Community pharmacies: promoting health and wellbeing

This guideline covers how community pharmacies can help maintain and improve peoples physical and mental health and wellbeing, including people with a long-term condition. It aims to encourage more people to use community pharmacies by integrating them within existing health and care pathways and ensuring they offer standard services and a consistent approach. It requires a collaborative approach from individual pharmacies and their representatives, local authorities and other commissioners.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Health and wellbeing hubs
This recommendation is for local authorities, clinical commissioning groups, health and wellbeing boards, community pharmacies and their representatives.
Work together to help all community pharmacies gradually integrate into existing care and referral pathways as health and wellbeing hubs. This could include arrangements for inward and outward referrals (see recommendation 1.6.1).
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on health and wellbeing hubs .
Full details of the evidence and the committee's discussion are in the evidence discussion for sections 1.1 and 1.2.
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# Overarching principles of good practice for community pharmacy teams

## Use an integrated approach
Work with local health and social care organisations to ensure community pharmacy interventions are delivered according to local need and as part of wider services in the local area.

## Ensure consistent, high-quality services
Use a tailored approach when providing community pharmacy health and wellbeing interventions to maximise their impact and effect.
Local providers should ensure interventions are carried out only by staff members with the skills and competencies to do so. For example, follow NICE's recommendations on training in the guidelines on:
behaviour change: individual approaches
tobacco: preventing uptake, promoting quitting and treating dependence.
When possible, the same member of staff should deliver all sessions of an intervention (if multiple sessions are needed) to promote continuity of care.
Use information, resources and support aids available from statutory, community and voluntary sector organisations (for example, Healthwatch and Public Health England). Ensure the materials used are:
not based solely on commercial interests or incentives
clear and professionally produced.

## Address health inequalities
Address health inequalities by working with other agencies to identify underserved groups. Tailor health and wellbeing interventions to suit their individual needs and preferences and maximise their impact. For example:
use knowledge of the local community (particularly from staff who live in the community where they work) to take into account the context in which people live and work (their physical, economic and social environment)
make use of the skills staff members already have (for example, if they speak languages commonly used in the area)
take into account other personal factors such as gender, identity, ethnicity, faith, culture or any disability that may affect the approach taken (for example, provide information in an appropriate format for people who may have difficulty reading).

## Promote community pharmacies
Consider promoting community pharmacies. For example:
Local commissioners could make it clear that community pharmacies are an integral part of NHS primary care services and offer people a link into the local health and care network.
Individual pharmacies could publicise the skills and competencies of their staff to increase the public's knowledge of and confidence in the health and wellbeing services on offer.

