The Pharmaceutical Journal
Vol 272 No 7284 p115-116
31 January 2004

This article
Reprint
Photocopy

PDF* 100K

How the minor ailments service works

Offering a minor ailments service will become a key role for community pharmacists in Scotland in the not too distant future. A pilot service is now being run in 176 pharmacies. Clare Bellingham (on the staff of The Journal) reports on its progress

All community pharmacists in two health board regions in Scotland can now prescribe medicines for minor ailments on the NHS for patients who are exempt from prescription charges. The simple message from those involved is that minor ailments schemes work.

Treating minor ailments was always going to be core to the new contract for community pharmacists in Scotland. But now that the pilot scheme has been such a success, a minor ailment service could be introduced across Scotland in advance of the new contract.

Scotland’s minor ailments service started as the “Direct supply of medicines” project which was piloted in seven pharmacies (PJ, 23 February 2002, p238). As the pilot grew, it developed into the “Direct care at the chemist” project before finally being named a “Minor ailments service” that will form one component of the new contract for community pharmacists in Scotland (see Panel right).

In October 2003, the project was rolled out to 176 pharmacies: 87 pharmacies in Tayside and 89 in Ayrshire and Arran. For the first time, a large urban population served by many pharmacies — Dundee — was included. This was seen as a real test of the service’s feasibility and its success or failure here would determine its future. Three months later there is little doubt that the minor ailments service is here to stay.

Alison Strath, of the pharmacy strategy implementation team at the Scottish Executive Health Department, is delighted with the way the project has gone. “We are currently working out what needs to be put in place for pharmacists to be able to deliver the minor ailments service as part of their core contract. Pharmacists are keen to see it in place sooner rather than later,” she says. “They would like it to be rolled out nationally before 2005 but legislation is needed to change it from a project to a service. Discussions are ongoing right now about whether or not the current legislation supports it and a decision is imminent.”

How did the roll-out go?

The roll-out of the minor ailments project across Tayside and in Ayrshire and Arran has gained support from all sides: pharmacists, patients, GPs and health authorities are in agreement over its merits. How the service works is outlined in the Panel (below).

The number of patients registered with pharmacies to receive the service is increasing every day. Figures taken at the end of December show that in Ayrshire and Arran, 34,000 patients are now registered with a further 12,000 patients in Tayside. This number reflects the fact that Tayside was slightly later in rolling out the project.

The number of patients registered per pharmacy varies from just a few to over 1,000. The average is between 400 and 500. “Pharmacists are finding the number of patients registered with them is manageable,” Ms Strath says. “We are currently doing some work on predicting the potential number for the whole of Scotland and this would be used for discussions about remuneration.”

Feedback from pharmacists has been positive. “They see its value in legitimising what they already do,” Ms Strath says. The top three most common ailments that pharmacists are dealing with are pain, headlice and coughs and colds. Figures to the end of October (data collection is two months in arrears) show that approximately 16,000 items had been dispensed across the scheme. In October, this equated to an average of 37 items per pharmacy. Evaluation of the longer-running pilot sites has shown that patients use the service only once a year. “It has not been over-used or abused by patients,” she adds.

But what do the pharmacists themselves say? From a city-centre multiple to an independent on the city outskirts to a village pharmacy, all pharmacists give the service resounding support.

Alistair Jack is manager of Boots in central Dundee and chairman of the contractors’ committee in Tayside. He points out that the minor ailments service will be an essential element of remuneration in future. Being involved in the project has helped to provide insight as pharmacy changes from a margin-led contract to a service-led contract. “This is the start of a service-led culture in pharmacy,” he says.

“Patients think the service is great,” says Boots pharmacist Neil Campbell. “It changes how pharmacists are perceived and promotes pharmacy in a good light. Patients can have a professional consultation and get medicines from us, rather than having to go to the surgery.” Together, the pharmacists at Boots are writing approximately 60 prescriptions a month for minor ailments.

Colin Lowe’s pharmacy is in the outskirts of Dundee, in a residential area with a large student population. He says that the service gives pharmacy a better profile. “I’ve got about 150 patients registered and the number is gradually building up,” he says. “For older and younger people the service is a great boon.” Analgesics are the most frequently prescribed medicines among older people and “something to treat thrush” is a common request among younger people. “So far we have not had a great workload demand but we have been lucky this winter. There is potential for a much bigger workload if there is a flu outbreak,” he comments.

In his pharmacy in the village of Muirhead, north of Dundee, John Carracher has between 500 and 600 patients signed up to the service. “Patients are saying it is great, why couldn’t it have been done years ago,” he says. Children and older people use the service most, he explains. For children, headlice is the most common condition he sees, with analgesics and antacids being the most frequently required medicines for adults.

