The NHS-funded Common Ailments Service (CAS) in Wales enables community pharmacists to manage 28 common ailments by providing advice and/or medication free of charge without the need for patients to book an appointment. The aim of this study was to evaluate the patient experience of the CAS using patient reported experience measures (PREMs) and determine the feasibility of digital data capture collected directly from patients through a pharmacist-led manual recruitment model. The study used prospective, primary data collected through an online survey accessible via a Quick Response code and census recruitment. A total of 3660 surveys were included in the analysis, completed between 27 October 2025 and 31 March 2026. Overall experience was rated as excellent by 95.1% of participants. A theory-based framework analysis of 1499 free-text comments across the six domains of healthcare quality confirmed the high standard of care provision, primarily influenced by consultation quality, convenience, accessibility, and short waiting times. It also identified targeted areas for improvement, such as the need for seamless referrals from other areas of primary care and consistent availability of the service across all pharmacies. While digital PREMs captured high-quality insights, the pharmacist-led recruitment model reached a “feasibility ceiling”, with an overall response rate of 3.2%.

OBJECTIVES:Valproate is a highly effective antiseizure medication but carries significant teratogenic and neurodevelopmental risks to offspring if used during pregnancy. A shared decision-making (SDM) approach is recommended to guide clinician/patient discussions on valproate suitability for women with pregnancy potential. This study applied the Capability, Opportunity, Motivation-Behaviour (COM-B) theoretical framework to explore barriers and facilitators to SDM in valproate prescribing from the perspectives of women with epilepsy who have pregnancy potential. DESIGN:Qualitative study using timeline-facilitated semi-structured interviews informed by the COM-B model. METHOD:Twelve UK-based women 18-50 years (Mage = 33.3, SD = 7.59) prescribed valproate were recruited via pharmacies and epilepsy organizations' social media. Interviews were thematically analysed and interpreted using the COM-B model. RESULTS:Participants were highly motivated to engage in SDM behaviour but reported limited opportunities. Challenges to COM-B domains included insufficient information exchange, low confidence navigating complex epilepsy/reproductive health care discussions, and tensions navigating valproate risks and benefits within broader contexts of seizure control and reproductive health. Initial prescribing during acute seizure crises may have precluded meaningful collaborative discussion. Valproate prescribing/deprescribing incongruent to reproductive goals often resulted in deep regret and deleterious health outcomes for women (and children exposed to valproate in utero). CONCLUSION:Comprehensive SDM when valproate is considered clinically appropriate could support informed, patient-centred decision-making. Equipping clinicians to navigate multifaceted risk/benefit discussions and empowering patients with clear, tailored information can help ensure treatment decisions align with reproductive goals. This study highlights the need to embed SDM in valproate prescribing consultations and throughout treatment duration.

BACKGROUND:A national community pharmacy urinary tract infection (UTI) service was piloted in Wales between June 2024 and February 2025. The aim of this study was to understand the utility of the service for patients and its broader impact on primary care. METHODS:We conducted a retrospective, cross-sectional, descriptive study using anonymized individual-level data from all UTI service pharmacy records between 17 June 2024 and 31 January 2025. Patient-reported outcome measures were collected through follow-up phone calls. RESULTS:A total of 9077 consultations were recorded during the study period. In total, 8813 women (mean age 39.8 years) accessed the service. Pharmacists assessed and managed (with advice with or without treatment) 7621 (84%) consultations without need for onward referral. Antibiotics were supplied in 78.7% of consultations (n = 7143). Only 1% of consultations were considered to have resulted in inappropriate antibiotic supply, where pharmacists deviated from the structured treatment protocol. In total, 1006 consultations (11.1%) took place out of hours or at weekends. Of 2138 women responding to follow-up (23.6% of total), 87.0% (n = 1861) reported symptom resolution, and 14.4% (n = 301) reported contacting another healthcare professional after their pharmacy consultation. Of these 301, 62.7% (n=189) were supplied antibiotics. CONCLUSIONS:Community pharmacists provided an accessible and effective UTI service, aligned with national diagnostic guidelines, and with antibiotic supply rates comparable to general medical practice. A pharmacy-provided treatment pathway, including urinalysis, may enhance UTI care by offering appropriate diagnosis and treatment that is widely accessible, reducing demand on general medical practice and without compromising antimicrobial stewardship.

OBJECTIVE:To evaluate the diagnostic performance of FeverPAIN against point-of-care test (POCT) results for Group A Streptococcus (GAS) among children and adults presenting with sore throat in community pharmacies. METHODS:Cross-sectional analysis of patients aged 6 years and over with sore throat presenting to community pharmacies across Wales delivering the Sore Throat Test and Treat service from November 2018 to September 2024. Patients scoring FeverPAIN ≥2 or Centor ≥3 who underwent POCT were eligible for analysis. We described GAS positivity by age group and assessed the diagnostic performance of FeverPAIN at the National Institute for Health and Care Excellence (NICE) antibiotic threshold (≥4), reporting sensitivity, specificity, positive predictive value, negative predictive value, and area under receiver operating characteristic curve (AUROC) with 95% CIs. We estimated potential missed treatment and unnecessary antibiotic use if antibiotics were supplied based on FeverPAIN alone. RESULTS:Among 73 617 eligible patients, 37.0% (n = 27 220) tested positive for GAS by POCT. Positivity was highest among children aged 6 to 10 years (47.0%: 5339/11 371). FeverPAIN was used in 92.5% (n = 68 099) of assessments. At the NICE-recommended threshold for antibiotic treatment (FeverPAIN ≥4), sensitivity was 55.0% (95% CI: 54.4-55.6%) and specificity 77.0% (95% CI: 76.6-77.4%). Positive predictive value was 57.6% (95% CI: 57.0-58.2%) and negative predictive value 75.1% (95% CI: 74.7-75.5%). Overall AUROC was 0.70 (95% CI: 0.70-0.71), with the lowest AUROC of 0.69 (95% CI: 0.68-0.70) observed among children aged 6 to 10 years. Using FeverPAIN alone would miss 44% of patients testing positive for GAS and result in unnecessary antibiotics for 23% of patients testing negative. CONCLUSIONS:FeverPAIN demonstrated limited diagnostic performance for identifying GAS when used alone, with greater discordance among children. Incorporating POCTs within community pharmacy sore throat pathways may support more targeted antibiotic prescribing. These findings support reconsideration of the role of POCT within community pharmacy sore throat pathways.