## Proactively seek opportunities
Proactively seek opportunities to promote people's physical and mental health and wellbeing. This includes: awareness raising and information provision, advice and education, behavioural support and referral and signposting to other services. Describe the interventions on offer and the benefits. Do this for example, when someone:
Regularly buys over-the-counter medicines, such as painkillers. For example, if relevant offer advice on other ways of reducing lower back pain including self-management and exercise. (See recommendations on non-invasive treatments in NICE's guideline on low back pain and sciatica.)
Regularly collects a prescription for themselves or someone they care for. For example, provide education and advice on how improving their diet, being more physically active or reducing alcohol intake may help the condition and improve their physical or mental health and wellbeing.
Regularly uses the pharmacy for over-the-counter medication or one-off prescriptions and, where appropriate, routine or occasional non-healthcare purchases. For example, offer behavioural support for stopping smoking (see NICE's guideline on tobacco: preventing uptake, promoting quitting and treating dependence); or information on effective sun protection (see NICE's guideline on sunlight exposure).
Is planning a pregnancy or is pregnant. For example, raise awareness of the benefits of, and provide information on, folic acid and other supplements (see NICE's guidelines on maternal and child nutrition and on vitamin D: supplement use in specific population groups).
For a short explanation of why the committee made these recommendation and how they might affect practice, see the rationale and impact section on overarching principles of good practice for community pharmacy teams .
Full details of the evidence and the committee's discussion are in the evidence discussion for sections 1.1 and 1.2.
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# Awareness raising and providing information
Ensure any pharmacy awareness raising campaigns or information is in line with NICE's guidelines on behaviour change: individual approaches (in particular, the first bullet of recommendation 9) and behaviour change: general approaches (particularly principle 6).
Tell people what the purpose of the health information is that you want to give them. For example:
when handing out leaflets explain their content and importance
point out the relevance of any posters that are displayed or highlight how people can easily get further information on the topic (for example, using QR codes)
if distributing leaflets with dispensed medicines, explain to the person collecting them  such as a carer, family member, friend or delivery person  why they are included and how to find out more, so they can pass this information on.
For a short explanation of why the committee made these recommendation and how they might affect practice, see the rationale and impact section on awareness raising and providing information .
Full details of the evidence and the committee's discussion are in evidence review 1: providing information on health and wellbeing.
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# Advice and education
Offer advice and education as the opportunity arises in line with NICE's guidelines on: behaviour change: individual approaches (see the recommendations on delivering very brief, brief and extended brief advice).
When someone uses pharmacy services to manage a long-term condition, use this as an opportunity to advise them on how to improve their general health and wellbeing. For example, follow recommendations on advice and education in NICE's guidelines on:
diabetes in adults (type 1, and type 2) and diabetes in children and young people (type 1 and type 2)
hypertension in adults for people with, or at risk of, hypertension (see the sections on lifestyle interventions and patient education and adherence to treatment).
Offer brief advice and education as the opportunity arises, on stopping smoking and reducing alcohol consumption:
For smoking cessation, follow NICE's guideline on tobacco: preventing uptake, promoting quitting and treating dependence (in particular see the sections on commissioning and designing services, identifying people who smoke, information on stopping smoking for those using acute, maternity and mental health services, and advice on nicotine-containing ecigarettes).
For alcohol issues, follow the recommendations on brief advice in NICE's guideline on alcohol-use disorders. In particular see recommendation 5 on resources for screening and brief interventions and recommendation 10 on brief advice for adults.
Use support materials and approaches to aid these discussions, if available. (For example, advice and education on smoking could be supported by photo-ageing software, if it is available.)
For a short explanation of why the committee made these recommendation and how they might affect practice, see the rationale and impact section on advice and education .
Full details of the evidence and the committee's discussion are in evidence review 2: offering advice or education to promote health and wellbeing.
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# Behavioural support
Offer behavioural support in line with NICE's guidelines on:
behaviour change: individual approaches (see the recommendations on using proven behaviour change techniques when designing interventions; and high intensity behaviour change interventions and programmes)
behaviour change: general approaches (see principles 4 and 5).
Help people to stop smoking by offering behavioural support programmes in line with NICE's guideline on tobacco: preventing uptake, promoting quitting and treating dependence.
Help people to manage their weight by offering behavioural support programmes in line with NICE's guidelines on:
-besity: identification, assessment and management (see the section on behavioural interventions)
weight management: lifestyle services for overweight or obese adults (see recommendation 11)
preventing excess weight gain
              and
-besity prevention.
Consider referring people to other behavioural support services within the local health and care network (for example, to voluntary or community services) for interventions that are not available in the pharmacy (see section 1.6).
For a short explanation of why the committee made these recommendation and how they might affect practice, see the rationale and impact section on behavioural support .
Full details of the evidence and the committee's discussion are in evidence review 3: offering behavioural support to promote health and wellbeing.
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# Referrals and signposting

## Referrals
Local commissioners and pharmacies could consider establishing a formal referral process with other pharmacies and service providers. This includes GP services and those offered by local authorities and organisations in the community and voluntary sectors. Specifically:
Consider basing pharmacy assessments, triage activities and referrals on agreed tools that support continuing treatment.
Consider designing triage activities to reduce multiple assessments and waiting times after people are referred. For example, after identifying harmful or dependent alcohol consumption, consider providing access to alcohol services that does not require reassessment and a return to the start of the treatment pathway. (Harmful and dependent alcohol consumption could be identified using the AUDIT tool or another threshold used locally.)
Consider referring people to other services and triage within the agreed local care or referral pathway to give fast access to an appointment if needed. For example, refer people to:
GPs or other healthcare providers for:
-ngoing contraception
assessment for sleep apnoea if agreed local assessment tools are in place
support for high risk or dependent alcohol consumption
drug misuse recovery support
weight reduction services
local authority, NHS or community and voluntary sector organisations for:
weight loss programmes or support groups
mental health and wellbeing support
specialist treatment and recovery support for drug misuse and dependence
support for carers
adult and children's social care.
When making a formal referral to another service, explain to the person why they are being referred, where they are being referred to and the service they can expect. Provide them with written information about the service if it is available.
When the pharmacy accepts a formal referral from another service:
ensure all relevant information has been provided so that care can start at the first opportunity without the need for a reassessment
-ffer care as a walk-in service or, if this is not available or suitable, agree an appointment time and date with the person and give them the name of the staff member they will see.

## Signposting
If the community pharmacy cannot support specific needs or offer a formal referral, signpost people to other local services. For example:
sexual health services
stop smoking services
social care services
mental health and wellbeing support
-ther community services such as: Citizens Advice; housing, benefits or employment advice; support services for carers; and government and third sector debt advice websites.

