Community Pharmacy England made a proposal to the Department of Health and Social Care and NHS England for a Pharmacy First service back in March 2022 and followed up on our bid with an extensive influencing campaign to build wider support for the proposal from stakeholders and influencers.

The Pharmacy First service, which will commence on 31st January 2024 (subject to the required IT systems being in place), is a crucial first step in recognising and properly funding the enormous amount of healthcare advice that community pharmacies provide to the public every day and in establishing and funding community pharmacy as the first port of call for healthcare advice.

What does the service involve?

The new Advanced service involves pharmacists providing advice and NHS-funded treatment, where clinically appropriate, for seven common conditions:

• sinusitis
• sore throat
• acute otitis media
• infected insect bite
• impetigo
• shingles
• uncomplicated urinary tract infections in women.

Consultations for these seven clinical pathways can be provided to patients presenting to the pharmacy as well as those referred by NHS 111, general practices and others.

The service will also incorporate the existing elements of the Community Pharmacist Consultation Service, i.e. minor illness consultations with a pharmacist and the supply of urgent medicines (and appliances), both following a referral from NHS 111, general practices and other authorised healthcare providers (i.e. patients are not able to present to the pharmacy without a referral).

In the clinical pathway consultations with a pharmacist, people with symptoms suggestive of the seven conditions will be provided with advice and will be supplied, where clinically necessary, with a prescription-only treatment under a Patient Group Direction (PGD) or in one pathway, an over-the-counter medicine (supplied under a clinical protocol), all at NHS expense.

In the future, we hope that independent prescribers will be able to use their skills to complete episodes of care within the service, without the need for a PGD. However, for the time being, all pharmacists providing the service must use the PGDs and clinical protocol.

The service requirements are included in the service specification and the associated clinical pathways.

Download the service specification and clinical pathways

The 23 patient group directions (PGD) and one protocol for the service will be used to authorise supply of medicines at NHS expense. These documents have been published in draft form:

Download the draft PGDs and protocol

These documents are currently going through the final part of the NHS England approval process and once that is completed, the final versions will be published. These final versions will be the documents which pharmacists need to use in the service and which they need to be authorised to work under by the pharmacy owner.

All of these documents will be essential reading for pharmacy owners and pharmacists who will be providing the service.

Distance Selling Pharmacies (DSPs) will be able to provide six of the seven Pharmacy First clinical pathways remotely via video consultations, but may not provide clinical pathways consultations on their premises (due to links with the support for self-care Essential service and restrictions regarding the provision of Essential services on the pharmacy premises).

The acute otitis media clinical pathway requires the use of an otoscope, so that pathway will not be provided by DSPs.

The Drug Tariff determination sets out the detail of the funding for the service (see also the Funding and claiming payment section below):

Drug Tariff determination on the Pharmacy First service

Pharmacy owner checklist: getting going with the Pharmacy First service

This checklist details the actions pharmacy owners can start to undertake to prepare to provide the Pharmacy First service, while waiting for further information and resources to be published. A list of important dates for the Pharmacy First service is also included in the Briefing.

Pharmacist checklist: getting going with the Pharmacy First service

This checklist details the actions pharmacists (including locums) can start to undertake to prepare to provide the Pharmacy First service, while waiting for further information and resources to be published.

Consultation room

Pharmacies must have a consultation room that will be used for the provision of the service which meets the requirements of the terms of service.

There must be IT equipment accessible within the consultation room to allow contemporaneous records of the consultations provided to be made within the NHS-assured Pharmacy First IT system (see below for further information on IT systems).

Equipment

Where ear examinations are performed within the pharmacy, the pharmacist must use an otoscope. Consequently, all pharmacies providing the service (bar DSPs) must have an otoscope.

Guidance on selecting a suitable otoscope can be found in Annex C of the service specification.

Standard Operating Procedure

Pharmacy owners must have a Standard Operating Procedure (SOP) for the service, which all staff participating in provision of the service must be familiar with and follow.

The SOP must include the process for escalation of any clinical and non-clinical issues identified during the provision of the service. To support this, the pharmacy must have available, signposting details for other local services, contact details for local out of hours and urgent care providers and contact details for the local integrated care board.

Various pharmacy support organisations provide template SOPs which their members can personalise for use in their pharmacy.

