Would Scotland’s government-backed Pharmacy First program work in Canada?

Pharmacists in Scotland have conducted more than two million consultations since the National Health Service (NHS)’s Pharmacy First Scotland program launched in July 2020, which saw them paid by government regardless of the outcome of the consultation. The program could be a model for Canadian pharmacy regulators and provincial governments to follow to ease the burden on a post-pandemic healthcare system. The NHS Pharmacy First Scotland program allows pharmacists to advise, treat and refer patients who come into the pharmacy with specific common conditions. It’s open to anyone registered with a general practice in Scotland or who lives in Scotland, people in long-term care homes, or people who are experiencing homelessness. More than 1,200 community pharmacies are involved in the service. In some ways, the program mirrors what is currently being practiced by Canadian pharmacists. Pharmacy regulators in eight out of ten provinces allow pharmacists to prescribe for certain minor ailments, with British Columbia and Ontario pharmacists sticking to dispensing for the time being. Yet the NHS Pharmacy First Scotland is miles ahead of any programs offered on this side of the Atlantic, partly because of it being actively promoted by government, partly because of the compensation model. Read: England’s CPhO calls for upgrade of tech and pharmacist skills The program came out of an existing effort called the minor ailments scheme (MAS), available since 2008, explained Adam Osprey, policy and development pharmacist of Community Pharmacy Scotland. MAS was designed to address the needs of cohorts who couldn’t afford their own self-care. “Whereas now with Pharmacy First, it is about using the right professional and the right team at the right place and the right time for your healthcare needs. It’s a whole new slant on the service.” Osprey said, noting pharmacy teams have enjoyed that, because there’s no concern about whom they can help. Of the more than two million consultations carried out so far, only 4% of patients seen by pharmacists had to be referred to a physician. More than 200,000 of the consultations were for UTIs, impetigo or minor skin infections. These are patients who'd normally go to a family physician or to an emergency department. “It takes a burden off the rest healthcare service,” Osprey said. Promotion One difference to Canadian minor ailment prescribing programs, is that NHS Pharmacy First Scotland is actively promoted to the public by government. Patients are encouraged to seek out care in a pharmacy for minor ailments instead of going to a family physician or emergency department. This has been happening for a while in the wider U.K. In early 2020, the U.K. government launched an advertising campaign to encourage people to seek out a pharmacist for help with minor illnesses. In Canada, it is up to pharmacy associations to inform the public. The Pharmacy Association of Nova Scotia (PANS) currently has television, radio and print ads informing patients about the services provided at pharmacies, but as yet there’s been little or no promotion from the provincial government. In Alberta, where pharmacists have the widest scope of practice, informing the public is mostly left to the Alberta Pharmacists’ Association, according to Matt Tachuk, director of pharmacy practice at the Alberta Pharmacists’ Association. Read: Manitoba pharmacists now able to assess, prescribe for bladder infections Pay With NHS Pharmacy First Scotland, pharmacists are paid regardless of the outcome of the consultation. This contrasts with some Canadian practices. In Saskatchewan, pharmacists are only compensated for their time if they end up prescribing a medication. If the end result is a referral to another healthcare professional or a suggestion of an over-the-counter product, the pharmacist isn’t paid. “We believe the consultation should be compensated regardless of the outcomes,” said Myla Bulych, director of professional affairs of the Pharmacy Association of Saskatchewan. In Manitoba, pharmacists are compensated for assessments of minor ailments such as uncomplicated cystitis, up to a limited number per patient per year. In Nova Scotia, pharmacists are paid for assessments of certain conditions, such as UTIs or contraception management, up to a limited number per patient per year. With NHS Pharmacy First Scotland, the end result of a consultation could be an over-the-counter medication, a prescription or a referral to another healthcare service. It gives patients a wider range of options when they seek care. “I think pharmacists have appreciated the fact that it is really a consultation-led service, and all the narrative has been very strong around that, trying to get rid of inadvertently setting up an expectation that there’s going to be a supply of medication made,” Osprey said. Pharmacists are paid using a base and fill model. “Every single pharmacy gets £1,250 regardless of what they do. If they do more than 100 consultations, then they can get funds from an activity pool,” Osprey said. The activity pool is a set amount of money shared among pharmacies. For example, if there are a total of 1,000 consultations a month and one pharmacist does 100 of them, then that pharmacist will get 10% of the funds in the activity pool. Over time, the base payment will decrease and the activity pool will increase, so “people will be more accurately rewarded for the actual work they are doing,” Osprey said. The initial base amount was to help pharmacies as they transferred from MAS to the new program, because the MAS was based on registration instead of consultation. Funding for NHS Pharmacy First Scotland has been secured for a number of years and Osprey said members of Community Pharmacy Scotland are pleased with the level of government investment. Scope of practice While the program comes with an expansion in the scope of practice, more conditions may be added in the near future. The Scottish Health Secretary Humza Yousef said on November 9 that the government is considering expanding the range of clinical conditions that can be treated by pharmacists, Chemist and Druggist reported. Sore throats could be one of the next ailments that pharmacists could treat through the program, according to The Pharmaceutical Journal. Like in Canada, pharmacists in Scotland require extra training before they are able to prescribe for common conditions. NHS has a board that deals with education (NHS Education Scotland) which develops the training packages for the pharmacists. Read: Rash or resourceful? Uproar over Ontario's go-ahead for pharmacies to test those with COVID symptoms Osprey said that pharmacists welcomed the expansion of the scope of practice. He said they enjoy being able to help a patient in need, rather than send them out to get a prescription for a medication the pharmacist knew the patient needed in the first place. “It adds to the toolbox that pharmacists have to help the person that’s right in front of them,” Osprey said. Future plans NHS Pharmacy First Scotland may expand further. There are plans for a community pharmacy hospital discharge and medicine reconciliation service, which will help speed up the process for people being discharged from hospital, according to Chemist and Druggist. Scotland also has a Pharmacy First PLUS service where qualified prescribers can treat even more patients. “Our aim is that in eight to 10 years we’d have a prescribing pharmacist in every pharmacy,” Osprey said. A report by family physicians in England suggested that NHS England should adopt a Pharmacy First program, The Pharmaceutical Journal said. In Canada, pharmacists in the midst of COVID-19 and flu vaccinations may not currently have the energy or time to dedicate to more consultations, but there is appetite to expand the scope of practice eventually. “We’re all trying to get to the same scope as Alberta,” said Diane Harpell, chair of the board of Pharmacy Association of Nova Scotia and pharmacy-owner of The Medicine Shoppe in Dartmouth, Nova Scotia. “Nova Scotia is one of the leaders, but I won’t be satisfied until we have basically full prescribing rights so we can help the healthcare system more and more,” she said. In Alberta, pharmacists with additional prescribing authorization can prescribe schedule 1 drug or blood products, adapt prescriptions and prescribe in an emergency. “We’re already doing a lot, but there’s so much more opportunity,” she said. Osprey said that Community Pharmacy Scotland members are proud of the NHS Pharmacy First Scotland program, saying that it leverages the accessibility that pharmacy can offer to help people stay well close to home. “It has given us a strong and stable base from which to work,” Osprey said. Read: Minor ailment prescribing—An update

Would Scotland’s government-backed Pharmacy First program work in Canada?

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