Details of the Advanced Services are outlined in Section 1.5.1.4.2 and the provision in Bexley is provided in Sections 6.2 and 6.3.

Section 6 discusses improvements and better access to services in relation to the health needs of Bexley.

Based on the information available at the time of developing this PNA, no gaps in the current provision of Advanced Services or in specified future circumstances have been identified in any of the localities across Bexley.

Section 7 also discusses the opportunities that may be available for expansion of existing services or delivery of new services from community pharmacies that may benefit the population of Bexley.

Details of the Enhanced Services are outlined in Section 1.5.1.4.3 and the provision in Bexley is provided in Sections 6.2 and 6.3.

Section 6 also discusses improvements and better access to services in relation to the health needs of Bexley.

Based on the information available at the time of developing this PNA, no gaps in the current provision of Enhanced Services or in specified future circumstances have been identified in any of the localities across Bexley.

With regard to LCS, the PNA is mindful that only those commissioned by NHSE are regarded as pharmaceutical services. The absence of a particular service being commissioned by NHSE is in some cases addressed by a service being commissioned through the council or local ICB; these services are described in Section 4.1 and 4.2.

Section 6 discusses improvements and better access to LCS in relation to the health needs of Bexley.

Based on the information available at the time of developing this PNA no gaps have been identified in LCS that if provided either now or in the future would secure improvements, or better access, in any of the localities. Future improvements and better access are best managed through working with existing contractors and improving integration with other services and within PCNs, rather than through the opening of additional pharmacies.

Based on current information, the Steering Group has not considered that any of these LCS should be decommissioned, however the HWB and commissioning organisations may want to consider incentivising community pharmacies to encourage further uptake of services.

Section 7 also discusses the opportunities that may be available for expansion of existing services or delivery of new services from community pharmacies that may benefit the population of  Bexley.

A full analysis has not been conducted on which LCS might be of benefit as this is out of the scope of the PNA.

No gaps have been identified that if provided either now or in the future (next three years) would secure improvements or better access to Locally Commissioned Services across Bexley.

LCS are those services that secure improvements or better access to or that have contributed towards meeting the need for pharmaceutical services in Bexley HWB areas, and are commissioned by the ICB or local authority, rather than NHSE.

Based on current information, no gaps have been identified in respect of securing improvements or better access to Locally Commissioned Services, either now or in specific future circumstances in the next three years across Bexley to meet the needs of the population.

Essential services could be developed as identified below:

• signposting posting for issues such weight management and health checks
• promote a self-referral route to the National Diabetes Prevention Programme
• developing Healthy living pharmacies and self-care to support the Bexley prevention agenda. Working with the local authority public health teams
• electronic repeat dispensing can reduce unnecessary patient trips to the GP practice to collect repeat medication and could help reduce waste medicines

The existing advanced services could be targeted in a way that improves patient access, reduces pressures in general practice, supports the primary care, urgent care, prevention  and medicines safety agendas. The ICB worked well with the community pharmacy teams to support the Pharmacy First Scheme so that the public consider Pharmacy First rather than seeking other primary or more urgent care services.

There are several new or recently introduced Advanced Services being implemented that could be beneficial to the population of Bexley based on the identified health needs, including:

Hypertension case-finding service

The service has two stages. The first is identifying people at risk of hypertension and offering them blood pressure measurement (a ‘clinic check’). The second stage, where clinically indicated, is offering ambulatory blood pressure monitoring. The blood pressure test results will then be shared with the patient’s GP to inform a potential diagnosis of hypertension. The ethnicity of the Bexley population where Coronary Heart Disease is a high risk would benefit from full implementation of the service. Over half the community pharmacies in Bexley have signed up to the service.

Smoking Cessation Advanced Service

The NHS Long Term Plan states all patients admitted to hospital who smoke are to be offered NHS-funded tobacco treatment services by 2023-24. The Smoking Cessation Service (SCS) is a referral service from hospital for patients who have been initiated on smoking cessation to continue their journey in community pharmacy.

Smoking is the highest cause of preventable ill health and premature mortality in the UK. Smoking is a major risk factor for many diseases, such as lung cancer, COPD and heart disease. It is also associated with cancers in other organs, including lip, mouth, throat, bladder, kidney, stomach, liver and cervix. Bexley has a lower smoking prevalence than the England average. The national SCS service is well placed to support Bexley smoking cessation priorities and an additional pathway.