Competency and training requirements

The pharmacy owner must ensure that pharmacists providing the service are competent to do so, including the use of an otoscope (except for DSPs) and be familiar with the clinical pathways, clinical protocol and PGDs. This may involve completion of training.

The pharmacy owner must keep documentary evidence that pharmacy staff involved in the provision of the service are competent and remain up to date with regards to the specific skills and knowledge that are appropriate to their role, and to the aspects of the service they are delivering.

The Centre for Pharmacy Postgraduate Education (CPPE) has a webpage which details training resources which may help pharmacists preparing to provide the service.

CPPE have also developed, with NHS England, a Pharmacy First self-assessment framework, which pharmacists can use to assess their knowledge in relation to the service and to identify any gaps in their knowledge, which need to be filled.

CPPE Pharmacy First page (including the Pharmacy First self-assessment framework)

The prior learning, knowledge and experience of each pharmacist will vary and consequently each individual will need to reflect on their own learning needs and identify any gaps in their knowledge which they need to fill.

Select an IT system

As with the current Community Pharmacist Consultation Service, an NHS-assured Pharmacy First IT system, which meets the minimum digital requirements of the service (as specified within the Community Pharmacy Clinical Services Standard and including an application programming interface (API) to facilitate transfer of data into the NHSBSA MYS portal) must be used by pharmacy owners.

When choosing an IT supplier, pharmacy owners may want to refer to the NHS CPCS IT Buyers Guide.

These IT systems allow pharmacy staff to make a clinical record for the service and the data in the record will then be used by the IT system to populate a claim for payment within the NHSBSA’s MYS portal.

The transfer of data via the API will happen throughout the month, as data is entered into the IT systems. The service provisions will then be available to view in MYS from the 1st of the following month. For example, service provisions in December will be available to view in MYS on 1st January. Pharmacy owners will then need to log into the MYS portal to check that the data matches the details in their IT system, and they will then need to submit their claim for payment.

The full dataset for the Pharmacy First service can be found in Annex B of the service specification.

The NHS-approved clinical IT system will also send messages containing a summary of the consultation to the patient’s general practice.

The following four IT suppliers are currently working with NHS England to develop their systems to include functionality to support the service, but over time, we expect other suppliers will add the service to their systems:

Read more about the IT requirements for all CPCF clinical services

Sign up to provide the service

Pharmacy owners must notify NHS England that they intend to provide the service by completion of an electronic registration through the NHS Business Services Authority’s (NHSBSA) Manage Your Service (MYS) portal.

Registrations opened on MYS on 1st December 2023; further information is included in the Funding and claiming payment section below.

Pharmacy owners providing CPCS and wanting to provide Pharmacy First must sign-up via MYS; there will be no rollover of the registrations for CPCS to the Pharmacy First service.

Withdrawal from CPCS or the Pharmacy First service

If your pharmacy is providing CPCS and you do not wish to provide the Pharmacy First service from 31st January 2024, you can notify NHS England you will not provide the service via MYS. Your declaration regarding the Pharmacy First service will act as your 30 day notice to cease provision of CPCS.

If your notice occurs fewer than 30 days before 31st January 2024, the notice period will be reduced to the number of days remaining before this date, and the final date of CPCS provision will be 30th January 2024.

In due course, if having registered to provide the Pharmacy First service, a pharmacy owner wishes to stop providing the service, they must notify NHS England that they are no longer going to provide the service via the MYS platform, giving at least 30 days’ notice prior to the cessation of the service. The pharmacy owner may be asked for their reason for withdrawal from the service.

Funding for the clinical pathways consultations within the new service will come from the new investment, which is outside of the Community Pharmacy Contractual Framework (CPCF) funding (‘the global sum’).

Initial fixed payment

Funding, caps and activity thresholds for the service have been the subject of much negotiation and we are pleased to have secured an initial fixed payment of £2,000 per pharmacy to be made available ahead of the launch.

The initial fixed payment will be reclaimed if pharmacy owners do not provide five clinical pathways consultations by the end of March 2024 (minor illness and urgent medicines supply consultations do not count towards this minimum consultation requirement).

Pharmacy owners can sign up to provide the service from its commencement date and claim the initial fixed payment by making a declaration on the NHSBSA’s Manage Your Service (MYS) portal by 23:59 on 31st January 2024. Declarations could be made from 1st December 2023.

