The NHS plan¹ indicated that all NHS Direct call centres will formally refer callers to community pharmacists by 2002. This followed a pilot study conducted by Essex and Barking and Havering NHS Direct in collaboration with the local pharmaceutical committees and the National Pharmaceutical Association. The pilot was fully supported by the pharmacy profession with representatives from the Royal Pharmaceutical Society and the Pharmaceutical Services Negotiating Committee also on the steering committee.

Since its inception, NHS Direct has traditionally referred callers to one of three end points:

• Accident and emergency/"dial 999"
• General practice
• Home-care/self-care

Within these three formal endpoints nurses may, and often do, refer callers to other health care professionals, including community pharmacists. This is currently based on the individual judgement and background of the nurse, in consultation with the caller.

The community pharmacy referral scheme recognises the role of pharmacists in managing minor ailments by formalising the referral process and ensuring a more consistent approach to the transfer of the caller to a community pharmacist.

NHS Direct is now a national service operating via 22 call centres. All sites now use the same decision support software, NHS CAS (Clinical Assessment System), which allows for a consistent approach in the decision making process. As part of the national roll-out of the community pharmacy referral scheme the entire CAS has been reviewed to identify where within the system it would be safe and appropriate to have a community pharmacy endpoint. Professor Alison Blenkinsopp, of the department of medicines management at Keele University, led a multidisciplinary team (including nurses and pharmacists) to conduct the review. The review was carried out in collaboration with NHS 24, the Scottish equivalent of NHS Direct, which also uses the same NHS CAS system with the pharmacy endpoints.

The review examined 180 algorithms within NHS CAS. Only algorithms with a "routine GP" or "home-care" endpoint were considered for a possible pharmacy disposition. The team identified 230 potential pharmacy endpoints affecting 77 of the guidelines. These recommendations have now been peer-reviewed and incorporated into the next version of NHS CAS, which is to be rolled out in the near future. As NHS Direct sites begin to go live with the next version of NHS CAS, nurses will begin formally to refer callers to community pharmacists across Britain.

A critical part of the roll out is training, both for nurses and pharmacists. The Centre for Pharmacy Postgraduate Education has been commissioned to develop a training module for nurses working within NHS Direct. This module is to be delivered jointly by a community pharmacist and a nurse, and will help nurses understand why and when referral to a community pharmacist is appropriate. It is also important that community pharmacists are aware of how NHS Direct operates and how they will fit into the new system. To assist with this, the CPPE has also been commissioned to design an information booklet for pharmacists — "Community pharmacy referral". This booklet is distributed with this week's issue of The Pharmaceutical Journal.

The booklet provides the necessary background that pharmacists need in order to deal with callers referred from NHS Direct. It also provides useful reading for medicines counter assistants. The key areas that it covers are:

• How NHS Direct operates
• Findings from the Essex pilot
• What the community pharmacy referral scheme does
• How pharmacists will be affected

The booklet does not cover any specific clinical issues because the introduction of this scheme will not affect the way pharmacists deal with symptom-based health enquiries. Callers likely to be referred to a pharmacist will be those with conditions that are routinely dealt with by a pharmacist, or where a pharmacy medicine could be an appropriate treatment. Callers referred by NHS Direct will be advised to speak to a pharmacist, as opposed to just visiting a pharmacy, since the referral is from one health care professional to another. Initial findings from the scheme have, however, highlighted that the introduction of the scheme is not likely to have a significant impact on the workload of community pharmacists.

The clinical assessment system used by NHS Direct is updated and reviewed regularly by the guardian groups, which each monitor a specific number of algorithms. There is a pharmacist on each group, which will consider issues, such as POM-to-P switches and changes in licensing or legislation, that might affect the role of the pharmacist. Therefore, the referral to a community pharmacist will be a fluid process and will continue to develop in line with changes in pharmacy.

The community pharmacy referral scheme has been instrumental in developing a much closer alliance between NHS Direct and community pharmacists. It has also led to the introduction of pharmacy co-ordinators (nurses with specific responsibilities for pharmacy) at all NHS Direct sites and for the development of service level agreements between NHS Direct and local pharmaceutical committees. It also enhances the role of the pharmacist as a clinician within the community by encouraging callers to use a pharmacist for advice and treatment when appropriate.

  * PDF files on PJ Online require Acrobat Reader 4 or later.