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An open learning programme for pharmacists

Minor ailments
services
A starting point for pharmacists
Updated March 2009

Assessing how ready you are to deliver


an NHS-funded minor ailments service

Educational solutions for the NHS pharmacy workforce


DLP 142
An open learning programme for pharmacists

Minor ailments
services
A starting point for pharmacists
Updated March 2009

Educational solutions for the NHS pharmacy workforce

Copyright Controller HMSO 2009


ii Acknowledgements

Lead writer
Lesley Grimes, primary care development pharmacist, Rowlands Pharmacy

CPPE programme manager


Dr Christopher Cutts, director

Project team
Paula Higginson, senior pharmacist, learning and development, CPPE

Reviewers
Alison Astles, CPPE pharmacy tutor
Geraldine Flavell, CPPE pharmacy tutor
This learning programme was piloted by the following pharmacists:
Pippa Crossley, Stephen DuBois, Rita Nerves de Faria, Julie Jackson,
Pamela Jackson, June Middleton, Chinjal Patel, Shamir Patel, John Reuben and
Jill Southworth

Programme guardian
Lesley Grimes, primary care development pharmacist, Rowlands Pharmacy

Production
Outset Publishing Ltd, East Sussex

Originally published in January 2007 by the Centre for Pharmacy Postgraduate


Education, School of Pharmacy and Pharmaceutical Sciences, University of
Manchester, Oxford Road, Manchester M13 9PT
Updated edition published in March 2009.
http://www.cppe.ac.uk

CPPE open learning programmes are printed on paper made only from sustainable forests, forest thinnings and sawmill residues.
Chlorine-free pulp is used, and other raw materials used in the manufacturing cycle are derived from natural products. All papers are
also fully biodegradable (or recyclable) without harmful effect to the environment.
MARCH 2009
Contents iii

About CPPE open learning programmes v

About this learning programme viii

Supporting you, your practice and the NHS xi

Reference sources for the clinical management of xii


minor ailments

Section 1 Self-care and minor ailments services: 1


new roles for pharmacy
1.1 Minor ailments and the concept of self-care 1
1.2 The importance of self-care to pharmacy 2
1.3 Milestones in the implementation of self-care policy 5
The community pharmacy contract 5
Practice-based commissioning 6
NHS Direct 6
NHS walk-in centres 7
Exercises 2, 3, 4, 7
Practice points 1, 7
Summary and intended outcomes 8
Suggested answers to exercises 1-3 9

Section 2 NHS-funded minor ailments services: 10


skill mix and service implementation
2.1 The rise of locally-tailored minor ailments services 10
2.2 Implementing a minor ailments service: an overview 11
Determining the need for a minor ailments service 12
The common features of an NHS-funded minor ailments 13
service
The patients journey through the minor ailments service 13
The minor ailments covered by the service 15
The medicines that can be supplied 16
How the community pharmacy will be paid 18
Exercises 10, 11, 13, 17
Practice points 12, 17
Summary and intended outcomes 19
Suggested answers to exercises 5-8 20

MARCH 2009
iv CONTENTS

Section 3 Clinical governance and minor ailments services 21


3.1 What is clinical governance? 21
3.2 Linking the key components of clinical governance and 22
minor ailments services
Patient and public involvement 22
Clinical audit and remedying underperformance 23
Risk management 23
Clinical effectiveness 25
Staffing and staff management 25
Education, training and continuing professional and 26
personal development
Use of information to support clinical governance and 26
healthcare delivery
Accountability 26
Practice points 21, 22, 23, 25, 26, 27
Summary and intended outcomes 28

Checklist Assessing how ready you are to deliver an NHS-funded 29


minor ailments service

References 30

Appendix 1 Example of a treatment protocol template used in an 33


established minor ailments service

Appendix 2 Example of an FFPharm used in an established 34


minor ailments service

Index 35

MARCH 2009
About CPPE open learning programmes v

About CPPE
The Centre for Pharmacy Postgraduate Education (CPPE) is funded by the
Department of Health to provide continuing education for practising pharmacists
and pharmacy technicians providing NHS services in England. We are part of the
Workforce Academy, within the School of Pharmacy and Pharmaceutical
Sciences, which is part of the Faculty for Medical and Human Sciences.
CPPE offers a wide range of learning opportunities for the pharmacy workforce.
Our full learning portfolio is available on the internet at:
http://www.cppe.ac.uk

Themes
We have allocated themes to all our learning programmes. There are 28 themes in
total and they allow you to navigate easily through our full learning portfolio. We
have assigned a different colour to each of our themes, and this is used to identify
the theme in the annual prospectus, in CPPE news&events, on our website, and on
the covers of all the learning programmes.
This learning programme is part of the Minor ailments theme.You will find
additional learning programmes within this theme in our prospectus and on our
website.
The programme can be downloaded in PDF format from our website:
http://www.cppe.ac.uk

We recognise that people have different learning needs and not every CPPE
learning programme is suitable for every pharmacist or pharmacy technician.
Some of our programmes contain core learning while others deliver more
complex learning that is only required to support certain roles. So we have created
three categories of learning CPPE 1 2 3 and allocated each programme to an
appropriate category. The categories are:

Core learning (limited expectation of prior knowledge).

Application of knowledge (assumes prior learning).

Supporting specialisms (CPPE may not be the provider and will


signpost you to other appropriate learning providers).

This is a learning programme.

MARCH 2009
vi ABOUT CPPE OPEN LEARNING PROGRAMMES

Continuing professional development


You can use this learning programme to support your continuing professional
development (CPD). Consider what your learning needs are in this area.You may
find it useful to work with the information and activities here in a way that is
compatible with the Royal Pharmaceutical Society of Great Britains approach to
continuing professional development (http://www.rpsgb.org.uk/registrationand
support/continuingprofessionaldevelopment) because you will be able to relate
it to your personal circumstances more closely. Use your CPD record sheets or go
to http://www.uptodate.org.uk to plan and record the actions you have taken.

Activities

E Exercises
Exercises are included throughout this programme as a form of self-assessment.
Use them to test your knowledge and understanding of key learning points.
Complete the exercises as fully as possible before looking at the suggested answers
at the end of a section. Dont be tempted to jump ahead until you have written
your own answers.

Practice points
Practice points are an opportunity for you to consider your practical approach to
the effective care of patients or the provision of a service. They are discrete
activities designed to help you to identify good practice, to think through the steps
required to implement new practice, and to consider the specific needs of your
local population.
We have designed the practice points in this programme to help you and your
team to make links between the learning and your daily practice and to
co-ordinate with other healthcare professionals.

Assessment
To enable you to gauge how much you have learnt from this programme you can
access the MCQ assessment, available via the My CPPE tab on our website:
http://www.cppe.ac.uk
If you would like to assess your own competences relating to the clinical
management of minor ailments, then work through the Minor ailment services:
a clinical approach assessment, available via the Assessment tab on the CPPE website:
http://www.cppe.ac.uk

MARCH 2009
ABOUT CPPE OPEN LEARNING PROGRAMMES vii

References and further reading


You can find references for all the books, articles, reports and websites mentioned
in the text, together with a list of further reading to support your learning, at the
end of the programme. References are indicated in the text by a superscript
3
number (like this ).

Programme guardians
CPPE has adopted a quality assurance process called programme guardians.
A programme guardian is a recognised expert in an area relevant to the content of
a learning programme who will review the programme every six months. We will
post any corrections, additions, deletions or further supporting materials that are
needed as an update to the programme on the CPPE website.
We recommend that you refer to these updates if you are using this (or any other)
programme significantly after its initial publication date. A full list of programme
guardians is available on our website.You can email your comments about this
programme to them at: info@cppe.ac.uk

External websites
CPPE is not responsible for the content of any non-CPPE websites mentioned in
the programme or for the accuracy of any information to be found there. The fact
that a website or organisation is mentioned in the programme does not mean that
CPPE either approves of it or endorses it.

Disclaimer
CPPE recognises that local interpretation of national guidance may differ from
the examples used in this programme and you are advised to check with your own
relevant local guidelines.You are also advised to use this learning programme with
other established reference sources. If you are reading this programme
significantly after the date of initial publication you should refer to current
published evidence. CPPE does not accept any responsibility for any errors or
omissions.