Pharmacy owners who make the declaration on MYS before 23:59 on 31st December 2023 will receive the £2000 payment on 1st February 2024, with those that subsequently make a declaration before 23:59 on 31st January 2024 receiving the payment on 1st March 2024.

Consultation fees and monthly fixed payment

Pharmacies will be paid £15 per completed consultation.

From February 2024, in addition to the £15 consultation fee, a monthly fixed payment of £1,000 will be paid to pharmacy owners who meet a minimum activity threshold of clinical pathways consultations (the threshold will increase over time as set out below).

Q. How will the national Pharmacy First service work?

The new national Pharmacy First service aims to support communities in staying well and local healthcare systems to meet the needs of their populations. The service will launch on 31st January 2024 (subject to the required IT systems being in place). The service involves providing consultations to give advice and NHS-funded treatment (via Patient Group Directions), where appropriate, for seven common conditions (clinical pathways consultations).

The consultations can be provided to patients who self-refer to the pharmacy (e.g. walk-ins) as well as those referred by NHS 111, GPs and others. The service will also incorporate the current Community Pharmacist Consultation Service (CPCS), meaning there will be three elements to the Pharmacy First service:

• Pharmacy First (clinical pathways consultations) – 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 clinical pathways cover sinusitis, sore throat, acute otitis media, infected insect bite, impetigo, shingles and uncomplicated urinary tract infections in women

Q. How have concerns around antimicrobial stewardship been addressed in the design of the service?

NHS England has led work to ensure that the clinical pathways for the Pharmacy First service and the associated Patient Group Directions (PGDs) will allow community pharmacists to supply antimicrobials, only where clinically appropriate, without increasing the risks of antimicrobial resistance (AMR). A large number of experts have fed into this detailed programme of work, supported by clinical pharmacists from Specialist Pharmacy Service. The participating experts have included AMR Consultant Pharmacists, Infection Control Specialists (medical), the UKHSA’s ESPAUR team, senior GPs, academics, Primary Care Network clinical pharmacists, NHS England’s Medical Director and Chief Pharmaceutical Officer. The UK’s Chief Medical Officer has also been involved in decisions made on the approval of the clinical pathways and PGDs, alongside Government and NHS advisory committees on antimicrobial stewardship.

The clinical pathways for the service, set out requirements which the patient must meet (e.g. signs, symptoms and key diagnostic criteria, duration of illness, prior history of the same condition) to determine whether they may be suitable to receive a supply of an antimicrobial. The clinical pathways have been designed drawing upon the guidance provided to all primary care healthcare professionals in NICE’s Clinical Knowledge Summaries.

If those requirements are met, the requirements of the PGD will then be considered by the pharmacist, to assess whether it would be safe and appropriate to make a supply of the antimicrobial, or whether another option may be appropriate, such as delaying any treatment with an antimicrobial or referring the patient to their general practice, where clinically appropriate.

Pharmacists are highly trained healthcare professionals who understand medicines and their potential risks, and the experience of the Scottish and Welsh Pharmacy First schemes, not to mention many local services in England, suggests that pharmacists are more cautious about supplying antibiotics than other healthcare professionals. Pharmacists understand the issues and have already been contributing to anti-microbial resistance efforts for several years through their Pharmacy Quality Scheme.

Q. What digital systems will be in place to support the Pharmacy First service?
To support the launch, pharmacy owners will have access to clinical services IT systems in which to make their clinical records for the service. These systems will also automatically send data on service provisions to the NHSBSA’s MYS portal, via an application programming interface (API), which will populate the end of month payment claim. The systems will also allow more parts of the GP record to be seen, via GP Connect: Access Record and they will send automatic updates to the GP record on the consultation and any medicines provided. This is a significant step forward towards the integration of pharmacy and GP care records that will support the future development of community pharmacy services. We have been pressing for this interoperability for many years, so this investment in it is very welcome.

Work is also being undertaken with NHS Pathways to develop their clinical triage system to send electronic referrals from NHS 111 and Urgent and Emergency Care settings to community pharmacy that may otherwise go to a GP practice for the seven common conditions. Further work is ongoing with existing IT suppliers to streamline referrals from GPs to community pharmacies, moving those away from reliance on NHSmail.

