How to set up a Pharmacy Minor Illness Management Service
'How to...' Guide
Contents
Summary
Background
Getting started
- Identifying needs
- Why set up a MAS?
- Securing Funding
- Planning & Preparation
- Design & development
- The patient pathway
- Training
Clinical Governance
Reporting
Auditing the Service
References
Minor ailments are generally described as common, often self-limiting, conditions e.g. coughs & colds, hay fever, head lice. They normally require little or no medical intervention and are usually managed through self care and the use of products that are available to buy without a prescription.
A community pharmacy minor ailments scheme is a system whereby patients can conveniently access advice and, where required, treatment for a minor condition via their local pharmacy, without the need for a GP appointment. Such schemes have restrictions, hence only those conditions listed within the treatment protocol can be addressed via the minor ailments scheme, and only with medications from the agreed formulary. Treatment is free of charge for those patients who are exempt from standard NHS prescription charges e.g. under 16's, medical exemption certificate, with all other patients usually paying either the over-the-counter price or the current prescription charge (whichever is cheaper).
As GP/Practice and Primary Care Trust (PCT) workload continues to increase, and patient demand continues to grow, community pharmacy minor ailments schemes can help to improve patient access to care and support PCTs in achieving both local and national targets.
The introduction of minor ailments schemes (MAS) has become an important and valuable resource in helping the NHS meet treatment targets. Typically, many PCTs have developed their own initiatives, despite the absence of an overall policy framework. Although similar processes are applied throughout each initiative, steps are taken by individual PCTs to tailor their MAS to the needs and demands of the public it serves.
The overall aim remains the same: to deliver cost-effective local health services, improve accessibility to primary care across the local community and establish a lesser degree of reliance on GP consultations for self-limiting conditions. Minor ailments account for between 100 and 150 million GP consultations per year, for conditions that are potentially self-treatable1. In addition, the latest research from the Proprietary Association of Great Britain (PAGB) shows that up to 40% of GP time is taken up dealing with patients suffering from minor ailments2. In the absence of a MAS, these patients would have sought a GP appointment for treatment. An estimated 60% of PCTs in England³ currently commission a minor ailments scheme.
A MAS is designed to address a particular local need e.g. high incidence of head lice due to school-age dominated population, therefore each MAS provides a unique service that is tailored to the needs of the local population.
The rationale for commissioning a MAS is typically driven by local priorities which, in turn, are influenced by national targets. For example:
- Seeking to support GPs to meet the NHS access targets
- Releasing capacity in general practice
- Filling gaps left by changes in GP opening hours, particularly on Saturday mornings
- Part of a wider service e.g. our of hours
- To better integrate community pharmacy and GP services
Preston Primary Care Trust identified a need for a minor ailments scheme in their locality, due a small cluster of deprived areas where some patients were having difficulty accessing a GP, due to demand. Thus, to improve patient access to a healthcare professional, a minor ailments scheme was introduced.
The scheme has been running since early 2004, and involves all community pharmacies (33) and GP Practices (30) in the area. A range of 21 ailments are covered and around 400 patients now access the service each week. Approximately one third of patients are referred to a participating pharmacy by their GP Practice, however 70-80% self-refer.
For more information contact: Stephen Gough, Community Pharmacy Development and Clinical Governance Facilitator on 01772 676179 or stephen.gough@prestonpct.nhs.uk
THINK ABOUT THE FOLLOWING:
- Where are the demands greatest in your locality? e.g. are they focused in a particular neighbourhood?
- Are there days of the week / times of the day when resources are lacking and patient access is poor?
- What are the characteristics of the local population? e.g. young families, older people, refugees, unemployed, university students
- What existing services are in places? e.g. nurse-led services, walk-in centres
ACTION POINTS
√ Perform a needs assessment
- establish baseline data and current service provision
- measure the needs of your population
- identify current systems in place at GP Practices, to deal with the treatment of minor ailments
- assess the resource implications to the PCT and other healthcare professionals who will be involved
In general, a MAS is commissioned where there is a need to attenuate demand for GP appointments. MAS help to reduce demand for GP appointments by encouraging patients to have their condition assessed and treated by the pharmacist instead of their GP.
