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Pharmacists continue to flag ‘inappropriate’ CPCS referrals 1 year on

Community pharmacists are still receiving “inappropriate” CPCS referrals from NHS 111 and have concerns about call handlers’ training, they have told C+D.

Under the Community Pharmacist Consultation Service (CPCS), patients calling NHS 111 or using its online version can get a referral to their nearest pharmacy if they have a minor illness or need an urgent medicines supply.

Although the service launched more than a year ago, several pharmacists told C+D last month that they are still receiving inappropriate referrals and fear some patients might be abusing the service.

Others have argued that NHS 111 call handlers should receive better training as they are the ones referring patients to pharmacy.

However, an NHS Digital spokesperson told C+D last month (February 23) that “health advisors don’t independently make the decision to refer a patient to a pharmacist”.

Read NHS Digital’s full response below.

“Liable to abuse by patients”

Derryn Cottrill, pharmacist at Euro Chemist in Liverpool, thinks the CPCS is “a good service and I can see its potential”. However, she has seen “only a handful of genuine cases and the service is liable to abuse by patients”, she claimed.

“The majority is simply patients who have not ordered their medication on time. When their surgery is open, surely, they should provide a prescription.

“Several have tried to get emergency supplies [from] their own chemist who have declined, as the surgeries are open, so they get a referral to a different chemist around the corner. We have also had a problem with several patients trying to obtain controlled drugs,” Ms Cottrill added.

Pharmacists cannot supply schedule 2 and 3 controlled drugs – with the exception of phenobarbitone or phenobarbital sodium for the treatment of epilepsy – if they receive an urgent medicines supply request through the CPCS, according to guidance by the Pharmaceutical Services Negotiating Committee.

London-based pharmacist Patricia Ojo said that having worked for NHS 111, she appreciates the “limitations of the referral system”.

“The system selects the pharmacy nearest to [a patient’s] current location. However, if the person using the system knows what they are doing, they should be able to input a postcode of choice and search for an alternative pharmacy,” she said.

“I can recollect two or three distinct cases of potential abuse of the system. I used the opportunity to educate the patient about future use,” Ms Ojo added.

Ms Ojo believes that although the CPCS is “not perfect and could be improved, it is better to have a commissioned service from NHS England than not”.

Examples of red flag conditions triaged 

Bhavna Tailor, a locum pharmacist based in Leicestershire, told C+D that she has dealt with different inappropriate referrals.

On one occasion, a patient with an acute injury was sent to the pharmacy where she was working. “The patient really needed an x-ray to determine if anything was broken,” she said.

She also encountered a “lady [expressing] milk from [her] breasts who was not pregnant or had a baby”, who she promptly referred to a GP, Ms Tailor told C+D.

“How was that appropriate as a minor ailment [referral]?”.

Another episode involved a young man calling NHS 111 every time he needed salbutamol. “I spoke to his surgery the second time he was referred to the pharmacy, and he got booked in for a review – he wasn’t using his preventer,” Ms Tailor added.

Rifat Asghar-Hussain, superintendent pharmacist of Evergreen Pharmacy and Green Cross Pharmacy in Birmingham, also told C+D about a series of inappropriate CPCS referrals, including: “Vaginal injury from a tampon; suspicious lump on hand; chest pain and arm numbness; a rash ongoing for weeks; and emergency supplies while surgeries are open”.

Both Ms Asghar-Hussain and Ms Tailor believe that the NHS 111 call handlers need extensive training to make appropriate CPCS referrals.

Unsuitable referrals “lead to delayed treatment, which would potentially harm a patient”, Ms Asghar-Hussain said.

“Most people who call 111, I feel, are usually more ill than a simple minor ailment,” she added.

“Call handlers undergo intensive training”

C+D approached NHS Digital to report pharmacists’ experiences of receiving incorrect CPCS referrals and asked how NHS 111 call handlers’ training is kept up to date.

A spokesperson told C+D last month that “all health advisors and clinicians using NHS Pathways – a clinical decision support system – undergo an intensive training programme that spans approximately over 10 weeks in the case of health advisors, and 14 weeks in the case of clinicians”.

Employees need to pass “a number” of assessments before they are able to “practice independently”, the spokesperson added. Their performance is then monitored monthly and they receive “ongoing professional development”.

Call handlers also have access to a “huge range of educational resources supplied by the NHS Pathways training team”, NHS Digital added.

“These resources include six release training packages per year, hot topics on a wide range of issues related to telephone triage, case studies, self-reflection tools and distance learning materials.

“Health advisors are not required to undertake independent decision making about a patient’s likely condition and required care; they do this on the basis of applying the decision support inherent within NHS Pathways,” the spokesperson stressed.

“It must be recognised therefore that health advisors don’t independently make the decision to refer a patient to a pharmacist,” they added.

Every day this week – March 15-19 – C+D will be analysing the Community Pharmacist Consultation Service (CPCS) a year into its launch. Read all the coverage in the dedicated hub and join the conversation on the C+D Community.

How many inappropriate referrals did you receive since the start of the CPCS?

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