Read below to find out about NIHR research that could help community pharmacists and their teams improve and expand their pharmacy services.
Introduction: Community pharmacies are changing
Community pharmacies on high streets across the UK remained accessible and supported people throughout the COVID-19 pandemic. Our local pharmacies are at the heart of NHS primary care services; their teams interact with 1.6 million people every day. From this strong base, their role is now being expanded and transformed through the Community Pharmacy Contractual Framework (2019-2024).
The new direction places more emphasis on providing advice and healthcare services for people in the community. The aim is for community pharmacies to emphasise self-care. For many people, they will be the first point of contact to support healthy living, and for minor illnesses.
These changes could improve people’s access to health services, and ease the demand on general practice and urgent care. But community pharmacies are themselves struggling to recruit. In January 2022, there was an estimated shortfall of more than 3,000 community pharmacists in England.
New national services have been introduced, and people calling their GP practice or NHS 111 can be referred for a same-day, face to face consultation with a pharmacist. There are plans to develop services further, for example, to improve access to palliative care medicines. Insight from research could ensure that changes are based on evidence.
This Collection brings together messages from research highlighted in accessible summaries - NIHR Alerts - over the past couple of years. It provides useful information for community pharmacists and their teams, and those commissioning their services.
Help people to manage their medicines
“My father was relatively on the ball. He knew what he was doing. But he was becoming frailer and had been very dependent on my mother to help him manage his medication. But she was getting to a point where she couldn’t. But nobody kind of realised and she thought she was still managing.” Participant in a study exploring medication management in older people
Community pharmacies are well-placed to support people with their regular medication, and can provide useful resources such as reusable boxes for daily pills. This is especially helpful for people with multiple health conditions who take a complex array of medicines.
Managing multiple medicines is hard work, and a huge responsibility for people in the community and their family or carers. Recent research explored this burden on older people and those reaching the end of their life, and suggested ways that community pharmacy teams and others could help.
A key finding from the first study was that older people and their families may not tell anyone when they find managing medication a burden. Pharmacists, doctors and nurses could help by considering this burden in the same way as they think about possible side effects when they give a new or different medicine. The study suggests that health and care staff need a simple strategy, such as asking a couple of questions, to find out who is not coping and needs more help, advice or support.
The second study showed that pharmacists and other healthcare professionals were not equally aware of the difficulties people faced in managing medicines towards the end of life. Some, more than others, recognised the need to be proactive in offering help. The research suggested simple, quick methods to reduce the burden on patients and their families. These included:
- writing clear instructions on the box
- giving out laminated prompt cards for patients to record daily doses and wipe clean each week
- asking direct questions about how patients take their medications, and any problems they experience.
Timely access to medicines
Palliative medicines
NICE guidelines recommend that community pharmacists, along with other healthcare practitioners in the community, should support end of life care for people at home. For example, some community pharmacists in England are paid to stock a core list of palliative medicines for pain and other symptom control. This gives people timely access to relief. Recent research gathered views from community pharmacists and other healthcare professionals. They were asked how effective the system for providing palliative medicines to people at home is, and what makes a difference to their ability to support patients’ access to medicines.
The study found that several factors prevent palliative medicines services at community pharmacies from reaching their potential. For example, community pharmacists did not always know whether patients were receiving palliative care. Half of those surveyed (112/219) felt this always or often affected their ability to help patients access medicines. Short expiry dates for palliative medicines also drove them to limit their stock. Greater integration and better communication between services would help. For example, community pharmacists need to be able to access GPs’ registers of patients receiving palliative care.
Contraceptive pills
“I think it was good because I probably would’ve taken a lot longer to figure it out and how to get it [the contraceptive pill] myself. And it was really convenient. It made me kind of realise that it was time to go on one and that it was something I did need to do.” Participant in a study about pharmacists providing contraception
Women may go to community pharmacies for emergency contraception after unprotected sex or a burst condom. Pharmacists can supply emergency contraception pills, and at the same time, are in a good position to advise women to get reliable long-term contraception. But it can take time to get the necessary appointment with their GP or at a sexual health clinic.
Community pharmacists are well-placed to provide a short supply of oral contraception to bridge this gap. Recent research found that a small supply of the progestogen only pill, given along with emergency contraception, helped women get started with effective contraception.
As a result of this study, pharmacists in Scotland can now provide a bridging supply of contraception for 3 months to women who need emergency contraception. The intervention could be rolled out widely to increase access to contraception and could decrease unintended pregnancies across the UK.
More support for people who use drugs
“There was no water actually and I had to use a bit of saliva. It worked, I still got my hit, but I also got the worst infection of my life, I nearly died … Yeah, I was in hospital for nearly 3 months. Septicaemia.” Participant in a study exploring alternatives to sterile water among people who inject drugs
Community pharmacists and their teams support and provide treatment for people who use drugs, as well as offering harm reduction services and advice. But the Royal Pharmaceutical Society recommended in 2021 further actions that could reduce the harm and improve the health of people who use drugs. Recent research highlights ways services could be improved.
Some pharmacies offer a needle and syringe exchange service for people who inject drugs; this promotes safe injection and reduces the spread of viruses. However, because of local budget constraints, most injection packs do not contain sterile water for injection. As a result, research found that homeless people were using puddle water, alcoholic and soft drinks, toilet cistern water and saliva to prepare injections when sterile or clean water was not available. Using unsterile water can increase the risk of bacterial and fungal infections; using alternatives such as saliva can be life-threatening. Pharmacies could distribute water for injection more widely and help meet the realities of drug users living on the streets.