Feedback
We hope you find this learning programme useful for your practice. Please help
us to assess its value and effectiveness by completing the online feedback form
available on our website: http://www.cppe.ac.uk via the My CPPE tab. Simply
scroll down to find the learning programme title and click on the Tell us what you
think icon. CPPE may email you a reminder to do this.You can also email us
direct if you feel your comments are urgent, using the email addresss:
feedback@cppe.ac.uk

MARCH 2009
viii About this learning programme

The advent of the contractual framework for community pharmacy and the
governments latest policies on the provision of healthcare have brought about
changes in the way that minor ailments services are delivered to patients. This
open learning programme supports the changes in the community pharmacy
contract and provides a foundation upon which you can develop a minor ailments
service with your local primary care trust (PCT).
The programme begins by explaining the policy changes set out in The NHS
1
improvement plan; putting people at the heart of public services, and the change in
emphasis from reactive treatment to the prevention of illness and self-care. It also
considers the skill mix and clinical governance measures needed within the
pharmacy to help you to assess your own competences and to deliver an efficient
service. What it is not is a reference source on minor ailments or the clinical
management of minor ailments. (If you wish to develop your own learning around
the diagnosis and treatment of minor ailments there are many literature
references, websites and training programmes to help you. There is a short list to
get you started at the end of this introduction.)
The Department of Health White Paper, Pharmacy in England. Building on
2
strengths delivering the future discusses the benefits of implementing minor
ailments services in deprived areas. CPPE are aware that the Government intend
to work with the Pharmaceutical Services Negotiating Committee (PSNC) and
NHS employers to examine how best minor ailments schemes can be
incorporated within the community pharmacy contractual framework (you can
find further details in Chapters 4 and 8 of theWhite Paper).
We plan to update this learning programme once we learn more about these
outcomes.
This programme is listed as underpinning knowledge in the Provision of Minor
Ailments Services competency and training framework developed by the
Harmonisation of Accreditation Group (HAG).You can find more information
about HAG on the primary care contracting website:
http://www.pcc.nhs.uk/200.php
The programme is likely to take you about four hours to complete, depending
on your learning style and pace (you should record the actual time in your
continuing professional development record).

Target audience
This programme is aimed primarily at community pharmacists and community
pharmacy locums who are thinking about providing an NHS-funded minor
ailments service. It is also relevant to primary care pharmacists who might be
involved in implementing such a service.
Hospital and prison-based pharmacists may find the programme of interest even
though it does not relate directly to their area of practice.

MARCH 2009
ABOUT THIS LEARNING PROGRAMME ix

Learning style adopted in this programme


Unlike some other CPPE programmes which take you through a complete
learning process, this programme has been written as a starter guide.You will
need to access some of the many websites and web links given in the text to
further your learning.

Learning objectives
CPPE has linked all its learning programmes to the Royal Pharmaceutical Society
of Great Britains competences for pharmacists and pharmacy technicians. This
will make it easier for you to connect your professional practice to your learning
needs and learning activities. We have selected only the competences for general
pharmacists and pharmacy technicians, but we are aware that others exist.
We have also linked the learning to the dimensions of the NHS Knowledge and
Skills Framework.
The competences and dimensions relevant to this programme are:

Learning objectives RPSGB pharmacist KSF dimensions


competences

Discuss the government G1, G8 Quality Level 1 or 2


policies that have influenced
changes in the delivery of Service improvement Level 2
minor ailments services to
patients.

Describe what is meant by a G1, G7 Personal and people development Level 1


minor ailments service

Describe the patients journey G2, G3 Communication Level 1


from referral through to
consultation in a minor Service improvement Level 2
ailments service.

List the clinical governance G1, G4, G5 Quality Level 2 or 3


processes that apply to a
minor ailments service.

Working through this programme


Section 1 introduces the concept of minor ailments services and gives background
information on the key government policies that have influenced the development
of these services. Section 2 gives an overview of the common features of an NHS-
funded minor ailments service, while Section 3 considers clinical governance
issues and gives guidance on evidence-based practice. The programme concludes
with a checklist with which you can assess your readiness to provide a minor
ailments service in your own pharmacy. Each section has its own objectives to
help you to achieve this.

MARCH 2009
x ABOUT THIS LEARNING PROGRAMME

Online resources
Some of the references given in this programme are to material that is only
available online, and it is assumed that you will have access to a computer
connected to the internet. If you do not wish to retype all the web addresses into
your browser you may find it helpful to download this programme from the
CPPE website as a PDF document containing live web links. Log on to:
http://www.cppe.ac.uk
Where we think it will be helpful we have provided the URL to take you directly
to an article of specific part of a website. However, we are also aware that web
links can change (eg, the Department of Health links) so in some cases we have
provided the URL for the organisations home page only. If you have difficulty
accessing any web links, please go to the organisations home page and use
appropriate key words to search for the relevant item.
Alternatively, search via: http://www.google.co.uk and type the name of the
paper or article that you want in full. It can also be helpful if you add in, at the
end of the search criteria, the website where the information can be found, eg,
dh.gov.uk

MARCH 2009
xi

Supporting you, your practice and


the NHS
When devising this programme we paid special attention to how it would
contribute both to your own professional development and to the overall
improvement of NHS services. We have illustrated some of these benefits in the
diagram below (you will find more detail as you progress through the
programme).

Supporting skill mix Commissioning


This programme will This programme will allow
show you how you can use you to provide a new service
your whole pharmacy team which a PCT or PBC* group
to deliver a quality may wish to commission.
minor ailments service.

You,
your practice
and this learning
programme

Policy drivers Community pharmacy


This programme will allow This programme will allow
you to offer services to you to embed clinical
patients closer to where governance systems into your
they live, proposed by practice as part of the essential
Our health, our care, our say services tier in the
policy. pharmacy contract and deliver
an enhanced service.

Pharmacist prescribing
Minor ailments services
could be expanded to
cover more ailments by the
support of a non-medical
prescriber.

* Practice-based commissioning

MARCH 2009
xii

Reference sources for the clinical


management of minor ailments
If you would like to learn more about the clinical management of minor ailments
you may find the following references useful:

Books
Blenkinsopp A, Paxton P and Blenkinsopp J. Symptoms in the pharmacy. A guide to
the management of common illnesses. 6th edition. Oxford: Blackwell Science, 2008.
Edwards C and Stillman P. Minor illness or major disease? The clinical pharmacist in
the community. 4th edition. London: Pharmaceutical Press, 2006.
Rutter P. Community pharmacy. Symptoms, diagnosis and treatment. 2nd edition.
Edinburgh: Churchill Livingstone, 2008.

Websites
National Library for Health clinical knowledge summaries
(http://www.cks.library.nhs.uk) the NHS online information resource for
health professionals
GPnotebook (http://www.gpnotebook.co.uk/homePage.cfm) an online
encyclopaedia of medicine for clinicians with useful information on minor
ailments
Royal Pharmaceutical Society of Great Britain (http://www.rpsgb.org.uk/
informationresources/downloadsocietypublications) guidance on recent
POM to P switches
NHS Direct Online (http://www.nhsdirect.nhs.uk) intended for the general
public but has an encyclopaedia section with good information on minor ailments

Other sources
The Chemist & Druggist guide to OTC medicines and diagnostics lists all the over-
the-counter medicines that are available in the UK and a useful summary of
treatments for each condition.
Available online at: http://www.chemistanddruggist.co.uk/otcguide

Links to other CPPE programmes


The following CPPE programmes support your learning on the clinical
management of minor ailments:
Responding to minor ailments open learning
Minor ailments services: a clinical approach e-assessment.

MARCH 2009
Section 1 1

Self-care and minor ailments services:


new roles for pharmacy

Objectives
On completion of this section you should be able to:

define self-care

discuss the government policies that have influenced changes in the


delivery of minor ailments services to patients

describe how minor ailments services make a valuable contribution


to the implementation of government policies relating to self-care,
and how they fit in to the pharmacy contract.

This section looks at what is meant by minor ailments services, the re-emergence
of the concept of self-care, and the policies that are guiding the development of
new roles for community pharmacy. It is important to understand this
background, especially when considering issues around skill mix and service
implementation.

1.1 Minor ailments and the concept of self-care


A key document relating to pharmacists and minor ailments services is Better
management of minor ailments: using the pharmacist, published by the Royal
Pharmaceutical Society of Great Britain (http://www.rpsgb.org.uk/pdfs/
bettmanminail.pdf). This defines minor ailments as conditions that are self-
3
limiting and generally require little or no medical intervention.

Practice point
Take a look at Better management of minor ailments and familiarise
yourself with its contents.
Consider what it means to you and the service you are delivering now,
and the service you would like to deliver in the future.
Think about the benefits a minor ailments service can provide to the
Recent NHS strategy
pharmacy, the GP practice and, more importantly, the patient.
documents and the

implementation of the new


Minor ailments services have been recognised as a valuable resource in the NHS
community pharmacy
for many years. Historically, community pharmacists have spent a great deal of
their working day providing valuable advice and medicines to patients presenting contract have directed
4
with a minor ailment and signposting them to other healthcare professionals. community pharmacy teams
5
Pharmacies are local, accessible and convenient for patients and the public.
towards expanding their roles
Recent NHS strategy documents and the implementation of the new community
in supporting self-care.
pharmacy contract have directed community pharmacy teams towards expanding
their roles in supporting self-care.
MARCH 2009
2 SECTION 1

E xercise 1
Visit the Department of Health website, look at the document, Self care: a real
6
choice. Self care support: a practical option and write down the Department of
Healths definition of self-care. You can download the document from:
http://www.dh.gov.uk

A Turn to the end of this section for suggested answers.

