Pharmacy First: ambition thwarted by unrealistic fees

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This was the month in which the prime minister, Andy Burnham, said nice things about community pharmacy – specifically referring to Pharmacy First, which he is apparently going to make bigger and better.

As ever, though, the reality is a bit different from the political spin. The five new pathways are prescribing-only, which means only a fraction of pharmacy contractors will be able to deliver them. The current guesstimate is that about 20% of pharmacies in England have an IP. Some aren’t using the qualification, while many won’t deliver the new service because of a lack of funding.

So let’s look at what is actually on the table.

Future focus

Let’s start with the good stuff. This is the first time prescribing has formed part of the contractual framework in England, which ought to be a cause for celebration because it is the future. The downside is that there is no additional fee although there is a little extra that covers the infrastructure costs of the prescribing system, despite all the additional governance work involved.

Any pharmacist prescriber could tell you that it takes longer to issue a prescription (using the only IT platform the NHS has approved) than it does to work through a PGD. The documentation requirements are higher, and the clinical and professional risk is greater. So it will be owners who end up funding Andy’s announcement, unless they simply exercise their right not to bother.

Consultation cost

Earlier this year, some people were setting unrealistic expectations for IP consultation fees. Estimates ranged from £45-£60, or even higher. The problem is that ministers won’t pay pharmacy above the artificial ceiling of a GP consultation cost of between £43-45 for 9-12 minutes.

This is because the bean counters will say, “it is cheaper to get a GP to do it”, conveniently ignoring all the money spent on staff that has been pumped into general practice through the ARRS. Anyway, I make the real figure more like £75, but we are stuck with the official one for now. Yet even at, say, £30 per IP consultation, that would be a poor reflection of the true cost of providing the expanded Pharmacy First service.

Odd indications

Now let’s look at the new conditions covered in the service: acute otitis externa, seasonal allergic rhinitis, mild to moderate acne, migraine, and mild skin infections including scabies. It is something of a hotch-potch.

The addition of migraine could help many people and reduce the problem of medication overuse headache. Skin infections should be a win-win-win, as they would ensure people get treated earlier. Otitis externa means more otoscopy, which I personally hate because it is time-consuming and often pointless when ears are full of wax.

Hay fever is just weird. Maybe it’s me, but I can’t remember the last time I spoke to the parent of a symptomatic child and thought: “What this four-year-old needs is a nasal steroid.”

Spot check

Which leads me to acne. Pharmacists will need to confirm the diagnosis and consider treatment options, the patient’s mental health and contraception if appropriate, document it all, issue the prescription, educate the patient, agree a review schedule and consider referrals. That’s not reasonable for £17, and I’m not even sure it is safe.

Nor is it obvious how referrals are meant to work. How will GP practices know which pharmacies are providing the services, which pharmacist happens to be in on a particular day, and what their scope of practice is? A far more sensible option would be to use Manage Your Appointments to let pharmacies advertise condition-specific appointment slots.

Cash concerns

Which brings me back to the money. Is an item-of-service fee really a fair way to commission prescribing services, where the costs are front-loaded onto training and higher salaries? Pay for a block of appointments, or a block of time, and filling that capacity becomes the NHS’s problem – it would soon build the systems to push people our way. Instead, we have a bolt-on to a bolt-on, priced accordingly. The ambition is limited, so the payment is too. Whether pharmacy owners sign up this time or not, ultimately we need prescribing to work because it is the future of this profession.

* Alexander Humphries is the pen name of a practising community pharmacist. The views in this article are not necessarily those of Pharmacy Magazine. What contract reforms would you support? Email pm@1530.com