## Record keeping, auditing and monitoring
Consider using minimum data sets and summary care records to encourage record keeping and auditing, particularly when exchanging information through formal referrals in the local care network.
For a short explanation of why the committee made these recommendation and how they might affect practice, see the rationale and impact section on referrals and signposting .
Full details of the evidence and the committee's discussion are in evidence review 4: signposting and referral to other services and support.
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# Terms used in this guideline
This section defines terms that have been used in a specific way for this guideline. For other public health and social care terms, see the Think Local, Act Personal Care and Support Jargon Buster.

## Photo-ageing
A smoking cessation intervention in which photos of participants are digitally aged so they can see images of themselves as a lifelong smoker and a non-smoker.

## Underserved groups
Adults and children from any background are 'underserved' if their social circumstances, language, culture or lifestyle (or those of their parents or carers) make it difficult to access health services or attend healthcare appointments.
Many of these groups may be more likely to go to a community pharmacy than a GP or another primary care service. As an example, this includes: people who are housebound, homeless or sleep rough; people who misuse drugs or alcohol; and Gypsy, Traveller and Roma people. A full list can be found in the equality impact assessment for this guideline.# Recommendations for research
The guideline committee has made the following recommendations for research.

# Key recommendations for research

## Referral within a formal care pathway
Is referral from a community pharmacy within a formal local care pathway framework more effective and cost effective than signposting alone in improving access to, and uptake of, services by underserved groups and the general population?
For a short explanation of why the committee made the recommendation for research, see the rationale section on health and wellbeing hubs .
More details about how this research could be conducted can be found in recommendations for research: in detail.
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## Health and wellbeing interventions
How effective and cost effective are awareness raising, advice and education or behavioural support interventions delivered by community pharmacy teams to improve health and behavioural outcomes in underserved groups and the general population?
For a short explanation of why the committee made the recommendation for research, see the rationale sections on awareness raising and providing information , advice and education , and behavioural support .
More details about how this research could be conducted can be found in recommendations for research: in detail.
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## Addressing health inequalities
What are the barriers to and facilitators for increasing access to community pharmacy services by underserved groups? How should health and wellbeing interventions be tailored to increase service uptake in underserved groups?
For a short explanation of why the committee made the recommendation for research, see the rationale section on addressing health inequalities .
More details about how this research could be conducted can be found in recommendations for research: in detail.
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## Characteristics of a person delivering an intervention
How do the professional characteristics of pharmacy staff affect the effectiveness and cost effectiveness of delivering information, advice, education or behavioural support to underserved groups and the general population? (Characteristics include, for example, job roles such as health champion, as well as competencies and level of training.)
For a short explanation of why the committee made the recommendation for research, see the rationale section on ensure consistent, high-quality services .
More details about how this research could be conducted can be found in recommendations for research: in detail.
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## Patient activation
How effective and cost effective is advice, education or behavioural support offered by community pharmacy teams to improve patient activation and measures of behaviour and health changes, particularly in areas where activation levels are lower? This includes evaluating factors such as frequency, intensity and duration of the intervention.
For a short explanation of why the committee made the recommendation for research, see the rationale section on behavioural support .
More details about how this research could be conducted can be found in recommendations for research: in detail.
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# Other recommendations for research

## Local social prescribing interventions
How effective and cost effective is it for community pharmacy teams to provide local social prescribing interventions? What is the differential impact in both effectiveness and cost effectiveness of community pharmacies carrying out this activity compared with providing only referral or signposting to these interventions?# 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.

# Health and wellbeing hubs
Recommendation 1.1.1

## Why the committee made the recommendation
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.

## How the recommendation might affect practice
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.
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# Overarching principles of good practice for community pharmacy teams
Recommendations 1.2.1 to 1.2.8

## Why the committee made the recommendations
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 20minute 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.

