since October 2019, community pharmacists have had the opportunity to secure referrals through the community pharmacist consultation service (CPCS). This advanced service, which replaced the NUMSAS and DMIRS pilots, connects patients who have a minor illness or need an urgent supply of a medicine with a community pharmacy.
The CPCS takes referrals to community pharmacy from NHS 111, but there are plans for referrals to be taken from other parts of the NHS in time, PSNC says.
The CPCS aims to relieve pressure on the wider NHS by connecting patients with community pharmacy, “which should be their first port of call and can deliver a swift, convenient and effective service to meet their needs. It also provides the opportunity for community pharmacy to play a bigger role than ever within the urgent care system,” PSNC says.
Development of the CPCS will take place over the five-year period of the revised Community Pharmacy Contractual Framework (CPCF). The piloting of DMIRS and NUMSAS through the Pharmacy Integration Fund (PhIF) has enabled NHSE&I to introduce “a well tried, tested, safe and sustainable service into the CPCF,” PSNC says.
It has also enabled the demonstration of the value that community pharmacy can add. NHSE&I wants to build on this model to ensure that any further services are fully evaluated before their introduction at a national scale.
How will the CPCS evolve?
This year, the CPCS will take referrals from NHS 111 but over the course of the five years of the CPCF agreement, this is expected to expand to include referrals from GP practices, NHS 111 online, urgent treatment centres and possibly A&E, PSNC says.
Each phase will be piloted first using funding from the PhIF, with roll-out subject to successful evaluation.
PSNC says the potential volume of referrals is not certain at this stage, but the GP Forward View suggested that around 20 million appointments in general practice alone do not require a GP.
The pharmacy contractual framework will bring “a range of new services to community pharmacies, many of which will help improve public health and early detection of heath concerns”, says Mr Buxton.
Key activities in this area will include championing public health. All pharmacies are to become healthy living pharmacies (HLPs), making them local hubs for promoting health, wellbeing and self-care, and providing services to prevent ill-health. Pharmacies will be crucial supporters of NHS public health campaigns.
Another element of the contract will be identifying those at risk of disease. Pharmacies will provide hepatitis C testing as well as potentially identifying people with high blood pressure, subject to the findings of a pilot in 2020.
Under the current contract, pharmacies will provide diagnostic point-of-care testing (POCT) and treatment services for common ailments, “subject to the findings of pilots,” Mr Buxton says.
“The focus is yet to be determined, but it could include urinary tract infections and strep throat infections. This will mean that pharmacies can provide appropriate treatment while also supporting efforts to tackle antimicrobial resistance,” he says.
According to the PSNC these services will be introduced in stages. Hepatitis C testing will shortly begin to be offered to people who inject drugs, tying in with the national hepatitis C elimination programme. Then, from April 2020, all pharmacies will need to have attained HLP status.
Alongside these changes, NHS England and NHS Improvement will use the PhIF to pilot a model for detecting undiagnosed cardiovascular disease, and the use of point of care test (POCT) around minor illnesses to support efforts to tackle antimicrobial resistance. If these pilots are successful, they will be considered for full commissioning and national roll-out.
Salim Jetha, CEO of Avicenna, says pharmacists’ capability to participate in diagnostic testing is well recognised, “especially the ease of accessibility and the clinical knowledge on medication”. Common tests available in primary care include warfarin clinics, weight management and healthy living checks, he says.
Heart checks, coeliac disease screening, HbA1c long term diabetes screening, COPD lung function testing, and mole screening are available in some pharmacists. Whether people pay for their screening, or if services are commissioned by individual clinical commissioning croups (CCGs) will depend on the local area.
It’s not all about England…
There is also the prospect of POCT being rolled out in other parts of the UK. As Ms Mangion highlights, a new sore throat test and treat service is now available in many pharmacies in Wales.
Pharmacists assess patients' symptoms, including undertaking a throat examination and a simple swab test for those with symptoms which suggest they have a bacterial infection. “People accessing diagnostic tests in pharmacies value the convenience and the relative informality of the setting and overall this is likely to be a growth area,” she says.