Misusing drugs has been associated with many poor health outcomes. For example, recent research showed poor outcomes among people with asthma who had current or past opioid use disorder. People were less likely to attend an annual asthma review, and more likely to use the oral steroid prednisolone (a sign of an acute asthma attack), than people without a history of opioid misuse. They were also likely to miss out on flu immunisation. Pharmacies which provide opioid substitution therapy could promote flu vaccination alongside medication pick up, the research suggested. This is already happening in Sheffield, and vaccination rates have gradually improved.
Help overcome misconceptions about skin conditions
“I avoid eating sweets but if I eat one piece of chocolate, my family tell me that’s the reason I break out. If I leave my face towel on the couch for one second, they tell me that’s the reason I break out.” A study participant’s experience of living with acne
Misconceptions about the common skin conditions acne and eczema can be a barrier to effective management, recent reviews found. People with acne often blame themselves for their condition, wrongly thinking it is caused by their diet or skin care routine. People with eczema may be reluctant to use creams containing corticosteroids because they believe they can lead to skin damage and other long-term negative effects. Both conditions are common but people often do not realise they require long-term treatment; this can lead to frustration and disappointment.
Community pharmacists are well-placed to address these misunderstandings since people often use them as a source of advice and treatment. They could help people understand what to expect from acne and eczema treatments. For example, how long acne treatments take to start working, what to do about side effects and how to use them appropriately over the long-term. And that eczema creams containing corticosteroids are safe and effective, provided they are used correctly. Pharmacists could also signpost people to reliable sources of information and help reassure them that they are not to blame for their condition.
Offering innovative services
The Community Pharmacy Contractual Framework highlights the future of pharmacies as an integral part of the NHS in England, delivering services as a full partner in local primary care networks. This will include expanding the evidence-based services they offer. Research can help inform future plans.
IRIS (Identification and Referral to Improve Safety) is a national programme to help GPs identify patients experiencing domestic violence and abuse, and refer them to specialist support services. Research has shown that IRIS works as well in the real world as it did in the original clinical trial. It led to a 30-fold increase in referrals for domestic abuse, meaning that many more vulnerable women accessed the help and support they needed. More recent research, by some of the same researchers, concluded that, with ongoing training and funding, community pharmacies could play a role in identifying and referring victims of abuse. Pharmacies supply up to 50% of all emergency contraception, which may be a sign of domestic violence and abuse. The researchers are working with pharmacists to adapt the standard IRIS training for them.
Another innovation is for people with heartburn, which is caused by acid reflux from the stomach up into the gullet (oesophagus). This common condition is usually treated with acid suppressant medicines, which people may collect from their pharmacy for many years. But acid reflux can lead to a pre-cancerous throat condition called Barrett’s oesophagus. At present, there is no easy way within primary care to check for Barrett’s oesophagus, so many people who complain of heartburn are referred for an endoscopy. Recent research has shown that an innovative swallowable sponge (a Cytosponge), suitable for use in primary care, can detect the condition. This simple new technique could serve as a screening tool for early oesophageal cancer. General practice nurses administered the Cytosponge during the study, but the researchers are exploring how community pharmacies could be involved to ensure this technology is available to more people.
Conclusion
Community pharmacies are changing. In recent years, they have gone way beyond their traditional role of dispensing prescription medications. They now offer an increasing range of clinical and public health services to help people look after themselves. Every week, pharmacies advise more than 865,000 people about their symptoms.
As the role of community pharmacies evolves, it is important that changes are underpinned by research evidence. This Collection provides examples of ways to improve and expand their services.
Community pharmacies are changing, in recent years, they have gone way beyond their traditional role of dispensing prescription medications.
With the expertise they have, community pharmacists and their teams could be more proactive in helping people to manage multiple medications. Research suggests that they consider the burden of treatment in the same way as they already think about side effects when they dispense new or different medications. Other suggestions include giving out wipeable laminated prompt cards for people to record daily doses. Timely access to medicines is important, especially for people nearing the end of life. Pharmacies are well-placed to help, but adjustments such as better access to palliative care registers of patients held by GPs, would allow them to do more. Many community pharmacies already support people who misuse drugs. But again, small changes could make big differences. Providing sterile water with injection packs could reduce infections in people living on the streets; promoting flu vaccinations alongside opioid substitution therapy could improve vaccination rates for those with asthma.
Community pharmacies already provide emergency contraception, but this service could be expanded to allow them to offer women a short supply of a contraceptive pill at the same time. This would increase access to contraception and potentially reduce unintended pregnancies. Emergency contraception can be a sign of domestic violence and abuse. A future role for pharmacists could be to join the IRIS programme to help identify victims and refer them to specialist services. Additional resources and training would be needed.
Community pharmacies are a hugely important part of NHS primary care services. People rely on their accessibility, support and advice. This Collection provides examples of NIHR research that could help them further support their local communities.
You may be interested to read
Community pharmacy explained: this Kings Fund article how pharmacies are contracted and funded, the types of services they provide and future trends in the sector.
How to cite this Collection: NIHR Evidence; Making the most of community pharmacies; December 2022; doi: 10.3310/nihrevidence_54936
Author: Jemma Kwint, Senior Research Fellow (Evidence), NIHR
Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
