Pharmacy First, launched in England in January 2024, allows community pharmacists to assess and in some cases supply antibiotics for seven specified conditions under a Patient Group Direction (PGD). Two years in, the service is now part of the routine landscape for sore throats, UTIs and infected insect bites. It is not, however, a universal counter-antibiotic scheme — the authorisation is narrow, age-banded, and sits within a wider antimicrobial stewardship framework.

This piece summarises where the service permits supply, where it still refers, and the stewardship considerations that shape pharmacist decision-making.

The seven clinical pathways

The conditions covered by the Pharmacy First clinical service, as set out by NHS England, are:

For every pathway, supply depends on a structured assessment including symptom duration, severity indicators, red-flag exclusions and patient-specific contraindications. Where criteria are not met, the pharmacist refers — usually back to the GP, or to an urgent care route if red flags are present.

What supply actually involves

The service is delivered under PGDs, which are written directions authorising designated healthcare professionals to supply specified medicines to patients meeting defined criteria without a prescription. Each PGD for Pharmacy First specifies:

• The clinical inclusion criteria (for example, a FeverPAIN score of 4–5 for sore throat antibiotic supply).
• Exclusion criteria (pregnancy, immunosuppression, recurrent presentation, severity markers).
• The specific antibiotic, dose and duration — typically first-line per NICE and the BNF.
• Record-keeping and reporting requirements back to NHS England.

Pharmacists retain clinical discretion: the PGD sets the ceiling on what can be supplied, not a requirement to supply every eligible case.

Where the service still refers

The pathway is designed for self-limiting, uncomplicated presentations. Patients who fall outside the age bands, meet any red-flag exclusion, or present atypically are referred on. Examples include:

• Pregnant women with UTI symptoms (excluded from the Pharmacy First UTI pathway — GP or equivalent prescriber required).
• Children under 5 with sore throat (below the age threshold).
• Men with urinary symptoms (not covered by the UTI pathway).
• Recurrent UTI within the last six months (requires GP review).
• Sore throat in immunocompromised patients.
• Severe or rapidly progressing infections of any site.

The service is positioned as a first port of call for a defined subset of presentations, not as a replacement for general practice or urgent care.

The stewardship frame

Antimicrobial stewardship underpins the whole structure. The UK's five-year action plan on antimicrobial resistance commits to reducing unnecessary antibiotic use, and Pharmacy First supply is recorded centrally so that prescribing patterns can be audited.

Several design choices reflect the stewardship priority:

• Symptom duration thresholds. Acute sinusitis requires symptoms ≥10 days before antibiotic supply, consistent with NICE guidance that most cases are viral and self-limiting.
• Scoring tools. FeverPAIN and Centor criteria are embedded in the sore throat pathway to avoid supplying antibiotics for viral pharyngitis.
• First-line narrow-spectrum choices. The PGDs specify narrow-spectrum first-line agents — for example, phenoxymethylpenicillin for sore throat — rather than broad-spectrum alternatives.
• Record-back to NHSBSA. Every supply is captured, enabling later analysis of antibiotic supply rates by condition, pharmacy, and region.

Supply-vs-referral ratios are a key future indicator. Once NHSBSA publishes full-year figures for the service, it will be possible to see what proportion of Pharmacy First consultations resulted in antibiotic supply versus referral, and whether rates vary meaningfully by region or pharmacy type.

What it means for pharmacists and patients

For pharmacists, Pharmacy First is a significant expansion of clinical scope but not a free hand to prescribe. The PGDs are prescriptive: the criteria either apply, or they don't. Good practice involves documenting the assessment, being comfortable referring when criteria aren't met, and communicating with patients about why an antibiotic may not be appropriate.

For patients, the service means that for a defined set of common infections, a pharmacy can now be the end point rather than a stop on the way to the GP. That helps shorten the pathway, but it doesn't mean every sore throat, earache or urinary symptom will result in antibiotics. Community pharmacy is also a significant employer of the workforce delivering these consultations — PharmSee's database of UK pharmacy vacancies continues to show pharmacist roles as the largest single category, many advertising Pharmacy First accreditation as essential or desirable.

Caveats

This is a summary of publicly available NHS England service specifications and NICE CKS guidance as of April 2026. Individual PGDs are updated periodically; practitioners should rely on the current national PGD document rather than this summary.

Sources

• NHS England — Pharmacy First service specification
• NICE CKS — Sore throat (acute), UTI (lower, women), Sinusitis, Otitis media, Impetigo
• UK five-year action plan for antimicrobial resistance (DHSC)

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