Coeliac disease requires strict adherence to a gluten-free diet to prevent health complications. While gluten-free foods (GFF) are traditionally available on the National Health Service (NHS) prescriptions, the cost and limited product range have prompted consideration of alternatives. Wales is exploring replacing prescriptions with a subsidy card scheme, piloted and implemented by the Hywel Dda University Health Board. This study explores potential service users’ views on the advantages and challenges of transitioning to a subsidy card scheme, as well as their priorities as individuals with coeliac disease. A qualitative study was conducted with 23 participants from six Welsh health boards where the subsidy card scheme has not been implemented. Participants included individuals eligible for GFF prescriptions and carers of eligible individuals. Recruitment was via social media and Coeliac UK’s Wales mailing list, with purposive sampling to ensure diversity. Data were collected through semi-structured interviews (April-July 2024) and analysed thematically using NVivo software. Four themes and 20 subthemes were identified. Participants viewed the subsidy card as offering greater choice, autonomy in dietary management, and convenience compared to prescriptions, with the potential to better align with everyday shopping habits. Concerns centred on the card’s monetary value amid inflation, risks of technical or top-up failures, misuse, and limited retailer participation in rural areas. Sixteen participants expressed a clear interest in switching to the subsidy card system, six were ambivalent, and one expressed no interest. Participants also highlighted six key priorities that they felt were essential to improving GFF access and ensuring better support for people with coeliac disease. These priorities included: ease of access, variety and freedom of choice, a tasty and healthy diet, consistency, cost, and better awareness and education of coeliac disease. The subsidy card model presents a promising, cost-effective, and patient-centred alternative to prescriptions, offering greater dietary autonomy and alignment with consumer practices. However, its success will depend on ensuring equity across geographic areas, addressing infrastructure and retailer participation, safeguarding nutritional adequacy, and maintaining prescription access during transition. Careful implementation will be essential to support diverse patient needs and optimise the scheme’s success.

BACKGROUND:Acute sore throat is managed in community pharmacies in England and Wales under different clinical pathways: Acute Sore Throat Pharmacy First (ASTPF) and Sore Throat Test and Treat (STTT), respectively. ASTPF launched in 2024 and allows antibiotic supply with FeverPAIN scores 4 and 5. STTT launched in 2018 and allows antibiotic supply with FeverPAIN ≥2 or Centor ≥3, if point-of-care testing confirms presence of group A Streptococcus (GAS). OBJECTIVES:To compare antibiotic supply rates of ASTPF and STTT, between 1 February 2024 and 30 July 2024, covering the first 6 months of ASTPF. METHODS:A descriptive study using anonymized individual-level data from electronic pharmacy records of STTT and anonymized population-level aggregate data from electronic records of ASTPF consultations meeting the gateway criteria for reimbursement. RESULTS:During the study period, 317 864 ASTPF and 27 684 STTT consultations were recorded across participating pharmacies, representing 551.0 and 874.9 consultations per 100 000 population in England (57 690 300) and Wales (3 164 400), respectively. The antibiotic supply rate was 72.7% (95% CI: 72.5% to 72.8%) for ASTPF and 29.9% (95% CI: 29.4% to 30.5%) for STTT. CONCLUSIONS:In this natural experiment in two similar healthcare systems with pharmacy-led sore throat services, we found different rates of antibiotic supply. Differences could be attributable to service implementation, pharmacists' initial training, engagement with GPs, pathway differences (e.g. gateway criteria and use of point-of-care tests), symptom severity, or most likely a combination of multiple factors. This early analysis suggests adapting the ASTPF pathway, to include point-of-care testing, could lead to reductions in unnecessary antibiotic supply.

Background: In June 2024, urinary tract infections (UTIs) were added to the list of conditions that could be treated by community pharmacists providing the national Common Ailments Service in Wales. The aim of this study was to describe patient-reported experiences of UTI management by pharmacists. Methods: A positivist research paradigm was selected, with data collection through a survey. Results: In total, 309 surveys were received between 29 June 2024 and 14 July 2025. Patients rated their experience using a scale of 1 (very poor) to 10 (excellent), with a median score of 10 (IQR = 10 to 10, range 6 to 10). High satisfaction was independent of age and provision of antibiotics, with the same median and IQR and a similar range between the groups who received and did not receive antibiotics (7–10 and 6–10, respectively). Of the 309 respondents, 297 (96.1%) stated that the next time they had a UTI, they would return to the pharmacy instead of trying to see a GP, and 253 (81.9%) that they understood why antibiotics are not always recommended. Conclusions: Community pharmacists managed patient expectations, improved patient confidence in managing current symptoms and provided information on self-care strategies for preventing future infections, demonstrating their valuable role in health promotion and antimicrobial stewardship.

