Facilitating self-care through community pharmacy in England

Abstract

In England, almost all the population are within a short walk of a community pharmacy. This network of pharmacies provides a range of services, most of which are commissioned and remunerated through a nationally agreed contract with the National Health Service (NHS). Over time this contract has seen funding move from the traditional core service of dispensing medicines, toward patient-facing clinical services. All of these services have elements of self-care built in to the service specification, which pharmacists are mandated to deliver. These services significantly expand the role of the community pharmacist beyond facilitating self-care by supplying “over the counter” (OTC) medication. The increased public health role, where promotion of healthy living and prevention of disease is now seen as an essential activity by and for pharmacists. Changes to UK health policy, where the focus has been on delivering care closer to the patients' home, means community pharmacists have an increasing role in the effective management of acute and long-term conditions. The most recent contract afforded to pharmacy has now started to integrate pharmacy services with medical services, in both primary and secondary care, in attempt to provide greater continuity for the patient. It is very likely that self-care activities provided by community pharmacy will expand further, especially around the management of long-term conditions as the pharmacy workforce transitions in to having prescribing rights for medicines other than non-prescription medicines.

1. The English healthcare system

Healthcare to the population of the United Kingdom (UK) (England, Wales, Scotland and Northern Ireland) is ‘free’ at the point of delivery. However, all UK citizens contribute to the funding of the National Health Service (NHS) through direct taxation, providing they earn over a threshold yearly income. The level of funding afforded to the NHS is set by central government through a spending review process and in 2021 health expenditure as a percentage of Gross Domestic Product (GDP) was 11.9%, and is comparable to many other Western countries.¹ Despite this, many commentators have stated that funding is still inadequate due to ever increasing demand placed on its services.² The NHS, which celebrates its 75th anniversary in 2023, has undergone radical change over this time. Most notably, devolution of power (and therefore services offered) to UK principalities of Wales, Scotland and Northern Ireland and the introduction of an element of private healthcare provision. The structure of the NHS in England is complex and made up of a wide range of different organisations with different roles, responsibilities and specialities. The Kings Fund provides useful animated and audio guides to the NHS structures.³ However, from an end user's perspective, little has changed in the way the NHS is accessed. The general practitioner (GP) is the ‘gate keeper’ to most NHS services. Patients will be triaged by their local doctor (GP) in primary care and where appropriate referred to secondary and tertiary centres for further investigations and procedures. Access to primary care medical services is currently under huge pressure, and recent additional funding has been announced to help ease the situation.⁴ Reasons behind this pressure are multifactorial but include greater demand, especially from an increasingly elderly population, a move to provide certain secondary services in primary care and a shortage of doctors. Implementation focuses on four strategic imperatives, one of which is to empower patients to make greater use of NHS services (e.g. NHS App, self-referral pathways) and community pharmacies to support self-care practice.

By definition, self-care is a broad concept, with The World Health Organisation (WHO) defining self-care as ‘the ability of individuals, families and communities to promote health, prevent disease, and maintain health and to cope with illness and disability with or without the support of a health-care provider’..⁵

This most recent acknowledgement of the contribution pharmacy can make reaffirms government thinking toward community pharmacy being well placed to facilitate consumer self-care and self-medication. However, this was not always the case as the formation of the NHS in 1948 saw significant increases in the number of prescriptions requiring dispensing, and for the next five decades was the principal activity of community pharmacies.

2. UK Health Policy and its effect on pharmacy's in all settings contribution to self-care

The catalyst for change in pharmacy services was heralded by the publication of the Nuffield Report in 1986, which recommended ‘extended’ pharmacy roles in response to concerns over an excessively educated workforce to principally dispense prescriptions.⁶ These recommendations were furthered with the publication of the Pharmaceutical Care Report in 1992.⁷ It advocated a new model of community pharmacy practice, with the pharmacy acting as a health hub offering a wide range of non-dispensing related services that promoted health and wellbeing. Subsequent UK policy documents have reflected a need to shift from dispensing to non-dispensing services, in particular advocating their role in health promotion, health prevention and self-care.8, 9, 10, 11, 12, 13, 14. In 2005, a new community pharmacy contract was introduced, and was the start of translating policy in to practice by introducing new services and shifting remuneration away from dispensing.

