The NHS has a chronic access problem, linked to ever increasing demand for healthcare. This means that patients sometimes have to wait a long time for advice and treatment. Long waits run counter to modern consumer expectations and can have adverse clinical consequences. Community pharmacy – a walk in service located close to where people live, work and shop - must surely be part of the solution.

1. Improving access to
NHS care by investing in
community pharmacy
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2. 2

3. 3
Introduction
The NHS has a chronic access problem, linked to ever increasing demand for healthcare.
This means that patients sometimes have to wait a long time for advice and treatment.
Long waits run counter to modern consumer expectations and can have adverse clinical
consequences. Community pharmacy – a walk in service located close to where people live,
work and shop - must surely be part of the solution.
Most people believe that access to care has eroded over recent
yearsi
. Average waiting times are going up in primary careii
,
meanwhile the nationwide A&E four-hour waiting time target
has been missed every year since 2013/14. This is something of
a barometer for overall performance of the NHS and social care
system, because A&E waiting times can be affected by changing
activity and pressures in other services including community-
based careiii
.
General practitioners have a pivotal position in the health
and social care system, performing many vital functions. The
Royal College of GPs wants to increase average consultation
times in order to give “more holistic” adviceiv
. At the same
time, many doctors are planning to retirev
. Therefore, more
capacity for primary care needs to be created than is currently
being achieved.
One cost effective way to release more capacity into the
system would be to develop community pharmacies as
neighbourhood health & wellbeing centresvi
– offering support
which encompasses prevention, treatment for common ailments,
health surveillance and the routine medicines management
of long term conditions, in collaboration with patients’
GP practices.
This in turn would have a positive, unblocking, effect elsewhere
in the health and social care system, with each provider and
professional group playing to their strengths.
This document highlights how, by making more of their clinical
skills, community pharmacists can be engaged to transform
access to health care. By putting into practice the ideas outlined
in this document, the NHS can help to ensure that people get
the face to face support they need, when and where they need
it, at less overall cost – while at the same time reducing pressure
on GPs and hospitals.
Research commissioned by the National Pharmacy
Associationvii
shows that there will be a considerable
knock-on effect to other parts of the health system
if access to pharmacies diminishes, under pressure
from government funding cuts. Two in five people
(41%) said they would go their GP if it became
more difficult to access their local pharmacy for
the treatment of common conditions. 28% would
go to an NHS walk-in centre, call 111 or 999 or
visit A&E, putting even more pressure on stretched
NHS services.
Properly supported, community pharmacy can dramatically
improve access to healthcare, face to face and close to home.

4. 4
The current level of access to health and
wellbeing services in pharmacies
“It is important to me that a pharmacist is on the premises
of my local pharmacy throughout opening hours”
(Survey of 1003 UK adults, RWB, March 2018)
Pharmacies already provide a range of NHS
and self care services, ensuring that people
can get face to face care without an
appointment, and taking pressure off GPs
and hospitals.
Community pharmacies are a highly accessible part of the
healthcare system. 89% of the population are within a 20
minute walk of a community pharmacy and opening hours
are generally longer than many other settings. There are 1.6
million visits to a community pharmacy every day. That adds
up to 14 visits per person per year. Community pharmacists
are used to delivering a walk-in service and patients generally
have access to the pharmacist within minutes of entering the
pharmacy, usually without an appointment.
Seven in 10 people (66%) regard face to face advice from
a pharmacist or other member of the pharmacy team as
very important to them; the importance of face to face
advice increases significantly amongst certain key groups of
pharmacy users, including carers, older people and parents of
young childrenviii
.
Community pharmacists are specialists in medicines, but also
have a broad training in disease and its prevention and treatment.
Pharmacists undergo a minimum five years’ training before
registering as a healthcare professional and then undergo
continuing professional development throughout their careers.
They operate from conveniently located premises across the UK
and are more concentrated in areas of deprivation where the
health needs are greatest.
Access in deprived areas
In 1971, academic Julian Tudor Hart described the inverse
relationship between deprivation and healthcare provision, i.e.
that those with the highest need for healthcare suffer from the
worst access. Deprived areas tend to have a lower ratio of GPs
and nurses to patients, and where the ratio is lower it is harder
for patients to get appointmentsix
. In contrast, Todd et al, writing
for the British Medical Journal, were able to demonstrate that
there are more pharmacies in the most deprived decilex
.
England wide data, 2016xi
16%
14%
12%
10%
8%
6%
4%
2%
0%
1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th
Distribution of pharmacies by deprivation decile
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
83%
9% 8%
Yes No Do not know