Self-care is one of the key pillars of the NHS Plan. This is the governments vision
Self-care is about more than
for a patient-centred care system and is an important strand in its overall strategy
for health. Self-care is about more than managing minor self-limiting conditions;
managing minor self-limiting
it is a persons ability to look after themselves and their family, including what
conditions; it is a persons they do to stay healthy, to manage minor ailments, and to manage chronic
7 8
ability to look after conditions. Pharmacists have the knowledge and skills to drive this agenda.

themselves and their family, To find out more about self-care visit these web links:
7
including what they do to http://www.pharmj.com/pdf/news/pj_20031011_selfcare.pdf
stay healthy, to manage 9
http://www.pagb.co.uk
minor ailments, and to
Minor ailments services support self-care by helping patients to manage their
manage chronic conditions.
ailments more effectively, with an emphasis on patient choice. This means that
people are helped to take care of themselves.

1.2 The importance of self-care to pharmacy


To appreciate the importance of self-care and its implications for community
pharmacists practising under the community pharmacy contractual framework it
is necessary to be familiar with the policies that have shaped the governments
vision for improving patient care.
Since 1986 there have been a number of reports by the Royal Pharmaceutical
Society of Great Britain and the Department of Health outlining the future of the
pharmacy service and its integration into the NHS. All of these have promoted a
more proactive role for community pharmacy in managing minor ailments. Here
is a summary of the key policies that have influenced this change.You may be
familiar with some of these documents. Web links have been added for those of
you who may wish to learn more.

MARCH 2009
SELF-CARE AND MINOR AILMENTS SERVICES: NEW ROLES FOR PHARMACY 3

10
The NHS plan
Available on the Department of Health website at: http://www.dh.gov.uk
The pharmacy professions aspirations were realised in principle in 2000 with the
publication of this policy document on the future of the NHS, which outlines a
vision of services designed around the patient. It aims to achieve this by:
highlighting self-care as the key to modernising the NHS
supporting pharmacists in promoting self-care
making better use of the skills of NHS staff
encouraging manufacturers to reclassify more medicines for over-the-counter
supply.

11
Pharmacy in the future implementing the NHS plan
Available on the Department of Health website at: http://www.dh.gov.uk

E xercise 2
Download Pharmacy in the future and summarise the key points specific to self-
care and minor ailments.

A Turn to the end of this section for suggested answers.

12
A vision for pharmacy in the new NHS
Available on the Department of Health website at: http://www.dh.gov.uk

This document, published in July 2003, states that community pharmacies:


should be an integral part of the NHS in providing community services
should be the first port of call for patients
should be a source of innovation in the delivery of services
should tackle inequalities in health.

MARCH 2009
4 SECTION 1

13
Our health, our care, our say: a new direction for community services
Available on the Department of Health website at: http://www.dh.gov.uk

Launched in January 2006, this document has four central ambitions; to:
improve prevention and early intervention
tackle inequalities and improve access to community services
increase support for people with long-term needs
increase public choice and influence on public services.

It was developed in part from a listening exercise which allowed the public to
speak directly to ministers, to health professionals and to each other on ways of
making improvements to local services. People said they wanted local services to:
be based on an understanding of how they live and to support them in leading
healthier lives
help them to live independently if they have ongoing health or social care needs
be easy to get to and convenient to use
be nearer to where they live, or easily available in the areas where they work.

8
The self-care challenge: a strategy for pharmacists in England
http://www.rpsgb.org.uk/pdfs/selfcarechallenge.pdf
This is an important document; published by the Royal Pharmaceutical Society in
March 2006, it supports the role of pharmacists in self-care. It states: Self care is
all about individuals taking responsibility for their own health and well-being. Self care
covers a spectrum from staying fit and healthy, through preventing ill health, achieving
better use of medicines, managing minor ailments to improving care of long term
conditions.

E xercise 3
Download The self-care challenge: a strategy for pharmacists in England. First
summarise the key points specific to self-care and minor ailments, then make a
note of the three types of self-care proactive self-care, facilitated self-care and
more supported self-care and give examples of each.

MARCH 2009
SELF-CARE AND MINOR AILMENTS SERVICES: NEW ROLES FOR PHARMACY 5

A Turn to the end of this section for suggested answers.

The national service framework for children, young people and maternity
14
services
Available on the Department of Health website at: http://www.dh.gov.uk
This document was published in October 2004. It sets standards for childrens
health and social services and clearly identifies a role for pharmacists in the self-
care of children. Standard 10 provides information about medicines for children
and young people.

1.3 Milestones in the implementation of self-care policy


There have been a number of initiatives to ensure that the government health
policies outlined above are implemented. These include:
the community pharmacy contract
practice-based commissioning
NHS Direct
NHS walk-in centres.

15,16
The community pharmacy contract
The community pharmacy contract is intended to enable community pharmacies
to contribute to the governments priorities for service provision, in which self-
Pharmacists may have to take
care is a key element. For these reasons minor ailments services appear twice
a proactive approach to
within the new contract, both as an essential service (ES6: Support for self-care),
which recognises the professional role that the pharmacy team can play in the sale developing a minor ailments
and supply of general sales list and pharmacy medicines, and also as an enhanced service locally, by convincing
service (EN8: Minor ailment service).
their PCT or local
Note. Enhanced services are not included among the services that must be
commissioning group of the
provided nationally within the contract, and there is no reserved funding for them.
Instead, they are commissioned locally at the discretion of each individual PCT. advantages of such a service

Therefore pharmacists may have to take a proactive approach to developing a in terms of increasing access
minor ailments service locally, by convincing their PCT or local commissioning for patients or making more
group of the advantages of such a service in terms of increasing access for
appropriate use of GP time.
patients or making more appropriate use of GP time.
The service specifications for ES6 and EN8 can be downloaded from:
http://www.psnc.org.uk

MARCH 2009
6 SECTION 1

Practice-based commissioning
The advent of practice-based commissioning may also have a significant impact
A local commissioning group on how minor ailments services are funded. A local commissioning group or GP
practice may consider it appropriate to develop a minor ailments service with
or GP practice may consider
their local community pharmacy.
it appropriate to develop a
To learn more about practice-based commissioning read Practice-based
minor ailments service with 17
commissioning bulletin 5 (http://www.pcc.nhs.uk/uploads/pbc_files/bulletin_5/
their local community pbc_bulletin_5__pharmacy.pdf) or visit the Department of Healths website on
pharmacy.
practice-based commissioning available via: http://www.dh.gov.uk/

NHS Direct
Essential service 5 (Signposting) in the community pharmacy contract states that
community pharmacists will be expected to help people who seek assistance by
directing or signposting them to the most appropriate sources of help. This could
include local self-help groups, relevant booklets and other publications, the NHS
website (http://www.nhs.uk/england), and NHS Direct.
Conversely, community pharmacies are included as an official referral point from
NHS Direct in appropriate situations.
The service specification for ES5 can be downloaded from:
http://www.psnc.org.uk/

How to contact NHS Direct


By telephone (0845 4647). NHS Direct is the national direct-access
telephone service for healthcare. It provides advice from fully-qualified
nurses in response to specific health queries, information about general
health problems, and information about health services. One of its main
functions is to advise callers about which health service to use if a condition
or symptom cannot be self-treated.
Online. The NHS Direct website (http://www.nhsdirect.nhs.uk) contains
an algorithm-based self-help guide on symptoms, together with advice on
self-treatment or referral to a health service, as appropriate. There is also a
health encyclopaedia providing useful information about minor ailments and
how to treat them.
The NHS Direct self-help guide. This is printed as a reference section at the
back of every Thomson Local telephone directory.
Digital television. Some providers of digital television offer access to NHS
Direct via the red button on the handset.

MARCH 2009
SELF-CARE AND MINOR AILMENTS SERVICES: NEW ROLES FOR PHARMACY 7

NHS walk-in centres


NHS walk-in centres were created to improve the way people get treatment for
injuries and minor health problems by providing immediate access to primary NHS walk-in centres were
care services. Some nurses working at NHS walk-in centres are qualified to issue
created to improve the way
NHS prescriptions for selected medicines and products. Additional prescription-
only medicines (POMs) can be supplied under a patient group direction (PGD). people get treatment for
(See Section 2.2 for further information on PGDs). injuries and minor health

problems by providing

E xercise 4 immediate access to primary

care services.
Use the following web link to find the address and telephone number of your local
walk-in centre and details of the services it provides:
http://www.nhs.uk/AboutNHSservices/walkincentres

You may find it useful to involve the pharmacy team in this exercise. It will help to
familiarise them with the use of websites to access signposting information.

