Antimicrobial resistance, or AMR, occurs when antibiotics are overused or misused to the point where they become less effective. A study by The Lancet in May revealed eight million deaths each year are caused by bacterial infections, and five million of those were because the bacteria had grown resistant to the antibiotics used to treat them.
What has this worldwide issue of overprescribing antibiotics got to do with community pharmacy? Because when Pharmacy First rolled out across England in February, it allowed community pharmacists to prescribe antibiotics to alleviate the pressure on GPs. That led to fears among GPs that pharmacists would dole out antibiotics irresponsibly. The British Medical Association’s (BMA) top GP went so far as to tell C+D last year that pharmacists shouldn’t “work beyond their areas of capability and competence”.
This comes despite the NHS and the Department of Health (DH) insisting they will closely monitor the Pharmacy First service to guard against the risk of increasing AMR.
So does Pharmacy First pose an AMR threat? Or are community pharmacists being undervalued, underrated and undermined?
A success
It’s been five months since the launch of Pharmacy First, and although that gives the sector little data to extrapolate, Community Pharmacy England (CPE) revealed in January that more than 90% of community pharmacies had already signed up to provide the service.
Meanwhile, NHS England's (NHSE) head of strategy Pallavi Dawda told delegates at Clinical Pharmacy Congress (CPC) in May that although Pharmacy First is in its “early stages” there have been consultations for all seven conditions meaning “it’s appropriate to be seen” in community pharmacy.
Read more: Pharmacy First to be ‘closely monitored’ for antimicrobial resistance risk
Pharmacy First is a “brilliant opportunity” for the sector,” says Shilpa Shah, who is CEO at Community Pharmacy North East London (NEL).
“The public trust us. We are experts in medication, and we are antibiotic stewards, and patients are happy being seen quickly without waiting for a GP appointment.”
Yet in May 2023, 14 scientists wrote an open letter to Rishi Sunak strongly cautioning against the Pharmacy First scheme and a potential knock on increase in AMR, calling it a recipe for “harmful consequences” if not “implemented with due consideration.”
Jonathan Cooke, an honorary professor of pharmacy at the University of Manchester, signed the letter and tells C+D that Pharmacy First is an “excellent innovation, however it needs to be complete. Proper access to point of care testing would improve this.”
And Dr Leonid Chindelevitch, who also signed the letter, told C+D that Pharmacy First could “simultaneously be a step in the right direction” freeing up GP appointments but also “a step in the wrong direction” leading to a “rise of AMR in local communities”.
“Even with the right training, pharmacists may not have sufficient time with a patient to decide on the appropriateness of an antibiotic prescription for conditions like impetigo, strep throat, and uncomplicated UTIs,” he says.
“These conditions can be misdiagnosed, especially in situations where the patient puts pressure on the pharmacist to prescribe them antibiotics. The lack of a clear diagnosis is a major concern for AMR as inappropriate antibiotic prescription creates risks for the patient but also for the community as a whole.”
Chindelevitch, a lecturer in epidemiology at Imperial College London, says the solution lies in pharmacists being “appropriately supported” with point of care tests.
Point of care testing
This isn’t the first mention of point of care testing. Back in January, NHSE’s clinical lead for AMR diagnostics, Dr Jane Freeman, said tests may be “introduced” into Pharmacy First to tackle AMR, describing them as the “first step in AMR stewardship”.
However, in May, NHSE told C+D that as it stands, point of care testing won’t be introduced because there “isn’t enough evidence to support their use.”
Read more: Empowering pharmacy: Leading the charge against antimicrobial resistance
Professor Cooke believes it isn’t being introduced because there isn’t enough funding to support it, adding that it’s “of great concern” recommendations made by the AMR report by Lord O’Neill in 2015 advocating the use of point of care testing haven’t been widely adopted.
“Financial pressures facing the NHS are mainly due to the three Ds: demographics, diagnostics and drugs,” he says. “We need to look at the overwhelming evidence for the value of point of care testing in reducing antibiotic use.”
But Shah doesn’t believe they are currently required, unless more clinical pathways are added, then they could be introduced “if appropriate”.
“It's important the remuneration reflects the time taken to carry out diagnostic testing and that the tests and associated consumables are free for community pharmacy,” she adds.
“If point of care testing is needed, it should be done by both pharmacists and GPs. Patients need consistency and to be confident in the service, they need to see we are doing the same as general practice.”
Pharmacists versus GPs
As that debate continues, so does the rollout of Pharmacy First. So do community pharmacists lack the “capability and competence” to carry out Pharmacy First without diagnostic tests as the BMA suggests?
Shah believes community pharmacists are perfectly competent, and points out that pharmacy has made little contribution to the problem so far.
Read more: Revealed: ‘Over 90%’ of pharmacies signed up to deliver Pharmacy First
“We are where we are with AMR due to current levels of prescribing,” she says. “That’s something very few community pharmacists have been a part of.”
And though both scientists may have raised concerns with the PM, they both believe an uptick in training and monitoring would make the situation acceptable.
Professor Cooke says “many pharmacists are no different from other primary care clinicians, such as GPs, in their knowledge.
“I fully support the Pharmacy First service, and pharmacists should be increasing their clinical skills and prescribing under evidence-based protocols. Most community pharmacies are closer to patients than GP surgeries.”
And Dr Chindelevitch is hopeful that “surveillance efforts, coupled with all pharmacists receiving additional training and support tailored to the specific risks in their community, in particular AMR, will mitigate the downsides while improving public health overall”.
And few would argue with that.