5. 5
Improving access to care through community
pharmacy: the proposition in a nutshell
Only by mobilising the entire healthcare
workforce, including community pharmacists
and their teams, can there be any prospect
of addressing the NHS access challenge on a
sustainable basis. The NHS must think more
imaginatively about how and where care is
delivered, and consider local pharmacies to
be people’s front door to health.
As well as providing convenient, face to face care in the
pharmacy setting, a major benefit will be to reduce pressure in
general practice, thus increasing the appointment times available
to those with the most complex problems and the greatest need
– in turn addressing congestion elsewhere in the health and
social care system.
Many general practice appointments concerning minor ailments
could be treated effectively elsewhere in NHS primary care.
Meanwhile, 8% of emergency department consultations are
for minor ailmentsxii
, which would be better suited to self
care supported by local pharmacies. In addition, many more
medicines-related interventions to manage long term medical
conditions could be carried out by community pharmacists in
pharmacy consultation roomsxiii
.
So, these are our aspirations:
• For the treatment of minor ailments such as coughs and colds,
no-one should have to wait to see a doctor. Instead there
should be fewer limitations on the range of NHS treatments
that local pharmacists are able to supply, without the patient
needing to go to a GP for a prescription.
• For the routine management of their medicines for stable
long term conditions, no-one should have to wait to see a
doctor. Instead, people should be fully supported in their
local pharmacy to understand, review and if necessary modify
medicines (within protocols agreed with the wider local
healthcare team)
• For routine health checks such as blood pressure, people in all
parts of the country should have an option to access these at
local pharmacies. Currently there is only patchy commissioning
of health checks in community pharmaciesxiv
.
Our proposition is to dramatically improve access to healthcare,
face to face and close to home. We will be able to say to
patients: Local pharmacies are your front door to healthy
living and the first place to come for healthcare. Come first to
pharmacy and you will get advice and support to help yourself,
treatment at the pharmacy, or prompt access to treatment
elsewhere, by referral from the pharmacist.
This is not just about self care and the treatment
of minor ailments, vitally important though that
is. The idea is to release more capacity into a NHS
system that is under very severe strain, by developing
community pharmacies as neighbourhood health
wellbeing centres – offering support which
encompasses prevention, treatment for common
ailments, health surveillance and the routine
medicines management of long term conditions.
“NHS medicines review services in pharmacies should be
expanded, to help people with long term medical conditions
to manage their medicines and to take pressure off GPs”.
(Survey of 1003 UK adults, RWB, March 2018)
56%60%
50%
40%
30%
20%
10%
0%
Strongly agree
35%
8%
1%
Agree Disagree Strongly disagree

6. 6
The journey from where we are now
to where we need to be
It is not an impossible leap to get from the current situation to a situation where it can
truly be said that people are able to get the community based care they need, when and
where they need it. The community pharmacy infrastructure and skills are fundamentally in
place. In some places, these are already being brought into play, as the case studies in this
document show.
Start using what you
have in better ways...
“ “