Name of local walk-in centre:

Address:

Contact telephone number:

Services provided:

Practice point
After reflecting on what you have read so far, ask the members of your
pharmacy team what they understand by the terms self-care and minor
ailments services. If they are not familiar with the concepts you could
consider running an in-house training session, writing a summary of the
main points for them, or getting together with other colleagues who are
interested in developing their own staff.
Note the main points of your discussion below:

You could use these points as a discussion tool to plan how self-care
might be included in the day-to-day processes within the pharmacy.
Remember that this may help to gain the commitment of your team and
facilitate the setting up of a new minor ailments service.

MARCH 2009
8 SECTION 1

Summary
By referencing a number of key government policies this section has shown how
ordinary people are being encouraged to take more responsibility for their own
health. As a result, the concept of self-care for minor ailments is being facilitated
through the provision of many NHS services, including NHS Direct, walk-in
centres and pharmacy-based minor ailments services in some PCT areas, and by
the reclassification of many prescription-only medicines to non-prescription
status.
The pharmacy contract and the advent of prescribing by pharmacists should
create further opportunities for the community pharmacy service to fulfil its
potential and play a full role in this important area of healthcare.

Intended outcomes
By the end of this section you should be able to:

Learning objective Well can you?


Define self-care.

Discuss the government policies that have


influenced changes in the delivery of minor ailments
services to patients.

Describe how minor ailments services make a


valuable contribution to the implementation of
government policies relating to self-care, and how
they fit in to the pharmacy contract.

MARCH 2009
SELF-CARE AND MINOR AILMENTS SERVICES: NEW ROLES FOR PHARMACY 9

Suggested answers

A Exercise 1 (page 2)
The Department of Healths definition of self-care is:

Self-care is a part of daily living. It is the care taken by individuals towards their
own health and well-being and includes the care extended to their children, family
and others in neighbourhoods and local communities.

A Exercise 2 (page 3)
Pharmacy in the future, published in September 2000, states that:

community pharmacies are well placed to help people cope with everyday health
problems

there is a need for more community pharmacies to be made an official point of


referral from NHS Direct

by 2004 every PCT should have a minor ailments scheme in place so that
pharmacists can give people the help they need in using their medicines.

A Exercise 3 (page 4)
The self-care challenge: a strategy for pharmacists in England, published in
March 2006, has the following key messages:

opportunities exist for developing self-care support in five key areas: staying fit
and healthy, taking action to prevent illness, achieving better use of medicines,
managing minor ailments, and improving the care of long-term conditions

pharmacists need to consider ways of engaging with all health and social care
professionals to give consistent messages about self-care to patients and the
public

PCTs need to maximise the opportunities to promote self-care, patient choice and
ways in which the pharmacy service can support patients

pharmacists need to consider ways of engaging with service commissioners.

Examples of the three types of self-care

Proactive self-care: individual takes action to stay fit; pharmacists can have a role
in health promotion; signposting.

Facilitated self-care: individual purchases a medicine for a minor ailment and is


given advice by the pharmacist on how to use the medicine and how to self-
manage the condition if it recurs; signposting.

More supported self-care: support for self-care in long-term conditions; advice on


medicines management.

MARCH 2009
10 Section 2
NHS-funded minor ailments services:
skill mix and service implementation

Objectives
On completion of this section you should be able to:

describe what is meant by a minor ailments service

list the common features of a minor ailments service

access appropriate web links to find out more about the


development of minor ailments services

describe the patients journey from referral through to consultation.

In Section 1 we looked at the key government health policies which are shaping
the future of healthcare and how the treatment of minor ailments fits into the
community pharmacy contract by enabling patients to self-manage their
conditions. Such initiatives also improve access to healthcare and make more
appropriate use of the skill mix within a community pharmacy.You will have
started to work more closely with your team in considering the importance of
minor ailments services and self-care.
This section will give you some useful background information which may
There are now many minor support a PCT accreditation process to provide an NHS-funded minor ailments
service in your area as an enhanced service under the community pharmacy
ailments services running
contract. There are now many minor ailments services running throughout the
throughout the country and country and often they have been locally tailored. This section will cover the
often they have been locally general features which are most commonly seen.You will need to liaise with your
PCT to gain an understanding of the features of your local service.
tailored.

E xercise 5
What do you understand by the term NHS-funded minor ailments services?

A Turn to the end of this section for suggested answers.

2.1 The rise of locally-tailored minor ailments services


Many GP consultations are for conditions that could be treated with an over-the-
counter medicine and appropriate advice from an alternative healthcare
professional. It has been estimated that between 100 -150 million GP
3
consultations a year are for conditions that are potentially self-treatable.
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The reason so many patients request prescriptions for minor ailments is that they
are exempt from prescription charges and cannot afford to buy medicines in the NHS-funded, locally-tailored
pharmacy. This has led to the development of NHS-funded, locally-tailored minor
minor ailments services give
ailments services which give patients the opportunity to consult their community
pharmacist for a specified minor ailment and receive self-care advice and a patients the opportunity to
medicine to treat the condition, if appropriate. The pharmacist may supply a consult their community
medicine from an agreed formulary which includes both over-the-counter
pharmacist for a specified
medicines and certain prescription-only medicines (POMs) that the pharmacist
has been trained to supply under a patient group direction (PGD).You will have minor ailment and receive

the opportunity to learn more about PGDs by completing the Practice point at the self-care advice and a
end of this section. If a patient is exempt from prescription charges the medicines medicine to treat the
are supplied free of charge. There is also usually a facility within the service for
condition, if appropriate.
referring patients who present with alarm symptoms directly to a GP.
For promotional purposes minor ailments services are usually given names like
Care at the chemist.

E xercise 6
Refer back to Section 1 and remind yourself of five key issues from the
governments policies that have led to the introduction of minor ailments services.
List them below.

A Turn to the end of this section for suggested answers.

2.2 Implementing a minor ailments service: an overview


The way that PCTs implement local services cannot be covered in detail in this
programme. However, in general it is their responsibility to:
define a local strategy within the context of their own policies and priorities
perform a local needs assessment
develop the strategy with the full commitment of the board
develop an agreed action plan with a timetable and milestones
pilot the service
implement the service
audit the service
develop existing services.

MARCH 2009
12 SECTION 2

When developing a minor ailments service it is very important to obtain the


support of local GPs. This is because the care of their patients is, in effect, being
transferred to the community pharmacist. GPs will need to be reassured that their
patients will receive appropriate advice and efficient treatment in a way that
reflects their own practice.

Determining the need for a minor ailments service


When PCTs are considering whether to commission a minor ailments service as
an enhanced service it is important that they first establish the need for such a
18
service locally. They determine this need by:
assessing the levels of deprivation within the area. In areas where there is a
high level of deprivation a high proportion of the population may not be able to
afford to buy medicines from the pharmacy. This could pose an obvious barrier
to increasing the use of community pharmacies and may lead to inappropriate
requests for prescriptions from GPs.
conducting a pharmaceutical needs assessment. This is useful for identifying
gaps in patient care and service provision. The assessment may look at the
current levels of service for minor ailments across the PCT (for instance, from
walk-in centres) and audit the number of GP consultations for minor ailments.
This is useful baseline data which can then be used to monitor the desired
outcomes of the service.

As explained in Section 1, minor ailments services are an enhanced service within


the community pharmacy contract, which means there is no reserved funding for
them. Nonetheless, some innovative community pharmacists have successfully
negotiated funding to provide a service from their local PCTs.

Practice point
Learn more about pharmaceutical needs assessment by reading this
19
article in Primary Care Pharmacy. You can access it at:
http://www.pharmj.com/PrimaryCarePharmacy/200009/articles/needs_
assess_112-113.html

If you would like to learn If you would like to learn more about implementing, monitoring and reviewing a
more about implementing, minor ailments service visit the National Pharmacy Associations website and
20
download their toolkit for primary care organisations and health professionals.
monitoring and reviewing a
You can access it at:
minor ailments service visit http://www.npa.co.uk/members/pdf/nhsdev/minorails/minorailstoolkit.pdf#
the National Pharmacy search=%22minor%20ailments%20npa%22

Associations website and This is essential reading for any community pharmacist who is proposing a new
download their toolkit for
minor ailments service to a PCT.You may be able to access your local PCTs
pharmaceutical needs assessment via the PCTs website.
primary care organisations

and health professionals.