Sexual health services

The chlamydia detection rate of those aged 15 to 24 Bexley was below the figures for England. In addition, under 18 conception rates were lower in the borough than the England averages. This provides an opportunity for the local authority to maximise LCS sexual health services with the community pharmacy network.

The local authority and ICS could explore the interdependencies between the LCS sexual health service and the CPCF Advanced PCS services to provide a more comprehensive service offering.

Based on the local and national health needs identified throughout this document, there are opportunities for community pharmacy to positively affect outcomes. The services detailed below are currently not commissioned within Bexley, however commissioners may wish to consider these to meet the health needs of Bexley. The most appropriate commissioning route would be through the ICS as Enhanced Pharmaceutical services or through the local authority and locally commissioned services, which would not be defined as necessary services for this PNA.

Community pharmacy infrastructure

NHS community pharmacy clinical services are increasingly being commissioned alongside their core dispensing role, creating new demands on pharmacy space, particularly consultation rooms. Many contractors are proactively investing in expanding clinical spaces to accommodate these NHS services, often at their own financial risk, to provide care closer to home for the population in SEL. This demonstrates the untapped potential of community pharmacies in supporting the broader healthcare system.

Despite their contribution, community pharmacies currently fall outside the scope of NHS Premises Cost Directions. Nevertheless, they are required to comply with NHS England's Approved Particulars for Premises, including the provision of consultation rooms for confidential patient interactions. This highlights the need for recognition of the community pharmacy estate as a valuable resource for NHS primary care and locally commissioned services, particularly in terms of premises capacity.

Additionally, community pharmacies bear the cost of their IT infrastructure, often resulting in lower IT maturity compared to general practice due to the diverse range of IT providers in the sector. This lack of standardisation creates challenges for interoperability between general practice and community pharmacy, presenting barriers to the seamless delivery of services and integrated patient care.

To fully harness the potential of community pharmacies, the ICB must consider an investment framework for infrastructure development in this sector. This should encompass workforce development, premises enhancements, and IT upgrades to bolster primary care capacity and capability, enabling community pharmacies to play a more integral role in the healthcare system.

Independent prescribing

Introducing independent prescribing as part of the CPCF will mean pharmacist training and clinical service delivery can be used to work towards an integrated workforce model in primary care (subject to funding and negotiation). This will lead to the development and implementation of integrated clinical services that enables ICBs to commission pathways and more clinical community pharmacy services that will widen primary care access and reduce health inequalities through utilising the increased clinical services community pharmacy can provide in local neighbourhoods.

From September 2026 newly qualified pharmacists will enter the General Pharmaceutical Council register as independent prescribers. For existing pharmacists there will be access to training and education initiatives funded through the NHS England Pharmacy Integration fund.

The development of the community pharmacists to prescribe will complement PCNs and PCN pharmacists and provide increased clinical capacity in the localities as well as opportunities to develop more advanced community pharmacy services where independent prescribing will be integral to delivery.   

The pharmacy team

The pharmacy team can provide the pharmacist capacity by supporting services to assist the lead community pharmacists.

From 26th June 2024, registered pharmacy technicians in England can supply and administer medicines under patient group directions (PGDs), following the amendments made to the Human Medicines Regulations 2012 (note this is not extended to controlled drugs). Front line community pharmacy staff could be developed as healthcare assistants supporting Making Every Contact Count (MECC) interventions.   

The ICB should consider the skill mix implications to deliver CPCF services and provider skill mix support as well as leadership development for lead community pharmacists, analogous to the principles of the 2017 Clinical Pharmacy programme.   

NHS health check

This is a national programme for people aged 40-74 that assesses a person’s risk of developing diabetes, heart disease, kidney disease and stroke. It then provides the person with tailored support to help prevent the condition, advising on lifestyle changes to reduce their risk. Nationally, there are over 15 million people in this age group who should be offered an NHS health check once every five years, and local authorities are responsible for commissioning NHS health checks. Health checks are available from other providers in Bexley, e.g. GP practices.

Diabetes prevalence is lower in Bexley than the England average, but the gap is decreasing, although the prevalences of many of these other areas of ill health are not currently above the national averages. NHS health checks would complement on LCS smoking cessation services, and Advanced SCS and hypertension case-finding services.

Making Every Contact Count (MECC)

Making Every Contact Count (MECC) is a behaviour change using the millions of day-to-day interactions that organisations such as community pharmacy have with the public to support positive changes to their physical and mental health and wellbeing. MECC enables the opportunistic delivery of consistent and concise healthy lifestyle information and enables individuals to engage in conversations about their health at scale across organisations and populations. The evidence base shows that a MECC approach to care could potentially improve the  health of the population.

