20/56 HS&DR Community pharmacies supporting information
Commissioning brief – supporting information
20/56 – Community pharmacies
(Two stage – Stage 1 to Stage 2)
The following is intended to provide further information on the background of this call but does not constitute an exhaustive review of the literature in this area.
Health and social care context
Primary care services in the UK are under pressure to meet rising demand due to the changing health and social care needs of an ageing population with more people living with long term conditions and increased multimorbidity. This is combined with well documented challenges facing the primary care workforce such as the decline in numbers of general practitioners across the UK. Furthermore, recent policy reforms such as the NHS Long term plan  are also placing greater emphasis on the provision of out of hospital care and promise to ‘finally dissolve the historic divide between primary and community health services’ through the development of integrated care systems, such as Primary Care Networks. Solutions to meet the growth in demand for services have driven the need for new models of primary care that utilise a more diverse skillset in the workforce .
Community pharmacies (CP) are a multiskilled workforce and with over 11,000 in England, a 9.8% increase since 2008/09 , they have potential to coordinate and deliver a wider range of health and social care services closer to home than have been traditionally part of their role. The government liberalisation of market entry, means there are approximately 2000 more pharmacies than fifteen years ago . The majority (60%) are part of multiple chains, with the remaining 40% of pharmacies being independents or small chains of less than 6 outlets . The changing role of community pharmacies is reflected in the recent Community Pharmacy contractual Framework  which places greater emphasis the provision of services that go above and beyond just the dispensing of medicines. These are sometimes referred to as cognitive or non-supply services. For the purposes of this brief we refer to them as extended community pharmacy services.
The recent publication of The Marmot review, 10 Years On  highlights widening health inequalities across the UK and particularly in the most deprived neighbourhoods. Todd et al.  conducted area level analysis to determine the percentage of the population in England that have access to a community pharmacy within 20-minute walk. They found that overall 89.2% of the population live within 20 minutes’ walk of a community pharmacy; this increases to 99.8% in areas of highest deprivation, and has been referred to as a positive pharmacy care law; unlike other healthcare services there is greater proximity to a CP in the most deprived areas compared to the least deprived. The physical proximity of CPs in areas of higher deprivation makes them well-placed to engage with local people and communities, improve quality of care for everybody and support goals to reduce health inequalities. CPs also have potential to engage communities for whom accessing other forms of healthcare may be a barrier e.g. traveler communities and people who are homeless and may not be registered with a GP.
A review of reviews published in 2019  explored the effects of CP public health interventions on health inequalities. It identified a lack of review level evidence of the effects on health inequalities, as many studies did not report sub-group differences. There was some support for the potential of interventions that had been targeted at specific deprived communities. But it was found that there was also the potential for CP interventions to increase health inequalities e.g. in case of chlamydia testing, where older women from less deprived areas were more likely to use the service.
The draft Quality standard published by NICE (2019)  recognises the potential of CP to reach people who may not access other healthcare services. However, more evidence is needed to inform the design and delivery of CP services in helping to address health inequalities.
Extended community pharmacy services
A recent (2018) Cochrane review  evaluated the impact of extended services delivered by pharmacists to non-hospitalised patients, on patient outcomes. It identified 116 studies involving over 41,000 participants across 25 countries. Most studies were conducted in community pharmacies (CPs) and hospital outpatient clinics*. A wide range of health conditions were targeted including hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), depression, cardiovascular disease, heart failure and cholesterol/lipid management.
This review concludes that pharmacy services can have positive effects e.g. patients were less likely to have blood pressure outside the target range compared with patients receiving usual care. However, results from trials varied, with limited understanding of which components of extended pharmacy services deliver positive outcomes, in what circumstance, and for which health conditions.
* Please note, for the purposes of this call the focus is on extended community pharmacy services i.e. pharmacy services delivered by other primary healthcare services e.g. pharmacy services based in GP practices or hospital outpatient clinics should not be the focus of applications for funding in this call.
In support of the ambitions set out in the NHS Long term Plan, the Community Pharmacy Contractual Framework 2019/20 – 2023/24  outlines key changes to the role of CPs placing much greater emphasis on the provision of extended community pharmacy services. It specifically focusses on those addressing service need in three areas; urgent care, medicines optimisation and prevention.
