PHARMACY FIRST – A Waiting Times Panacea Or an Anti-Microbial Resistance (AMR) Time Bomb

The Waiting Times Problem

The NHS's announcement of Pharmacy First scheme, which will allow community pharmacists to prescribe and dispense of antibiotics independently for seven minor infections, has drawn mixed reactions across different professional and stakeholder groups[1,2,3]. This policy direction has been in response to a nagging failure of the British healthcare system in the form of poor patient access otherwise called long waiting times.

'Waiting time', the duration between logging an intent to access healthcare and the actual healthcare appointment, is both a feature and a bug of the British healthcare system. While generally perceived as a flaw, it has the inherent utility of acting as a rationing mechanism for optimal healthcare consumption[4]. In recent times, however, waiting times have veered more to the bug end of this spectrum, a situation worsened by the COVID-19 pandemic. It is estimated that the median referral-for-treatment waiting time in 2023 was about 14.5 weeks, about double the median waiting time of approximately 7.5 weeks in the pre-pandemic era [5]. Similar waiting times statistics are seen in primary care with about 1 in 6 patients having to wait for over 2weeks to see their GPs[6] and others unable to reach their GPs at all [7]

A Proposed 'Waiting Times' Solution

In addition to the increased healthcare demand, there is a simultaneous decline in available primary care capacity, particularly in the GP practitioner workforce [7]. In response, health policymakers must explore options to increase primary care capacity. One such strategy which has been successful in the UK has been the 'Minor Ailment Scheme', a scheme where the management of minor non-infectious illnesses is delegated to pharmacists [8].

Following this success, NHS England in 2023 proposed the ‘Pharmacy First’ scheme with the same philosophy, albeit, focused on common 'minor infectious diseases'. The 7 conditions captured in the scheme include sinusitis, sore throat, earache, infected insect bites, impetigo, shingles, and uncomplicated UTIs. Alongside other community pharmacist-led health access initiatives like the blood pressure check and the oral contraceptive services, it is projected that these pharmacy-led services will free up about 10 million GP appointments by 2025 [9].

The Problems with the Solution

The primary concern with the Pharmacist First scheme is its potential to exacerbate antimicrobial resistance (AMR). It is estimated that in 2019 AMR accounted for over one million deaths worldwide, with projections of over 10 million deaths per annum by 2050 if not curbed. Beyond health outcomes implications, AMR could potentially result in a significant economic loss amounting to trillions of dollars[10]. With declining interest in new antibiotic drug development by ‘Big Pharma’[11], the outlook for AMR is certainly concerning and those raising the alarm ought to be taken more seriously.

A discussion of how some aspects of the Pharmacy First scheme as currently constituted may contribute to exacerbating AMR is warranted:

Firstly, of the seven conditions on the list, at least half pose considerable diagnostic complexity. Conditions like sinusitis, sore throat, and earache can be caused by viruses, bacteria, and/or fungi; and it is not usually easy to differentiate between these causative organisms clinically. In some cases, primary bacterial infections may be treated without antibiotics while viral conditions superimposed with bacterial infections may require antibacterial treatment. This diagnostic complexity is further compounded by the expectation on community pharmacists to perform certain clinical examinations for which they may not have the required competencies.

Secondly, with the community pharmacist workforce itself in decline[12], the Pharmacy First scheme is bound to create additional work pressures as voiced by community pharmacists in this survey[13]. More so, patients with poorly informed expectations regarding the scheme could potentially worsen these pressures on the pharmacist.

Lastly, a key role of pharmacists in upholding antibiotic stewardship is that they act as a final layer of scrutiny for antibiotic prescriptions. With this scheme, community pharmacists must be both the prescribers and the checkers of their own prescriptions, effectively eroding that extra layer of scrutiny. These factors acting alone or in concert can potentially increase antibiotic prescription rates predisposing to antimicrobial resistance.

It Can Work, It Will Just Need to be Reworked!

The NHS, Pharmacist bodies, and Pharmacy chain representatives appear confident that AMR is not likely to worsen, despite providing little data (whether from the literature or pilot studies) to back up this position.

A cursory search of the literature suggests that pharmacy-led antibiotic prescriptions may potentially yield positive outcomes for primary care access. However, the available supporting evidence must be placed in the proper context. For instance, one study showed that pharmacist prescriptions in Low and Middle-Income Countries (LMIC) do not increase incidents of indiscriminate antibiotic prescriptions among pharmacists. Also, Pharmacists tended to have a higher awareness of antibiotic resistance and have a more positive attitude towards acting to prevent AMR. However, this study compared pharmacists' prescription of antibiotics to prescriptions from non-pharmacist-run drug stores in LMICs [14].

In the UK, pharmacists have played a key role in antimicrobial stewardship. Surveys of pharmacists in the UK show that most pharmacists are aware of the problem of AMR and act to curb it. The Pharmacy Quality Scheme provides training and tools like the TARGET antibiotics checklist to aid pharmacists in maintaining antibiotics stewardship[15]. Nevertheless, this must be placed within the context of the pharmacist acting as the last line of stewardship rather than as the primary prescriber.

Furthermore, a systematic review of independent and supplementary community-pharmacist antibiotic prescribing showed high cure rates(especially for UTIs), improved care access, improved patient satisfaction, and yielded positive impacts on antimicrobial stewardship[16]. Unfortunately, this review did not distinguish between studies where pharmacists were primary prescribers and those where they offered only supplemental prescription services.

Moving Forward...

The studies cited in the preceding section suggest that if properly administered, the Pharmacy First scheme could potentially deliver on its promise without creating an AMR nightmare. However, there are important caveats within these studies which if not addressed remain valid points of concern for AMR exacerbation.

Fortunately, some of these weaknesses if addressed could position the Pharmacy First scheme for success without exacerbating AMR;

Firstly, pharmacist training must go beyond the patient group direction (PGD) manuals. Where community pharmacists are required to perform clinical examinations, proper in-person training must be provided. Patients must also be educated properly on the scheme and campaigns announcing the scheme must also simultaneously manage patient expectations regarding the high possibility of not requiring or receiving antibiotics treatment.

Secondly, provisions should be made for supplementation of clinical diagnosis with rapid diagnostic test (RDT) kits. In one study, the rate of community pharmacist-led antibiotic prescriptions for pharyngitis was less than half that of primary care physicians when they had access to RDT kits[17]. Thus for conditions with diagnostic complexity, policymakers should invest in RDT kits to aid community pharmacists.

Lastly, policymakers must carefully consider the impact of an additional service on the already strained community pharmacist workforce. As captured in the pharmacist survey for the scheme, only 4% of pharmacists were confident that the service could be delivered efficiently in addition to the existing workload[18]. Careful planning of the rollout of this service must be undertaken to ensure ownership by pharmacists and to reduce pressure-related spikes in antibiotic prescriptions. Furthermore, concerns regarding perverse incentives on the part of pharmacies must be taken into consideration, and care taken in designing the scheme’s funding such that it does not incentivize overutilization of the Pharmacy First service.

In conclusion, the Pharmacy First scheme could be a viable solution for reducing primary care waiting times and even potentially reducing costs, however, care must be taken in its administration given the potential implications for AMR.