Background: In the UK and globally, pharmacy professionals (pharmacists and pharmacy technicians) contribute to the delivery of local and national public or population health interventions. The existing literature on pharmaceutical public health predominantly focuses on micro-level activities, primarily describing community pharmacies delivering public health interventions to individuals. There is little-known evidence on pharmacy professionals’ involvement in delivering public health interventions at meso- (e.g., organisational) and macro (national/policy) levels, nor to what extent pharmacy professionals have specialist/advanced roles within public health practice. This study specifically explored pharmacy professionals’ specialist/advanced roles within public health as well as the opportunities and barriers to career development. The analyses of this mixed-methods study makes a series of important recommendations for future action. Methods: This study included two independent cross-sectional electronic surveys for pharmacy professionals and public health professionals, a call for evidence, and two workshops to develop recommendations. Results: Pharmacy professionals (n = 128) and public health professionals (n = 54) across the UK participated in the surveys. Most of the Pharmacy Professionals respondents were female (70%), pharmacists (85%), working in primary (33%) or secondary (25%) care settings, mainly based in England (75%), and most (63%) lacked formal public health qualifications although they were involved in a diverse range of public health interventions. The public health professionals were mostly females (67%), practicing in England (58%). Both professional groups identified opportunities and barriers to pharmacy professionals’ involvement in public health. Almost half of the public health professionals respondents (44%) stated that they had a pharmacy professional working as part of their current public health teams. Eighty-seven percent of public health professional respondents (45/52) agreed that having pharmacists or pharmacy technicians specialising in public health would be beneficial or very beneficial. Most of the documents, reports, and case histories provided through the call for evidence were unpublished. The workshops generated 94 recommendation statements, highlighting collaboration and the need to acknowledge pharmacy professionals’ contributions to public health. Conclusion: The recommendations for strategic action at meso- and macro-levels included three main themes: adopting a national strategic approach to pharmaceutical public health, including improving commissioning; formalising pharmaceutical public health workforce development; and promoting further evidence-based pharmaceutical public health research and development.

Background Prescribing is the most common intervention made by healthcare professionals. Our study aimed to compare prescribing between general practitioner (GP) practices with the highest and lowest levels of deprivation.Methods The deprivation level of each GP practice was determined using data from the income domain of the Welsh Index of Multiple Deprivation and individual patient postcodes. We compared prescribing data between the highest and lowest deprivation quintiles for selected groups of medicines. The prescribing measures used were selected as the most appropriate to the specific medicine group being considered. Data were analysed across the period of April 2018-March 2023.Results For the medicine groups of statins, hypnotics and anxiolytics, and antidepressants, there was a statistically significantly higher level of prescribing in the highest deprivation quintile. For anticoagulants, there was no significant difference in prescribing between the different quintiles. For hormone replacement therapy, there was a significantly higher level of prescribing in the quintile of lowest deprivation.Conclusion Our study shows variation in the prescribing of different medicine groups between the highest and lowest deprivation quintiles in Wales. Further investigation into this variation is required.

Background: To date, no research has compared longer-term outcomes (antibiotic provision; re-consultations; hospital admissions for quinsy; cost-effectiveness) following presentation with acute sore throat at general practice (GP) versus newer, pharmacy-led services. Methods: A retrospective, longitudinal cohort study of sore throat consultations between 1 November 2018 and 28 February 2020 either with the Wales pharmacy-led sore throat test and treat (STTT) service or with a healthcare professional at GP. Individual-level pharmacy consultation data from the national Choose Pharmacy IT application were securely uploaded to the Secure Anonymised Information Linkage Databank and linked to routinely collected, anonymized, population-scale, individual-level, anonymized health and administrative data. Results: Of 72 736 index consultations, 6495 (8.9%) were with STTT and 66 241 (91.1%) with GP. Antibiotic provision at the index consultation was 1382 (21%) with STTTand 25 506 (39%) with GP [adjusted odds ratio (AOR), 0.30; 95% CI, 0.27 to 0.32]. Antibiotic provision within 28 days of index occurred in 1820 (28%) STTTand 26 369 (40%) GP consultations (AOR, 0.44; 95% CI, 0.41 to 0.47). GP re-consultation rate within 28 days of index date was 21% (n = 1389) with STTT compared with 7.4% (n = 4916) with GP (AOR, 3.8; 95% CI, 3.5 to 4.1). Coding limitations may lead to overestimates of GP re-consultations rates in the STTT group. Hospital admissions for quinsy were rare in both STTT (n = 20, 0.31%) and GP (n = 274, 0.41%) (AOR, 0.68; 95% CI, 0.43 to 1.1). STTT was less costly than consultation with GP. Conclusions: The pharmacy-led STTT service is safe, cost-effective, and contributes to antimicrobial stewardship.

OBJECTIVE:To compare the effectiveness of molnupiravir, nirmatrelvir-ritonavir, and sotrovimab with no treatment in preventing hospital admission or death in higher-risk patients infected with SARS-CoV-2 in the community. DESIGN:Retrospective cohort study of non-hospitalized adult patients with COVID-19 using the Secure Anonymised Information Linkage (SAIL) Databank. SETTING:A real-world cohort study was conducted within the SAIL Databank (a secure trusted research environment containing anonymised, individual, population-scale electronic health record (EHR) data) for the population of Wales, UK. PARTICIPANTS:Adult patients with COVID-19 in the community, at higher risk of hospitalization and death, testing positive for SARS-CoV-2 between 16th December 2021 and 22nd April 2022. INTERVENTIONS:Molnupiravir, nirmatrelvir-ritonavir, and sotrovimab given in the community by local health boards and the National Antiviral Service in Wales. MAIN OUTCOME MEASURES:All-cause admission to hospital or death within 28 days of a positive test for SARS-CoV-2. STATISTICAL ANALYSIS:Cox proportional hazard model with treatment status (treated/untreated) as a time-dependent covariate and adjusted for age, sex, number of comorbidities, Welsh Index of Multiple Deprivation, and vaccination status. Secondary subgroup analyses were by treatment type, number of comorbidities, and before and on or after 20th February 2022, when omicron BA.1 and omicron BA.2 were the dominant subvariants in Wales. RESULTS:Between 16th December 2021 and 22nd April 2022, 7013 higher-risk patients were eligible for inclusion in the study. Of these, 2040 received treatment with molnupiravir (359, 17.6%), nirmatrelvir-ritonavir (602, 29.5%), or sotrovimab (1079, 52.9%). Patients in the treatment group were younger (mean age 53 vs 57 years), had fewer comorbidities, and a higher proportion had received four or more doses of the COVID-19 vaccine (36.3% vs 17.6%). Within 28 days of a positive test, 628 (9.0%) patients were admitted to hospital or died (84 treated and 544 untreated). The primary analysis indicated a lower risk of hospitalization or death at any point within 28 days in treated participants compared to those not receiving treatment. The adjusted hazard rate was 35% (95% CI: 18-49%) lower in treated than untreated participants. There was no indication of the superiority of one treatment over another and no evidence of a reduction in risk of hospitalization or death within 28 days for patients with no or only one comorbidity. In patients treated with sotrovimab, the event rates before and on or after 20th February 2022 were similar (5.0% vs 4.9%) with no significant difference in the hazard ratios for sotrovimab between the time periods. CONCLUSIONS:In higher-risk adult patients in the community with COVID-19, those who received treatment with molnupiravir, nirmatrelvir-ritonavir, or sotrovimab were at lower risk of hospitalization or death than those not receiving treatment.