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E xercise 7
Make a list of some of the issues that may act as barriers to implementing a minor
ailments service. Compare your list with the one that appears on page 2 of this
18
issue of MeReC Briefing, which you can access at:
http://www.npc.co.uk/ebt/merec/other_non_clinical/resources/merec_
briefing_no27.pdf

A Turn to the end of this section for suggested answers.

The common features of an NHS-funded minor ailments service


Here are the key common features of a minor ailments service:
they are commissioned by a PCT to meet local health needs and to tackle
inequalities in healthcare
they are run by community pharmacies in collaboration with local GP practices
they have systems in place to notify each GP practice about the consultations
that have taken place in the pharmacy, and to provide feedback about the
number and type of consultations to the PCT
the patients journey through the service follows a set process from referral
through registration to consultation
patients who are exempt from prescription charges receive their medicines free
of charge
the community pharmacy is paid for providing the service through either a
one-off annual fee and/or a fee per consultation. They are reimbursed for the
cost of medicines on the basis of their current cost price or drug tariff price.

The patients journey through the minor ailments service


The patients journey through the minor ailments service consists of three main
stages:
1. Referral into the service.
2. Registration with the service.
3. Patient consultation.
It is worth walking through the process to consider each stage in more detail and
to understand how it works in practice.
MARCH 2009
14 SECTION 2

Referral into the service


A patient can be referred to a minor ailments service in two ways:
Direct referral. This is when a GP practice refers patients directly to the
community pharmacy when they request a GP appointment or a prescription
for a minor ailment. This route was widely used when minor ailments services
were being piloted and in some of the first schemes to be set up. Patients must
be confident that their referral to an alternative healthcare professional is
appropriate and that the process will be efficient and easy for them to follow.
While this route has the advantage of enabling the GP practice to become more
familiar with the process of signposting patients to the community pharmacy, it
may be somewhat restrictive.
Self-referral. This is when patients take responsibility for their own care and
Self-referral is now a refer themselves to the community pharmacy. It is now a common method of
referral for many minor ailments services and ties in with the governments
common method of referral
policy of improving access to services and encouraging self-care. This enables
for many minor ailments patients to access the service when the GP practice is closed.
services and ties in with the
Registration with the service
governments policy of
One of the most common concerns about minor ailments services is that they are
improving access to services
open to abuse by patients who use several different pharmacies to obtain
and encouraging self-care. medicines free of charge for other members of their family who are not registered
with a GP in the area. As a result, many PCTs have introduced a patient
registration process. Registration may take place either at the patients GP practice
or at the community pharmacy, providing the patient can produce suitable
identification and verify that they are registered with a local GP (this is usually
done by referring to their patient medication records or asking them to provide an
FP10 or repeat slip). The registration details are then passed to the PCT and kept
on a database for service evaluation purposes.
At the point of registration the patient is usually issued with their own record
book in which details of their consultations can be recorded. If the service allows
patients to use a number of different local pharmacies the record book enables the
community pharmacist to identify those who are presenting regularly with the
same symptoms.
Some well-established services use information leaflets to encourage patients to
register as a matter of routine via their GP practice rather than waiting until they
are suffering from a minor ailment.

Patient consultation
When a patient presents at the community pharmacy with a minor ailment the
pharmacist or a member of the pharmacy team assesses the symptoms and
determines the cause and severity of the condition.
It is likely that the pharmacys standard operating procedure (SOP) for
consultations (see Section 3.2) will specify that patients should be seen in person,
but it may also allow a pharmacist to use their professional judgment to provide
advice and treatment via the patients carer or representative, providing they are
known to the pharmacy.

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Once a diagnosis has been made there are three possible outcomes:
Advice only. The provision of counselling and advice is an essential part of
pharmaceutical care. There is usually some facility within the service for the
pharmacy to claim a consultation fee from the PCT when advice only is the
most suitable option for the patient.
Advice, treatment with a medicine from the formulary, and counselling. The
pharmacist confirms the diagnosis of a minor ailment covered by the scheme
and, if treatment is appropriate, supplies a medicine from an agreed formulary
(see Appendix 1).
Referral to a different healthcare professional. There may be occasions when
the pharmacist has serious concerns about a patients symptoms (eg, the
Most minor ailments services
severity of the symptoms, or associated factors such as weight loss). Most
minor ailments services include a rapid referral process which enables the include a rapid referral

pharmacist to contact the patients GP practice by fax and a follow-up process which enables the
telephone call to ensure that the patient gets an urgent appointment. pharmacist to contact the

patients GP practice by fax


The minor ailments covered by the service
and a follow-up telephone
The ailments covered by each individual service will depend on several factors:
call to ensure that the patient
available funding for the service from the PCT
gets an urgent appointment.
whether the PCT has the capacity to provide training for ailments that can be
treated with the medicines that may be supplied under a patient group
direction
the presentation rates for particular ailments at local GP practices
whether GPs will agree to transfer the care of patients with a particular ailment
to the community pharmacy
the availability of over-the-counter medicines to treat the ailment.

Most services initially concentrate on the common ailments that have a major
impact on inappropriate GP prescribing and on consultation time. These include:
respiratory disorders (eg, dry cough, chesty cough, nasal congestion)
gastrointestinal disorders (eg, diarrhoea, constipation, indigestion)
head lice
allergies.

However, as the government continues to increase the number of medicines


switching from POM to P status for pharmacy supply there is the potential to
extend the range of ailments that may be covered.
For more information on how medicines are reclassified read the Medicines and
21
Healthcare products Regulatory Agencys business plan for 2004-2005. You can
download it from:
http://www.mhra.gov.uk/home/groups/comms-sp/documents/publication/con
008356.pdf
See also the Department of Healths press release from 1 May 2002 on extending
22
patient choice at:
http://www.dh.gov.uk/

MARCH 2009
16 SECTION 2

Each ailment covered by the service usually has an associated treatment protocol
(see Appendix 1) or standard operating procedure for the supply of medicines.
Treatment protocols include information such as:
the criteria for including or excluding a patient from treatment for a particular
ailment
the recommended medicines from the formulary (see below) with dosages and
side-effect profiles
follow-up advice for patients
advice on when and how to refer a patient to another healthcare professional.

To see an example of a treatment protocol refer again to the National Pharmacy


20
Associations toolkit at:
http://www.npa.co.uk/members/pdf/nhsdev/minorails/minorailstoolkit.pdf#
search=%22minor%20ailments%20npa%22

The medicines that can be supplied


The range of ailments covered by the service is complemented by a PCT-defined
The range of ailments formulary which lists the medicines that may be supplied after the consultation
has taken place and appropriate advice has been given. It is important that there is
covered by a minor ailments
some flexibility within the formulary; the medicines that are included may depend
service is complemented by a on several factors such as whether the patient is an adult or a child, is pregnant or
PCT-defined formulary which breast-feeding, or has any other co-morbidities which may contraindicate certain
medicines.
lists the medicines that may

be supplied after the


To ensure consistency it is important that the formulary contains medicines that
could normally be prescribed by a GP. As far as possible, the choice of medicines
consultation has taken place 18
should be evidence-based. It is important to review the formulary regularly as
and appropriate advice has drug costs fluctuate, medicines are reclassified, and changes occur in product
been given. licences.
To see an example of a medicines formulary refer again to the National Pharmacy
20
Associations toolkit at:
http://www.npa.co.uk/members/pdf/nhsdev/minorails/minorailstoolkit.pdf#s
earch=%22minor%20ailments%20npa%22
If a medicine is supplied to a patient a three-part proforma, similar to a
prescription form (sometimes known as an FPPharm [see Appendix 2] ) may be
completed: one copy is forwarded to the patients GP to inform them of the
treatment that has been provided, one copy is kept at the pharmacy, and one copy
is forwarded to the PCT to claim payment for the consultation.
Any medicines that are supplied should be labelled in the same way as
prescription medicines and the details entered into the pharmacys patient
medication record. A note of the consultation and the outcome should be entered
in the patients record book, including details of the presenting ailment, the date,
the medicines supplied, and the pharmacists signature.
The involvement of a non-medical prescriber in a minor ailment service would
widen the access to more medicines.

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E xercise 8
List three reasons why it may be important for a GP to receive information about a
minor ailments consultation a patient has had with a pharmacist.

A Turn to the end of this section for suggested answers.

