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‘CPCS made more of a shuffle into pharmacy than a major step’

"Pharmacists can’t afford to waste time dealing with inappropriate referrals"

The CPCS has some way to go to if it is to fulfill its potential of becoming a vital part of the NHS puzzle, says Valeria Fiore

The Community Pharmacist Consultation Service (CPCS) was launched with much fanfare in October 2019. NHS England and NHS Improvement (NHSE&I) deputy chief pharmaceutical officer Bruce Warner heralded the introduction of the service as a “major step change” for the NHS.

However, the CPCS made more of a timid shuffle into the world of pharmacy. Pharmacies were quick to sign up to the new service, with more than 10,000 doing so within three weeks of its launch. But contractors told C+D that within the first month of the rollout they had only received a handful of referrals.

Now, over 16 months into the service, it’s fair to say that the volume of CPCS referrals hasn’t massively improved. This month, the Company Chemists’ Association (CCA) revealed that big multiple branches receive, on average, fewer than three CPCS referrals per week. Other pharmacists have recently reported receiving as few as one referral per week.

The rollout of GP referrals under CPCS has been especially slow. Pharmaceutical Services Negotiating Committee director of NHS services, Alastair Buxton, attributed this to the pandemic, which he said is “distracting many general practices from considering the implementation of the pathway”. Would the introduction of “incentives” encourage more GP practices to formally refer patients to pharmacies under the CPCS, as suggested by PSNC?

Rolling out a new service during a pandemic can’t have been a walk in the park for NHS chiefs. But COVID-19 is here to stay to a greater or lesser degree over the coming years. The CPCS could be the key to pharmacy reducing pressures on other parts of the NHS struggling to cope with the impact of the virus.

60k claims over one year

My C+D investigation revealed that pharmacies claimed for just 60,316 CPCS referrals between December 1, 2019 – the first month they could claim – and November 30, 2020, according to the NHS Business Service Authority (NHS BSA). Contractors were paid just over £6 million for these consultations.

It’s worth noting that contractors have six months to submit their claims for a completed referral to the NHS BSA, meaning the actual number of CPCS consultations completed over the time period may be higher. But while 60,000 consultations will doubtless have helped patients, it equates to fewer than six consultations per pharmacy in England over one year.

Inappropriate referrals

Several pharmacists have flagged that they continue to receive “inappropriate” CPCS referrals. This means that pharmacists may end up dealing with patients in need of urgent care. Some pharmacists raised concerns over the training that NHS 111 call handlers receive to be able to refer patients to the most appropriate healthcare professionals.

An NHS spokesperson told me that “health advisors don’t independently make the decision to refer a patient to a pharmacist”. Are we therefore supposed to deduce that it is NHS Pathways – NHS 111’s tool for triaging patients – that needs a revision?

Pharmacists can’t afford to waste time dealing with inappropriate referrals. One contractor said it takes their pharmacists 20 minutes on average to complete a CPCS referral, for which they believe the £14 fee “does not represent a professional payment for our pharmacists’ professional time”.

It might be too soon to establish whether CPCS will pay dividends in the future. However, the testimonies shared by pharmacists show that there’s a long way to go before the service can fulfil its potential of becoming a vital piece of the NHS puzzle.

 Valeria Fiore is C+D deputy news editor

Every day this week – March 15-19 – C+D has been 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.


Jenny Etches, Community pharmacist

I've been working on Covidcas PharmCAS 111 for a year. My clinical skills have improved beyond recognition as a result. However I have been concerned about some of the lack of skills in colleagues. When working in CP the quality of CPCS I've done have been low and inappropriate.  And in 11 months on 111 I've only referred 2 patients to CPCS as usually not appropriate. In contrast Ive spent more time talking to patients who had been referred to 111 by pharmacists for issues that I found myself being puzzled as to why they weren't dealt with on the spot - eg, lower back pain with no red flags, conjunctivitis, medicine information queries etc. As a pharmacist of over 40 years experience these are normal grist to the mill. Do we not bother with these in community pharmacy any more? 

Angela Channing, Community pharmacist

Part of the problem lies in the universities nearly all being in Clearing in August. Even the top ones some years. The A* students know about the low pay rates and high stress rates in CP these days from family, friends and the internet. So they all aim for medicine and dentistry or biomed with an aim to do Graduate entry medicine later.
This then leaves people who wouldn't have got a place back in the day when there were 15 schools of pharmacy and not 30, as there currently are. For medicine you are selected, for pharmacy you are recruited.
As someone who works with many pharmacy students every summer, you can certainly see the drop in calibre, from even just 5 to 10 yrs ago. When I read on websites that people are getting in with CCC or even CCD then this goes someway to explaining what is happening.
I feel some pharmacists, especially younger ones, seem scared to handle even simple queries like conjunctivitis. They have probably been scared to death by overzealous university lecturers that if they miss say, iritis then the patient could go blind, so they refer everything.

ABC DEF, Primary care pharmacist

GPs simply do not trust community pharmacists' judgement and whether they can handle the referral entirely themselves, or does it end up being a re-referral to GPs at the end of the day, hence creating unnecessary extra appointments and workload.

To be fair many community pharmacists who I have come across indeed have really poor clinical skills, assessment skills and clinical decision making. Many are not aware of current guidelines, monitoring requirements, treatment options and algorithm in various clinical areas, and have not a single clue about local formulary choices and prescribing policies. Some even tell me they have never heard of CKS before this CPCS started! How shocking! I wouldn't be surprised if the GPs feel the same and hence the pity number of referrals. 

With a large number of community pharmacists having such a low level of clinical skills and knowledge, I have nothing to blame but the education and training provided by the unis and CPPE. I can still recall I have learnt literally nothing useful for my daily practice from my 4 years in uni and have never been taught any kind of clinical examination and assessment skills. CPPE should also take a lot of blame for the poor design of their training workshops, where you are often just left to discuss among yourselves without guidance from an expert speaker. Their facilitators are just a bunch of clowns who don't really know much more than you do, and if you expect to actually learn anything from them, I can only wish you good luck on it. You may as well just spend an hour or two reading up some CKS guidelines yourself, and watching some osce guide videos on geeky medics.

Angela Channing, Community pharmacist

You make an interesting point, ABC, but I thought the increase of the degree length from 3 to 4 yrs was to teach such clinical skills?
From what you say, teaching the students how to prescribe in the next few years is either going to be a huge improvement or a huge disaster!?

Benie Locum, Locum pharmacist

The increase is actually about another year of fees for the university. It's a business.

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