Background: A pilot Independent Prescribers' Service (IPS) was introduced in 13 community pharmacies across Wales in June 2020. Independent Pharmacist Prescribers (IPPs) could prescribe in the areas of management of acute conditions, contraception, or opioid withdrawal, as agreed with local commissioners. Access to the patients' medical records was provided via Choose Pharmacy, the national community pharmacy IT platform.Objective: To explore the experiences of IPPs delivering the service and commissioners responsible for financial resources regarding the IPS in Wales.Methods: A qualitative methodology was employed, with purposive sampling, semi-structured interviews, and inductive thematic analysis.Results: Five themes were constructed from 13 interviews (n=9 IPPs; n=4 commissioners): (i) patient experience and safety; (ii) professional enablement and rebalancing workload of GPs; (iii) role and limitations of remote consultations; (iv) funding and business model; (v) functionality on Choose Pharmacy to support patient care. The design of the service allowed pharmacists to determine how best to deliver the IPS, maximizing access for patients and promoting a sense of professional value amongst pharmacists.Conclusion: This study builds on the body of evidence on enhanced patient experience with prescribing services in the community, reinforcing that IPPs have a key role in rebalancing management of common conditions from GP surgeries to community pharmacies. Several considerations need to be addressed to ensure future success of the service implementation, delivery and enhanced sustain-ability, such as formal referral pathways and access to medical records. These can be used by other commissioning bodies in the UK and internationally to build a network of suitably supported IPPs, confident to appropriately deal with uncomplicated acute and chronic conditions; and liaise with primary and/or secondary care when referrals are needed.

Background Community pharmacies have long been advocated as an accessible source of advice on health improvement in communities. This cross-sectional study explored the association between provision of pharmacy public health services and factors that might influence the extent to which pharmacies contribute to tackling inequalities. Methods Publically available data were used to explore the association between pharmacy public health service provision and pharmacy characteristics (socioeconomic deprivation, urbanity, opening hours and workload). Regression models were fitted to the number of service consultations. The association between the number of services provided and the mean number of consultations across each service was investigated using regression models. Results Pharmacies showed a propensity for being situated in areas of higher socioeconomic deprivation. There was no association between socioeconomic deprivation and number of service consultations a pharmacy provided. Clustering of pharmacies in less affluent areas led to over half of all public health service consultations being in the two most deprived quintiles. Conclusions Providing healthcare services from pharmacies in more deprived areas does not mean the public use them or that pharmacies will prioritize their delivery. The higher prevalence of pharmacies in disadvantaged communities is an important factor in ensuring pharmacy services support reducing inequalities.

BACKGROUND:Pharmacy professionals (pharmacists and pharmacy technicians; PPs) are recognised for delivering public health interventions (micro level). There is increased policy focus on population health management, but limited knowledge regarding the role of PPs within UK's public health meso and macro levels. This study aimed to explore UK PPs' public health qualifications, specialisations, and motivations and barriers to pursuing advanced public health practice. METHODS:In this cross-sectional study, we developed and piloted two surveys, and we disseminated them separately via email to UK pharmacy and public health networks and social media, between June 19, and Oct 26, 2021. PPs with an interest or experience in public or population health were invited to participate in the study. We asked PPs questions about public health qualifications, specialisations, motivations, and barriers, and we also asked PHPs for opinions regarding the value of specialist public health skills for PPs. Numerical data were summarised, and responses collated into themes. NHS Health Research Authority tool identified ethics approval not required; and the questionnaire included consent request. FINDINGS:128 PPs (85% pharmacists) and 54 PHPs responded. Of the PPs who responded, 90 (70%) were female and 35 (27%) were male; 62 (48%) were White British, 19 (14%) were Asian or Asian British, 14 (12%) were Black or Black British. They worked in primary care (34%, n=43), secondary care (26%, n=33), Community Pharmacy (13%, n=16), and public health bodies (13%, n=16). Overall, 34 (27%) of 128 PPs (32 pharmacists; 2 pharmacy technicians) possessed public health qualifications (MPH, PhD). Motivations for these qualifications were ambition to work as PP in public health PP (31%; 17/55 respondents), public health as alternative career (29%; 16/55), general interest (27%; 15/55) recommended or required for current role (11%; 6/55). Themes of barriers included limited training opportunities and poor career pathways. For the PHP survey, 36 (67%) of 54 were female and 16 (30%) were male. They worked as Consultants or Directors (28%, n=15), Registrars (24%, n=13), Practitioners (15%, n=8). 45 (87%) of 52 PHP respondents agreed that specialist PPs in public health would be beneficial to public health; 13 (45%) of 29 respondents recommended a public health Master's degree, eight (27%) recommended experience or postgraduate modules in health economics and health inequalities, three (10%) recommended credentialing for PPs to specialise. INTERPRETATION:Findings suggest responding PPs are motivated to advance in public health practice, despite barriers. Collaboration with PHPs and development of communities of practice might address barriers identified and contribute to advanced public health practice for PPs, supporting the increased focus on population health management in the UK. Limitations include the exploratory nature of the study, and the fact that PPs responding to public health surveys might be more motivated to advance in public health practice than those not responding. FUNDING:NHS England and UK Health Security Agency.