The Community Pharmacy Consultation Service (CPCS) was launched in October 2019 with an aim to increase capacity and reduce pressure on existing urgent care services and deliver care closer to home, by offering a community pharmacy as a first point of access to treatment of minor injuries and illnesses . It follows the success of Digital Minor Illness Referral Service (DMIRS) pilot sites which have been running since December 2017. The CPCS enables call handlers from NHS 111 centres to make a digital referral to a convenient CP for an individual to receive treatment for a range of minor injuries and illnesses. A further expansion to CPCS is currently underway to include referral from GP surgeries following an initial assessment by trained GP reception staff. In total, Seventy-four GP practices have been selected to be involved in this pilot which is taking place until March 2020 . N.B. Due to Covid-19, CPCS’s have been adjusted so that unless there is a clinical need to visit in person, pharmacists provide a consultation via telephone and only GP referral pilot sites that are already in place remain active, but are not being extended at this time .
The medication taken by patients in the community and prescribed by their GP or other primary care health professional is often changed during a hospital admission. Several studies have tested the effectiveness of offering optional referrals to patients leaving secondary care to see a community pharmacist to discuss and review their medications post-discharge . This is designed to ensure that any changes made in secondary care are implemented appropriately when the patient is discharged, supporting safe transitions of care and reducing risk of readmission due to medicines errors. In this systematic review of ‘the role of community pharmacies in improving the transition from secondary to primary care’  concluded that interventions can improve drug related problems post discharge e.g. medication errors, but there was mixed evidence for other outcomes such as hospital use, patient knowledge and satisfaction. The review called for process evaluations and controlled trials to understand the organisation and communication between secondary care and CP that could be used to inform best practice.
A more recent study found that referral from secondary care to CP did help to reduce the rate of readmission amongst those who received a follow up and found it to benefit patients through the opportunity to ask questions and be reminded of how to take medication . A case study of the Bridgend Community Resource Team  includes pharmacy technicians as part of a multidisciplinary team who, in partnership with a person’s community pharmacist, deliver medicines optimisation; ensuring that people can manage their medication in their own home, reducing the risk of hospital admission due to medication errors. As well as reducing avoidable hospital admission and improving patient experience, conducting medicines optimisation also has the potential to save costs and avoid spend on wasted medicines as found in a pilot carried out by Bath and North East Somerset CCG .
From April 2020, CPs will be required to become Level 1 Healthy Living Pharmacies (HLP), creating teams that are aware of local health issues and consistently demonstrate they are promoting public health . This requires trained healthy living champions be in place to deliver interventions on key issues such as smoking and weight management as well as providing wellbeing and self-care advice, and signposting to other relevant services.
A range of interventions are already being delivered within community pharmacy settings including smoking cessation, weight management, sleep disorders, cardiovascular disease, women’s health and sexual health. A review by NICE  found mixed support for the use of CP interventions to provide information, advice, education or behavioural support on a range of health conditions. With regards to the provision of information, several studies found that information increases leaflet uptake but there was limited evidence or inclusion of outcome measures to understand if the provision of information led to healthy behaviour change.
Evaluating the success of delivering such interventions via CP in respect of uptake and models of delivery, will be helpful to understand their role in supporting population health. Research that also identifies the mechanisms by which CCGs and CPs can identify and improve appropriate uptake of services and those that have the potential to bring the most benefit to the local populations they serve, is needed to inform if and how these services should be delivered.
A key factor in determining the effectiveness of extended community pharmacy services is their acceptability amongst users and the public. A recent systematic review (2018)  including 30 studies exploring patient and public perspectives of community pharmacies or pharmacist’s role, suggests patients and public have perceptions of community pharmacy services but there is low awareness of services provided by CP’s beyond dispensing of medicines i.e. extended community pharmacy. There is also some evidence to suggest there are certain health issues that service users may not feel comfortable discussing within a CP setting due to concerns about confidentiality e.g. reducing alcohol consumption  and a lack of understanding from the public of the skills and competencies of community pharmacy staff and the free local health and wellbeing services they offer . These issues could limit their uptake.
In all areas, integration with existing primary care and social care is important for the sustainability of these extended community pharmacy services. Integration is especially important for primary care health care services, in order to maintain their ability to deliver holistic person-centred care. Previous research funded by the NIHR  has identified the importance of integration and communication between community pharmacies and other services e.g. GP practice in delivering quality care in CP settings.
In the future, there is also the potential for CPs to deliver other services in addition to those mentioned above. Novel interventions and models of integrating community pharmacy services into existing care pathways will also be considered and are encouraged in applications.