In addition to the over-the-counter and pharmacy-only medicines that are


routinely supplied, a minor ailments service can also supply POMs under a PGD.
This means that ailments for which a POM is the most effective treatment may be
included in the service (eg, trimethoprim for the treatment of uncomplicated
urinary tract infection in women).
Supplying POMs via a PGD has implications for training and workload for the
PCT that is running the service, and also for the community pharmacy team. Supplying POMs via a PGD
However, the use of PGDs supports the governments vision of promoting self-
has implications for training
care, and also makes appropriate use of the pharmacists clinical skills.
and workload for the PCT

that is running the service,

and also for the community


Practice point pharmacy team.
A PGD is defined as a written direction, signed by a doctor or dentist and
by a pharmacist, relating to the supply and administration, or
administration only, of a POM or pharmacy medicine to persons
generally, subject to any exclusions that may be set out in the direction.
Do you and your pharmacy team need to know more about supplying
medicines under a PGD? Make a list of PGDs relating to the provision of
a minor ailments service and discuss as a team their potential impact on
the service you might provide. Find out if your PCT has any plans to
provide training in this area to enable you to become accredited to supply
certain medicines under a PGD. (There is a list of useful resources below.)
Write down the findings from your discussions.

MARCH 2009
18 SECTION 2

Additional learning on patient group directions


If you would like to find out more about PGDs you may find the following
sources helpful:
Royal Pharmaceutical Society of Great Britain.
23
Patient group directions: a resource pack for pharmacists. Factsheet 7.
Available online at: http://www.rpsgb.org/pdfs/factsheet7.pdf
National Prescribing Centre.
A practical guide and framework of competencies for all professionals using
patient group directions; incorporating an overview of existing mechanisms
24
for the supply and prescribing of medicines.
Available online at:
http://www.npc.co.uk/prescribers/resources/patient_group_directions.pdf
National electronic Library for Medicines.
Patient group directions website:
http://www.portal.nelm.nhs.uk/PGD/default.aspx
CPPE
Patient Group Directions open learning programme
Available online at: http://www.cppe.ac.uk

How the community pharmacy will be paid


Community pharmacists who provide a minor ailments service receive either a one-
Community pharmacists who off annual fee or a payment for the professional service they provide and the cost of
the medicines they have supplied. The way in which payment is claimed varies from
provide a minor ailments
pharmacy to pharmacy depending on how much information the PCT requires.
service receive either a one-
Some PCTs request a copy of each FPPharm document to confirm that the
off annual fee or a payment medicines have been supplied (but patient confidentiality must be taken into
for the professional service consideration) while others ask for a summary sheet each month. There is usually a
they provide and the cost of
facility within the service for a consultation fee when the pharmacist has used his or
her professional judgment to refer a patient to the GP rather than supply a medicine.
the medicines they have
Some PCTs are now moving towards electronic fee claims for minor ailments
supplied.
services. This usually involves the pharmacy submitting monthly claims via a secure
website.

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Summary
Minor ailments services are now one of the most commonly commissioned
enhanced services in the country. Although there are local variations, you and
your pharmacy team should now have a clearer understanding of the common
features of such a service and of the patients journey through referral, registration
and consultation.
Good communication links between PCTs, community pharmacies and GP
practices are essential for the provision of a successful and efficient service and
help the integration of community pharmacy into the NHS.

Intended outcomes
By the end of this section you should be able to:

Learning objective Well can you?


Describe what is meant by a minor ailments service.

List the common features of a minor ailments


service.

Access appropriate web links to find out more


about the development of minor ailments services.

Describe the patients journey from referral through


to consultation.

MARCH 2009
20 SECTION 2

Suggested answers

A Exercise 5 (page 10)


In Better management of minor ailments (http://www.rpsgb.org.uk/pdfs/
bettmanminail.pdf) the Royal Pharmaceutical Society offers the following
definition: A systematic referral process from the general practice to the pharmacist
3
for specified minor conditions.

A Exercise 6 (page 11)


The key issues from government policies that have led to the introduction of minor
ailments services are:

support for self-care


improving access for patients
making more appropriate use of GP time
making better use of the skills of pharmacy staff
tackling health inequalities.

A Exercise 7 (page 13)


Some of the barriers to implementing a minor ailments service could be:

the service may be abused by patients who try to obtain medicines from different
pharmacies or for other members of their family for the purpose of replenishing
their medicines cupboard

the service may be more costly than anticipated

GP practices and community pharmacies may not have the time to deal with the
additional workload

patients may not be happy about being referred to a pharmacist if they have
requested an appointment with their GP.

A Exercise 8 (page 17)


Reasons why it is important for a GP to receive information from a minor ailments
consultation:

over-the-counter medicines may be the cause of the presenting symptoms

knowing which over-the-counter medicines have been taken, and what their
effects are, is an important diagnostic tool

all current medication, including over-the-counter medicines, need to be


considered for interactions when prescribing.

MARCH 2009
Section 3 21

Clinical governance and minor ailments


services

Objectives
On completion of this section you should be able to:

list the clinical governance processes that apply to a minor ailments


service

use clinical governance processes to promote skill mix within the


pharmacy to provide a more efficient, quality service.

This section outlines the key clinical governance issues relating to the provision of
a minor ailments service. Clinical governance is an essential element of any
service in the NHS. It is important to be able to demonstrate the quality of a
service, to manage the risks within it, and to continually monitor it to ensure that
20
standards are maintained, or to improve it when failures or lapses are identified.

Practice point
Make a note here of what you understand by the term clinical
governance.

3.1 What is clinical governance?


As a pharmacist you have a legal and ethical obligation to ensure that you are
operating within your own sphere of competence, whatever type of
As a pharmacist you have a
pharmaceutical service you are providing. Clinical governance is a tool to help
you recognise and celebrate good professional practice, and to highlight areas legal and ethical obligation
25
where there is potential for improvement. For this reason it is an essential to ensure that you are
16
service (ES8) under the community pharmacy contract and is an essential operating within your own
element that should underpin all NHS services.
sphere of competence,
The Royal Pharmaceutical Society of Great Britain suggests that clinical governance
whatever type of
can be divided into several elements:
pharmaceutical service you
1. Responsibility and accountability for the overall quality of clinical care all
are providing.
professionals are individually responsible for the quality of care they deliver.
2. A comprehensive programme of quality improvement activities:
clinical audit
continuing professional development
evidence-based practice
MARCH 2009
22 SECTION 3

research and development


effective monitoring of clinical care.
3. Policies and processes aimed at assessing and managing risk.
4. Audit procedures to confirm delivery of a quality service and highlight areas
for redesign and development.

Practice point
Access this document, Clinical governance, standards for better health and
the new community pharmacy contract (England & Wales): making the
26
links, at:
http://www.rpsgb.org.uk/pdfs/cpcontracthealthmap.pdf
This is a detailed statement on clinical governance which contains useful
connections between the core clinical governance standards, the
27
Department of Healths Standards for better health and the pharmacy
contract. Look at the document and highlight the areas that apply to you
when providing a minor ailments service. Make a note of these below.

3.2 Linking the key components of clinical governance and


minor ailments services
The key components of clinical governance are:
patient and public involvement
clinical audit and remedying underperformance
risk management
clinical effectiveness programmes
staffing and staff management
education, training and continuing professional and personal development
use of information to support clinical governance and healthcare delivery
accountability.

Patient and public involvement


Pharmacists need to involve patients and the public in redesigning and improving
25
the services they deliver.

MARCH 2009
CLINICAL GOVERNANCE AND MINOR AILMENTS SERVICES 23

Practice point
You can make contact with local patient group forums to promote the
minor ailments service and gain feedback from patients on the service
you provide. Patient questionnaires may also be a useful way of gathering
information, especially if a service is in the pilot stage.

Clinical audit and remedying underperformance


Audit is an efficient way of service monitoring and should be built in to all minor
18
ailments services. It is likely that a PCT will include audit in the service level
agreement (see below) for a new service. This will ensure that all participating
pharmacies are delivering a quality service.
Audit will help to demonstrate the quality of the service and highlight areas that
may require changes in practice. Pharmacists should always be prepared to Audit will help to
change their practice when an audit is completed.
demonstrate the quality of
28
You may find the following article in the Pharmaceutical Journal helpful:
the service and highlight
http://www.pharmj.com/pdf/society/pj_20050813_guidetoaudit.pdf
areas that may require

changes in practice.

Pharmacists should always


Practice point be prepared to change their
Can you list the areas of a minor ailments service that could be audited? practice when an audit is

completed.