Background Community pharmacies in Wales delivered an NHS-funded sore throat test and treat (STTT) service during the period of increased invasive Group A Streptococcus (iGAS) incidents in winter 2022-23. Service users were screened using FeverPAIN/CENTOR scores, offered GAS rapid antigen detection tests (RADT) if appropriate, and antibiotics if indicated.Objectives To evaluate the service's response to a substantial rise in sore throat presentations during a period of heightened public anxiety.Methods Cross-sectional study with anonymized individual-level data from electronic pharmacy records of all eligible STTT service users, between January 2022 and March 2023.Results Antibiotics were supplied to 24% (95% CI: 23-24) of people who used the STTT service and 31% (95% CI: 31-32) of those who met the threshold for an RADT. Of 27 441 STTT consultations, 9308 (33.9%) occurred during December 2022. In the week commencing 2 December 2022, following the announcements of increased iGAS incidents, we observed a statistically significant increase of 1700 consultations (95% CI: 924-2476) and a statistically significant decrease in supply rate of 13.9 antibiotics per 100 RADT (95% CI: -18.40 to -9.40). Antibiotic supply rates increased thereafter to those observed before the announcements of iGAS incidents. Referral rates to other primary care or emergency settings remained below 10% throughout the study period.Conclusions Our findings suggest that, despite a dramatic increase in sore throat consultation rates in response to media reports, the pre-specified pathway followed by pharmacists ensured appropriate use of antibiotics, and absorbed a substantial workload that would otherwise end up in other healthcare settings.

Background An NHS-funded sore throat test and treat (STTT) service was introduced in selected community pharmacies in Wales. Service users were screened using FeverPAIN/Centor scores, offered rapid antigen detection testing (RADT) to detect group A Streptococcus if appropriate, and supplied with antibiotics (by the pharmacist) if indicated. Following an initial evaluation, the service was rolled out nationally. Objectives This study forms part of the long-term STTT evaluation. The aim was to describe characteristics of the service and service users, the delivery, service outcomes, patient safety and antibiotic prescribing. Methods Cross-sectional descriptive study using anonymized individual-level data from electronic pharmacy records of all eligible STTT service users between November 2018 and February 2020. Results We identified 11 304 pharmacy STTT consultations in service users aged 6 years and over, with a median age of 25 years (IQR: 12 to 44). RADT was undertaken in 8666 (76.7%) consultations with 2503 (28.9% of RADT) positive tests. In total, 2406 (21.3%) service users were supplied with antibiotics. Pharmacists managed 91% of consultations in the pharmacy and referred only 937 (9.3%) service users to a GP and 27 (0.2%) to the Emergency Department. Higher rates of antibiotic supply were observed in out-of-hours consultations when compared with in-hours (24.9% versus 20.9%). Conclusions This is the largest description of a pharmacy-led STTT service to date and suggests it can be delivered at scale to align with a pre-specified pathway that promotes appropriate use of RADT and antibiotics. The service could substantially reduce workload from a common illness in other heavily pressurized areas of primary and emergency care.

Objectives A Sore Throat Test and Treat (STTT) service was introduced in selected community pharmacies to screen against Streptococcus A and appropriately treat infections, relieving pressure on General Practices (GP). The long-term impact on patient and NHS outcomes is unclear. A robust evaluation is required to inform future policy and roll-out. Approach A matched cohort study comparing patients who received an STTT consultation in community pharmacy (exposed) compared to consultation with GP (unexposed). Individual-level data from participating STTT pharmacies were extracted from the Choose Pharmacy IT platform, anonymised and acquired into the Secure Anonymised Information Linkage (SAIL) Databank. Both cohorts were linked to other longitudinal health and administrative data within SAIL to create study outcomes (e.g. antibiotic prescribing, re-consultation, attendance/admission at Emergency Department/hospital). The impact of the STTT service was evaluated by modelling the outcomes using logistic regression to calculate odds ratios. Results 7553 patients exposed to the STTT service (8,313 consultations) in community pharmacies in Cwm Taf Morgannwg and Betsi Cadwaladr University Health Boards between 1st November 2018 and 28th February 2020, were successfully anonymised and acquired into the SAIL Databank (97.16%). 99.5% of these individuals were then linked to the Welsh Demographic Service Dataset (WDSD), enabling demographics to be generated. 6,665 distinct consultations remained in the exposed group after exclusion criteria were applied. A matched unexposed cohort will be created, and odds ratios will be presented to compare the risk of each outcome for those exposed to the STTT service compared to usual care. Conclusion This innovative study is the first to link national pharmacy service data to individual-level population-scale longitudinal health and administrative data in the SAIL Databank. Our findings will inform clear and actionable recommendations regarding the service design and future roll-out of STTT services across the UK and internationally.

Abstract Background The community pharmacy-led Sore Throat Test and Treat (STTT) service in Wales allowed pharmacists to undertake a structured clinical assessment with FeverPAIN/Centor scores and a point-of-care test (POCT) for Group A Streptococcus (GAS) infection. A new service model was temporarily agreed as a result of COVID-19, without routine use of POCT. Objectives To explore the impact of removing the requirement for GAS POCT from a community pharmacy STTT service on antibiotic supply. Methods Analysis of STTT consultation data, obtained for two periods: November 2018 (date the service went live) to September 2019 (pre-pandemic); and November 2020 (date the new service model was introduced) to May 2021. Results For consultations eligible for POCT, the antibiotic supply rate increased from 27% (922/3369) (95% CI: 26%–29%) with the pre-pandemic service model (FeverPAIN/Centor + POCT) to 63% (93/147) (95% CI: 55%–71%) with the new model (FeverPAIN/Centor only); the percentage of patients who were not issued an antibiotic, despite their high clinical score, decreased from 56% (646/1154) to 9.3% (8/86). Conclusions Preliminary data suggest that for every 100 STTT consultations with patients with a Centor score of ≥3 or a FeverPAIN score of ≥2, the use of POCT may spare up to 36 courses of antibiotics, increasing to 47 for patients with higher clinical scores, suggesting that the pre-COVID delivery model (FeverPAIN/Centor + POCT) is the optimal pathway and POCT in addition to clinical scores may result in fewer antibiotic prescriptions for sore throat symptoms. These findings have implications for STTT service delivery during and beyond the COVID-19 pandemic.