While there are disparities in the diagnostic services being offered by pharmacies across the UK, that more referrals are being encouraged means the profession is in a “better position to carry out those diagnostic testing available to them,” says Lila Thakerar, superintendent pharmacist at Shaftesbury Pharmacy in Harrow.
Lindsey Fairbrother, owner and superintendent pharmacist of Goodlife Pharmacy, in Derbyshire, believes CPCS is a “great idea” and that triage to pharmacy is reducing the workload for GPs. But she points out the limitations of the initiative as pharmacists are “only supposed to advise on OTC items enabling self-treatments so [the service] is not as effective as it could be.”
“It would be more effective if it was ‘hand in glove’ with patient group directions (PGDs) to allow all pharmacists, for instance, to provide antibiotics if appropriate following ENT examinations,” she says.
“It’s highly frustrating for those of us that want to provide treatments to people with minor ailments that need more than just a cough and cold remedy.”
Ms Fairbrother would also like to see funding to allow more pharmacists to do diabetes screening. “We would love to be able to offer that service, but it needs to be funded,” she says.
Pharmacies being funded to detect diabetes at an early stage would “be more cost effective and avoid patients suffering,” she adds.
It’s all about customer service
For pharmacists able to provide diagnostic testing services, word-of-mouth about positive experiences can boost referrals “as they will be known as clinically focussed and competent pharmacies locally,” says Ade Williams, lead pharmacist at Bedminster Pharmacy in Bristol.
“If people have previously had good experiences they will give testimonials to their friends and relatives and feel confident that this is a place they would like to receive care from,” he says.
To increase referrals to diagnostic testing services, pharmacists can signpost access to their consultation rooms. “It’s a good reminder that you are a clinically focused practice,” he says.
Self-diagnostic tests is another area where pharmacy can expand. Traditionally these tests have been limited to pregnancy tests and diabetes management (blood glucose testing) but this sector is evolving.
Ms Thakerar says self-diagnostic tests are becoming more popular because of the drive for patients to take responsibility for their own care rather than relying totally on service providers and the NHS. “The results are available in minutes rather than having to wait for results from a GP, and they are more accurate than they used to be,” she notes.
Fertility testing is proving popular, she says, with self-diagnosis ovulation kits that allow women looking to conceive to monitor their cycle. Bacterial vaginosis (BV) testing kits are also available for women to self diagnose from home.
While self-testing is evolving in the UK, the US has developed further, where kits are available to assess cardiac enzymes, and to test for HIV and hepatitis C. But the self-testing market is set to expand in the UK, and “is a long-term trend pharmacists should be looking at,” says Ms Thakerar.
Basic genetic testing, such as My DNA, is also an evolving market. Mr Jetha says advances on DNA testing could help detect early signs of disease but also poses many questions such as impact on relationships, stress and fear within individuals, and life insurance. “Changes in the law are required to govern ethical use of such data,” he says.
However, while medicine is moving towards genetic testing, for UK community pharmacy it is “very much in the future”, Ms Thakerar believes, “and we are not equipped or trained to do such testing yet.”
Looking to the future, the PSNC would like to see the national commissioning of the NHS Health Check service from pharmacies to address the current patchy local commissioning.
“The service should include greater follow-up support for people who have agreed lifestyle changes following their check, provided by pharmacies,” says Mr Buxton.
As healthcare moves towards self-care and prevention, the NPA’s Ms Mangion says there should be nationally commissioned health checks where community pharmacists can screen for common long-term conditions such as hypertension, diabetes and asthma.
“In our response to the Department of Health and Social Care (DHSC) consultation on Advancing our health: prevention in the 2020s, we also called for an England-wide service involving the provision of oral contraception and advice which includes monitoring blood pressure and weight. This would have a positive impact and help reduce health inequalities,” she says.
With GP services under increasing pressure, community pharmacy’s role in delivering diagnostic point-of-care testing for customers and patients looks set to grow.
As Ms Thakerar says: “What may start as a private service, if proved to be successful and evidence-based, will hopefully be commissioned in the future. Our role has changed so much in the last decade and that shows service providers have a lot of faith in our profession.”
Picture: iStock (FatCamera)