Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion.
The current NHS sustainability and transformation partnerships (STPs) and the Five Year Forward View both aim to improve the integration of healthcare services in the UK. The committee agreed that, as part of this, community pharmacies need to gradually become part of existing health and care pathways. This would mean they could act as health and wellbeing hubs, with inward and outward referrals established and consistently managed.
This will ensure they are aware of what services are offered locally and where formal referrals can be set up. But because it is not clear how to effectively refer in and out of pharmacies to improve people's care, the committee made research recommendation 1.
Once community pharmacies are integrated with other local health and care services, the idea is that they can operate as neighbourhood health and wellbeing centres (health and wellbeing hubs). This means they would become the first place that people go to for support, advice and resources on staying well and healthy. It may involve working closely with community leaders to identify local resources and needs, develop related interventions and services, and collect data on impact and outcomes.
Some investment may be needed to carry out these activities and to set up a formal referral process within community pharmacies. But this is in line with the movement towards better integration of health and care services within the NHS, and national resources are being put in place to support this. For example, the Pharmacy Integration Fund was established to support clinical pharmacy integration within the NHS and the community.
Community pharmacies offer a socially inclusive, easily accessible service for all members of the public and, as such, should be the first place people go for help with a non-urgent health issue. A key way to encourage more people to use services is to ensure they are fully integrated within the health and care system – including with other pharmacies.
Better integration of community pharmacies in the wider health care system will have a positive impact on patient choice and result in better health outcomes for people in both primary care and the community.
The committee agreed that if more people are to use the interventions on offer they need to know what they can expect, regardless of which pharmacy they visit, so a consistent standard of service is important.
A typical community pharmacy is staffed by people with various levels of training and competencies in health promotion services. Healthy Living Pharmacies also have qualified health champions who take responsibility for the healthy living programme.
But there is a lack of research on how the training or other characteristics of the person delivering a health and wellbeing intervention influence its effectiveness or cost effectiveness. This includes a lack of research on whether using a recognised behaviour change competency framework (see NICE's guideline on behaviour change: individual approaches) has an impact on this. So the committee made research recommendation 4.
Evidence showed that people are more likely to trust information resources that are clear, professional and relatively free of any commercial links. The latter is particularly important because it makes it clear that there is no profit motive behind any information given.
An expert pointed out to the committee that because of their accessibility, community pharmacies could address health inequalities. In England, 90% of people (99% in the most deprived communities) live within a 20‑minute walk of a community pharmacy.
But more research is needed to determine whether community pharmacies are better than other health services at reaching underserved groups. In addition, there is no evidence on how these services should be tailored to benefit different groups. (People from different ethnic or socioeconomic groups, or of different ages, may gain more or less from the services on offer.) So the committee made research recommendation 3.
Another way to encourage the public to make full use of community pharmacy interventions could be to make them aware that many staff are qualified or specialists in certain areas. This could improve the public's perception of the pharmacy as a trusted source of health and wellbeing advice and support.
Community pharmacy interventions to help improve people's physical and mental health and wellbeing are usually delivered as the opportunity arises – when people come in for prescriptions, buy other products or make general enquiries.
The committee agreed that identifying opportunities to provide interventions and referrals should be encouraged. It would mean that more people using pharmacies could get support, either from the pharmacy itself or from other local multidisciplinary teams, to prevent health problems from developing or deteriorating. This, in turn, would reduce the burden on other areas of health and care.
Establishing links to integrate community pharmacies with other health and care organisations may result in upfront costs such as the time it takes to develop pathways and make a referral. But this may be offset by:
more efficient use of resources in the wider system
better continuity of care
quicker access to the right treatment (including for underserved or underprivileged communities).
It may not always be practical or feasible for the same member of staff to deliver all sessions of an intervention, but where it is possible this will reduce variation in current practice.
Identifying underserved groups and tailoring interventions to suit an individual's needs and preferences may increase service uptake in these groups and help community pharmacies to potentially address health inequalities.
Promoting community pharmacies by highlighting the services on offer and the skills of pharmacy staff may have some resource impact. But this may be offset by an improvement in health outcomes resulting from more people using the services.
It may not always be practical or feasible to seek opportunities to promote health and wellbeing services within the pharmacy. But if staff are trained to identify opportunities to offer services then there should be no significant cost implications. The Making Every Contact Count initiative offers training for health and social care staff on how to identify opportunities to talk to people about their health and wellbeing and deliver brief interventions. Some funding to support or implement this training may be available.
General health and wellbeing advice is covered in general pharmacy training and some pharmacists and pharmacy technicians are trained in core public health priorities. Some staff will also have the Royal Society for Public Health Level 2 award in improving health. Some pharmacy staff may need additional training in effective behaviour change techniques, which may incur a small resource cost. Some free behaviour change training may be available, for example from Health Education England and the Centre for Pharmacy Postgraduate Education.
The way community pharmacies provide information on health and wellbeing varies across the UK, as does the way they present and use these resources.
Evidence showed that providing information to raise people's awareness of an issue is the first step to helping them change their behaviour. Evidence also showed that it is most effective to give people information as part of a discussion, rather than just handing them a leaflet or other resource.
But there is limited evidence on its effectiveness and cost effectiveness for specific issues such as alcohol or drug misuse, diabetes, falls, smoking, cancer, and mental health and wellbeing. So the committee made research recommendation 2.
Speaking to people about the information you want to give them before you hand it out may involve a small amount of additional staff time (to explain why the information is relevant). But this cost could be offset by improved health outcomes and resource savings elsewhere in the health or care system. For example, the person might, as a result, seek advice or receive other support that prevents them from becoming ill or generally improves their health.
