Use of the Pharmacy First service in England in the first 12 months: geographic variation and health system context

Technical Summary: Use of the Pharmacy First Service in England in the First 12 Months

Problem Statement
The English primary care system has faced long-standing supply constraints, characterized by increased demand, longer appointment waiting times, and delayed specialist referrals, a situation exacerbated by the COVID-19 pandemic. To address these pressures, the NHS Primary Care Recovery Plan (2023) identified expanding the clinical role of community pharmacists as a strategic priority. Consequently, the Pharmacy First (PF) service was launched across England on January 31, 2024. This service allows patients to access assessment and treatment for seven specific clinical conditions (acute otitis media, uncomplicated urinary tract infection, acute sore throat, sinusitis, impetigo, shingles, and infected insect bites) directly through community pharmacies. While previous minor ailment schemes were locally commissioned and fragmented, PF aims to provide a standardized national approach. However, evidence regarding its implementation, geographic variation, and operational patterns within the first year remained limited, necessitating a comprehensive analysis of its uptake, outcomes, and cost implications.

Methodology
This study presents a descriptive analysis of the first 12 months of PF implementation (February 1, 2024, to January 31, 2025). The research utilized routinely collected administrative data from the NHS Business Services Authority (NHSBSA), specifically consultation data submitted for payment and antimicrobial supply data from the ePACT2 dashboard.

• Data Linkage: Pharmacy-level consultation data were linked to national datasets regarding population demographics, location, and pharmacy characteristics via postcode. Pharmacies were mapped to Lower Super Output Areas (LSOAs), Sub-Integrated Care Board (ICB) areas, ICBs, and NHS England regions.
• Metrics: Two primary metrics were constructed to capture service activity:
  1. Consultations per 1,000 eligible population: To represent population-adjusted uptake and patient demand. Eligibility was based on condition-specific age and sex criteria.
  2. Consultations per pharmacy: To represent delivery intensity and provider engagement.
• Financial Analysis: The study analyzed reimbursement costs, including initial fixed payments, monthly fixed payments (contingent on consultation thresholds), and variable per-consultation payments.
• Statistical Approach: The analysis employed summary statistics (mean, median, standard deviation, interquartile range) and inferential statistics (Spearman's rank order correlation) to examine associations between consultation volumes and pharmacy characteristics (e.g., opening hours, business type) and local contextual factors (e.g., deprivation, rural-urban classification, proximity to other healthcare facilities).

Key Contributions and Results

• National Uptake and Volume: Over the first 12 months, 11,349 unique pharmacies delivered 2,205,731 consultations, with a total NHS payment of £122.8 million. Uptake increased steadily over time without evidence of a plateau. Monthly consultations rose from 125,270 in February 2024 to 259,323 in December 2024.
• Clinical Conditions and Outcomes: Acute sore throat (33.4%) and uncomplicated urinary tract infection (UTI) (27.5%) accounted for over 60% of all consultations. Most patients (74.2%) self-referred, and 95% of consultations were managed within the pharmacy without onward referral. Of those managed in-pharmacy, 74.8% resulted in medicine supply.
• Antimicrobial Supply: 69.1% of consultations resulted in the supply of an antimicrobial. Phenoxymethylpenicillin (for sore throat/sinusitis) and nitrofurantoin (for UTI) were the most supplied antibiotics.
• Geographic Variation: Substantial heterogeneity was observed across regions. Northern regions showed higher utilization rates per eligible population, whereas the South East and Midlands demonstrated higher activity per pharmacy. London emerged as a distinct outlier, characterized by higher self-referral rates, lower medication supply, and higher rates of onward referral to other NHS services.
• Pharmacy Characteristics: Consultation volume was weakly but positively associated with pharmacy opening hours, particularly for UTIs. Independent pharmacies accounted for the largest share of total consultations (56.3%), though large supermarket pharmacies had the highest median consultation volumes per pharmacy. Consultation volumes were higher in pharmacies located near GP practices but further from hospitals and walk-in centers, suggesting a substitution effect where PF acts as an alternative when other urgent care is less accessible.
• Financial Thresholds: While the average payment per pharmacy was approximately £10,873, many pharmacies failed to meet the minimum consultation thresholds required for the £1,000 monthly fixed payment. The study noted a "cliff-edge" incentive effect where a single additional consultation could significantly increase revenue (e.g., from £285 to £1,300) when crossing the monthly threshold.

Significance and Claims
The paper claims that the Pharmacy First service achieved immediate and sustained uptake in its first year, operating primarily as a direct-access model for common acute conditions. The findings suggest that PF is successfully contributing to improved access to care and may be shifting demand away from general practice.

However, the authors emphasize that service uptake is not uniform; it is significantly shaped by geographic location, proximity to other healthcare services, and specific pharmacy characteristics. The study concludes that while PF is a nationally standardized policy, its local implementation and impact vary based on the surrounding health system context. The authors note that the service has not yet reached saturation, indicating that public awareness and familiarity are still developing. They caution that while the service shows promise in alleviating GP pressure, the full potential of freeing up 10 million GP appointments has not yet been realized, and ongoing evaluation is required to understand long-term impacts on general practice and urgent care demand. The paper also highlights that the current funding model creates specific financial incentives that may influence pharmacy behavior, particularly around consultation thresholds.