Making GPs accessible to patients is an important performance measure for the NHS. PCT's in England are required to ensure that their practice can offer an appointment within 48 hours with a GP and within 24 hours with a healthcare professional. Capacity in the GP workforce is also critical to achieving the aspirations of the most recent health White Paper4 which seeks to deliver more services in primary care that have been traditionally provided in hospital.
By taking demand for minor illness appointments and channelling this through community pharmacy, then GPs will be more likely to succeed in meeting their access targets and have the capacity to take on work that is being moved from secondary to primary care.
The reason that patients do not seek out the pharmacist as an alternative to the GP in the first place may be:
- The cost of the treatment: the patient may be exempt from prescription charges, thus the over the counter price acts as a barrier to the pharmacy route
- The patient is seeking reassurance: the patient lacks confidence in clinicians other than their GP, in which case the GP has an important role in promoting the pharmacist as a credible alternative.
MAS are a relatively new enhanced service in community pharmacy, the first schemes appeared in the North West of England in 19995 and were quickly followed by large scale schemes in Scotland. Since this, adoption of MAS by PCTs in England has been rapid.
A national survey of PCTs in England3 showed that in 2003 15.1% of PCTs commissioned a MAS from community pharmacy, with a further 30.7% actively developing such a scheme. By 2004 the number of PCTs commissioning had risen to 35.6% with a further 24.2% actively developing such a scheme. More recent data are not available, however it is clear that there has been rapid growth in commissioning MAS and that there is the potential for around 60% of PCTs to commission MAS at some point in the future.
ACTION POINTS
- Does the PCT have funding available for commissioning a MAS? Are these funds sustainable? Find out what the application process is.
- What impact will a MAS have on PCT staff who will commission and manage the service?
- Who will lead and manage the service? Develop a clear strategy.
- Will specific training be necessary and for whom? Where will this training be sourced?
- Is the current technology adequate for the purpose of auditing/reporting or will new software need to be purchased? Agree on how data will be captured and the service will be audited.
- Will there be any implication regarding workforce and the workload, for GP practices and community pharmacies? How will this be managed?
Pharmacy contractors providing a MAS usually receive payment for the professional service and for the drugs supplied. This, together with the costs in setting up and administering a MAS, comprise the investment required to commission a scheme. The professional fee for patient consultations varies across schemes, however in Wales indicative rates have been agreed as as £3.46 consultation fee and £134.45 annual fee6.
Often resources for commissioning a MAS will be secured through a local bid for funding. These funds may have explicit criteria associated with them, for example local regeneration funding will be conditional on the scheme benefiting residents of a particular community. In any case it is likely that the available funds are limited, consequently the commissioner will want to be able to monitor the scheme and to control volumes appropriately. Commitment from the PCT at board level is important to the successful implementation and sustainability of a MAS. To align with the PCT annual planning process, your proposal should ideally be put forward to the PEC or board in September/October.
Payments to community pharmacists providing MAS will attract VAT on the medicines supplied and may also attract VAT on the professional services fee. This latter point will depend on how the scheme is specified and in particular what elements of the service must be provided by a pharmacist. A review of MAS has found that the prescribing costs for community pharmacy MAS were less than or similar to the costs for GP minor ailment prescribing7.
The following are some examples of funding sources:
- Central prescribing budget
- Enhanced Services budget
- Sure Start monies
- Community Pharmacy Development Fund
- GMS enhanced services budget
- PCT access fund
Leeds North East Primary Care Trust piloted their minor ailments scheme in one pharmacy and 1 practice before full rollout, in 2004. The scheme involves all community pharmacies in the PCT (27) and all GP Practices (29). This service is accessed by around 50-70 patients per week.
Funding for the scheme is sourced through two budgets: Drugs/Medication costs are reimbursed from the Prescribing Budget, which has been 'top-sliced' to accommodate and remuneration for consultation fees is sourced from the Community Pharmacy Development Fund.
For more information contact: Kim Taylor, Medicines Management Facilitator on 0113 2033440 or kim.taylor@leedsnortheast-pct.nhs.uk
ACTION POINTS
- involve and gain support from all the key local stakeholders
- target the 'movers & shakers' in your area
- develop a clear, structured plan; be prepared for questioning
Local protocols for MAS provide community pharmacists and health care professionals with a shared basis for assessing and treating patients. Typically the protocol will set out:
- Aims/objectives
- Characteristic symptoms of the condition
- Associated history or precipitating factors
- Referral criteria
- Treatment options and advice
With many MAS being commissioned by many PCTs very few will need to spend time developing local protocols, most will use protocols developed elsewhere and have these reviewed and adapted for local use.