3. Evolution of the community pharmacy contrac

From 2005 to 2019 a number of new versions of the contract were implemented, each successively introducing more non-dispensing roles, for example, ‘minor ailment schemes,’ ‘medicines use review’ and ‘healthy living pharmacies’. All have required pharmacists to demonstrate a level of competency and achieve some form of accreditation before these services can be offered. These credentialing activities seems, in part, a recognition that pharmacists lacked the pre-requisite knowledge or skills needed to perform such roles. This may be a reflection on the education and training received either at undergraduate or postgraduate level as the UK regulator for pharmacy did not mandate specific educational requirements. The UK regulator has recently updated educational standards, which now require Schools of Pharmacy to meet certain outcomes related to self-care (Table 1), although the word self-care is not explicitly used. Whilst these outcomes are welcomed, they do not standardise delivery with regard to curricula or minimum time spent on these topics. Lessons could be learned from other countries that have managed to adopt a more universally accepted approach to self-care interactions,¹⁵ especially as contractual pharmacy services continue to develop.

Table 1.

Examples of General Pharmaceutical Council (GPhC) learning outcomes for the initial education and training of pharmacists that facilitate self-care.

GPhC Learning Outcome		Seven pillars of self-care
5.	Proactively support people to make safe and effective use of their medicines and devices	•Knowledge and health literacy •Mental wellbeing, self-awareness and agency •Physical activity •Healthy eating •Risk avoidance •Good hygiene •Rational and responsible use of health products and services
10.	Demonstrate effective consultation skills, and in partnership with the person, decide the most appropriate course of action
11.	Take into consideration factors that affect people's behaviours in relation to health and wellbeing
13.	Recognise the psychological, physiological and physical impact of prescribing decisions on people
28.	Demonstrate effective diagnostic skills, including physical examination, to decide the most appropriate course of action for the person
30.	Appraise the evidence base and apply clinical reasoning and professional judgement to make safe and logical decisions which minimise risk and optimise outcomes for the person
33.	Effectively promote healthy lifestyles using evidence-based techniques

4. English community pharmacy in 2023

As of 2021–22 there were 11, 522 community pharmacies in England¹⁶ meaning that almost 90% of the population are within a 20-min walk of a pharmacy.¹⁷ Every day there an estimated 1.2 million visits for health-related reasons. Community pharmacy revenues are heavily dependent on the services they provide to the NHS and account for approximately 90% of a pharmacy's turnover. The remaining turnover is made up primarily from retail sales, including the supply of non-prescription medicines to treat minor illness. There is also a small, but growing market, for pharmacies to provide private services for healthcare related activity such as travel vaccination clinics. Ownership of a pharmacy in England is not dependent on having to be a pharmacist, and 62% of pharmacies are classed as ‘multiples’ – owning six or more pharmacies, with major ownership by companies such as Boots, who own approximately 1700 pharmacies.¹⁸ Although ownership is not pharmacist dependent the day-to-day running of every pharmacy has to be overseen by a pharmacist at all times.

In July 2019, the Government agreed a five-year Community Pharmacy Contractual Framework (CPCF) to help fulfil the ambitions of the NHS Long-term plan.¹⁹ At the time, the then Secretary of State, Matt Hancock stated the settlement will ‘Expand and transform the role of community pharmacies and embed them as the first port of call for minor illness and health advice in England.’

Fig. 1 is an infographic produced by Community Pharmacy England highlighting the contracted services that will be provided by 2024.

Fig. 1.

Community Pharmacy: 2019/20 to 2023/24.

5. Current contractual service provision

The current contract, reflecting years 4 and 5 of the CPCF agreement adopts a three-tier model of service provision:

• •essential services: nationally set mandatory services that must be provided (Table 2)
• •advanced services: nationally set optional services that pharmacies can choose to deliver provided they meet certain minimum requirements (Table 3)
• •locally commissioned services: can be contracted via a number of different routes and by different commissioners. Key to local services is to meet a local need. There are many examples of local services – alcohol screening and brief interventions, minor ailments, sexual health and weight management.

Table 2.

Essential pharmacy services as specified in the CPCF.