Some pharmacy staff, such as those who have become health champions, are competent to provide information in this way.
In addition, pharmacists and pharmacy technicians receive or have access to training in communication and consultation skills as part of their undergraduate, postgraduate and pre-registration training programmes. They can also get free training in these skills from The Centre for Pharmacy Post Graduate Education (funded by Health Education England).
Community pharmacies are well placed to offer health and wellbeing advice and education to everyone in a local community, whether they have a long-term health condition or need help to adopt a healthier lifestyle. However, there is significant variation in what is offered.
Evidence showed that pharmacy staff can provide effective advice and education to people with diabetes and hypertension. It also showed that brief advice can help people stop smoking. There was limited evidence that the use of photo-ageing software to support such advice was effective and cost effective. But based on their experience, the committee agreed that it could be worth trying if resources were available on the premises.
In addition, advice and education can potentially help people reduce their alcohol consumption. But further research is needed to see if it is effective in: improving cancer awareness and people's sexual health and mental health and wellbeing, or preventing drug misuse and falls. So the committee made research recommendation 2.
These recommendations should reduce variation in current practice.
General health and wellbeing advice is covered in general pharmacy training. Some pharmacists and pharmacy technicians are also trained in core public health priorities. Some staff will have gained the Royal Society for Public Health Level 2 award in improving health.
A lot of free training is available for pharmacy staff (such as the smoking cessation training provided by the National Centre for Smoking Cessation and Training). But some may involve a small cost. So pharmacy teams that currently provide the least health and wellbeing advice and education are likely to have the biggest expenditure as a result of implementing the recommendations.
The type of behavioural support offered by community pharmacy teams varies across the UK, so the committee recommended that they follow NICE guidelines for the relevant issue or condition.
Evidence showed that certain behavioural interventions, specifically interventions to help people stop smoking or manage their weight, are effective and cost effective when provided by community pharmacy teams.
Some evidence suggests that interventions delivered in community pharmacies that involve people setting their own health goals may help people improve their patient activation. However, more research is needed to support this and to show how delivering these interventions in community pharmacies can be used to improve people's health. So the committee made research recommendation 5.
Further research is also needed before behavioural interventions can be recommended in pharmacies for: improving cancer awareness, sexual and mental health and orthopaedic conditions, and preventing alcohol or drug misuse, diabetes and falls. So the committee made research recommendation 2.
The committee agreed that written information or support aids given alongside behavioural support may be beneficial. They also agreed that it is worth referring people to other services in the local care network for behavioural support if the pharmacy doesn't provide this itself.
These recommendations should reduce variation in practice and ensure commissioners focus on behavioural support activities that have been shown to be both effective and cost effective.
Some pharmacy staff may need training in effective behaviour change techniques and this may incur a small resource cost. However, local authorities may provide their own training. In addition, some free behaviour change training may be available for pharmacy staff from, for example, Health Education England and the Centre for Pharmacy Postgraduate Education.
Members of the public may need to be directed to other services for support, advice or treatment if it cannot be provided by the community pharmacy.
Formal referrals, involving an agreed process with another provider, may be more effective than signposting (giving people information on other organisations that can help). But often community pharmacy services are not part of a formalised care pathway. That means they cannot always make formal referrals to, or accept them from, other services. It also means that other services may not know what community pharmacies can offer.
An expert told the committee that links with other health and care providers were key to ensure effective continuity of care and to ensure people gain the most benefit from the system. The committee agreed this is particularly important for people who may not use other healthcare services, for example people from underserved groups.
The committee recommended that if community pharmacy teams do offer such a service, fast referrals will be needed for people at risk. In addition, it will be important to ensure people referred on are not reassessed as a matter of routine when they enter the care pathway. (Reassessment is a waste of resources and could also undermine the pharmacist's credibility.)
Based on their experience, the committee agreed it was useful to provide examples of the types of issues that community pharmacy teams could make referrals on, including to GPs, local authorities and social services.
Some evidence showed that people are more likely to take up the offer of a referral if they are given clear details about why they are being referred and what they can expect to happen. The committee also agreed that it was important for pharmacy staff to be fully informed when they accept a referral, so that assessments are not duplicated and people can enter at the correct point in the care pathway.
Some evidence showed that referral by community pharmacy teams increased service uptake more than signposting, but more evidence is needed to support a formal referral process. Establishing cost-effectiveness evidence for this in pharmacies is also important. That's because there may be cost implications for the time needed to make or accept individual referrals and for setting up the overall process, compared with signposting. So the committee made research recommendation 1.
If it is not possible to introduce a formal referral process, signposting people to other organisations is still important because it can increase the likelihood of people using the services. But committee members agreed with the evidence that formal referrals are more effective at increasing the uptake of services.
Recording and sharing information will prevent duplication in the care pathway, build relationships between service providers and encourage collaboration. Auditing could also help improve both efficiency and quality and inform the work of other organisations. But this can only be achieved if the service providers involved have a shared understanding of what data should be recorded and used for analysis (that is, the minimum data sets) and why.
Integrating community pharmacy interventions into health and care pathways will have a positive impact on patient choice and result in better health outcomes for people in both primary care and the community.
Signposting is currently the standard approach within community pharmacies. But clear methods of referral to and from community pharmacies should make it easier for people to access services and increase uptake. Effective referrals will also encourage people to choose the pharmacy as their first point of contact with healthcare professionals, potentially reducing pressure on A&E and GP practices.
In the long term these benefits may offset any upfront costs such as the time it takes to develop pathways and make the referral.
In terms of resource impact, it may not be practical to record every intervention, but it is something that is covered by professional practice, so there is no potential resource impact.