7. 7
Accessible medicines management in
the community, Sheffield
Jaunty Springs Medical Centre is situated in the middle of a post
war housing estate in the suburbs of Sheffield. A community
pharmacy in the neighbourhood is connected to the GP practice
via smart card and N3 connection, enabling the pharmacy to
provide a range of co-ordinated services from the pharmacy’s
consultation room. This includes management review of
repeat prescriptions, delivering structured medication reviews,
and professionally led medicines triage. The scheme has saved
GP time and significantly improved access to care.
Pharmacy First minor ailments scheme, Scotland
Nationwide in Scotland there is a Pharmacy First scheme,
specifically aimed at reducing unnecessary trips to AE as well
as GPs. Community pharmacists carry out a consultation in the
pharmacy with the patient and provide advice and treatment
under a locally agreed protocol. The service is available from
local community pharmacies both within GP opening hours
and out of hours. It allows patients access to treatment for
uncomplicated urinary tract infections and impetigo from a
community pharmacy. Due to the success of the Pharmacy
First Service, Forth Valley has extended the service to include
additional common clinical conditions – so patients can now
access treatment for bacterial conjunctivitis, recurrent vaginal
candidas and minor skin conditions.
Acute triage, Fife
Bernadette Brown, owner of Cadham Pharmacy, explains that
the episodes of care in her pharmacy can usually be described
as ‘consult and complete’, rather than the visit to the pharmacy
being a staging post to another episode of care. “The acute triage
offered in our pharmacy is very rewarding – it is a great feeling
when you can reassure someone they do not need antibiotics, or
you treat an asthma exacerbation, UTI, ear infection or psoriasis,
for example, without the need to refer to the GP practice.”
Direct referrals into the NHS, Bristol
Old School Pharmacy in Bristol would recognize many of the ‘See
You Sooner’ features in their own pharmacy practice, including
independent prescribing, direct referrals into the NHS, and triage
for the local surgery when its appointments are almost full. The
Superintendent Pharmacist, Jonathan Campbell, has made it his
mission to develop a close partnership with the adjoining GPs
surgery, beginning in 2011 when the pharmacy gained full access
to the EMIS patient medication records.
Referrals from NHS111, North East England
The North East Urgent Care Community Pharmacy Referral
Scheme is a trial which enables NHS111 to refer set groups of
patients to community pharmacies in an area covered by 10
clinical commissioning groups and a population of nearly 3 million.
Over 300 pharmacies in the region have thereby been brought
into the urgent care pathway, bringing into play an extensive
network for the assessment, advice and treatment of patients
for arrange of low acuity conditions, such as coughs and colds.
Patients are clinically assessed in pharmacy consultation rooms
rather than urgent care centres. The pharmacy receives electronic
notification that a patient has been referred and will follow up
with the patient if they do not attend the pharmacy within 12
hours of referral. As of December 31, 2017, around 60 per cent of
callers who were referred attended pharmacies and of these: 39
per cent received advice and an over the counter medicine, 22 per
cent received advice only, 18 per cent were escalated for ‘in hours’
GP appointments and 11 per cent were escalated to attend out-
of-hours appointment/walk-in centres.
Independent prescribing, Barrow-in-Furness
As part of the Minor Ailments Scheme commissioned by Cumbria
CCG, community pharmacist Paul Blake has been trained as an
independent prescriber and given a prescribing budget, allowing
him to improve access to health care in his community. Referrals
usually come from the adjacent surgery, with whom Paul has
worked closely for over 15 years, but can come from other local
surgeries and even the out of hours GP service. Access to both his
own prescription pad and the patient’s full medical records means
Paul can make sure his patients can get the treatment they need
for a whole host of symptoms there and then.
How long is it reasonable to have to wait for a non-urgent
appointment with a GP to discuss concerns about long-term
medicines? (Survey of 1003 UK adults, RWB, March 2018)
41%45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
24 hours 48 hours 1 week 2 weeks A month
17%
28%
11%
2%