Essential Services	Description
Discharge medicines service	A digital referral from hospital to the community pharmacy is sent allowing the community pharmacy to compare the patient's medicines at discharge to those they were taking before admission to hospital. This allows the pharmacist to ensure that the patient/carer understand which medicines the patient should now be taking, facilitating shared decision making and reducing harm from medicines at transfer of care. National training prior to offering the service is recommended but not mandatory.
Dispensing medicines and appliances	The supply of medicines and appliances ordered on NHS prescriptions, together with information and advice, to enable safe and effective use by patients and carers, and maintenance of appropriate records.
Disposal of unwanted medicines	Pharmacies are obliged to accept back unwanted medicines from patients and safely sort and dispose of them.
Healthy Living Pharmacy	The Healthy Living Pharmacy concept is primarily about adopting a change in culture and ethos within the whole pharmacy team to improve people's health and help reduce health inequalities by providing a mechanism for community pharmacy teams to utilise their local insight and experience in the delivery of high-quality health promoting initiatives. Service specifications mean the pharmacy has to meet certain premise requirements and staff training is in place to qualify as ‘health champions’ who pro-actively engage in local community outreach within and outside the pharmacy. The whole ethos is to facilitate self-care.
Public Health – promotion of healthy lifestyles	Pharmacies are required to participate in up to six health campaigns to promote public health messages to general pharmacy visitors during specific targeted campaign periods. It is also expected that pharmacists provide opportunistic healthy lifestyle advice and public health advice to patients receiving prescriptions who appear to have diabetes, cardiovascular disease, who smoke or are overweight.
Repeat dispensing/ electronic repeat dispensing	Patients can obtain repeat supplies of prescriptions for their regular medicines directly through the pharmacy rather than having to obtain the prescription from their doctor each time a supply is required
Self-care	To help manage minor ailments and long-term conditions, by the provision of advice and where appropriate the sale of medicines.
Signposting	Pharmacies are expected to direct people who require help that cannot be provided by the pharmacy to the most appropriate source for advice, support or treatment. To facilitate this, local NHS organisations have to provide details of health and social care providers to whom patients can be referred.

Table 3.

Advanced pharmacy services as specified in the CPCF.

Advanced service	Description
Appliance use reviews and stoma appliance customisation	These services aim to ensure proper use and wear of such products and includes safe storage and disposal.
Community Pharmacist Consultation Service (CPCS)	The service allows patients to be directed to a community pharmacy to access an urgent supply of a medicine or get advice/treatment for minor illness. Referrals can be made by doctors from general practice or via a national NHS helpline (NHS 111) and through urgent and emergency care units. (https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-use-111/)
Flu vaccination service	Offered to eligible patients (set by the NHS) between September and March each year.
Hypertension case finding service (since 2021)	Targeted at people over the age of 40, people are offered a blood pressure check. If readings are high then the pharmacist can refer to the patient's doctor or provide ambulatory blood pressure monitoring.
New medicine service (NMS)	This service provides support to people who are newly prescribed a medicine to manage a range of long-term conditions. After initial supply and advice, a follow-up consultation is provided usually within 14 days to identify any problems (e.g. adherence).
Pharmacy contraception service (since April 2023)	Initially the service will involve community pharmacists providing ongoing management of routine oral contraception that was initiated in general practice or a sexual health clinic. If deemed successful the service will expand to allow community pharmacists to initiate oral contraception.
Smoking cessation service (since 2022)	Opportunistic and locally commissioned smoking cessation services have been offered for many years. However, in 2022 a new commissioned service was introduced. As part of the NHS long term plan, all people admitted to hospital who smoke will be offered NHS-funded tobacco treatment services. On discharge, to ensure continuity of care and on-going smoking cessation support hospitals will make referrals to pharmacies. To facilitate onward care pharmacies will follow the National Centre for Smoking Cessation and Training treatment programme. (https://www.ncsct.co.uk/publication_ncsct-standard-treatment-programme.php)

It is clear that many of these services fall under the umbrella of the WHO definition and align to one or more of the seven pillars of self-care (Table 4).²⁰

Table 4.

Contractual pharmacy services mapped to seven pillars of self-care.

The seven Pillars	Tier of CPCF
Knowledge and health literacy	Essential •Dispensing medicines •Discharge medicines service •Public health •The healthy living pharmacy •Self-care •Disposal of unwanted medicines Advanced •NMS •CPCS
Mental wellbeing, self-awareness and agency	Essential •The healthy living pharmacy
Physical activity	Essential •The healthy living pharmacy •Public health •Signposting Advanced •Hypertension case-finding service
Healthy Eating	Essential •Public health •The healthy living pharmacy •Self-care Advanced •Hypertension case-finding service
Risk avoidance	Essential •Public health •The healthy living pharmacy •Self-care Advanced •Flu vaccination •Smoking cessation •Hypertension case-finding service •Pharmacy contraception service
Good hygiene	Essential •Public health
Rational and responsible use of health products and services	Essential •Dispensing medicines •Discharge medicines service •Public health •The healthy living pharmacy •Self-care Advanced •Flu vaccination •Smoking cessation