The efficacy of nirmatrelvir/ritonavir, an orally active chymotrypsin-like cysteine protease inhibitor in combination with a CYP3A4 inhibitor, in reducing hospitalisation or death from COVID-19 infection has been demonstrated in a high-risk adult population.1Hammond J. Leister-Tebbe H. Gardner A. Abreu P. Bao W. Wisemandle W. Baniecki M. Hendrick V.M. Damle B. Simón-Campos A. Pypstra R. Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19.New Engl J Med. 2022; 386: 1397-1408Crossref PubMed Scopus (218) Google Scholar Treatment within five days of COVID-19 symptoms was associated with a progressive reduction in viral load compared to the placebo arm; the duration of COVID-symptoms and changes in symptom severity were not reported.1Hammond J. Leister-Tebbe H. Gardner A. Abreu P. Bao W. Wisemandle W. Baniecki M. Hendrick V.M. Damle B. Simón-Campos A. Pypstra R. Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19.New Engl J Med. 2022; 386: 1397-1408Crossref PubMed Scopus (218) Google ScholarThe effectiveness of nirmatrelvir/ritonavir in vaccinated individuals or against novel SARS-CoV-2 variants remains uncertain. Case reports are emerging of a recurrence (“rebound”) of COVID-19 symptoms during or shortly after nirmatrelvir/ritonavir therapy without evidence of infection with an alternative variant in vaccinated, immunocompetent individuals.3M. Charness, K. Gupta, G. Stack, J. Strymish, E. Adams, D. Lindy, H. Mohi, D. Ho. Rapid relapse of symptomatic omicron SARS CoV-2 infection following early suppression with nirmatrelvir/ritonavir. 13 May 2022, PREPRINT (Version 2). Accessed at Research Square doi:10.21203/rs.3.rs-1588371/v2.Google Scholar, 4A.F. Carlin, A.E. Clark, A. Chaillon, A.F. Garretson, W. Bray, M. Porrachi, et al. Virologic and immunologic characterization of COVID-19 recrudescence after nirmatrelvir/ritonavir treatment. 18 May 2022, PREPRINT (Version 1). Accessed at Research Square doi:10.21203/rs.3.rs-1662783/v1.Google Scholar, 5COVID-19 rebound after paxlovid treatment. CDCHAN-00467. 24th May 2022. Accessed on 26th May 2022 at https://emergency.cdc.gov/han/2022/han00467.asp.Google Scholar No universally agreed definition of “rebound” COVID-19 associated with antiviral treatment currently exists, however, the United States Centres for Disease Control and Prevention describes rebound as a recurrence of COVID-19 symptoms or a new positive viral test after negative testing within two to eight days of initial recovery.5COVID-19 rebound after paxlovid treatment. CDCHAN-00467. 24th May 2022. Accessed on 26th May 2022 at https://emergency.cdc.gov/han/2022/han00467.asp.Google ScholarNirmatrelvir/ritonavir has conditional marketing authorisation in the UK for the treatment of COVID-19 in adults not requiring oxygen therapy and who are considered at risk of hospitalisation and/or death from COVID-19.6Summary of product characteristics for paxlovid. Medicines and healthcare products regulatory agency. 9th February 2022. Accessed on 26th May 2022 at https://www.gov.uk/government/publications/regulatory-approval-of-paxlovid/summary-of-product-characteristics-for-paxlovid#date-of-first-authorisationrenewal-of-the-authorisation.Google Scholar In December 2021, the Cardiff and Vale University Health Board was commissioned to provide a National Antiviral Service (NAVS) with responsibility for the clinical assessment of and supply of oral antiviral medicines to clinically extremely vulnerable patients in Wales who test positive for COVID-19. The first patients began receiving nirmatrelvir/ritonavir from NAVS in February 2022 in accordance with a UK wide clinical access policy.7https://awttc.nhs.wales/files/covid-hub/covid-19-therapies/interim-clinical-commissioning-policy-antivirals-or-neutralising-monoclonal-antibodies-non-hospitalisedpdf/.Google Scholar As of 5 June 2022, the National Antiviral Service (NAVS) has recommended treatment with nirmatrelavir/ritonavir, molnupiravir and neutralising monoclonal antibodies (Casirivimab/Imdevimab or Sotrovimab) for 939, 647 and 1498 patients respectively. To date, NAVS has received three spontaneous reports from service users of apparent recurrence of COVID symptoms associated with new positive antigen lateral flow tests, Table 1.Table 1Cases describing relapse of COVID-19 symptoms during out of hospital Paxlovid treatment.Case numberAge (years)SexComorbiditiesMedicationsSymptom onsetLFT +vePaxlovid durationSymptoms improvedLFT -veSymptoms reoccurredLFT +veHospitalised155MaleRheumatoid arthritis, vasculitisRituximabPrednisoloneDay 1Day 1Day 2 to Day 6Day 5 to Day 7Day 6Day 8Day 8No244FemaleCrohn's diseaseUstekinumabDay 1Day 1Day 2Day 3Day 4 to Day 9Day 5 to Day 11Day 5 to Day 11Day 14Day 14 (x3)Day 15No359FemaleVasculitisRituximabMycofenolatePrednisoloneHydroxychloroquineDay 1Day 1Day 2 to Day 7Day 3 to Day 5Day 6Day 19Day 19Assessed but not admitted Open table in a new tab Two cases were female and one male. Ages ranged from 44 to 59 years. All three cases had underlying active immune-mediated inflammatory disease, for which they were receiving treatment, and had received a full course of COVID-19 vaccination. Nirmatrelvir/ritonavir was started within one to three days of the onset of typical COVID-19 symptoms and a positive lateral flow test. All three cases reported taking nirmatrelvir/ritonavir, as prescribed, for five days.Symptomatic improvement was reported from three to five days after initial onset and persisted for two to six days until symptoms were reported to reoccur. Lateral flow tests were newly positive eight to 19 days from initial onset. Two out of three cases did not require hospitalisation but the third was referred to her local Medical assessment Unit to exclude a complication of COVID, such as venothromboemobolism or secondary infection, and received sotrovimab for on-going symptoms associated with positive lateral flow tests.It is unclear if COVID-19 “rebound” associated with nirmatrelvir/ritonavir is a distinct clinical phenomenon. The number needed to treat in the pivotal nirmatrelvir/ritonavir was approximately 18,1Hammond J. Leister-Tebbe H. Gardner A. Abreu P. Bao W. Wisemandle W. Baniecki M. Hendrick V.M. Damle B. Simón-Campos A. Pypstra R. Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19.New Engl J Med. 2022; 386: 1397-1408Crossref PubMed Scopus (218) Google Scholar suggesting that failure to respond to nirmatrelvir/ritonavir therapy may be an explanation. Alternatively, “rebound” may reflect the natural history of certain SARS-CoV-2 variants.8Gousseff M. Penot P. Gallay L. Batisse D. Benech N. Bouiller K. Collarino R. Conrad A. Slama D. Joseph C. Lemaignen A. Lescure F.X. Levy B. Mahevas M. Pozzetto B. Vignier N. Wyplosz B. Salmon D. Goehringer F. Botelho-Nevers E. in behalf of the COCOREC study groupClinical recurrences of COVID-19 symptoms after recovery: viral relapse, reinfection or inflammatory rebound?.J Infect. 2020; 81: 816-846Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Investigators have reported second peaks in viral load in “rebound” cases,2K. Gupta, J. Strymish, G. Stack, M. Charness Rapid relapse of symptomatic omicron SARS CoV-2 infection following early suppression with nirmatrelvir/ritonavir. 26 April 2022, PREPRINT (Version 1) Accessed at Research Square doi:10.21203/rs.3.rs-1588371/v1.Google Scholar,3M. Charness, K. Gupta, G. Stack, J. Strymish, E. Adams, D. Lindy, H. Mohi, D. Ho. Rapid relapse of symptomatic omicron SARS CoV-2 infection following early suppression with nirmatrelvir/ritonavir. 13 May 2022, PREPRINT (Version 2). Accessed at Research Square doi:10.21203/rs.3.rs-1588371/v2.Google Scholar however, these do not correlate well with either symptoms or antigen test positivity. The inclusion of untreated controls and other COVID-19 therapies in future, formal, observational studies would address both alternative hypotheses.In summary, we describe three cases of apparent recurrence of COVID symptoms associated with new positive lateral flow tests in immunosuppressed adults at high risk of severe COVID-19 treated with nirmatrelvir/ritonavir. The number of reported cases represents a small proportion of all those treated (<1%) although we cannot account for unreported cases. The strengths of our conclusions are limited by the strong risk of reporting bias and a lack of viral load or viral genomic data to exclude early re-infection with an alternative or mutant SARS-CoV-2 subvariant. Our adverse reaction information for patients letter has been amended to encourage patients to report recurrence of COVID symptoms during or following treatment. The efficacy of nirmatrelvir/ritonavir, an orally active chymotrypsin-like cysteine protease inhibitor in combination with a CYP3A4 inhibitor, in reducing hospitalisation or death from COVID-19 infection has been demonstrated in a high-risk adult population.1Hammond J. Leister-Tebbe H. Gardner A. Abreu P. Bao W. Wisemandle W. Baniecki M. Hendrick V.M. Damle B. Simón-Campos A. Pypstra R. Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19.New Engl J Med. 2022; 386: 1397-1408Crossref PubMed Scopus (218) Google Scholar Treatment within five days of COVID-19 symptoms was associated with a progressive reduction in viral load compared to the placebo arm; the duration of COVID-symptoms and changes in symptom severity were not reported.1Hammond J. Leister-Tebbe H. Gardner A. Abreu P. Bao W. Wisemandle W. Baniecki M. Hendrick V.M. Damle B. Simón-Campos A. Pypstra R. Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19.New Engl J Med. 2022; 386: 1397-1408Crossref PubMed Scopus (218) Google Scholar The effectiveness of nirmatrelvir/ritonavir in vaccinated individuals or against novel SARS-CoV-2 variants remains uncertain. Case reports are emerging of a recurrence (“rebound”) of COVID-19 symptoms during or shortly after nirmatrelvir/ritonavir therapy without evidence of infection with an alternative variant in vaccinated, immunocompetent individuals.3M. Charness, K. Gupta, G. Stack, J. Strymish, E. Adams, D. Lindy, H. Mohi, D. Ho. Rapid relapse of symptomatic omicron SARS CoV-2 infection following early suppression with nirmatrelvir/ritonavir. 13 May 2022, PREPRINT (Version 2). Accessed at Research Square doi:10.21203/rs.3.rs-1588371/v2.Google Scholar, 4A.F. Carlin, A.E. Clark, A. Chaillon, A.F. Garretson, W. Bray, M. Porrachi, et al. Virologic and immunologic characterization of COVID-19 recrudescence after nirmatrelvir/ritonavir treatment. 18 May 2022, PREPRINT (Version 1). Accessed at Research Square doi:10.21203/rs.3.rs-1662783/v1.Google Scholar, 5COVID-19 rebound after paxlovid treatment. CDCHAN-00467. 24th May 2022. Accessed on 26th May 2022 at https://emergency.cdc.gov/han/2022/han00467.asp.Google Scholar No universally agreed definition of “rebound” COVID-19 associated with antiviral treatment currently exists, however, the United States Centres for Disease Control and Prevention describes rebound as a recurrence of COVID-19 symptoms or a new positive viral test after negative testing within two to eight days of initial recovery.5COVID-19 rebound after paxlovid treatment. CDCHAN-00467. 24th May 2022. Accessed on 26th May 2022 at https://emergency.cdc.gov/han/2022/han00467.asp.Google Scholar Nirmatrelvir/ritonavir has conditional marketing authorisation in the UK for the treatment of COVID-19 in adults not requiring oxygen therapy and who are considered at risk of hospitalisation and/or death from COVID-19.6Summary of product characteristics for paxlovid. Medicines and healthcare products regulatory agency. 