Supporting Self Care Community Pharmacy Common Ailments Service GP Practice Guide September 2016 Version 1 1 Contents Section 1: Introduction Section 2: Service Information Section 3: Conditions to be treated Section 4: Referrals & Communication Section 5: Promoting the Service Section 6: Comments & Suggestions Section 7: Participating Pharmacies Section 8: Resources & Useful contacts Appendix 1: Comments and Suggestions Form 2 Section 1: Introduction Community Pharmacists already advise patients on a wide range of common ailments and either recommend treatment or refer on to another healthcare professional. The NHS Common Ailments Service builds upon this expertise allowing community pharmacists to offer some treatments, if they are considered necessary, free of charge to eligible patients on the NHS. There is no cost to the practice for this service. This document is intended to help practice staff understand the Common Ailments Service and support GP Practice staff when they are offering patients access to the service. It should be used in conjunction with the advertising material available to GP practices for promotion. It may also be linked to information about making an appointment with the most appropriate healthcare professional. 3 Section 2: Service Information Background The Welsh Government’s “Programme for Government” includes a commitment to “Make better use of pharmacists to improve access to services by providing the first port of call for the consultation and treatment of common minor ailments”. The community pharmacy Common Ailments Service (CAS) is a scheme whereby patients are encouraged to consult a participating community pharmacy, rather than their GP, for a defined list of ailments (Section 3). The pharmacist will give advice, supply medication from an agreed formulary or refer the patient to the GP if necessary. Medicines will be supplied free of charge. Process The CAS is intended to:  encourage patients who would otherwise have visited a GP for a common ailment to visit the pharmacy instead;  provide advice and, where necessary, treatment;  promote self-care, thereby increasing resilience. The service is not intended to:  be viewed as a ‘free medicines supply’ service;  convert people, who would otherwise have purchased a medicine, from self- care to pharmacy care. CAS consultations will be undertaken in the pharmacy’s consultation area and with a registered pharmacist. The pharmacist will provide advice about the self-management of the presenting common ailment(s) such that the patient can choose to self-care in the future. For patients who currently purchase medicines and receive advice from a pharmacist, CAS will represent a less accessible means of receiving care, and it is expected that they will in the main continue to take responsibility for purchasing any medicines that they require. However, for patients who currently perceive a need to see a GP to manage any of the ailments covered by the service, CAS will be an accessible option. Patients who currently see the GP in order to get a prescription for free treatment will have the payment barrier to accessing a pharmacy for treatment removed. Patients who currently see the GP because they wish to receive advice and reassurance from a professional in a clinical setting will be reassured by consultations being with a pharmacist in a consultation room. It is envisaged that this will facilitate the transfer of care of these individuals. 4 Registration and remuneration Patients will be required to register with CAS; to do so they must be registered with a GP in Wales. Registration is underpinned by an IT system which also provides a means of recording consultations. A patient’s pharmacy consultation history will be viewable in any pharmacy in which the patient presents for treatment under CAS. This will promote good care and prevent abuse of the service. In future, it is intended that these electronic pharmacy consultation records will be shared with a patient’s GP, until this functionality is available, practices will receive a paper based consultation summary. Evidence-based approach - Formulary The CAS formulary will be used to ensure that treatments offered through the service are clinically effective and represent value for money for NHS Wales. In order to realise the benefits of CAS, it is important that the treatments and principles set out in the formulary are adopted across Wales by all healthcare professionals involved in treating common ailments. There is a significant risk that to not do so would undermine confidence in CAS and result in patients returning to their GP for treatment if they perceived the treatments prescribed by them to be more effective. The CAS formulary has been developed by AWMSG (All Wales Medicines Strategy Group) to provide evidence-based guidance for minor ailments, which would support a consistent approach between pharmacists and GPs. It was developed via multi- professional discussion and consultation. The formulary is available via the Inform Formulary website: http://cas.inform.wales.nhs.uk/IndexAMG.aspx Evaluation The Common ailments service was implemented as a Pathfinder Service in two localities within Cwm Taf & Betsi Cadwaladr University Health Boards. The pathfinder was centrally funded from October 2013 – September 2015. An All Wales evaluation of the scheme was carried out in the two pathfinder sites. This was carried out between September 2013 – November 2014. The National evaluation concluded:  That the Choose Pharmacy pathfinder service has been well designed and delivered.  