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

NHS Digital: Call handlers do not make independent triage decisions to pharmacy

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?

Katie O'Donnell, Community pharmacist

The call handlers are not medically trained. They follow the computer and this generates the outcome. Pharmacists need to start thinking of themselves as the second line in this process. Their role is to assess the appropriateness of the outcome using their medical knowledge and either treat or refer to an appropriate service. Basically the same thing the second line 111 clinicians have to do, except community pharmacists get the benefit of seeing the patient in person. Of course you will receive inappropriate referrals... it's your role to appropriately refer.

Leon The Apothecary, Student

Indeed, maybe it would be worth discussing with the Paramedics who end up going to plenty of non-emergency calls as part of the NHS111 triage. It's always going to over triage, so you have to be the clinical filter. 

Interleukin -2, Community pharmacist

Am not sure you actually work in community pharmacy..cos then you 'd know that those referals apart from being time consuming and unneccesary, set expectations for the patients even before the pharmacist reviews the case, that are sometimes difficult not not mention confrontational to manage, leading many a pharmacist into grey areas ladden with legal landmines ...God help you if you are newly qualified with little experience

Michael Mustoe, Community pharmacist

Well put VKP. Pharmacists would do well to stop moaning!
Giving an emergency supply whether the surgery is open or not is good practice. Take responsibility for your actions

V K P, Community pharmacist

giving an emergency supply is legal however giving an emergency loan is not. Deducting the amount loaned from when the prescription is received is not legal. The full quantity on the prescription has to be dispensed. Hence whether the surgery is open or not, charge the patient for the emergency supply and see how they will never forget to order their repeats on time. Or even better, get a CPCS for it. then the supply is made legally and you get re-imbursed for the supply plus a fee for your troubles. Good Practice at the detriment of the business does not flush and is not acceptable. Therefore the good practice point is disputed. 

V K P, Community pharmacist

why would the NHS need the pharmacy if the call handler were going to do all the assessment and appropriateness checks prior to referring???? think about it. Atleast there is a formal referral which is part of a paid service, that is coming through now. it is better than the patient simply walking in an getting free advice. Stop maoning people. carry out the consultation and claim the £14 fee. When do you ever receive a fee for providing over the counter advice??? NEVER. 

Even if you sold paracetamol post over the counter advice, the POR is not near £14. 

Ruth Hulton, Community pharmacist

I know there are some frustrating CPCS referrals eg. CD requests etc. but overall I've got to agree, we're still weeding out people who don't need non-pharmacy care which personally I've found is not uncommon, we can signpost appropriately to routine GP care or more urgent care and we actually get paid for providing this service.

Jenny Etches, Community pharmacist

I've been working on Covidcas 111 for nearly a year and I've rarely referred a patient for CPCS.  They're simply not appropriate for the service but a lot of the pharmacists on the emergency register working on 111 do not understand how CPCS works. So I'm guessing the nurse clinicians on the main 111dont either. 
It is important though to remember that CP can still do emergency supplies when surgeries are open -if appropriate. And that's down to the RPs professional judgement. 
By the same token we have patients referred to111 by community pharmacists for headaches or similar minor ailments when they could deal with them in store. Unless they're hoping to cash in on the vast fortune of £14 for CPCS referral back to them. But of course that wouldn't happen as not allowed to tout for CPCS business. 
When I've worked in store I can't say any of the Cpcs I did were worth all the effort they took and the disruption to other more pressing activities 

Catherine Spencer, Community pharmacist

Never ending cd requests and baby milk, contraceptive pill because patient doesn't want to go for a review, requests for antibiotics and medications not on repeat and a lot of system abuse, weekly script patients with requests for diazepam, Co codamol, lorazepam, zopiclone and care homes with six cpcs requests at a time. I've been providing this service for a long time, as cpcs and as it's previous incarnations and it started out as a really good service, you provided genuine supplies, could gain new patients and referral was easy, now its few and far between if we receive appropriate requests, and referral is a nightmare.

Farmer Cyst , Community pharmacist

Cpcs emergency supply was launched to save GPs time by avoiding the need for emergency prescriptions. I believe the service works.

GPs and pharmacists no longer need to jump for for a 'I have no medicines left' patient.

It's good to see pharmacy being reimbursed for the headache.

It's also important to point out that 'emergency loans' pharmacy used to make are Illegal. We are only allowed to make emergency supplies, not emergency loans.

There is no provision for 'loaning' a patient any medicine and then cutting it from a future prescription.

You either charge the patient for the supply and then dispense the FULL amount due when their prescription arrives, or you refer the patient to 111 so that the NHS can be charged for the emergency supply.

chris langtry-lynas, Community pharmacist

Too many to mention. My favourite is still the man who was referred to have his toe nails cut. 10 weeks training? BS

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