1. NHS England. NHS Long Term Plan. 2019. Available Online. Accessed March 2020.
2. Anderson C, Sharma R. Primary health care policy and vision for community pharmacy and pharmacists in England. Pharm Practice, 18. 2020. Available Online. Accessed May 2020
3. NHS Digital. General Pharmaceutical Services in England 2008-09 – 2018/19. 2019. Available Online. Accessed May 2020.
4. The Community Pharmacy Contractual Framework for 2019/20-2023/24: supporting delivery for the NHS long term plan. 2019. Available online. Accessed March 2020
5. Marmot, M., Allen, J., Boyce, T., et al. Healthy equity in England: The Marmot review 10 years on. Healthy Equity for England. 2020. Available Online. Accessed March 2020.
6. Todd, A., Copeland, A., Husband, A., Kasim., A and Bambra, C. The positive pharmacy care law: an area level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England. BMJ Open, 2014.
7. Thomson, K., Hillier-Brown, F., Walton, N., et al. The effects of community pharmacy-delivered public health interventions on population health and health inequalities: A review of reviews. Preventative medicine, 124. 98-109. 2019.
8. NICE. Community Pharmacy promoting health and wellbeing. Quality Standard. 2020. Available Online. Accessed April 2020.
9. de Barra M, Scott CL, Scott NW, et al. Pharmacist services for non-hospitalised patients. Cochrane Database of Systematic Reviews 2018, Issue 9. Art. No.: CD013102.
10. NHS England. NHS Community Pharmacist Consultation Service (CPCS) – integrating pharmacy into urgent care. 2020. Available online. Accessed March 2020.
11. Pharmaceutical Services Negotiating Committee. Contractual and regulatory changes during the pandemic. 2020. Available Online. Accessed May 2020.
12. Nazar, H., et al. A systematic review of the role of community pharmacies in improving the transition from secondary to primary care. Br J Clin Pharmacol 80(5). 2015.
13. Nazar, H., Brice, S., Akhter, A., et al. New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation. BMJ Open. 2016. Available Online. Accessed March 2020.
14. Welsh Pharmaceutical Committee. Pharmacy: Delivering a Healthier Wales. 2019. Available online. Accessed April 2020.
15. The Pharmaceutical Journal. Community pharmacy medicines optimisation boosts cost savings. The Pharmaceutical Journal. 2017. Available Online. Accessed April 2020.
16. NICE. NICE Guidance: Community Pharmacies; NG102. 2018. Available online. Accessed March 2020.
17. Hindi AMK, Schafheutle EI, Jacobs S. Patient and public perspectives of community pharmacies in the UK: A systematic review. Health Expectations, 21. 2018.
18. Jacobs S, Bradley F, Elvey R, Fegan T, Halsall D, Hann M, et al. Investigating the organisational factors associated with variation in clinical productivity in community pharmacies: a mixed-methods study. Health Services Delivery Research, 5(27). 2017.
Relevant NIHR Studies
PHR 14/186/11 - Community pHarmaciEs Mood Intervention STudy (CHEMIST). Feasibility and Pilot Study. CI – David Ekers; Completed 2019
RfPB PB-PG-0815-20053 - Telephone delivered Incentives for Encouraging adherence to Supervised methadone consumption: development and feasibility study for an RCT of clinical and cost effectiveness (TIES). CI – Nicola Metrebian; Completed 2019
Fellowship KMRF-2015-04-007 - Optimising knowledge mobilisation surrounding antibiotic utilisation in the community setting. CI – Raheelah Ahmad; Start date – 01/06/2016; End date – 31/05/2019
PGfAR RP-PG-0609-10181 - Optimising pharmacist-based treatment for smoking cessation. CI – Robert Walton; Start date – 01/04/2012 End date 14/11/2019
HS&DR 11/1025/5 - Investigating the organisational factors associated with variation in clinical productivity in community pharmacies. CI – Sally Jacobs; Published 2017
PHR 12/153/52 - Community pharmacy interventions for public health priorities: a systematic review of community pharmacy delivered smoking, alcohol and weight management interventions. CI – Carolyn Summerbell; Published 2016
PRP 029/0124. Understanding and appraising the new medicines service in the NHS in England. CI Rachel Elliot; Start date 01/01/2012 End date 28/02/2014.