Q. Can distance selling pharmacies offer the Pharmacy First service?

Where it is safe to do so, Pharmacy First clinical pathways consultations with patients can be provided remotely via good quality video consultation by all pharmacies. However, distance selling pharmacies (DSP) will not be able to provide these consultations on their pharmacy premises due to the link with the Support for the Self Care Essential service. They will also be limited to providing six of the seven clinical pathways – the acute otitis media pathway is excluded as it requires otoscope examination of ear.

Q. Why must pharmacies, including DSPs, carry out remote consultations by video consultation, rather than by phone?
This is because the conditions covered by the clinical pathways will often require the pharmacist to examine the patient (e.g. a rash) or examine a sample of urine, in the case of the UTI pathway. The service specification requires a live video link of sufficient quality to be used to carry out an examination, as part of the consultation.

The requirement to use video consultation only applies to clinical pathway consultations; pharmacies can continue to use the telephone for remote consultations for the urgent supply of medicines and minor illness consultations.

Q. Why are DSPs not able to provide clinical pathways consultations from their premises?
This is because the clinical pathways consultations have links to the Support for Self-care Essential service, which under their terms of service, DSPs are not allowed to provide from, or in the vicinity, of their premises.

Q. What will happen to any locally commissioned Pharmacy First services?

Where locally commissioned services include one or more of the seven clinical pathways, we expect those elements of the local services will be decommissioned by the commissioner. We are working with the affected LPCs to help them to identify other options which could potentially be discussed with the local commissioner.

Q. How will pharmacies be paid for providing the Pharmacy First service?
Pharmacy owners providing this service will be able to claim the following:

• Initial fixed payment: £2,000 can be claimed from 1st December 2023 up to the launch of the service. Note, the pharmacy must provide 5 clinical pathway consultations by 31st March 2024 otherwise the payment will be recovered.
• Service fee: £15 per consultation. Note, as CPCS becomes part of Pharmacy First, the current £14 fee will become £15 to align with the new service.
• Medicine reimbursement (where applicable): Where a medicine is supplied as part of this service, reimbursement will be paid, with details to be set out in the Drug Tariff.
• Monthly fixed payment: £1,000 monthly can be claimed from February 2024 onwards, subject to meeting the clinical pathways consultation thresholds (see the table earlier on this webpage).

Q. Will the activity around the Pharmacy First service be monitored?

Although extensive modelling and analysis has been conducted, the level of service delivery that can be expected upon the launch of the service is highly uncertain, and a very lenient service volume cap of 3,000 consultations per month per pharmacy has been agreed as a temporary measure. This level was agreed in order not to hinder the uptake of the service in its early months, and should not be seen as a ‘target’.

We have agreed to work at pace with DHSC and NHSE to establish a formula for managing activity volume caps going forwards. Once this is agreed and initial service volume data is available, the new approach will replace the initial temporary cap of 3,000 per pharmacy per month.

Q. Do pharmacies need to provide all three services (i.e. Pharmacy First, Pharmacy Contraception and Hypertension Case-Finding) to receive the monthly payments?

DHSC and NHSE want to encourage pharmacy owners to provide all three services, but we pushed back on a proposal for compulsory provision of the Pharmacy Contraception and Hypertension Case-Finding Services for those wanting to provide the new Pharmacy First service. Instead, provision of all three services in a bundle is due to become a requirement to receive the monthly £1,000 Pharmacy First payment by 31st March 2025. Delaying the pace of this change will give pharmacy owners more time to prepare for and introduce the three services.

Guidance for pharmacy owners

Pharmacy owner checklist: getting going with the Pharmacy First service

This checklist details the actions pharmacy owners can start to undertake to prepare to provide the Pharmacy First service, while waiting for further information and resources to be published. A list of important dates for the Pharmacy First service is also included in the Briefing.

The following briefings provide summary information about what the overall agreement on the Delivery plan for recovering access to primary care negotiations means in practice.

Guidance for pharmacists

Pharmacist checklist: getting going with the Pharmacy First service

This checklist details the actions pharmacists (including locums) can start to undertake to prepare to provide the Pharmacy First service, while waiting for further information and resources to be published.

Information for pharmacy teams

Briefing 040/23: Initial briefing for pharmacy teams – the Pharmacy First service

This Briefing provides initial information for pharmacy teams on the Pharmacy First service.

Information for Local Medical Committees and general practices

Briefing 041/23: Briefing for Local Medical Committees and general practices on the Pharmacy First service

Pharmacy First Clinical pathways – medicines included in the PGDs and medicines protocol