The Pharmaceutical Journal Vol 265 No 7113 p359
September 9, 2000 The Society

Guidance on counter prescribing

The Royal Pharmaceutical Society's Practice Committee has produced a guidance document on the process of counter prescribing, with the objective of ensuring consistency and quality of advice in community pharmacies. A downloadable PDF version of the document is to be made available on the Society's website

The advent of clinical governance and an increasing emphasis on teamworking in health care have heralded the Government's commitment to supporting consistency and quality of advice throughout the NHS. Two of the key issues that the Government has sought to address in its policies on the NHS are improving access to services and reducing variability.
These developments have been evident in the general move within the NHS towards clinical decision support systems. NHS Direct uses computer-based clinical decision support systems to ensure that callers receive consistent advice. The National Institute for Clinical Excellence has been set up to issue clinical guidelines to prescribers to ensure patients receive maximum benefit from their medicines while being cost-effective, while computer systems such as Prodigy are increasingly used in a general medical practice setting to help ensure that the most appropriate treatment is given.
This practice guidance on counter prescribing for self-limiting minor illness and common conditions has been produced by the Society against this current background. It provides a framework for the provision of advice on the treatment of symptoms rather than responding to requests for medicines by name. It is intended to offer pharmacists an aid to reflective practice, audit and training and to enable a wider audience to understand the generic process of counter prescribing, while offering advice on good practice.
There is considerable confusion over the use of terms such as algorithms, guidelines, protocols and clinical decision support systems. Systems which would support quality and consistency while allowing the user to bring in their own knowledge and experience seem most likely to be relevant to pharmacists. An appropriate system could also aid data collection and audit. It is hoped that this guidance will form part of a phased approach to examine ways in which the provision of high quality, consistent advice could be supported, both in pharmacy settings and elsewhere within the NHS.

Practice guidance on counter prescribing for self-limiting minor illness and common conditions

This guidance is applicable to requests for advice on the treatment of symptoms rather than to requests for medicines by name. It is intended to:

• Provide advice on good practice
• Act as an aid to reflective practice, audit or training
• Enable a wider audience to understand the generic process of counter prescribing

Pharmacists are reminded that, under the terms of the Code of Ethics, they have a professional responsibility to exercise control over all medicinal and related products which are purchased or supplied (Principle One, Obligation 1.2). They must, on each occasion that a pharmaceutical service is provided, use their professional judgment to decide whether they need to see the patient or carer in person (Principle One, Obligation 1.22).
This guidance supplements the standards for the sale of non-prescribed medicines and for relationships with patients and the public set out within the Society's ‘Medicines, Ethics and Practice' guide.

General principles

• Patients should be made aware that counselling and advice on non-prescription medicines and appliances is offered as a professional service by the pharmacy
• Pharmacists should ensure that they, and where appropriate their staff, have the knowledge and skills required to provide counselling and advice to patients effectively and efficiently
• The principles also apply to the provision of advice on veterinary medicines by pharmacists and their staff

(a) Recognising and interpreting the condition To make an assessment of the presenting symptoms, the following should always be explored with the patient or customer.

• The identity of the patient: do not assume it is the person presenting in the pharmacy
• The nature and duration of the symptoms
• Concurrent or recent medication or treatment
• Other symptoms that may or may not be associated with the condition. Where appropriate, observe other signs, visible or otherwise (eg, if the patient is present in the pharmacy, does he or she appear ill?)

The possibility of serious disease should always be excluded. The following should always be referred:

• Symptoms that are potentially serious
• Persistent symptoms
• Patients at increased risk

Particular care should be exercised when dealing with babies, infants and children, pregnant women, breast-feeding mothers and older people.

(b) Determining the goal of treatment (therapeutic objective) The objective of the treatment recommended should be one of the following:

• Curing a disease or disorder
• Reducing or eliminating a symptom
• Arresting or slowing disease progression
• Preventing a disease or pregnancy
• A combination of any of the above

(c) Recommending a treatment Three basic categories of action should be considered, taking account of the patient's own health beliefs and preferences:

• Give self-care advice and/or reassurance without recommending a medicine or other treatment
• Recommend a medicine or other treatment
• Refer to someone else
• A combination of any of the above

Assess the risks of the proposed course of action. Remember that in many instances a medicine may not be necessary and indeed may be contraindicated.

(d) Provision of advice The following information should be provided where appropriate:

• Information on why a particular course of action is being suggested and how best to achieve the intended outcomes
• Information on the condition as assessed during the consultation and any changes that need to be monitored
• Information on any medicine or treatment recommended and how to use it
• A combination of any of the above
• Advice on when it would be appropriate seek further advice from either the pharmacist or someone else if the condition does not improve.

Information provided must be appropriate and provided in a way that the patient can understand.

(e) Quality assurance and audit In order to allow monitoring of the treatment that has been recommended and allow audit of interventions, a record of the intervention should be made in appropriate cases on a patient medication record system.