RfPB PB-PG-0408-16082 - Evaluation of outcomes, costs and benefits of a community pharmacy based cardiovascular risk assessment service. CI – Alison Blenkinsopp; Completed 2012
Fellowship RTF/01/015 - Exploring the integration between community pharmacists and general practitioners: a novel application of social network analysis. CI – Fay Bradley; Start date 01/01/2009; End date 31/12/2011
HTA 15/113/01 - A randomised controlled trial to determine the effectiveness of bridging from emergency to regular contraception: The 'Bridge-it' study. CI – Sharon Cameron; Start date 01/04/2017; End date 31/03/2020
RFPB PB-PG-0815-20042. A novel smartphone app for increasing medication adherence in patients prescribed antihypertensive medication in a community pharmacy setting randomized feasibility study. CI – Stephen Sutton; Start date 01/10/2017 End date; 31/03/2020.
RfPB PB-PG-0317-20010. Optimising post-discharge medicines-related care for older people living with long term conditions. CI- Justine Tomlinson Start 01/09/2018 End date; 31/03/2021
NIHR Fellowships DRF-2016-09-163. A text message intervention to support medicines adherence mobilized through community pharmacy (TIMELY). CI Gemma Donovan; Start 01/10/2016 End 30/09/2021.
HS&DR NIHR129209. NHS Health check programme: a realist review. CI Geoff Wong. Start date 01/03/2020 End date 31/05/2021.
PGfAR RP-PG-0514-20009. Improving the safety and continuity of medicines management at care transitions. CI; Jonathan Silcock & Peter Gardner. Start date 01/03/2016 End date 31/03/2022.
PGFAR RP-PG-0216-20002. Community pharmacy; highlighting alcohol use in medication appointments (CHAMP-1) research programme. CI Jim McCambridge Start date 01/01/2018 End date 31/12/2022.
Other Relevant Studies
On-going non-primary studies
Shweta Pathak, Carrie Blanchard, Beth (Elizabeth) Moreton, Ben Urick. A Systematic Review of the Impact of Telepharmacy Services in the Community Pharmacy Setting on Care Quality and Patient Safety. PROSPERO 2020 CRD42020129511 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020129511
Adam Rathbone. Social prescribing in community pharmacy: a systematic review and thematic synthesis of existing evidence. PROSPERO 2019 CRD42019135729 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019135729
Ranjita Dhital, Glenn Robert, Carolina Vasilikou, Rama Gheerawo, Jacqueline Sin. Systematic review on the effects of the physical and social aspects of the community pharmacy environment on pharmacy patients' and staffs' engagement with pharmacy health services. PROSPERO 2018 CRD42018075031 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018075031
Marianna Liaskou, Margaret C Watson, Alistair Brandon-Jones. A systematic literature review of collaboration models involving community pharmacists and general practitioners. PROSPERO 2018 CRD42018087846 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018087846
Joy Thorneycroft, Helen Pattison, Hannah Church, Jonathan Ross. A systematic review of sexual health interventions based in community pharmacies. PROSPERO 2018 CRD42018096287 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018096287
Chase Kooyman, Matthew Witry. The developing role of community pharmacists in facilitating care transitions: a narrative review . PROSPERO 2017 CRD42017060977 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017060977
Natalie Weir, Andrew Laird, Rosemary Newham, Marion Bennie, Emma Dunlop Corcoran, Nouf Abutheraa. A systematic review of barriers and facilitators to national implementation strategies within community pharmacy. PROSPERO 2016 CRD42016038876 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016038876
Manon Kieffer, Michael Twigg. A systematic review of community pharmacist interventions aimed at managing and supporting patients with type 2 diabetes. PROSPERO 2015 CRD42015026442 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015026442
Seston EM, Magola E, Bower P, Chen L-C, Jacobs S, Lewis PJ, Steinke D, Willis SC, Schafheutle EI. Supporting patients with long-term conditions in the community: evaluation of the Greater Manchester Community Pharmacy Care Plan Service. Health and Social Care in the Community; 2020. Available Online. Accessed May 2020.
Katangwe T, Bhattacharya D, Twigg MJ. A systematic review exploring characteristics of lifestyle modification interventions in newly diagnosed type 2 diabetes for delivery in community pharmacy. International Journal of Pharmacy Practice. 2019 Feb; 27(1): 3-16. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ijpp.12512
National Association for Primary Care. Primary care home: community pharmacy integration and innovation. 2018. Available Online Accessed April 2020.
Stokes G, Rees R, Khatwa M, Stansfield C, Burchett H, Dickson, K, Brunton G, Thomas J (2019) Public health service provision by community pharmacies: a systematic map of evidence. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University College London. 2019. Available Online. Accessed May 2020.
Healthy Living Pharmacies https://www.healthylivingpharmacies.org/ Accessed April 2020.