Risk management
Robust risk management procedures protocols and standard operating
procedures are an essential part of every service provided by the pharmacy.
They are usually drawn up by the working group that is responsible for
developing services in your area and they apply universally to all pharmacies and
GP practices that provide the services.
Here are some examples of the protocols and procedures you may see:
Service level agreement. This is a signed agreement between the pharmacy and
the PCT that is responsible for the service. It sets out the obligations of both
parties and the terms and conditions for the provision of the service, such as:
the mechanisms for funding and payment
the responsibilities for clinical governance
how the service will be terminated
the responsibility of pharmacists to notify their professional indemnity
insurers that they are providing the service.
MARCH 2009
24 SECTION 3

Standard operating procedure. A standard operating procedure for each step


in the patients journey should be followed by the pharmacy team. These
usually cover such things as:
registration
patient consultation
reporting to the PCT and the patients GP
payments and claims.
Having standard operating procedures in place provides reassurance that
processes are being followed in a consistent manner. The pharmacy should
keep standard operating procedures under constant review.
To see examples of both a service level agreement and a standard operating
20
procedure visit:
http://www.npa.co.uk/members/pdf/nhsdev/minorails/minorailstoolkit.
pdf#search=%22minor%20ailments%20npa%22

Treatment protocols. Treatment protocols (or clinical formulary protocols) are


developed by the PCT for each of the minor ailments included in the service
and act as a guide for the supply of the medicines that are included in the
formulary (see below). They also usually contain information such as:
the criteria for including or excluding a patient from treatment for a particular
ailment (eg, some medicines may only be suitable for children over 12 years
of age)
advice to be given during consultations
dosage regimens
the expected side-effects
guidance on when and how to refer patients.
20
To see an example of a treatment protocol see Appendix 1 or visit:
http://www.npa.co.uk/members/pdf/nhsdev/minorails/minorailstoolkit.
pdf#search=%22minor%20ailments%20npa%22

Medicines formulary. The medicines formulary is agreed by the local PCT


working group that is developing the services. It includes a list of the medicines
that can be supplied for each specific ailment. There may be more than one
medicine for each ailment to ensure that a wider patient group can be served
(eg, children and pregnant women).

Rapid referral process. It is essential to have a protocol in place that gives clear
guidance on referring patients directly to a GP if a patient presents with alarm
symptoms. This may consist of a proforma that can be faxed directly to the GP
practice to ensure that the patient is given an urgent appointment.

Reauthorisation process. Some minor ailments services put a limit on the


number of consultations a patient may have before requiring their GP to
reauthorise their continued use of the service. Consultations should be
documented in the patients record book; this will enable the GP to identify
patterns of recurrent symptoms that may concern them. It is the professional
responsibility of the pharmacist to identify problems such as recurrent symptoms
in a patient. This process may also help to deter potential abuse of the service.
MARCH 2009
CLINICAL GOVERNANCE AND MINOR AILMENTS SERVICES 25

Significant event recording. Each service should have a clear process in place
for documenting significant incidents and guidance on when the information
should be passed on, and to whom. The purpose is to share the experience with
others involved in the service, highlight any potential risks, learn from the
events, and put measures in place to prevent them happening again. Since the
advent of the pharmacy contract, pharmacies should be familiar with recording
significant incidents.

Locum arrangements. It is important that the minor ailments service is


provided consistently, even when the pharmacy has a locum pharmacist for the
day. Most services now operate a fast-track accreditation scheme for locums. It
is the responsibility of the pharmacy to make sure the locum is familiar with all
the processes that are in place to operate the service.

Complaints procedure. All pharmacies should have a robust complaints


procedure in place to deal with patients who raise an issue about the service
they have received.

Practice point
In light of the requirement to maintain a consistent minor ailments
service it would be sensible to nominate a member of the team to take
responsibility for running the service on a day-to-day basis. Consider who
this might be.What are their training needs?

Clinical effectiveness
Pharmacists should remain aware of current evidence relating to over-the-counter
prescribing and apply it to their practice. They should also be open to sharing Pharmacists should remain
25
ideas with professional colleagues and patients. When supplying medicines
aware of current evidence
under the minor ailments service it is important to monitor patient care and to
consider drug interactions and adverse drug reactions. relating to over-the-counter

prescribing and apply it to


Staffing and staff management
their practice. They should
Good organisation and knowledge about the processes involved with a minor
also be open to sharing ideas
ailments service are essential for the provision of a quality service. Although an
identifiable pharmacist should always be accountable for the service, the with professional colleagues
pharmacy team has an important role to play in its delivery. and patients.

The advent of the community pharmacy contract has created greater


opportunities to extend the services provided by the pharmacy and has
encouraged further training and development within pharmacy teams.
Pharmacists are realising the advantages of developing the knowledge and skills
of their staff.

MARCH 2009
26 SECTION 3

Practice point
If you are considering encouraging your pharmacy technicians to help you
develop the minor ailments service, direct them to the CPPE open
learning programme Minor ailments services: pharmacy technicians
29
leading the way.
To find out more about skill mix in the pharmacy read Skill mix in
community pharmacy: exploring and defining the roles of dispensary
30
support staff which you can access at:
http://www.pprt.org.uk/Documents/Publications/skill_mix_in_community
_pharmacy.pdf

Education, training and continuing professional and personal


development
Most PCTs that are implementing a minor ailments service provide initial training
on processes and procedures for pharmacists and their staff. However, identifying
your own learning needs is a professional responsibility that should be ongoing
working through this programme is part of this process.

Use of information to support clinical governance and healthcare


delivery
Maintaining patient records is an important aspect of clinical governance and for
Maintaining patient records this reason is usually included in the standard operating procedure for patient
consultations. Details will be recorded in the patient-held records, on the GP
is an important aspect of
information forms and in the pharmacy patient information record system.
clinical governance and for
Some PCTs also require the pharmacy to set aside a private consultation area in
this reason is usually which to provide its NHS-funded minor ailments service.
included in the standard

operating procedure for


Accountability
The pharmacist and pharmacy will be accountable for the service they provide. It
patient consultations.
is essential that the clinical governance systems described above are implemented
to ensure a safe and effective service is delivered.

MARCH 2009
CLINICAL GOVERNANCE AND MINOR AILMENTS SERVICES 27

Practice point
Think about all the clinical governance measures that are involved in the
provision of a minor ailments service.Then consider the individual skills
of your pharmacy team and complete the following table:

Identify ways in which your pharmacy team can support you to embed clinical governance
within the delivery of your minor ailments service?

Patient and public involvement

Clinical audit and remedying


underperformance

Risk management

Clinical effectiveness programmes

Staffing and staff management

Education, training and continuing


professional and personal
development

Use of information to support


clinical governance and healthcare
delivery

Accountability

MARCH 2009
28 SECTION 3

Additional learning on clinical governance


If you would like to find out more about clinical governance you may find the
following resources helpful:
Pharmaceutical Services Negotiating Committee. Service specification ES8
(Clinical governance requirements) in The new contract for community
16
pharmacy. Available online at:
http://www.psnc.org.uk/
Royal Pharmaceutical Society of Great Britain. Clinical governance for
community pharmacy website (http://www.cg4cp.org.uk)

Summary
Like all other pharmaceutical services, a minor ailments service should be
underpinned by the key elements of clinical governance. These processes are put
in place to ensure that pharmacists can deal appropriately with the transfer of
patient care from the GP to the community pharmacy. Ongoing audit is essential
to assess services as they develop and expand, and to ensure that a standard,
quality service is provided.

Intended outcomes
By the end of this section you should be able to:

Learning objective Well can you?


List the clinical governance processes that apply to
a minor ailments service.

Use clinical governance processes to promote


skill mix within the pharmacy to provide a more
efficient, quality service.

MARCH 2009
Checklist 29

Assessing how ready you are to deliver


an NHS-funded minor ailments service
Answer the following questions to assess your knowledge and readiness to
implement and operate a minor ailments service, and to identify any further
learning needs. This checklist may provide evidence to a PCT or commissioning
body of your ability to deliver a minor ailments service.

Yes/No Learning need

1. I understand why minor ailments


services have been created and
developed.

2. I can describe how minor ailments


services fit into government health
policies and pharmacy
modernisation.

3. I can discuss the broad concept


of self-care.

4. I am aware of resources which can


support a PCT in implementing a
minor ailments service.

5. I can list the common features of a


minor ailments service.

6. I understand the importance of


local treatment policies and
formularies as part of a minor
ailments service.

7. I am familiar with the patients


journey through a minor ailments
service, including referral,
registration and consultation.

8. I can list eight clinical governance


measures that relate specifically to
a minor ailments service.

9. I can describe and provide evidence


of clinical governance processes
that would support a quality minor
ailments service.

10. I have put processes in place to


train my pharmacy team to enable
them to actively participate in the
implementation and delivery of a
minor ailments service.