8. 8
Lewisham Community Pharmacy Health Checks
The London Borough of Lewisham started using pharmacies to
deliver NHS Health Checks from the start of their programme
in 2011. By March 2015, a quarter of all the checks carried
out were delivered via the 17 pharmacies signed up to the
programme. Pharmacy staff have direct access to a secure web-
based recording system which allows them to check eligibility
and transfer the results securely to the patient’s GP practice.
An evaluation showed that the pharmacy service was effective
at engaging people from deprived communities. According to
the local Cardiovascular Prevention Programme Manager, “it is
about giving people greater access. One of the great benefits of
the pharmacy is that people can have the NHS Health Checks
done in the evenings and at weekends”.
The ability to ‘assess, consult and complete’
By more treatments and other interventions being available in
pharmacies, pharmacy would less often be a staging post, and
more often the one stop shop for support, thereby being more
convenient for service users.
Therefore, minor ailments schemes (MAS) should be in place
across the country, so that people can get NHS treatments
for coughs and colds and other self limiting conditions from
pharmacies without the need for a doctor to issue a prescription.
Data collected from nearly two million patient consultations in
local schemes showed that 87% of patients would have gone to
their GP if MAS was not available. In 98% of consultations no
onward referral to other NHS providers was necessaryxv
.
Thinking more radically, we should move much further
on pharmacist independent prescribing, to create a more
convenient service for patients and make fuller use of the clinical
skills of the pharmacist.
In addition, diagnostic tests such as blood pressure monitoring
should become common place in pharmacies. Based on
the results, the pharmacy would either make the necessary
intervention themselves, or refer appropriately. This happens
routinely in Canada, where community pharmacists in Alberta
province are able to optimise their clinical skills.
Better integration including formal referrals
The GP has long been established as the ‘gatekeeper’ to the
NHS and currently determines the patient pathway from primary
care, through to secondary and more specialised care. People
would be encouraged to come first to pharmacy if signposting
from pharmacies more frequently took the form of a formal
referral, embedded in NHS care pathways. Other mechanisms for
communication between all parts of the system also need to be
optimized, in particular pharmacists having read write access
to patient care records.
A Summary Care Record pilot that ended in March
2015 showed that in 92% of encounters where the
SCR was accessed, the pharmacist avoided the need
to signpost the patient to other NHS care settings.
In 82% of encounters where SCR was accessed, the
pharmacist indicated that overall waiting time was
reduced and 90% of patient respondents agree that
treatment is quicker if pharmacists have access to
SCRxvi
.
Public awareness
In line with the developments in pharmacy practice, there will
need to be an evolution in public understanding of how and
where care is delivered. Patients will need to feel certain that
if they go first to pharmacy their needs will be addressed in
every instance – in the form of advice, treatment and/or prompt
onward referral.
Funding
Ultimately, this approach has the potential to create huge cost
savings by moving more episodes of care closer to home and
encouraging appropriate use of NHS services. Nevertheless, it
must be clearly understood that community pharmacy requires
a sustainable funding settlement now, if it is to make the
necessary investments for the long term. Initially, monies from
the Pharmacy Integration Programme should be used to develop
accessible care in the community pharmacy setting. Since NHS
England has invested heavily in the general practice pharmacist
scheme, there is surely a strong justification for investment
in community pharmacy based schemes which deliver similar
benefits but can cater for many more patients, conveniently and
probably at lower costxvii
.

9. 9
Canada – an example of a journey
to more accessible healthcare
With the success of an effective, pharmacy led hypertension service, the general acceptance
in Canada of pharmacy undertaking clinical services has increased. In only a decade, clinical
services across a wide range of conditions are finding a home in community pharmacy and
patients are benefiting greatly as a result.
2005
Renew/extend prescriptions
Change drug dosage/formulation
Make therapeutic substitution
Prescribe for minor ailments/conditions
Initiate drug therapy independently
Order and interpret lab tests
Administer a drug injection
PHARMACISTS’ SCOPE OF PRACTICE IN CANADA Not completed
BC AB SK MB ON QC NB NS PEI NL NWT YT NU
2017
Renew/extend prescriptions
Change drug dosage/formulation
Make therapeutic substitution
Prescribe for minor ailments/conditions
Initiate drug therapy independently
Order and interpret lab tests
Administer a drug injection
PHARMACISTS’ SCOPE OF PRACTICE IN CANADA
Not completed
Pending legislation, regulation
or policy for implementationImplemented in jurisdiction
Implemented with limitations
BC AB SK MB ON QC NB NS PEI NL NWT YT NU

