Pharmacy First launched in England in January 2024, enabling community pharmacists to supply prescription-only medicines for seven common conditions through patient group directions (PGDs) — without requiring a GP appointment. It is the biggest expansion of community pharmacy clinical scope in a generation.
Finding a single, consolidated reference covering all seven pathways with clear inclusion/exclusion criteria is surprisingly difficult. Most pharmacists are navigating between multiple NHS sources, PharmOutcomes templates, and PGD documents for each condition. This page puts all seven in one place.
1. Acute Sinusitis
Inclusion criteria: Adults (≥12 years) with symptoms of acute sinusitis (nasal congestion, facial pain/pressure, purulent nasal discharge) for ≥10 days or worsening after initial improvement.
Exclusion criteria (refer to GP/urgent care): Periorbital swelling or redness. Visual disturbance. Severe frontal headache. Neurological signs. Immunocompromised patients. Recurrent sinusitis (≥4 episodes/year). Children under 12.
Supply via PGD: Clarithromycin 500mg twice daily for 5 days (first-line for those meeting antibiotic criteria). Phenoxymethylpenicillin may be an alternative in some PGDs.
Self-care advice: Steam inhalation, saline nasal irrigation, paracetamol/ibuprofen for pain, adequate hydration. Most acute sinusitis is viral and resolves without antibiotics.
2. Acute Sore Throat
Inclusion criteria: Adults and children (≥5 years) with acute sore throat. Use FeverPAIN score to assess: Fever in last 24 hours (1), Purulence/tonsillar exudate (1), Attend rapidly (within 3 days) (1), severely Inflamed tonsils (1), No cough or coryza (1).
Exclusion criteria: FeverPAIN ≤2 (self-care only). Peritonsillar abscess (quinsy — hot potato voice, trismus, uvula deviation). Immunocompromised. Epiglottitis features (drooling, stridor, severe dysphagia). Under 5 years.
Supply via PGD: For FeverPAIN ≥4: phenoxymethylpenicillin 500mg four times daily for 5 days. Alternative for penicillin allergy: clarithromycin.
3. Acute Otitis Media (Earache)
Inclusion criteria: Children (≥1 year) and adults with acute ear pain consistent with otitis media.
Exclusion criteria: Under 1 year (refer to GP). Systemic features (high fever, lethargy). Mastoid tenderness or swelling (possible mastoiditis — urgent referral). Ear discharge lasting >14 days. Recurrent otitis media. Presence of grommets. Immunocompromised.
Supply via PGD: Amoxicillin (first-line) — delayed antibiotic strategy may be appropriate (give prescription with advice to start only if symptoms worsen after 3 days). Safety-net: return if worsening, high fever, or discharge.
4. Infected Insect Bite
Inclusion criteria: Adults and children (≥1 year) with signs of localised bacterial infection around an insect bite — spreading erythema, warmth, swelling, purulent discharge.
Exclusion criteria: Systemic signs of infection (fever, rigors, lymphangitis — red tracking line). Rapidly spreading cellulitis. Immunocompromised. Animal/human bite (different pathogen profile — not covered by this pathway). Facial bites with infection.
Supply via PGD: Flucloxacillin 500mg four times daily for 5 days (first-line). Alternative for penicillin allergy: clarithromycin or erythromycin.
5. Impetigo
Inclusion criteria: Adults and children (≥1 year) with non-bullous impetigo — localised, superficial, crusted lesions (golden crusting is classic).
Exclusion criteria: Bullous impetigo (large blisters — may indicate staphylococcal scalded skin syndrome in young children). Widespread infection (>3 lesion clusters). Immunocompromised. Periorbital impetigo. Recurrent impetigo (≥3 episodes in 12 months — investigate carriage).
Supply via PGD: Topical fusidic acid 2% cream three times daily for 5 days (for localised, non-bullous impetigo with ≤3 lesion clusters). If extensive or topical treatment fails: oral flucloxacillin.
6. Shingles (Herpes Zoster)
Inclusion criteria: Adults (≥18 years) presenting within 72 hours of rash onset with a typical dermatomal vesicular rash consistent with shingles.
Exclusion criteria: Under 18 years. Immunocompromised. Ophthalmic shingles (forehead/nose involvement — Hutchinson's sign, any eye symptoms). Ramsay Hunt syndrome (shingles affecting the ear/facial nerve — facial weakness, ear pain). Disseminated shingles. Pregnancy.
Supply via PGD: Aciclovir 800mg five times daily for 7 days (if presenting within 72 hours of rash onset). Valaciclovir may be available in some PGDs.
Important: Antiviral treatment is most effective when started within 72 hours of rash onset. After 72 hours, benefit is less certain — clinical judgment required.
7. Uncomplicated UTI in Women
Inclusion criteria: Women aged 16-64 with symptoms of uncomplicated lower urinary tract infection — dysuria, frequency, urgency. No complicated features.
Exclusion criteria: Men (any age). Children (<16). Pregnant women. Women over 64. Recurrent UTI (≥3 in 12 months). Upper urinary tract symptoms (loin pain, fever, rigors — possible pyelonephritis). Catheterised patients. Known urinary tract abnormalities. Immunocompromised.
Supply via PGD: Nitrofurantoin 100mg modified-release twice daily for 3 days (first-line, if eGFR ≥45). Alternative: trimethoprim 200mg twice daily for 3 days (if low risk of trimethoprim resistance). Check local antibiogram for resistance patterns.
Self-care advice: Adequate hydration. Paracetamol for pain. Cranberry products have limited evidence but are not harmful.
Using iatroX Alongside Pharmacy First
Ask iatroX provides instant guideline-grounded answers to clinical questions arising during Pharmacy First consultations — "Is clarithromycin safe in pregnancy?" "What is the trimethoprim resistance rate guidance for UTI?" "Does this patient's medication interact with flucloxacillin?" — cited, with guideline references, in seconds.
For trainee pharmacists preparing for the CRA, Pharmacy First pathways are directly examinable. The iatroX GPhC Q-Bank includes questions on all seven conditions.