Within the essential services, there is specific service specification on self-care, where the pharmacy is expected to enable people to derive maximum benefit from caring for themselves or their families by providing access, choice and advice to help them self-manage a self-limiting or long-term condition, which includes promotion of healthy lifestyles, and provision of information to facilitate them making appropriate choices. The pharmacy is also obligated to signpost patients to other health and social care providers, when appropriate and receive self-care referrals from other NHS services and health care professionals.

6. Future Self-care opportunities for pharmacy

The CPCF has successfully embedded new non-dispensing services into the paid activities of community pharmacy and started to realise the ‘health hub’ first described in the 1992 Pharmaceutical Report.⁷ The newer services have started to integrate pharmacy activity with primary and secondary care allowing for greater continuity of care for patients, through better sharing of information across sectors. The 5-year contractual framework runs out in 2024 and it is currently uncertain what any new agreement will look like. However, in May 2023 the government announced a £645 million investment in community pharmacy over the next two years.⁴ This investment was part of a wider package of measures to improve access to primary care and empower patients to exercise greater levels of self-care.

For community pharmacy this additional funding is to support the blood pressure checking and contraceptive services (outlined in Table 3) but also to provide a ‘pharmacy common conditions service’, Pharmacy First, by early 2024. Historically, locally commissioned ‘minor illness schemes’ have been in place but a nationally commissioned and funded service has long been called for to bring England in line with Wales and Scotland.^21,22

The Pharmacy First service is intended to enable pharmacy to manage more conditions without onward referral to a doctor as a number of Prescription Only Medicines will be accessible to treat conditions such as impetigo, uncomplicated urinary tract infections and shingles, as well as providing OTC medicines free of charge to eligible patients. It is hoped that this service could free up to 30 million GP appointments each year.²³

In addition to enhanced funding and services a major change in pharmacy, as a profession, will be that from 2026 all newly qualified pharmacists will also qualify as independent prescribers. Whilst bodies such as NHS England²⁴ are working on this transition to the workforce being prescribers, and pilot ‘pathfinder sites’ are exploring logistics of how a pharmacist prescribing workforce might integrate in to the NHS, the implications for community pharmacy practice has yet to be clearly articulated. Obviously, this provides opportunity for pharmacists to extend their scope of practice, whether specialising in prescribing in a single therapeutic area or to be more generalist.

7. Realising the future

It is well recognised that access to the right healthcare professional at the right time is difficult. Community pharmacy is seen as part of the solution to improve patient access to primary care services. The governments ambition is to utilise pharmacy more and allow them to take on extended and new roles. However, similar to the medical workforce in primary care, community pharmacy is facing workforce and financial pressures. Whilst prescribing rights for all pharmacists are to be welcomed there will be a legacy workforce who may not hold a prescribing qualification unless they undertake postgraduate training. This may result in the profession only being partially able to deliver new services.

The number of community pharmacies in England are falling. There has been a reduction of 4% since a peak in 2015–16 (n = 11, 949), and this downward trend is continuing in 2022–23 with recent closures announced. Most notably, the closure of 237 Lloyds Pharmacy branches from June 2023.²⁵ This decline is largely attributed to government funding of pharmacy not keeping pace with inflation, resulting in ‘real term financial loss’ making many pharmacies vulnerable or unviable.²⁶ A recent (April 2023) survey found contractors reported rising costs and shortage of pharmacy staff leading to increased workload and a consequent negative impact on staff wellbeing.²⁷ This raises questions over whether the current, and future expansion, in contractual services can be delivered.

8. Conclusion

Empowering patients to exercise greater levels of self-care is central to health policy in England. Community pharmacy has always played a part in facilitating self-care, predominantly through sales of non-prescription medicines. However, changes to the community pharmacy contract have seen government recognition of the role it can play and new funded services allow closer working and integration with healthcare pathways across primary and secondary care. This only looks set to expand over the coming years, although the financial viability of pharmacies may slow such service expansion.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Paul Rutter: Conceptualization, Data curation, Writing – original draft, Writing – review & editing. Nicola Barnes: Writing – review & editing.

Declaration of Competing Interest

None.