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Introduction Protocols and guidelines have been developed by health professions to set standards and assist practitioners to determine a course of action. United Kingdom pharmacists are required to have protocols to cover the procedures to be followed when advice is sought or a medicine sold for the treatment of a medical condition. The recent introduction of NHS Direct has given the public an additional 24-hour source of advice on medical conditions. This service, accessed via the telephone, is manned by nurses using accredited guidelines and decision support computer software.
Methods Examples of protocols and guidelines were collected from different types of community pharmacies (independent, chain and supermarket) and from two NHS Direct centres. Semi-structured interviews were conducted, after initial piloting of the interview framework, with a purposeful but not random volunteer sample of six community pharmacists and 10 NHS Direct nurses to assess attitudes towards the use of protocols and guidelines.
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Focal points
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Results Both pharmacy protocols and NHS Direct guidelines were presented as a series of questions with associated dispositions. All interviewees were familiar with the use of protocols or guidelines, although the nurses did not have previous experience of using them for the provision of advice.
The pharmacists felt that protocols allowed them flexibility and the opportunity for the application of professional judgment, but that protocols should be adhered to rigidly by counter staff involved in the sale and supply of medicines. All but one of the nurses adhered rigidly to the guidelines and felt that there was no room for flexibility. This was thought to be justifiable for legal reasons. Only one pharmacist mentioned litigation as a possible reason for using protocols.
All the pharmacists felt that protocols could be used as training tools for unqualified persons and that following training such a person could use protocols provided they had the right personal qualities. In contrast, the nurses felt that a medical background was essential to follow the guidelines.
Analysis of the "bee sting" scenario revealed that NHS Direct nurses, in accordance with their guidelines, initially concentrated on the risk of anaphylaxis. Having established non-anaphylaxis, home care advice was provided and a class of suitable medicinal treatment, eg, analgesics, recommended. Community pharmacists were more product-focused, suggesting a specific medicinal product for treatment of the "bee sting" and did not immediately consider the risk of anaphylaxis.
Discussion The differences observed in the nature and use of protocols can be partly explained by the different methods of contact, face-to-face and telephone, used by the pharmacists and NHS Direct nurses, respectively. As a new service, NHS Direct may yet evolve its guidelines to accommodate greater professional discretion in the management of certain conditions.
Recent developments in NHS Direct guidelines provide the opportunity for the patient to be recommended to see a community pharmacist for a specific medicinal treatment. This development may enhance both services to the benefit of the patient.
School of pharmacy and pharmaceutical sciences, University of Manchester, Manchester M13 9PL; *Department of clinical medicine, University of Bristol, Bristol BS8 2PR