Brighton & Hove City Primary Care Trust set up their MAS in 2004. The scheme is based on a combination of existing models, but mainly around the Sheffield model. The relatively small scale scheme covers 11 ailments and involves 5 pharmacies and 3 GP Practices.
The initiative was developed for a number of reasons including:
- Inequalities in GP Service provision in the area
- Reducing GP workload
- Increased involvement of Community Pharmacists in management of patients
For more information contact: Nazma Jabbar, Community Pharmacy Lead on 01273 545358 or nazma.jabbar@bhcpct.nhs.uk
Agreeing conditions and formulary
At the heart of the MAS is the list of conditions included in the scope of the scheme and the formulary of treatments that the pharmacist may dispense to patients presenting with these conditions.
The list of conditions is determined by reviewing local prescribing patterns and consulting with GPs and other healthcare professionals on the most appropriate conditions to include, for example it would be appropriate to include head lice treatment if there is a significant population of school-age children in the area. Historically, formularies have included GSL and P medicines only, however as schemes have become more established and increased local needs identified, PCTs have extended formularies to accommodate this. In doing so, the addition of POM medicines is a common observation, using a Patient Group Directive (PGD).
This introduces some complexity with respect to training and accreditation. PGDs require more work to develop and implement than MAS treatment protocols, pharmacists and pharmacies supplying under a PGD must be accredited. This accreditation is linked to specific training which the PCT will usually provide. Movement of the pharmacy workforce requires PCTs to provide training on a rolling basis in order to maintain access to the service.
Recent changes in drug classifications has meant that POM medicines such as chloramphenicol for conjunctivitis, or trimethoprim for unrinary tract infection, have been reclassified to P status. Consequently, it is no longer necessary to have PGDs in place to supply them via a MAS, although many PCTs still supply the POM product via a PGD as it usually costs less than the newly re-classified P product.
Central Cornwall Primary Care Trust launched their MAS as a pilot in September 2002 involving 2 community pharmacies and 1 GP Practice. Subsequently, in January 2005, this extended to the whole PCT encompassing 24 community pharmacies and 26 GP Practices.
The uniqueness of this MAS is that only medicines available via a PGD were authorised through the treatment protocol (e.g. Timodine® cream, fuscidic acid eye drops, chloramphenicol eye drops and trimethoprim tablets). At this time, around 120 patient consultations take place each month.
For more information contact: Rosalind Palmer, Prescribing Support Pharmacist on 01726 627923 or ros.palmer@centralpct.cornwall.nhs.uk
ACTION POINTS
- Look at the priority conditions in your area; review prescribing data to identify the common ailments presented that take up appointments in the Practices
- Involve the Practice decision-makers in agreeing the conditions and formulary to be included in the protocol
- Review existing MAS formularies and adapt to your needs, remembering to ensure a good range of cost-effective medicines are made available
GPs and their staff have significant influence over the success of local MAS schemes. The commissioning of a MAS will formalise their links with community pharmacy and has the effect of transferring the care of patients from the GP to the pharmacist.
GPs have been supportive of MAS, however they will have some reasonable concerns that any scheme should address:
- GPs will be concerned to know that their patients will be provided with speedy and appropriate advice and treatment and will be referred back to the GP in the appropriate circumstances
- GPs will want to know that they will be kept informed of the care that their patients receive, for example through the pharmacist issuing a treatment advice note
- GPs will want to know what impact the scheme will have on practice workload, for example the time taken to issue vouchers, or the time taken to transcribe treatment advice notes into the clinical system
- GPs will want to know that the scheme reflects their practice in dealing with minor ailments, for example, in the choice of treatment included in the formulary
The key to addressing each of these concerns is to ensure that GPs are involved in the design and development of the scheme from the outset and that the design reflects their concerns.
One of the most effective ways to engage with local GPs is to involve them (through their representatives) in the development of the treatment protocols and formulary.