## How the recommendations might affect practice
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.
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# Awareness raising and providing information
Recommendations 1.3.1 and 1.3.2

## Why the committee made the recommendations
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.

## How the recommendations might affect practice
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).
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# Advice and education
Recommendations 1.4.1 to 1.4.4

## Why the committee made the recommendations
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.

## How the recommendations might affect practice
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.
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# Behavioural support
Recommendations 1.5.1 to 1.5.4

## Why the committee made 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.

## How the recommendations might affect practice
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.
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# Referrals and signposting
Recommendations 1.6.1 to 1.6.6

## Why the committee made the recommendations
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.

## How the recommendations might affect practice
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.
Return to recommendations# Context
Community pharmacy contractors dispense NHS prescriptions under the NHS (Pharmaceutical Services and Local Pharmaceutical Services) Regulations 2013. As well as dispensing, community pharmacy contractors are required to:
promote healthy lifestyles
participate in 6 public health campaigns a year
dispose of unwanted medicines
provide support for self-care
signpost members of the community to appropriate services.
As of 7 November 2017, there were 11,699 community pharmacies in England (NHS Digital General Pharmaceutical Services in England  2007/08 to 2016/17).
Most prescription items are dispensed by community pharmacies. In 2016/17, for example, they dispensed 91.6% of the 1,000 million plus items dispensed in the community ('General Pharmaceutical Services in England  2007/08 to 2016/17'). In 2016, the net cost of prescriptions dispensed in the community was 9,205 million. Of the prescriptions dispensed, 89.4% were dispensed free of charge, with 61% provided free to people aged 60 and over (NHS Digital Prescriptions dispensed in the community, Statistics for England 2006 to 2016).
Community pharmacies are well positioned to promote health and wellbeing to their local community, including those from underserved groups, because 90% of people in England (including more than 99% of people in the most deprived communities) live within a 20minute walk of one. The location of community pharmacies, unlike other healthcare outlets, does not comply with the usual 'inverse care law' in that there is a greater concentration of community pharmacies in areas of deprivation. (The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England Todd et al. 2014).
The risk of many health conditions can be reduced by people adopting healthier behaviours. These include: type 2 diabetes, cardiovascular disease, respiratory diseases such as chronic obstructive pulmonary disease, and other conditions related to obesity and smoking.
Community pharmacies can help raise awareness of health conditions, improve physical and mental health, and reduce both health inequalities and individual health risks by providing advice and services to everyone entering their premises. This includes people who do not visit GPs or other healthcare services. In addition, they may support other primary care services, such as GP practices.
The Community Pharmacy Contractual Framework is a negotiated agreement between NHS England and the Pharmaceutical Services Negotiating Committee, which represents community pharmacy contractors. The framework includes a range of health-promoting services that community pharmacies should provide (Essential service 4 'Promotion of healthy lifestyles' and Essential service 5 'Signposting').
As part of the framework, pharmacies must participate in up to 6 public health campaigns each year at the request of NHS England (Public health  Pharmaceutical Services Negotiating Committee).
In May 2018, there were over 9,400 Healthy Living Pharmacies and at least 9,400 health champions. There is a profession-led self-assessment process for Level 1 Healthy Living Pharmacies. Levels 2 and 3 are led and implemented by local authorities (see Commissioning section). Public Health England's Healthy Living Pharmacies: Level 1 quality criteria sets out the enablers and quality requirements for this level. The framework for Level 2 services is being updated.
The NHS Five Year Forward View (NHS England) states that a 'radical upgrade in prevention' is needed to achieve financial stability for the NHS. It sets out how the NHS could improve the way it promotes wellbeing and prevents health conditions. Options include making greater use of pharmacies in preventing ill health, support for healthy living, supporting self-care for minor ailments and long-term conditions, medication review in care homes, and as part of more integrated local care models.
Public Health England's 7 priorities include obesity, smoking and alcohol (From evidence into action: opportunities to protect and improve the nation's health).
The community pharmacy offer for improving the public's health: a briefing for local government and health and wellbeing boards (Local Government Association and Public Health England) describes how health and wellbeing boards, local authorities and commissioners can work with community pharmacies to promote health and wellbeing.
Public Health England's Pharmacy: a way forward for public health. Opportunities for action through pharmacy for public health sets out opportunities for how pharmacy teams in the primary and community sectors can play a bigger part in helping people to better look after their health.
The Community Pharmacy Contractual Framework describes national commissioning arrangements for services to promote health and wellbeing. NHS England's regional teams commission all services in the framework.
The Community Pharmacy Contractual Framework includes specific mention of services to promote health and wellbeing, such as increased support for healthy living. This is to ensure there is a Royal Society of Public Health trained health champion in every community pharmacy, and that each community pharmacy obtains the Healthy Living Pharmacy Level 1 status.
Local authorities commission a range of public health services provided by community pharmacies, such as stop smoking, contraceptive and weight management services. Levels 2 and 3 of the Healthy Living Pharmacy framework are also commissioned by local authorities.
Local authorities and clinical commissioning groups can ask NHS England to commission services from community pharmacies on their behalf, such as advice services for people who are misusing drugs.
Most community pharmacies now have an up-to-date record of their Declaration of Service which details the services they offer following the Quality Payment Scheme incentive.