What has Pharmacy First delivered in two years?
Pharmacy First has delivered volume, coverage and patient approval at a scale no previous community pharmacy clinical service has reached. The service launched in England on 31 January 2024 with seven clinical pathways (acute otitis media, impetigo, infected insect bites, shingles, sinusitis, acute sore throat and uncomplicated urinary tract infections in women), absorbing the minor illness and urgent medicine supply strands of the old Community Pharmacist Consultation Service. Around 98% of pharmacies signed up, and NHS Business Services Authority (NHSBSA) data cited in the Pharmacists' Defence Association's April 2026 capacity report shows total consultations exceeding 6.2 million between February 2024 and January 2026.
The trajectory matters as much as the total. The Department of Health and Social Care reported more than 3.3 million consultations between March 2025 and February 2026, a 43% increase on the previous twelve months, alongside survey data showing 86% of users reporting a positive experience. Healthwatch England's polling of 7,029 adults, published in June 2025, found the same 86% satisfaction figure and, more strikingly, found 44% of respondents had visited a pharmacy for help with one of the covered conditions within a year. Demand is not the open question. It never really was: the question owners have asked from the first month is whether the service pays for the time it consumes, and whether the infrastructure underneath it can carry the weight now being loaded onto it.
Where is uptake actually coming from?
Uptake is real but uneven, and the variation maps to awareness and geography rather than clinical need. Healthwatch found 56% of Londoners had used a pharmacy for one of the covered conditions against 35% in the East of England, with local awareness ranging from 39% in Halton to 72% in Stockton-on-Tees. Among people unlikely to use the service, 29% simply did not know pharmacies could treat these conditions and 32% still preferred to see their GP. Two years of national marketing have moved awareness, but a quarter of the addressable public has still never heard the offer.
The evidence base is finally catching up with the service. The OpenSAFELY Pharmacy First dashboard now publishes monthly consultation trends from GP records covering roughly 40% of the English population, broken down by condition, age, region, deprivation and ethnicity, and the London School of Hygiene and Tropical Medicine is leading a national evaluation linking pharmacy claims data to GP, A&E and admissions records. For owners, the practical use of this is benchmarking: pharmacy-level consultation figures are published monthly, so you can see precisely how your delivery compares with your neighbours and your band, and so can your local commissioners.
In our experience the pharmacies at the top of those tables share one habit: they treat every eligible presentation at the counter as a consultation opportunity and have trained the whole team, not just the pharmacist, to recognise the seven pathways. The ones at the bottom are waiting for referrals that do not arrive, which brings us to the mechanics.
How does Pharmacy First payment actually work, and where does it pinch?
Pharmacy First pays a fee per consultation plus a volume-based monthly fixed payment, and the pinch points sit in the gateway rule, the caps and the thresholds. The consultation fee rose from £15 to £17 in April 2025. The monthly fixed payment pays £500 for delivering 20 to 29 clinical pathway consultations in a month and £1,000 for 30 or more, and receiving it also requires registration for the Hypertension Case-Finding Service and Pharmacy Contraception Service under the bundling rule retained in the 2026/27 settlement.
| Mechanic | How it works | Where it pinches |
|---|---|---|
| Consultation fee | £17 per clinical pathway or minor illness consultation | The sector view, put bluntly in the PDA's capacity report, is that a 15-minute consultation plus records and follow-up costs more than £17 to deliver |
| Gateway point | Walk-in consultations are only paid if the patient passes the pathway's gateway criteria | Time spent assessing a patient who does not pass earns nothing; a shingles presentation outside the age range is unpaid work |
| Fixed payments | £500 at 20 to 29 consultations a month, £1,000 at 30 or more | A month at 19 consultations earns £323 in fees and no fixed payment; the 20th consultation is worth £517. Cliff-edge thresholds distort a quiet month |
| Monthly caps | Banded allocations limit the number of paid consultations, published monthly by the NHSBSA; activity above the cap earns no fee | High performers can deliver unpaid consultations in strong months; band assignments update on actual delivery |
| Bundling | Monthly payment requires Hypertension Case-Finding and Contraception service registration | Three service obligations stand behind one payment |
| Claim window | Currently one month; a two-month late claim window giving three months in total was agreed in the 2026/27 settlement for introduction later in 2026 | Until the change lands, a missed month is missed income, and claims that do not match the Patient Group Direction can be withheld and investigated |
Read as a system, the design tells you what NHS England is managing: spend certainty. Caps bound the upside, thresholds reward consistency and the gateway rule polices clinical appropriateness. One genuine improvement arrived in the 2026/27 settlement: the Pharmacy First budget has been merged into the core Community Pharmacy Contractual Framework (CPCF) sum, which guarantees the funding envelope to the sector and removes the previous risk of unspent service budget being clawed back at year end. The money is now the sector's to earn rather than the Treasury's to recover.