Despite requests from some non-exempt patients to be allowed to participate in the scheme, there are no plans to extend it to other patient groups. Mr Carracher comments: “I’ve had one complaint from a patient who pays for prescriptions who wanted to register for the service. If prescription only medicines are included in the formulary then patient group directions are needed for patients who pay for prescriptions as well as those who are exempt.”

There have also been calls to extend the formulary. Mr Campbell would like it to include chloramphenicol eye drops and emergency hormonal contraception. Mr Lowe wants a short course of trimethoprim to be included for treating urinary tract infections.

Mr Carracher comments that doctors at the surgery in his village are supportive of the service. It is easy to see why. The service reduces GP workload, allowing them to see patients with more serious conditions. Considering the government target that patients should have access to a health professional within 48 hours, the minor ailments service helps on two fronts: through the accessibility of community pharmacists for minor ailments and by freeing GP time.

Angela Timoney, consultant in pharmaceutical public health at NHS Tayside, says that the service has been well received by everyone at board level. “From a public health perspective, this is a way of dealing with health inequalities by giving people equal access to medicines. It is also making appropriate use of pharmacists’ skills,” she comments.

Patient registration

To participate in the service, patients have to register with a pharmacy. The project found that registering patients has not been too problematic; it has, however, been one of the most time-consuming aspects for pharmacists. Patients are registered using their unique Community Health Index (CHI) number (which is similar to the NHS number in England). One hitch has been getting access to patients’ CHI numbers. They are printed on prescriptions, but if the patient has not got a prescription with them at the time of registration then the patient’s GP has to be contacted for the CHI number.

“Initially we thought that we would need pharmacies to be connected to NHSnet to register patients but the reality is that it can be done with a paper-based model. We will bring the IT in afterwards to underpin the paper system,” says Ms Strath. Sorting out registration of patients has been made the priority for the IT teams and she hopes that the system will be fully electronic by the end of this year.

Scotland is certainly pushing the agenda forwards when it comes to patient registration at community pharmacies. “We are keen to get patient registration in place by the middle of this year,” says Ms Strath. This registration would be held centrally, rather than at a local trust level. At the moment, the central process of registration with doctors and dentists operated by the Practitioner Services Division (the Scottish equivalent of the Prescription Pricing Authority) has both electronic and paper forms. Paper registration is needed because dentists do not have NHSnet access.

The process of connecting community pharmacies to the NHSnet is well under way in Scotland (see p111). So the idea is that pharmacists could register patients either electronically (if they have NHSnet connection) or on paper. If it all goes to plan— certain issues around patient’s ability to change the pharmacy they are registered at still need to be ironed out — then there is potential for all patients in Scotland to be registered with a pharmacy later this year.

In the minor ailments project, patients can only be registered at one pharmacy although they can transfer to another pharmacy if required. In the future, IT developments will allow pharmacists to make an instant check on the patient’s registration status. This will help pharmacists such as Mr Lowe. He comments: “We are open late in the evenings and people come from all over town to the pharmacy, particularly for something like headlice. It is a problem if they are already registered with another pharmacy.” Currently, each pharmacist sends a list of new registrants to the local primary care trust. A project manager working at trust level then identifies whether or not there have been any duplications and contacts the patient to ask them where they would like to be registered.

How the minor ailments service can be built into the e-pharmacy programme is being considered by the Scottish Executive. It is obvious that application of good IT would make the running of the service smoother. But Ms Strath is positive about the fact that the service has been set up before the IT has been developed. “Not having the IT in place has allowed us to get the service up and running, fine tune it and then look at the IT afterwards rather than letting IT drive the policy decisions,” she says.

Remuneration

The payment pharmacists in the project receive for the minor ailments service comes in two parts. First, there is a fee to provide the service which is banded according to the number of patients they have registered, termed a “per capitation” fee (see Table). Second, they are reimbursed the cost of the drug supplied but are not paid a dispensing fee.

What these arrangements mean is that there is no incentive for pharmacists to prescribe. This has been seen in the project: “Pharmacists are only prescribing when there is a clinical need,” says Ms Strath. The Scottish Executive is currently looking at future remuneration of the service, but she comments: “Discussions are ongoing with the Department and the Scottish Pharmaceutical General Council but the signs are that it will be on a capitation basis.” Pharmacists in the project are happy with the current rate of remuneration.

The cost of drugs is covered by top-slicing the prescribing budget. The average cost per item in the project is £2.20. “It is cost-effective,” Ms Strath says. “Pharmacists are prescribing generic medicines.”

It is understood that the reason the Department of Health in England is not keen to include a minor ailments service within pharmacists’ core contract comes down to fears over the cost of the service. Ms Strath’s message from Scotland is clear: “It has not proven to be costly.” She adds that ministers in the Scottish Parliament are keen on the minor ailments service because it delivers not just health but also social justice policies.

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