MECC approach offers opportunities to commissioners for both ICS and local authority services, particularly considering the seven public health areas of Stop smoking: Stop Smoking support; Diet, Nutrition and Healthy Weight; Alcohol consumption; Sexual Health, Reproductive Health & HIV; Substance Misuse; Cardiovascular Disease Prevention, and Public Mental Health.

Opportunities for MECC commissioning could include:

• staying healthy in winter (Winterfit Intervention service) - a winter fit support for the elderly to prevent hospital admissions and providing opportunistic advice to support patients in the harsh winter months
• making sure homes are safe
• making sure homes are warm
• healthy start – providing access to healthy start vitamins through community pharmacy   
• preventing feeling alone
• ensuring good nutrition
• preventing dehydration
• encouraging physical activity
• falls prevention – identifying elderly patients at risk of falls and signposting to appropriate care
• alcohol screening – providing opportunistic screening for patients who could be undiagnosed alcohol dependant and not accessing treatment services

This links into the recent report by Community Pharmacy England 2024 advice audit which highlighted Community Pharmacy provides several million walk-in consultations. This report showed the scale of underfunded work carried out by community pharmacy that potentially saves GP appointments and the increased demand that is placed on community pharmacy teams.     

The findings from Community Pharmacy England’s 2024 Pharmacy Advice Audit, highlighted that community pharmacy provide over 69 million walk-in health advice consultations per year. The report showed the scale of underfunded work pharmacies are taking on, including the number of GP appointments they are saving the NHS annually, and the huge demand pharmacies in England are facing for healthcare advice.

Bexley has a higher level of excess winter deaths in the elderly (over 65s) compared to London national levels. Community pharmacies are ideally placed to support the elderly during the harsh winter months. An initiative that has been successfully piloted in South West London ICB is a staying well at winter intervention for the over 65s. The aim is to keep the elderly well and out of hospital through this winter through appropriate referrals and connections to preventative help and services, winter warmth schemes, local support groups as well as advice on self-management and care. This has been driven during the winter months, that are fraught with a cost-of-living crisis. This service provides a bespoke intervention to those customers aged 65 years and older. Pharmacy staff are trained in providing 15-minute advice to those aged 65 years and older on what they can do to remain fit and healthy throughout this winter season. The prevention aspect of the service is key to reducing excess deaths and illnesses. 

Ear Health

TympaHealth is a platform that allows community pharmacies to provide ear and hearing healthcare services commissioned by some ICSs. A handheld device that allows trained pharmacy staff to examine the ear, remove earwax and perform hearing screenings. The patient experience provides access to ear health in a single 30-minute appointment.

One ICS has tested provision of a more efficient pathway for ear health care that could be delivered away from secondary care, reducing outpatient spend and providing better quality care at a lower cost. The service allows the community pharmacy teams to develop their skills in ear care.

Smoking cessation services

As mentioned earlier in this section, smoking cessation is a priority area for Bexley Public Health. Smoking prevalence in Bexley is lower than in England. However, there is still an opportunity to maximise smoking cessation services through community pharmacy. The local authority and ICS could explore the interdependencies between the local authority smoking cessation targets and the CPCF Advanced SCS to provide a more comprehensive service offering and maximise several patient pathways to support Bexley smoking cessation targets. There is no commissioned walk-in smoking cessation service in the borough. This could be explored and would complement the national SCS.

Possible disease-specific services

The following are examples of disease-specific services that have been commissioned in some areas of England either by NHSE or ICBs. These would be seen as add-on services to Advanced Services or could be commissioned separately. There are many examples of different service types on the Community Pharmacy England website; those below are described to give an idea of the type of service available. The conditions listed have been identified as health priorities either as causes of ill health in Bexley or in the NHS Long-Term Plan.

Weight management

There are many different examples of weight management services already provided from a number of community pharmacies in England. These may be targeted to localities, e.g. areas of higher deprivation, or coupled with programmes for other ill health, e.g. Cardiovascular Disease or diabetes. North Bexley has a relative high prevalence of school age children who are overweight. There are opportunities to explore commissioning of locality focused weight management services through community pharmacy.

Asthma/Chronic Obstructive Pulmonary Disease

The service is for patients with Asthma or COPD diagnosis registered to a Bexley GP. The aim is to improve patients’ management of their asthma and/or COPD through improving inhaler use and technique, and education around the impact of environmental factors such as air pollution external and internal using local authority clean air resources.