MARCH 2009
30 References

1. Department of Health. The NHS improvement plan 2004: putting people at the
heart of public services. London: HMSO, 2004.
2. Department of Health. Pharmacy in England. Building on strengths delivering
the future. London: The Stationery Office, 2008.
3. Royal Pharmaceutical Society of Great Britain. Better management of minor
ailments: using the pharmacist. London: RPSGB, 2003.
Available online at: http://www.rpsgb.org.uk/pdfs/bettmanminail.pdf
(accessed 12 March 2009)
4. Russell R. Community pharmacy service development: (1) How to establish a
new pharmacy service. Pharmaceutical Journal 2003; 271: 237-239.
Available online at:
http://www.pharmj.com/pdf/cpd/pj_20030823_cpsd1.pdf
(accessed 12 March 2009)
5. Department of Health. Choosing health through pharmacy. A programme for
pharmaceutical public health 2005-2015. London: COI, 2005.
6. Department of Health. Self care: a real choice. Self care support: a practical option.
London: COI, 2005.
Only available online at: http://www.dh.gov.uk/ (accessed 12 March 2009)
7. Bellingham C. How self-care is being made a reality. Pharmaceutical Journal
2003; 271: 486. Available online at:
http://www.pharmj.com/pdf/news/pj_20031011_selfcare.pdf
(accessed 12 March 2009)
8. Royal Pharmaceutical Society of Great Britain. The self-care challenge: a strategy
for pharmacists in England. London: RPSGB, 2006.
Available online at: http://www.rpsgb.org.uk/pdfs/selfcarechallenge.pdf
(accessed 12 March 2009)
9. Proprietary Association of Great Britain. Self-care website. URL (accessed
17/11/06): http://www.pagb.co.uk (accessed 12 March 2009)
10. Department of Health. The NHS plan. A plan for investment. A plan for reform.
London: HMSO, 2000.
11. Department of Health. Pharmacy in the future implementing the NHS plan.
A programme for pharmacy in the National Health Service. London: DH, 2000.
12. Department of Health. A vision for pharmacy in the new NHS. London: DH,
2003.
13. Department of Health. Our health, our care, our say: a new direction for
community services. Norwich: The Stationery Office, 2006.
14. Department of Health. The national service framework for children, young people
and maternity services: Executive summary. London: DH, 2004.
15. Department of Health (2005). Implementing the new community pharmacy
contractual framework, 2005.
Only available online at: http://www.dh.gov.uk/ (accessed 12 March 2009)
16. Pharmaceutical Services Negotiating Committee. The new contract for
community pharmacy. Aylesbury: PSNC, 2004.
Available online at: http://www.psnc.org.uk/ (accessed 12 March 2009)
MARCH 2009
REFERENCES 31

17. NHS Primary Care Contracting. Pharmacy and practice-based commissioning.


Practice-based Commissioning Bulletin 5, 2006.
Only available online at:
http://www.primarycarecontracting.nhs.uk/uploads/pbc_files/bulletin_5/
pbc_bulletin_5_ _pharmacy.pdf (accessed 12 March 2009)
18. National Prescribing Centre. Community pharmacy minor ailment schemes.
MeReC Briefing 27, 2004. Only available online at:
http://www.npc.co.uk/ebt/merec/other_non_clinical/resources/merec_
briefing_no27.pdf
19. Williams S. Pharmaceutical needs assessment easier said than done? Primary
Care Pharmacy 1 2000; (4): 112-113. Available online at:
http://www.pharmj.com/PrimaryCarePharmacy/200009/articles/needs_
assess_112-113.html (accessed 12 March 2009)
20. National Pharmacy Association. Implementing a community pharmacy minor
ailment scheme: A practical toolkit for primary care organisations and health
professionals. St Albans: NPA, 2003.
Available online at:
http://www.npa.co.uk/members/pdf/nhsdev/minorails/minorailstoolkit.
pdf#search=%22minor%20ailments%20npa%22
(accessed 12 March 2009)
21. Medicines and Healthcare products Regulatory Agency. Safeguarding public
health. Business plan for 2004/5. London: MHRA, 2004.
Available online at:
http://www.mhra.gov.uk/home/groups/comms-sp/documents/publication/
con008356.pdf (accessed 30 March 2009)
22. Department of Health. Government takes major step towards extending patient
choice. Press release issued on 1 May 2002.
Only available online at: http://www.dh.gov.uk/ (accessed 12 March 2009)
23. Royal Pharmaceutical Society of Great Britain. Patient group directions: a
resource pack for pharmacists. Factsheet 7. London: RPSGB, 2004.
Available online at: http://www.rpsgb.org/pdfs/factsheet7.pdf
(accessed 12 March 2009)
24. National Prescribing Centre. A practical guide and framework of competencies for
all professionals using patient group directions. Incorporating an overview of
existing mechanisms for the supply and prescribing of medicines. London and
Manchester: NPC, 2004. Available online at:
http://www.npc.co.uk/prescribers/resources/patient_group_directions.pdf
(accessed 30 March 2009)
25. Royal Pharmaceutical Society of Great Britain. Medicines, ethics and practice: a
guide for pharmacists. 30th edition. London: RPSGB, 2006.
26. Royal Pharmaceutical Society of Great Britain. Clinical governance, standards
for better health and the new community pharmacy contract (England &Wales):
making the links. London: RPSGB, 2005. Available online at:
http://www.rpsgb.org.uk/pdfs/cpcontracthealthmap.pdf
(accessed 12 March 2009)
27. Department of Health. Standards for better health. London: DH, 2004.
MARCH 2009
32 REFERENCES

28. Royal Pharmaceutical Society of Great Britain. Guide to audit. Pharmaceutical


Journal 2005; 275: 203-204. Available online at:
http://www.pharmj.com/pdf/society/pj_20050813_guidetoaudit.pdf
(accessed 12 March 2009)
29. Centre for Postgraduate Pharmacy Education. Minor ailments services:
pharmacy technicians leading the way. Manchester: CPPE, 2006.
30. Mullen R. Skill mix in community pharmacy: exploring and defining the roles of
dispensary support staff. Report submitted to the Pharmacy Practice Research
Trust, University of Manchester, 2004.
Only available online at:
http://www.pprt.org.uk/Documents/Publications/skill_mix_in_
community_pharmacy.pdf (accessed 12 March 2009)

MARCH 2009
Appendix 1 33

Example of a treatment protocol


template used in an established minor
ailments service

Cold Sores
Definition/Criteria
Recurrent infection with herpes simplex type 1 virus causing pain and blistering on or around the lips

Criteria for INCLUSION


Cold sore infection of the lips and surrounding area that require topical antiviral treatment

Criteria for EXCLUSION


Immunocompromised patients
Patients under 12 years
Lesions not healed within 3 weeks
Pregnancy / Breastfeeding
Blisters around the eye area or inside the lips/mouth

Action for excluded patients and non-complying patients


Referral to general practitioner

Recommended Treatments, Route and Legal status and frequency of administration


Aciclovir 5% cream (2g) Topical P Apply five times a day for 5 days

Product Reminder
Should be used as soon as prodromal symptoms e.g. tingling or itching occur.
Avoid contact with the eyes and mucous membranes.

Follow-up and advice


If healing has not occurred continue for a further 5 days.
Avoid kissing, sharing cups, towels, etc, when having a cold sore.

Possible side-effects
Local transient burning and stinging

When and how to refer to GP:


Rapid referral:
Patients with severe symptoms where a large area is affected

Evidence of blisters around the eye area

Evidence of secondary infection

Immunocompromised patients

Conditional referral:
Other patients under criteria for exclusion
Recurrent infection

Consider supply, but patient should be advised to make an appointment to see the GP:
Recurrent symptoms not previously diagnosed

MARCH 2009
34 Appendix 2
Example of an FPPharm used in an
established minor ailments service

MARCH 2009
Index 35

A
accountability 26
ailments covered 15
assessing needs 12
audit 23

C
clinical audit 23
clinical effectiveness 25
clinical governance 21
community pharmacy contract and self-care 5
complaints procedure 25
consultation 14
consultation area 26
continuing professional development 26

D
direct referral 14

E
education 26
enhanced service 8 6
essential service 5 6
essential service 6 5
essential service 8 21
event recording 25

F
formulary, use of 11, 16, 24
FPPharm 16

G
GP referral (see referral)

I
information, use of 26

L
locum arrangements 25

M
medicines formulary (see formulary)
medicines supplied 16
minor ailments services, features of 13
minor ailments, definition of 1

MARCH 2009
36 INDEX

N
NHS Direct 6

P
patient and public involvement 22, 23
patient consultation 14
patient group directions, use of 18
patient record book 14, 24
patient records 26
patient referral 14, 15
patient registration 14
payment 18
PCT commissioning 12
personal development 26
pharmaceutical needs assessment 12
pharmacy and self-care 2
practice-based commissioning 6
prescription charges 11
prescription form 16
protocols (see treatment protocols)

R
record book, patient 14, 24
referral 14, 15
referral, rapid 24
registration 14
risk management 23

S
self-care and the community pharmacy contract 5
self-care, definition of 2
self-referral 14
service level agreement 23
significant event recording 25
staff management 25
standard operating procedure 16, 24

T
toolkit 12
training 26
treatment protocols 16, 24

W
walk-in centres 7

MARCH 2009