The referral leak
The most expensive friction in Pharmacy First is the difference between a formal referral and a verbal one. GP practices, NHS 111 and other settings can refer patients electronically into the service, and referred minor illness consultations are payable. What happens instead, persistently, is verbal signposting: reception tells the patient to "pop to the pharmacy", the patient arrives with no electronic referral, and the consultation is only payable if the presentation fits a clinical pathway and passes its gateway. Pharmacy bodies flagged this within months of launch, with owners reporting patients being sent back to the surgery to obtain a proper referral, which is a miserable experience for everyone and exactly the friction the service was meant to remove.
The fix is unglamorous and local. The pharmacies that solved it invested in the relationship: a standing conversation with each practice's reception team about what a valid referral is, a named contact, and monthly sharing of referral numbers so the practice can see the workload it is shifting actually landing somewhere. PharmData's published figures let both sides see referral flows by surgery, which turns a vague grievance into a specific conversation. None of this is IT. It is accountability plumbing between two businesses that were given a shared service and no shared incentive, and two years on it still determines a meaningful share of each pharmacy's paid volume.
The IT gap, chronologically
The IT story of Pharmacy First is a service launched before its plumbing, and the record is worth setting out in order because independent prescribing is about to run through the same pipes.
| Date | Event | Consequence |
|---|---|---|
| 31 January 2024 | Service launches without GP Connect access ready | Pharmacists fall back on National Care Record Service access to view GP data in the opening weeks |
| April 2024 | Roughly three months in, only one pharmacy IT supplier is live with Update Record integration | Most pharmacies continue sending consultation summaries to practices by NHSmail PDF for manual transcription |
| Mid 2024 | The British Medical Association's GP Committee urges practices to switch off the Update Record functionality, citing future workload risk | Structured summaries bounce at practices that disabled the feature; pharmacies resend by NHSmail, often without knowing why the message failed |
| 2025 | A coding fault sends pregnancy codes to practices from Pharmacy First and contraception consultations, affecting almost 15,000 records; NHS England categorises it as a major incident | Pharmacies review records; some incorrect codes reach GP records; confidence in the information model is damaged |
| 15 September 2025 | The Royal College of General Practitioners and BMA's Joint GP IT Committee publicly urges a pause to the mandate, saying the implementation cannot yet command the profession's confidence | The dispute moves into the open weeks before the deadline |
| 1 October 2025 | The contractual requirement proceeds: all GP practices must enable Update Record | Structured flow becomes the default nationally; by September 2025 more than 10,000 pharmacies had already sent over 7 million consultation summaries |
Two years on, the honest status is: working at scale, trusted incompletely, finished nowhere. Update Record now moves Pharmacy First, blood pressure and contraception summaries into practice workflow in structured SNOMED-coded form, which is a genuine improvement on transcribing PDFs. But it carries routine summaries only. Urgent actions and referrals still go by telephone or NHSmail, safeguarding concerns sit outside it entirely, the urgent medicine supply strand is still a planned future addition, and messages still fail silently enough that every pharmacy needs a working fallback process and a habit of checking for rejections.
Update Record is the filing system, not the escalation route. Any consultation that needs a GP to act needs a phone call, on the day, documented.
What independent prescribing changes from autumn 2026
Independent prescribing turns Pharmacy First from a Patient Group Direction service into a prescribing service, and it inherits every friction described above at higher clinical stakes. Under the 2026/27 CPCF settlement announced on 29 May 2026, pharmacist independent prescribers will be able to prescribe within the existing seven pathways and the Pharmacy Contraception Service from autumn 2026, likely October, and to deliver up to five new prescribing-only pathways. The candidates under consideration by NHS England's clinical reference group include bacterial conjunctivitis, allergic conjunctivitis, oral thrush, skin infections and respiratory tract infections. Prescribers will also be able to supply an alternative medicine where the first choice is out of stock, a quietly significant power in a shortage-prone market.