This involves an inhaler technique review and a follow-up 6-8 weeks later (if required). This service is a holistic support package utilising a MECC and skill mix with the patient counselling.

Diabetes

Diabetes prevalence in Bexley is higher than the England figure. PCN QOF data showed that North Bexley had higher. Black and Asian populations are at higher risk of diabetes.

A community pharmacy-based screening service in localities where higher prevalence occurs could include prevention and lifestyle advice, screening, brief intervention and medicines management.

Point of care testing Community Pharmacy

Community pharmacies are suitable for expanding public access to point-of-care and rapid tests, but governance requirements must be followed to ensure the quality of results and advice. NHS England has released a document¹ providing guidance for commissioners and providers of community pharmacy clinical services in developing point-of-care testing in this setting. Examples included:

• non-invasive blood pressure monitoring as part of the hypertension case finding and blood pressure checks
• urinalysis for possible urinary tract infections
• chlamydia screening for the under 25s which could be linked to a locally commissioned sexual health service
• carbon monoxide monitoring as part of smoking cessation services
• COVID-19 rapid antigen testing
• blood glucose measurements as part of diabetes prevention services
• oxygen saturation using oximeters to assess people presenting with breathing difficulties
• peak flow measurements for patients with asthma

The PNA has noted the national pressures community pharmacies have faced resulting a reduction of community pharmacies, which has been experienced nationally. Bexley still has 18.3 community pharmacies per 100,000 population, which is higher than the England value. Bexley benefits from bordering HWBs including two London boroughs that also provide access to their community pharmacies near the  Bexley border. Whilst no gaps have been identified in the current provision of pharmaceutical services across Bexley now or in the future (over the next three years), there are opportunities to enhance provision and support improvement in the health of Bexley residents in the following areas:

• all pharmacies and pharmacists should be encouraged to sign up to deliver Advanced Services, particularly where there is identified need, i.e. smoking cessation Advanced Service and Hypertension case-finding, which can meet the health needs of the Bexley population. This needs to be supported by placed based ICS and local authority team. The existing community pharmacy network has adequate capacity to increase referrals and utilisation
• community pharmacy services such as NHS repeat dispensing, NMS and DMS can support the ICS Medicines Optimisation Agenda and should be integrated into medicines management strategies
• there are public health prevention agenda priorities and interdependencies in both CPCF and LCS services for both the local authority and ICSs
• there are interdependencies between SCS and LCS smoking cessation services, and between PCS and LCS sexual health services which include emergency contraception. These interdependencies could support increased service activities
• the local authority could work with the ICS to develop the prevention aspect of CPCF i.e. healthy living pharmacies, signposting and self-care
• commissioners should work with community pharmacies in more deprived areas to consider working to increase the offer and the uptake of Essential, Advanced, and Locally Commissioned services e.g. sexual health, smoking cessation, hypertension case finding service. Incentives should be considered for existing providers to deliver all services within the localities where deprivation is higher
• this would assist community pharmacy teams in promoting healthy lifestyle messages and participate in national and local health campaigns
• ICS and Local authority commissioners should explore how MECC intervention can be integrated into existing and new services to maximise the contribution of the whole pharmacy team to improve patient interventions
• public awareness of community pharmacy services should be increased to improve access in primary care; this is particularly relevant for communities where English is not a first language and improvement in accessing primary care services is required
• the ICS should consider commissioning community pharmacy workforce and skill mix development of the whole pharmacy team to support internal pharmacy team ability to help the lead community pharmacy deliver more clinical CPCF services. This builds on the innovative work led by SEL ICB to develop Community Pharmacy Leadership at place based and neighbourhood level
• methods to enhance the awareness and uptake of all services on offer by community pharmacies should be considered. This could be through the adoption of a range of communication methods appropriate to professionals and the local community, especially those in the more deprived localities. This will help to maximise existing service activity
• given the limited future housing growth anticipated in Bexley, the provision of pharmaceutical services should be monitored and reviewed to ensure the demands of the population are met

Commissioners should consider the provision of new Locally Commissioned Services listed in this section to help meet the health need in Bexley. Members of the public wish to see many of these services provided. Additional approaches to improve stakeholder and public engagement should be adopted for future PNAs to increase response rates and better understand the needs of the community.

¹ NHS. Point of care testing in community pharmacies. January 2022.