2. Process/Practical
We heard that the initial setting up of the service can sometimes increase the workload within general practice. If staff do not see the immediate impacts and benefits, then they may be reluctant to refer or triage to the service. This impacts on referral numbers and how much time and effort is invested in establishing the service locally.
Low numbers of referrals also have an impact on community pharmacists as they may not check the electronic system for the service as regularly.
As a result, unless the patient informs the pharmacist that they have been referred through the CPCS, they may not always be logged as a referral.
It was noted that not all GPs and practice management staff have the information or understanding of the service and what can or can’t be referred to a community pharmacist. Some participants said there was a general lack of awareness of the referral pathway, evaluation findings from the pilots, how the service is quality assured, and feedback to general practice.
These issues were raised as key factors causing a lack of buy-in at PCN or general practice level, which contributes to a reluctance to implement the CPCS. There is a clear need for better national and local engagement and communication regarding the service, and the process around referral and management of patients.
There was a general view that the referral process and IT systems currently used are not designed to make the process of referring to CPCS easy. General practice teams would like to see how this service could fit into their current triage systems and pathways to ensure their teams didn’t have to learn additional/different IT systems or processes.
General practice teams are more likely to engage and implement if the referral mechanism was more streamlined and easier to operate daily. The need for improvements to the technology involved is explored further below.
While not all CPCS consultations result in the supply of a medicine, there was frustration amongst GPs, pharmacists and patients’ representatives that the pharmacist was sometimes unable to ‘close’ an episode of care because they could not supply a medicine/product that a patient may need, due to the fact either:
- Patient is unable to afford a product
- Patient is exempt from prescription charges/entitled to free prescriptions
- There was a need to supply a licensed Prescription Only Medicine (POM) along with advice.
The community pharmacist would need to refer the patient back to general practice for an appointment with a prescriber for a prescription to be supplied.
This was seen to produce extra workload on general practice, taking up additional appointment slots, delaying care for the patients, and potentially widening health inequalities, despite community pharmacists being more than capable of completing the episode of care and supplying a medicine.
It was felt that while the CPCS has the offering to be extremely helpful, a more advanced service, which included the supply or prescribing of POMs by community pharmacist for minor ailments, would help general practice and patients even further.
Several workshop members pointed out the ‘NHS Pharmacy First Plus’ service in Scotland as a good example of how the CPCS should evolve in England. 8
During the workshop, there was a clear call for additional and extra national resources to support local project management and implementation beyond what has already been provided by NHS England and Improvement. This additional local support is needed to help to drive, engage, develop relationships, and provide practical solutions to support service implementation and uptake.
The practical implementation of the CPCS will happen at a neighbourhood and place level rather than at system level, as it will be individual practices making the referrals. Some conversations around the CPCS service implementation are happening at ICS level, requiring additional permissions/”sign off” and are not involving those who will be implementing the service in practice.
There is a need to ensure ICS leads are behind nationally commissioned services and do not further delay implementation plans across PCNs.
Clearer messaging and alignment of public facing messages are needed to avoid confusion as to where members of the public should go if they have a minor ailment.
Current national messages around ‘Pharmacy First’, for example, encourage people to go directly to their pharmacy for a minor ailment whereas with the CPCS service you need to be referred from your GP or NHS 111.
Discussion on doing things differently
Having an effective process in place in terms of electronic referral and making it easy for referrals to happen is critical to successful implementation. The current referral pathway needs to be streamlined, so it is easier for referrals to be made between GP practices and community pharmacy IT systems.
Suggestions from the group were to upgrade IT systems to enable ‘one-click’ style referrals, which have been seen to be feasible and easy and should be encouraged and supported by working collaboratively with system providers. Alongside this, there is a call to explore how the NHS could integrate the CPCS into e-consultation platforms/algorithms to triage a patient and refer them to the CPCS, building on current triage systems and pathways that general practices use regularly.
The group felt there was a need to understand the NHS plans and timelines (a roadmap) around integrating GP and community pharmacy IT systems and enabling read/write access to medical notes for community pharmacy teams. This was felt to have clear benefits to enabling referrals between general practice and community pharmacy, alongside helping improve continuity of clinical care for patients.
There is a need for additional project management support and resources at a local level, above what is currently being provided by the NHS.
Additional project support would provide local capacity to help engage stakeholders, promote the service, and drive implementation. Participants spoke of having appointed project teams going into PCNs/GP practices to provide training on how to implement the service, triaging to community pharmacists and managing referrals back from community pharmacy teams.
Alongside this there would be an opportunity to explain how the service worked, what it involved and the benefits for general practice teams and patients, i.e., what type of consultation patients would have with a community pharmacist and the potential outcomes.
Participants felt that having a clear definition of successful implementation, nationally and locally, would help with delivery of the service. Although the NHS England Improvement Impact and Investment Fund provides a new incentive and resourcing to help drive the CPCS, it was not felt to be enough to drive behavioural changes.
Some participants felt there needs to be more substantive national incentives and targets for referral rates, and a clear description of what ‘good’ looks like in terms of numbers (short, medium, and long term) and changes in where patients are being seen for minor ailments.
Having a named person within the GP practice who acts as a point of enquiry for the CPCS is helpful and this means that both the people who have been referred and pharmacists who may have queries, are not held in a telephone queue. Using PCN and GP practice pharmacy teams to support implementation within GP practices has shown to lead to better uptake and should be encouraged.
Participants would like there to be a greater focus on supporting GP practices with setting up the referrals to the service and embedding it into referral triage processes that may already exist. Alongside this, the group would like to see a more joined-up approach from the national NHS teams to engage and work with ICSs to help system leaders:
- Understand the valuable contribution of primary care teams
- Ensure they support the implementation of nationally commissioned services
- Explore how national services could be further enhanced and developed to support local population health approaches
- Meaningfully engage with all primary care teams, representatives, and professions on the future development of ICS plans and services.