ACTION POINTS
- build relationships with local GP Practices and their staff
- involve them in the development and decision making
- develop robust mechanisms for sharing of information and communication
- attend practice meetings, share your learnings and provide regular updates
A typical MAS will comprise the following elements:
- Description of the patient pathway and points of entry to the scheme including administrative inclusion and exclusion criteria
- Signposting to guide patients to the scheme
- Funding to commission the scheme
- Strategies to engage GPs
- Protocols and formulary setting out the scope of the scheme and clinical exclusion and inclusion criteria
- Clinical governance arrangements for providers and stakeholders
- Administrative arrangements for providers
MAS are mainly found to be delivered through the following settings:
- Pharmacist and/or nurse-led clinics in a GP practice;
- Community pharmacy-based schemes (either via practice or self-referral);
- A & E unit schemes (where patients are referred to an on-site pharmacist).
Determining how patients may access a local MAS is critical to achieving the objectives for the scheme. Typically the commissioner adopts one of three access designs:
- Voucher: referral is via the patient's practice using a voucher or token which the patient presents at the pharmacy to demonstrate entitlement to treatment
- Passport: a form of patient registration which is issued by the pharmacist, this confirms entitlement to treatment which can then be used without the need to go via the practice
- Open: Patients may present in the pharmacy for treatment as the need arises, eligibility criteria are often minimal or not specified
Vouchers offer the commissioner the greatest level of control; by using vouchers a patient may only access the scheme if they have first passed through their practice. A patient presenting at the practice seeking an appointment for a MAS is offered the option of the pharmacy service, if this is taken up then the practice staff will issue a voucher which the patient then takes to the pharmacy, vouchers may also be faxed to pharmacies where patients request an appointment by telephone. This approach requires high levels of engagement with practice and its staff.
The passport approach allows access to be targeted to specific groups of patients without the inconvenience of the patient going through the practice to access the scheme. A patient may present in the pharmacy for treatment, the pharmacist first assesses their eligibility and issues a passport confirming this eligibility. The passport entitles the patient to use the scheme at any time in the future. The number of episodes of treatment that may be used under a passport may be limited if this is necessary, e.g. four treatments in any 12 month period.
The open approach is similar to the passport scheme in that the pharmacist assesses eligibility before providing treatment, the more open the scheme the fewer criteria that are applied to assess the patient's eligibility.
Whatever mechanism is put in place for patients to access the MAS, the support of local GPs and the engagement of their staff is essential in ensuring that the MAS reaches its target audience.
In order for MAS to succeed, patients need to know that the service exists. This requires a combination of passive and active signposting of patients to the service.
- Passive signposting includes posters and materials describing the service.
- Active signposting is where the GPs or their staff refer the patient to the pharmacy service.
Materials used to promote the scheme need to target the populations that the PCT is seeking to reach, therefore using the right medium (e.g. radio vs. written), the right setting (e.g. health vs. non-health premises) and the right language can all have impact on the uptake of the service by the target group.
In order to encourage active signposting by GPs and their staff there needs to be some engagement between GPs and pharmacists. For example, once GPs have agreed that their practice will participate the PCTs could arrange a local visit by the community pharmacist to the practice to brief reception staff and to distribute materials. Proactive support from local community pharmacists will help to reinforce the PCT's messages and to build confidence among GPs of pharmacy's willingness to participate.
ACTION POINTS
- carry out some research to identify what materials have been developed already and what's freely available
- adapt and customise existing protocols/formularies to meet your needs
- liaise with your neighbouring PCT colleagues and share ideas and information on what works/what doesn't work
Assessing and recommending treatment for a minor illness is a core part of the community pharmacists' role. Taking this activity and formally commissioning this as part of an NHS service does not require significant additional training, however the pharmacist will need to become familiar with the local protocols for treatment and be willing to select a drug from an agreed formulary. This may require brief introductory training and some support from the commissioner to ensure a smooth launch.
Local protocols for the assessment and treatment of a minor illness, as described earlier, are part of the fundamental design of a MAS. Local clinical governance arrangements should ensure that these protocols are developed using the best available evidence. Community pharmacists will want to review their internal systems to ensure that staff and pharmacists working at the pharmacy are familiar with the protocols and that these are kept up to date.
Where the protocol calls for a referral from the community pharmacist to another member of the healthcare team then this process should be documented and agreed between the stakeholders involved. Established MAS schemes use fast track referral arrangements between pharmacy and practice to ensure that patients who need to see their GP are able to do so without a delay.
