Community Pharmacy: Under-utilised potential within primary care and the NHS - David Wright, Ruth Buchan & Reena Barai

Background

With 11,500 community pharmacies in the UK located at the heart of communities, it is estimated that over 80% of the UK population visit one every year and three quarters of these are for health related reasons.(1) All community pharmacies have at least one registered pharmacist available at any one time and in many there will be pharmacy technicians to manage the medicines supply function. Furthermore, just about all pharmacies additionally employ trained medicines counter assistants. Pharmacists undertake five years of education to master’s degree level, whilst pharmacy technicians undertake two years of regulated workplace training. Consequently, community pharmacies could be better viewed as primary care based healthcare centres with expertise in the use and management of medicines.

With the combination of a highly trained workforce and many opportunities for provision of patient screening, support and intervention, it is therefore perhaps surprising that community pharmacies are routinely described as an underutilised resource.(2) Over the last 20 years, simplification of the medication supply process due to advances in IT, automation and transfer of medicines compounding to pharmaceutical companies, has enabled the transformation of the role of the community pharmacist from pure medicines supply role to a more patient facing focus.

Evidence-based services provided within community pharmacies now routinely include smoking cessation support, supervision of methadone for the management of addiction, provision of vaccinations and support for patients who are receiving newly prescribed medicines.(3) In response to increasing demands on GP practices, community pharmacies are also now receiving referrals for minor ailments and emergency medicines supply from NHS111 services as part of their routine practice.

COVID-19 Experience

Whilst high streets closed during COVID-19, community pharmacies stayed open, frequently long into the evening and during weekends. Therefore, providing access to expert advice and essentially providing a triage service for patients, with GP practices often directing patients to community pharmacies to better manage their workload.

Initially community pharmacies witnessed a surge in demand as patients attempted to stock up on paracetamol and other treatments for use during a case of COVID-19 and then worried about maintaining the supplies of their long-term medications. The resultant demand for extended prescription durations resulted in community pharmacies and medical practices collaborating to manage patient expectations and therefore maintain medication supplies for all. In parallel to all of this, community pharmacists were undertaking the role of patient advocate to resolve medicine supply problems, fielding questions regarding potential COVID-19 symptoms, and resolving other problems which may have traditionally resulted in a GP or A&E visit. With significant reductions in government funding to pharmacies a number of years ago, many of these vital public health activities are now underfunded.

What community pharmacy has therefore shown, during this hopefully brief period in our history, is that it can assume a greater patient related workload which would enable other members of the primary healthcare team to engage in activities which will also better optimise their contribution to the NHS agenda. Whilst the workload during COVID-19 in community pharmacy was unsustainable and reflected a short term response to a national emergency, it does demonstrate that these relatively small healthcare teams located within primary care have significantly more to offer.

Evidence for community pharmacy services
The evidence for the value provided by community pharmacy continues to build and increasingly this needs to be presented to commissioners to enable them to make informed decisions regarding how best to spend their budgets in order to meet current targets and priorities.

The presentation of patients for cough medicines in community pharmacies provides an opportunity for community pharmacists to identify Chronic Obstructive Pulmonary Disease (COPD) and prevent progression to the point at which the cost to the NHS becomes prohibitive.(3) Similarly, ongoing community pharmacist support for patients with progressive COPD can represent good value for money for the NHS through improving quality of life and optimising resource utilisation.(3) Community pharmacists can also offer annual asthma reviews to patients who do not routinely access them from their GP and therefore represent one approach to addressing inequality of service access.(4) Some community pharmacies also now offer dermatological screening to enable early identification of skin cancer.(5) The advent of affordable pharmacogenomic testing whereby genetic material i.e. an inner cheek swab, is used to predict patient response to medicines thereby improving medicine and dose selection is another service which is already provided in other countries through community pharmacies and could be delivered through community pharmacy in the UK in the near future.(6)

Summary

COVID-19 resulted in the network of community pharmacies demonstrating their potential value and role within primary care. Today however it could still be argued that they remain somewhat on the periphery of primary healthcare. The COVID-19 experience, a burgeoning evidence base for a community pharmacy services which improve patient care, enhance skill mix and represent good value for NHS money, combined with further advances in information technology and personalised medicine, should provide the stimulus to integrate community pharmacies further into the primary care healthcare team and more naturally into current clinical pathways.

References

1. Department of Health. Pharmacy in England: Building on strengths, delivering the future. 2008.
2. Murray R. Community Pharmacy Clincal Services Review https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/12/community-pharm-clncl-serv-rev.pdf2016 [Available from: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/12/community-pharm-clncl-serv-rev.pdf.
3. Wright D. A rapid review of clinical services commissioned from community pharmacies https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/12/rapid-evdnc-rev-dec-16.pdf2016 [Available from: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/12/rapid-evdnc-rev-dec-16.pdf.
4. Craske M, Wright D, Blacklock J, Matthews H, Dean T, Farrow T, et al. Testing annual asthma reviews for those who fail to attend: proof-of-concept study. CLinical Pharmacist. 2018;10(8):Online.
5. Kjome RLS, Wright DJ, Bjaaen AB, Garstad KW, Valeur M. Dermatological cancer screening: Evaluation of a new community pharmacy service. Research in social & administrative pharmacy : RSAP. 2017;13(6):1214-7.
6. Wright D, Bhatt D. Targeted medicines: how pharmacists can lead a pharmacogenomics revolution. Clinical Pharmacist. 2018;10(6):162-4.

Content provided by David Wright, PhD, FRPharmS, Professor of Pharmacy Practice, School of Pharmacy, University of East Anglia

Ruth Buchan, BPharm, PG Dip, FFRPS, Chief Executive Officer, Community Pharmacy West Yorkshire

Reena Barai, FRPharmS IPresc Dip Clin Pharm, Community Pharmacist, Sutton, Surrey