That demand has continued to rise as awareness has improved and the service has been embedded. While engagement by pharmacists and GP practices has been variable, there are examples of high activity and effective practice in delivering the service.  Due to small pathfinder sample numbers the service has yet to make an impact at scale, although many stakeholders considered that the pathfinders have delivered positive outcomes, and would welcome the continuation of the service. 5  If Choose pharmacy was rolled out following the same pattern as the Cwm Taf and Betsi Cadwaladr pathfinder sites the impact and economic evaluation suggests a positive return on investment in Choose Pharmacy over the next five years based on the performance of the service in the two pathfinders. The full evaluation of the Pathfinder Service can be found at: http://gov.wales/statistics-and-research/evaluation-choose-pharmacy-common- ailments-service/?lang=en Section 3 Conditions to be treated Condition Advice/Treatment Age Restrictions 1 Acne Treatment 2 Athlete’s Foot Treatment 3 Backache (Acute) Treatment Aged 20 -55 years 4 Chicken Pox (In Children < 14 years Treatment Under 14) 5 Cold Sores Advice Only 6 Colic Advice Only 7 Conjunctivitis (Bacterial) Treatment > 2 years 8 Constipation Treatment >10 years 9 Dermatitis (Acute Treatment Exacerbation) 10 Diarrhoea Advice Only >1 years 11 Dry Eyes Treatment Refer to optometrist 12 Haemorrhoids Treatment 13 Hay Fever Treatment 14 Head Lice Treatment 15 Indigestion And Reflux Treatment >12 years 16 Ingrowing Toenail Advice Only 17 Intertrigo/Ringworm Treatment 18 Mouth Ulcers Advice Only >10 years 19 Nappy Rash Treatment 20 Oral Thrush Treatment 21 Scabies Treatment > 2 years 22 Sore Throat And Treatment Tonsillitis 23 Teething Treatment > 3 months 24 Threadworms Treatment > 2 years 25 Vaginal Thrush Treatment Aged 16 – 60 years 26 Verruca Treatment >2 years 6 Notes:  Where no specific age restrictions apply, the service will be delivered in line with the over-the-counter licensed age ranges for the included medications.  Advice only conditions – no NHS treatment is available for these conditions under the Choose Pharmacy Common Ailment Service, pharmacists will provide self care advice only. This is an AWMSG evidence based approach.  Occasionally, treatments specified in the Formulary will not be available (e.g. manufacturing delays). For most conditions, this should not interrupt service delivery as a number of treatments are available within the formulary. If all treatments are unavailable, a procedure is in place for pharmacists to escalate this to HB’s and AWMSG for consideration. GP practices will be informed by the HB and community pharmacies of these instances to ensure patient care is not interrupted.  The AWMSG Formulary restricts the number of times a pharmacist can treat a patient for a common ailment in a 12 month period. For most conditions this is one to two episodes per year, the exception is hayfever treatment that can be provided on up to six occasions. Patients presenting on multiple occasions for treatment will be referred to their GP practice for further consultation.  Patients who do not meet inclusion criteria will be offered self care or referral to another Healthcare Professional (HCP) where appropriate.  Patients requesting treatment for eye conditions (Conjunctivitis & dry eye) should be referred to a local optometrist offering the Eye Health Examination Wales (EHEW) Service in the first instance http://www.eyecare.wales.nhs.uk/ehew Referral pathways between this service and Choose Pharmacy will enable these patients to access appropriate treatment. 7 Section 4: Referrals & Communication The implementation of robust referral pathways both into the Common Ailment Service and onward referral to other practitioners is vital to the success of this service. Referrals to pharmacy GP Practices can refer eligible patients to the Common Ailments Service where appropriate. Practice staff should refer to practice procedures and ensure that staff have appropriate clinical knowledge if triaging calls and offering referral. The following good practice points may be useful when developing practice procedures for referral to the Choose Pharmacy Common Ailment Service1. For patients making an appointment by telephone: Patient describes symptoms unasked If a patient telephones or calls at a surgery for a prescription or an appointment, they will often describe their symptoms unasked. If the symptoms are among those included in the common ailments service, the receptionist may:  Explain the service; the patient may obtain advice and treatment from a participating pharmacist without having to wait for an appointment with a doctor.  