Clinical governance is an essential element that should underpin any service in the NHS. It is important to be able to demonstrate the quality of a service, manage the risks within it, and to continually monitor the service to maintain standards and improve. When providing any professional service, it is important that clinical governance guidelines are followed, including:
- an identifiable pharmacist is accountable for all activities undertaken in the pharmacy
- pharmacists and staff providing services are suitably trained and competent to perform the tasks required
- any necessary equipment and suitable facilities are available for the provision of the service and that these are maintained in good order
- risk assessment and management procedures have been identified and are followed
- adequate records are maintained to enable the service to be monitored
Planning the development and implementation of a new service should be accompanied by a review of the clinical governance arrangements that will apply. For example:
- Training
- Premises
- Record keeping
- Skills mix
- Transfer of care
In Central Cheshire Primary Care Trust a self-accreditation pack has been developed to allow pharmacists to assess their competence to provide the service and return a self-declaration form. This saves the PCT time and resources by not providing training sessions, and gives them the ability to identify specific training needs and gaps.
The service began in August 2004 and involves 48 pharmacies, with around 800 patient consultations taking place each month.
For more information contact: Gail Thomas, Head of Medicines Management or Dawn Colvin, Project
ACTION POINTS
- Ensure adequate ongoing training is completed by each member of personnel involved (pharmacists, pharmacy support/Practice staff)
- Develop standard operating procedures (SOPs), to incorporate all aspects of the MAS
- Review the protocols regularly making sure that all personnel, including new members, read, understand them and are made aware of any changes
Record keeping requirements for MAS require the community pharmacist to record details of their consultation with the patient. This is done for two reasons:
- To ensure that a contemporaneous record of the assessment and treatment exists
- To provide a system to remunerate the community pharmacist for providing the service.
These records also provide an opportunity for the pharmacist to undertake uni- and multi-disciplinary audit.
Under the new contract in England and Wales community pharmacists are required to keep records of some consultations with patients requesting over the counter treatment or advice. The requirement to keep records for the commissioner of the MAS consultation is not substantially different from this new contractual obligation and most pharmacists should now be accustomed to this requirement and have the systems in place to make appropriate records.
In England, locally commissioned IT solutions are available to support PCTs and community pharmacists to manage the administration of the MAS so that the impact of record keeping and claims administration is minimised8.
Whether a paper based or IT based solution is used community pharmacists will need to be prepared to make a detailed record of the consultation and to ensure that records are kept for the required time in an appropriate manner.
Auditing the service you are providing is important in establishing what is working well, what needs to be improved on, what should be reviewed, how satisfied users and providers of the service are and how it is perceived by patients, pharmacists/pharmacy staff, GP/Practices and the PCT. Essentially unless a mechanism for regular auditing is included in the process, it will be difficult sustain ongoing funding for a MAS.
The complexity and methods of auditing varies across each PCT, as does frequency. Some suggested methods for auditing your MAS include:
- Patient, pharmacist/pharmacy staff and GP/Practice staff satisfaction questionnaires
- Use the Plan, Do, Study, Act (PDSA) cycle (www.ihi.org)
- Collect activity data and identify patients who may have otherwise needed a GP appointment
- Hold structured focus groups (patient/pharmacy/practice) to discuss all aspects of the service, including areas such as impact on workload, the protocol/process and general feedback.
- Whittington. Community pharmacy management of minor conditions – the 'Care at the Chemist' scheme. PJ 2001 266 425-432. Available at www.pharmj.com.
- GPs recommend OTC medicines for 40% of minor ailment consultations. PharmaLife news Jul 2002. Available at www.pharmalife.co.uk.
- Keele University & Webstar Health, National Survey of Community Pharmacy Development 2003 & 2004.
- Department of Health (2006). 'Our health, our care, our say: a new direction for community services'. DH, London. J 2006.
- Whittington Z. et al. 'Care at the Chemist: A Question of Access. A feasibility study comparing community pharmacist and general practice management of minor ailments'.
- 'Indicative rates for enhanced services set in Wales'. The Pharmaceutical Journal Vol 277 p. 125
- Blenkinsopp A, Noyce P. 'Minor illness management I primary care: A review of community pharmacy NHS schemes'. NHS Confederation and BMA 2002.
- Service PACT software. http://www.webstar-health.co.uk (accessed 31st March 2006)