10. 10
Policy and practice proposals
– what are your views?
We invite the views of patients, pharmacists, GPs and other healthcare professionals on our
access proposition in general and the following specific proposals:
1.
Pharmacist independent prescribing should become common
place in community pharmacies, so that people can enjoy a
more convenient service in respect of health maintenance and
the management of long term conditions, as well as acute care.
2.
More NHS services and interventions should be available in
community pharmacies, to provide choice and convenience and
reach parts of the population that may otherwise go without the
support they need. For example:
The NHS Health Check (which includes a test for high blood
pressure) should be widely available in pharmacies. Currently
about 30% of local authorities in England commission
community pharmacies to provide the NHS Health Checkxviii
.
NHS medicines optimisation services in pharmacies should be
expanded, to help people with long term medical conditions
to manage their medicines and to take pressure off GPs
3.
Initiatives to allow pharmacists read and write access to patient
records (with the patient’s permission) should be stepped up - to
give people the assurance that wherever they access primary
care, their experience will be safe and seamless.
4.
Regulations should continue to guarantee that a pharmacist is
available at all times on the registered pharmacy premises, to
oversee safe supply of medicines and provide clinical advice.
5.
People in all parts of the UK should be able to get NHS
treatments for coughs and colds and other common ailments
from pharmacies, without the need to visit a GP for a
prescription. England is currently the only part of the UK without
a nationwide scheme.
6.
Community pharmacy requires a sustainable funding settlement,
if it is to make the long term investments necessary to improve
access to NHS care.
7.
The NHS Constitution should be updated to include guarantees
of timely face to face access in primary care. Currently, the
access pledges in the Constitution relate to emergency care
or interventions that follow referral to hospital specialists – it
currently has little to say about timely access to healthcare
provided in the community.
Please send your remarks to
independentsvoice@npa.co.uk

11. 11
i
Survey of 1003 adults, commissioned by the National Pharmacy Association, RWB, March 2018
ii
NHS England (2017) GP Patient Survey. The number waiting at least a week to see their GP has risen by a half in five years,
with one in five now waiting this long; while most people say that their appointments are convenient, that proportion has been
dropping since at least 2012. In 2017, 29% of people were unable to see a doctor or nurse in primary care at a time they wanted
or sooner.
iii
What’s going on with AE waiting times? The King’s Fund, 2017.
https://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters
iv
In her opening speech at the 11th RCGP annual primary care conference Prof. Helen Stokes-Lampard called for “holistic”
consultations with patients and not the current “tick-box” consultation.
v
An investigation by Pulse Magazine Feb 2018. 62 per cent of GPs who retired in 2016/17 did so before the age of 60 - having
made up just 33 per cent of cases in 2011/12.
vi
Community Pharmacy Forward View, Pharmacy Voice 2015
vi
Establishing the value of Community Pharmacy, base of 2001 consumers, Quadrangle, February 2016
vii
Establishing the value of Community Pharmacy, base of 2001 consumers, Quadrangle Feb 2016
viii
Stocktake of access to general practice in England, National Audit Office 2015
x
The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity
and social deprivation in England. BMJ, Todd et al. http://bmjopen.bmj.com/content/4/8/e005764
xi
Analysis conducted by EBI Solutions (University of Warwick) for the National Pharmacy Association, based on an England side
dataset 2016
xii
Community Pharmacy Management of Long Term Conditions (MINA Study), Pharmacy Research UK 2014
xiii
Draft report of medicines management pilot at Jaunty Springs Medical Centre Sheffield, April 2017, Garry Myers and James
Roach
xiv
A cross-sectional study using FOI requests to evaluate variation in local authority commissioning of community pharmacy public
health services in England. BMJ Open July 2017
xv
PSNC Briefing 044/17, Jan 2017. Based on PharmOutcomes data from 74 schemes including 1,722,230 patient consultations
xvi
http://content.digital.nhs.uk/article/6476/Summary-Care-Record-rolled-out-to-community-pharmacists
xvii
Draft report of medicines management pilot at Jaunty Springs Medical Centre Sheffield, April 2017, Garry Myers and James
Roach
xviii
Tackling High Blood Pressure Through Community Pharmacy, Pharmacy Voice 2017

12. 12
Join in the debate at
 : www.npa.co.uk/seeyousooner