9th February 2022. Accessed on 26th May 2022 at https://www.gov.uk/government/publications/regulatory-approval-of-paxlovid/summary-of-product-characteristics-for-paxlovid#date-of-first-authorisationrenewal-of-the-authorisation.Google Scholar In December 2021, the Cardiff and Vale University Health Board was commissioned to provide a National Antiviral Service (NAVS) with responsibility for the clinical assessment of and supply of oral antiviral medicines to clinically extremely vulnerable patients in Wales who test positive for COVID-19. The first patients began receiving nirmatrelvir/ritonavir from NAVS in February 2022 in accordance with a UK wide clinical access policy.7https://awttc.nhs.wales/files/covid-hub/covid-19-therapies/interim-clinical-commissioning-policy-antivirals-or-neutralising-monoclonal-antibodies-non-hospitalisedpdf/.Google Scholar As of 5 June 2022, the National Antiviral Service (NAVS) has recommended treatment with nirmatrelavir/ritonavir, molnupiravir and neutralising monoclonal antibodies (Casirivimab/Imdevimab or Sotrovimab) for 939, 647 and 1498 patients respectively. To date, NAVS has received three spontaneous reports from service users of apparent recurrence of COVID symptoms associated with new positive antigen lateral flow tests, Table 1. Two cases were female and one male. Ages ranged from 44 to 59 years. All three cases had underlying active immune-mediated inflammatory disease, for which they were receiving treatment, and had received a full course of COVID-19 vaccination. Nirmatrelvir/ritonavir was started within one to three days of the onset of typical COVID-19 symptoms and a positive lateral flow test. All three cases reported taking nirmatrelvir/ritonavir, as prescribed, for five days. Symptomatic improvement was reported from three to five days after initial onset and persisted for two to six days until symptoms were reported to reoccur. Lateral flow tests were newly positive eight to 19 days from initial onset. Two out of three cases did not require hospitalisation but the third was referred to her local Medical assessment Unit to exclude a complication of COVID, such as venothromboemobolism or secondary infection, and received sotrovimab for on-going symptoms associated with positive lateral flow tests. It is unclear if COVID-19 “rebound” associated with nirmatrelvir/ritonavir is a distinct clinical phenomenon. The number needed to treat in the pivotal nirmatrelvir/ritonavir was approximately 18,1Hammond J. Leister-Tebbe H. Gardner A. Abreu P. Bao W. Wisemandle W. Baniecki M. Hendrick V.M. Damle B. Simón-Campos A. Pypstra R. Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19.New Engl J Med. 2022; 386: 1397-1408Crossref PubMed Scopus (218) Google Scholar suggesting that failure to respond to nirmatrelvir/ritonavir therapy may be an explanation. Alternatively, “rebound” may reflect the natural history of certain SARS-CoV-2 variants.8Gousseff M. Penot P. Gallay L. Batisse D. Benech N. Bouiller K. Collarino R. Conrad A. Slama D. Joseph C. Lemaignen A. Lescure F.X. Levy B. Mahevas M. Pozzetto B. Vignier N. Wyplosz B. Salmon D. Goehringer F. Botelho-Nevers E. in behalf of the COCOREC study groupClinical recurrences of COVID-19 symptoms after recovery: viral relapse, reinfection or inflammatory rebound?.J Infect. 2020; 81: 816-846Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Investigators have reported second peaks in viral load in “rebound” cases,2K. Gupta, J. Strymish, G. Stack, M. Charness Rapid relapse of symptomatic omicron SARS CoV-2 infection following early suppression with nirmatrelvir/ritonavir. 26 April 2022, PREPRINT (Version 1) Accessed at Research Square doi:10.21203/rs.3.rs-1588371/v1.Google Scholar,3M. Charness, K. Gupta, G. Stack, J. Strymish, E. Adams, D. Lindy, H. Mohi, D. Ho. Rapid relapse of symptomatic omicron SARS CoV-2 infection following early suppression with nirmatrelvir/ritonavir. 13 May 2022, PREPRINT (Version 2). Accessed at Research Square doi:10.21203/rs.3.rs-1588371/v2.Google Scholar however, these do not correlate well with either symptoms or antigen test positivity. The inclusion of untreated controls and other COVID-19 therapies in future, formal, observational studies would address both alternative hypotheses. In summary, we describe three cases of apparent recurrence of COVID symptoms associated with new positive lateral flow tests in immunosuppressed adults at high risk of severe COVID-19 treated with nirmatrelvir/ritonavir. The number of reported cases represents a small proportion of all those treated (<1%) although we cannot account for unreported cases. The strengths of our conclusions are limited by the strong risk of reporting bias and a lack of viral load or viral genomic data to exclude early re-infection with an alternative or mutant SARS-CoV-2 subvariant. Our adverse reaction information for patients letter has been amended to encourage patients to report recurrence of COVID symptoms during or following treatment.

This study investigates public attitudes towards medicinal waste and medicines reuse within a ‘free prescription’ healthcare system. A quantitative online survey was employed in a sample drawn from the population of Wales, where prescription medicines have been ‘free’ since 2007. Qualitative interviews informed the content of the attitude statements with categorical or ordinal response options assigned. The questionnaire was hosted on the HealthWise Wales platform for 1 year from October 2017. Of the 5584 respondents, 67.2% had at least one medicine on repeat prescription. Overall, 89.1% held strong concerns about medicinal waste. High acceptance for the reuse of prescription medicines which have been returned unused by patients to pharmacies was reported for tablets (78.7%) and capsules (75.1%) if the medicine is checked by a pharmacist first (92.4% rated essential). Concerns identified related to tampering of packs (69.2%) and the need for hygienic storage (65.4%). However, those working in healthcare had less concern about the safety of reusing medicines. The level of public acceptance for the reuse of medication was higher than previously reported. This is the largest survey to capture these views to date, which has implications for the future design of medicines reuse schemes.