Advise the patient that they have the choice whether to see the GP or visit the pharmacist instead.  It is important to note that this should be left to the patient to make their choice. Patient request appointment without describing symptoms If the patient is telephoning a request for an appointment, the receptionist must avoid directly asking what the problem is.  The receptionist may, using his/her judgement, discern that the request is related to a common ailment. If so, the receptionist could say to the patient: “You may not be aware that there is a Common Ailments Service operating in the area now. Patients may go to a participating pharmacy to receive advice and treatment rather than having to wait for an appointment. The ailments included in the Service are … [, sore throat, nasal congestion, hay fever, athlete’s foot, oral thrush, vaginal thrush, threadworms, headlice or diarrhoea]. Does your illness come into any of these categories?” 8  This information could also be recorded on the practice phone-lines for information to the patient when they are waiting to be connected to the surgery. 1 Northern Ireland Health & Social Care Board, Minor Ailments Service GP Guide 2010  If the patient says yes, the receptionist may then ask if they would like to use this Service rather than coming to see the doctor.  Advise the patient that they have the choice whether to see the GP or visit the pharmacist instead.  It is important to note that this should be left to the patient to make their choice. For patients making an appointment in person:  If the patient is presenting in person, the receptionist should, using the same terminology as before, inform them that there is a Service in operation and that they can be directed to a local pharmacist for advice and treatment rather than waiting for an appointment.  Refer to the list of common ailments cards available for GP practices and given to the patient for them to decide if their presenting complaint is included on the list, in which case can then be directed to the pharmacist for further advise.  Advise the patient that they have the choice whether to see the GP or visit the pharmacist instead.  It is important to note that this should be left to the patient to make their choice. For all patients:  Patients may receive advice only, or advice and treatment after appropriate assessment by the pharmacist. If medication is required, it will be supplied from the agreed formulary free-of-charge.  Patients are expected to attend the pharmacy in person.  If a patient chooses not to take advantage of the Service to have a consultation with a pharmacist then an appointment with the GP should be made in the normal way.  Advise patients that they can use any of the pharmacies that are part of the Service. 9 Read Codes The following read codes should be used to record outcome of interventions: #8HHm –Referral to Minor* ailment scheme #8I3i – Refused referral to Minor* ailment scheme * GP systems do not recognise the terminology “Common Ailment” Who should not be referred?  If a prescriber has made a decision about the medicine a patient needs, then a prescription must be issued. A GP cannot write a prescription for one item and refer the patient to the Service for another named item.  Patients who are currently receiving treatment from a GP (e.g. repeat prescription) should not be transferred to the Choose Pharmacy Common Ailment Service. Pharmacists will have to refer patients back to the surgery if they are inappropriately referred into the service. Unable to treat On occasion patients may request an appointment for a Common Ailment that is not included in the current service or an exclusion criteria may apply. In these instances patients will be advised to contact the practice to discuss treatment needs. Pharmacists will provide patients with a form which they will need to present at the GP Practice. This form can be found on page 20 of this information pack. Referrals from pharmacy If a patient presents at the pharmacy with symptoms indicating the need for a consultation with another HCP the locally agreed method for referral should be instigated. Urgent Referrals Patients requiring an urgent appointment with either a GP, or other HCP will be given a referral letter (CP-001). This will include  Patient details  Details of presenting symptoms/condition  Reason for referral  Contact details for pharmacist  Advice to patients on making appointment (reverse of form) Pharmacists may contact the practice where they feel the need to speak to a clinician. 10