The funding is the contested part. Set-up is paid at a one-off £500, with a £525 monthly infrastructure payment intended to cover the Electronic Prescription Service (EPS) system costs, on top of standard consultation fees, and prescribing consultations count toward the monthly fixed payment thresholds. Community Pharmacy England signed the settlement while stating plainly that it is not persuaded the investment is sufficient for the workload, clinical responsibility and governance involved, and that owners must decide individually whether to provide the service. That is an unusually candid position from a negotiator about its own deal, and it should be read as the planning assumption: year one of prescribing within the CPCF is funded like a foundation year, and the business case for participating rests on volume, on the new pathways attracting patients who currently go elsewhere and on being positioned early for the years when the funding catches up. The capping mechanism extends to prescribing with its own cap per band, so the spend controls follow the service.
The timing pressure is real: the first pharmacists to qualify under the 2021 education standards join the register as independent prescribers from summer 2026, so the workforce arrives as the service does. What does not arrive automatically is the infrastructure: prescribing-grade records, EPS integration, audit trails and clinical governance evidence, which is the same records discipline the General Pharmaceutical Council (GPhC) already inspects, now with a prescription at the end of it.
The verdict: what two years proves and what it does not
Two years proves the model and leaves the economics unresolved. Proven: patients want condition care from pharmacies, will rate it highly when they get it and are shifting behaviour, with consultation volumes tripling across all clinical services since 2021 according to the PDA's analysis. Proven too, in a costly way: national clinical services cannot launch ahead of their IT and payment design without pharmacies absorbing the gap in unpaid time.
Unresolved: whether £17 per consultation with cliff-edge thresholds and caps is a price or a subsidy expectation. The PDA's April 2026 report called the growth trajectory unsustainable on current staffing, noting full-time equivalent staffing per pharmacy was flat between 2021 and 2024 while service volumes multiplied. The wider funding context softens but does not settle this: the 2026/27 CPCF rose 10.3% to £3.636 billion, the largest primary care uplift for the second year running, against a Frontier Economics analysis that found a £2.3 billion annual gap between pharmacy costs and NHS funding.
"Pharmacy First is the flagship of the clinical future everyone in the sector says it wants. Two years on, the flag flies from a ship still being built beneath it."
What owners should do now
The preparation for autumn 2026 is operational, and most of it compounds whether or not you opt into prescribing.
- Fix the referral leak with named contacts and monthly referral data conversations at every local practice.
- Watch your thresholds weekly, not at month end, because the difference between 19 and 20 consultations is £517 and the difference between 29 and 30 is £500.
- Confirm with your IT supplier, in writing, their readiness dates for prescribing workflows and EPS integration, because the two-year record says supplier timelines slip and the pharmacy carries the workaround.
- Keep consultation records to inspection standard on every supply, since the same evidence file serves NHSBSA claims scrutiny, GPhC inspection and, from autumn, prescribing governance.
- Model the prescribing decision on your own numbers using the published fees rather than on ambition: at £525 a month of infrastructure payment, the service pays its way on volume or not at all.
Key takeaways
- Pharmacy First delivered over 6.2 million consultations between February 2024 and January 2026, with volumes up 43% year on year and 86% of patients reporting a positive experience.
- Uptake varies sharply by region and awareness, with 56% of Londoners having used the service against 35% in the East of England, and 29% of non-users unaware it exists.
- Payment hinges on mechanics, not just volume: a £17 fee, £500 and £1,000 fixed payments at 20 and 30 consultations, banded caps and a gateway rule that makes failed walk-in assessments unpaid work.
- The Pharmacy First budget merged into the core CPCF sum in 2026/27, removing the risk of unspent funding being clawed back.
- The GP Connect Update Record integration launched late, was actively switched off by some practices in 2024 and suffered a major incident involving almost 15,000 records, before becoming mandatory for all practices from 1 October 2025.
- Independent prescribing joins Pharmacy First from autumn 2026 with up to five new prescribing-only pathways, funded by a £500 set-up fee and £525 monthly infrastructure payment that the sector's own negotiator considers insufficient.
- The service has proven patient demand conclusively; what remains unproven is whether the fee structure covers the cost of delivering it.
FAQs
A service that pays needs visibility.
Most of what separates a Pharmacy First service that pays from one that leaks is visibility: threshold position mid-month, evidenced gateway decisions and consultation records that satisfy the NHSBSA, the GPhC and, from this autumn, prescribing governance without extra work. Dataforge PMR runs bookings, clinical assessments and consultation records in one platform, and we are building for the prescribing workflows arriving in autumn 2026. See it against your service volumes in 30 minutes.
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