Management of minor ailments
The Council agreed that the report of a feasibility study evaluating
the management of minor ailments by community pharmacists should be published
and its executive summary made freely available through the Society's
website.
The study was the subject of a presentation to the Council by the Society's
pharmacy practice research manager, Ms ZOË WHITTINGTON, who began by stating
that the research had been funded by the Community Pharmacy Research Consortium,
which was made up of the National Pharmaceutical Association, the Pharmaceutical
Services Negotiating Committee, the Company Chemists Association, the
Scottish Pharmaceutical General Council and the Society.
Ms Whittington said that previous research had indicated that many patients
exempt from prescription charges were unable or unwilling to practise
self-medication because they received medicines free of charge from their
general medical practitioner. The aim of the feasibility study had been
to explore whether and to what extent it was possible to transfer the
management of minor ailments from general medical practice to community
pharmacy in the absence of that financial incentive.
The research compared consultation data before and after a community pharmacy-based
intervention in which pharmacists could prescribe from a limited formulary
under the same terms as a National Health Service prescription. Twelve
minor ailments had been included in the study, marking a departure from
previous research in which only one condition was transferred (for example,
the Nottingham head lice study). The setting for the study had been one
medical practice and eight pharmacies in the North-West of England. The
evaluation had also involved qualitative interviews with both patients
and practitioners.
Consultation data collected during a 16-week baseline period indicated
that the 12 minor ailments accounted for 8.9 per cent of the practice
workload. The normalised contact rate per 1,000 population per week was
higher for the pharmacists than for the GPs. In the context of the deprived
area in which the feasibility study took place 93 per cent of items dispensed
were exempt from charges. Despite the high level of prescription exemption
status people were still prepared to purchase medicines and self-treat.
Those figures were supported by the patient interviews.
During 26-week intervention period, 38 per cent of minor ailment consultations
were transferred to the study pharmacies. Patients expressed high levels
of satisfaction with the pharmacy service and there were low levels of
re-consulting. Minor ailment workload in the GP practice was reduced to
6.6 per cent of total workload.
It was important to note that the rate of transfer depended on the type
of minor ailment with high transfer rates for head lice and vaginal thrush
and low rates for cough, earache and upper respiratory tract infection.
So why did 62 per cent of patients opt not to transfer to the community
pharmacy? That might be partly explained by GP prescribing, as 23 per
cent of patients seen within the GP practice received a prescription for
an antibiotic. A further 10 per cent of patients consulting the GP received
a prescription for an unrelated condition; for example, one patient who
was recorded as consulting for a cough received a prescription for pholcodine
and an antidepressant. However, almost half of the patients seen in the
GP practice received a prescription for a product that was available on
the community pharmacy formulary. Other reasons for consulting a GP were
revealed in the patient interviews, for example the need or desire for
a physical examination. Patients were more likely to consult a GP with
symptoms they had not previously experienced or for children’s symptoms.
Some patients had already tried unsuccessfully to self-treat their symptoms
and so preferred to consult a GP.
The intervention appeared to be most successful when patients had previous
experience of the minor ailment and its treatment. In that case the patients
were looking not for a diagnosis but for easy access to the treatment,
as with head lice and vaginal thrush.
While the feasibility study demonstrated that management of minor ailments
could be successfully transferred to community pharmacy, there were a
number of issues to bear in mind. The first was that not all minor ailments
were equally amenable to transfer. Prescribing data and patient interviews
indicated that it might not be appropriate to transfer all consultations
because the patient might want to raise other issues during the consultation
or a POM medicine was required. For certain ailments, such as cough or
upper respiratory tract infection, targeted patient education on the value
of antibiotic use might be required to increase transfer rates.
As the baseline data suggested, it might not be desirable to encourage
the widespread community pharmacy management of minor ailments under this
type of system as it might have an impact on both GP prescribing budgets
and on community pharmacy revenues.
Finally, it was important to remember that the study had taken place in
one GP practice which offered a high level of accessibility to its patients
through open access appointments. It could be hypothesised that practices
with lower levels of accessibility might lead to higher levels of transfer
to the community pharmacy.
A number of similar interventions were currently operating or planned
as a result of the research. They included a Scottish pilot in which patients
were registered at a specific community pharmacy. Other areas where similar
work was being carried out included Croydon, Newcastle and Derbyshire.
The PRESIDENT thought that the open access surgery made a huge difference
in the ability to see a doctor. It would be important to know whether
the other areas where similar work was being carried out had open access
surgeries.
Ms TIMONEY said that the work in Scotland, which was being evaluated by
the University of Manchester, covered four practices. They had appointment
schemes, so it was not direct access. It was not limited to minor ailments
but included all medicines that a pharmacist would be able to supply.
Mr ARGOMANDKHAH thought that there was worry about spiralling costs, which
might be a barrier. If the scheme were to be expanded to all minor ailments
categories and all drugs, the costs would need to be considered.
Ms WHITTINGTON replied that the study had not examined that aspect.
The PRESIDENT was sure that by the time more work had been carried out
there would be a better grip on the cost factors.
Mr HEMANT PATEL asked what additional work needed to be done in order
to understand the decision-making framework in relation to a patient choosing
between a GP and a pharmacist.
Ms WHITTINGTON replied that it had been difficult to get patients to attend
interviews, and patients had had difficulty conceptualising the decision-making
process. Much prompting and questioning was needed to find out why patients
went to a GP or why they went to a pharmacy. Habits had a lot to do with
it. It was therefore difficult to say what work should be done in the
future. There was a big difference in the way the patients viewed their
own minor ailments and those of their children. They gave much more thought
to their children.
Mr HEMANT PATEL felt that an understanding of patients' decision-making
processes could help pharmacy services develop in the future.
Professor DAWSON said that it was interesting that the study related to
one particular type of surgery. It might be good to research more broadly.
That was key to what should be done in the future to try to expand to
a broader range of interests. The profession was good at pilot studies,
but did it have the co-ordination process to find out what best practice
was in order to move to the next stage? It was clear that there was useful
information available. If they could refine the responses of patients
in the questionnaire they could go a lot further forward.
The PRESIDENT then asked for agreement that the report should be published.
The Council agreed that the full report should be published and copies
distributed to the Department of Health and the Government’s research
councils. A copy of the report would be placed in the Society’s library,
and further copies would be made available for purchase through the Society’s
practice research division at a cost of £30. The executive summary of
the report would be circulated widely (eg, to health authorities and local
pharmaceutical committees) and would be made available for downloading
from the Society’s website.
Answering a question from Professor DAWSON, Dr SUE AMBLER (head of the
Society's practice research division) said that an appropriate covering
letter would go out with copies of the full report and the executive summary.
The PRESIDENT said that the practice research division was to hosting
a seminar at which Council members could explore issues raised with the
research team.
Dr GRAY felt that one interesting matter arising from the work was the
workload dynamic. It was an indication for pharmacists' workload and the
skills of the pharmacist. The visibility of the pharmacist was also a
consideration. It would be interesting to know whether that was a factor
in people did not always going to a pharmacy with minor ailments.
Ms WHITTINGTON replied that it was difficult to answer such questions
on the basis of such a small study.
Mr CURPHEY said that the work had shown that pharmacy organisations could
co-operate with each other to produce something good for pharmacy and
Council members should pat themselves on the back for that.
Mr Curphey added that he wanted to issue a warning. If the service was
offered to primary care trusts, etc, they would have difficulty in understanding
that they could get a free service from practice nurses and doctors but
they would have to pay extra for the pharmacist. That was a real worry.
The profession would have to think through how they could match the wider
access, the decreased workload on surgeries and the extra costs for pharmacists.
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