| Clare Bellingham is senior news and features writer at the Pharmaceutical Journal |
Before long, all community pharmacists in Scotland and many of their counterparts in England and Wales will be offering a minor ailments service. Why? Well, in Scotland, it forms one of the four core services in the new pharmacy contract. But many pharmacists in England and Wales will also offer the service since it is an enhanced service in the third tier of their new contract. Enhanced services have to be commissioned locally and a number of primary care trusts have already expressed interest in pharmacists providing minor ailments services.
Scottish service
This article examines how the minor ailments service developed in Scotland and how it works now. It all started in 2001, as the “Direct supply of medicines” project which was piloted in two locations (PJ, 23 February 2002, p238). As the pilot grew, it was renamed the “Direct care at the chemist” project before it finally became the “Minor ailments scheme”.
How the service works
The first step is for patients to register with a community pharmacy. Once they have done so, they can return to the pharmacy to use the service at any time. Patients are eligible to register if they are exempt from NHS prescription charges.
Pharmacists can prescribe any pharmacy or general sale list medicine so long as it is not blacklisted. They can also prescribe dressings from part 2 of the Drug Tariff. A number of patient group directions (PGDs) are used, mostly to allow pharmacists to dispense from bulk although a PGD for chloramphenicol eye drops is included in the Ayrshire and Arran area. A PGD is like a giant prescription: it is a written instruction (signed by a senior doctor) to allow the supply of a particular medicine to a defined group of patients. Using a PGD allows a pharmacist to supply a prescription-only medicine or a pharmacy medicine outside its marketing authorisation.
In the minor ailments scheme, it is most common to give a week’s supply of treatment which is why dispensing from bulk is needed and allowed through a PGD.
The pharmacist writes a prescription on a special prescription form called a CP1. They are encouraged to do this even if they give advice or refer to a GP and do not prescribe a medicine.
The pharmacist also records what is supplied on the patient’s pharmacy medication record. Pharmacists send the CP1 forms to the Practitioner Services Division where the prescription data are recorded.
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The scheme is open to all patients who are exempt from prescription charges and who are registered with a GP in the local area. It allows them to get treatment for minor ailments from the pharmacy free of charge, without having to go to a GP for a prescription first. How the service works is outlined in the Panel.
Following the initial pilot, the project was rolled out in October 2003 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. It quickly became clear that the service was here to stay.
To use the service, patients have to register with one pharmacy. The number of patients registered is increasing every day. In September 2004, a total of 51,179 patients had registered in Ayrshire and Arran, which equated to about 20 to 25 per cent of the eligible population.
Support from all sides
The roll-out across Ayrshire and Arran and across Tayside gained support from all sides: pharmacists, patients, GPs and health authorities are in agreement over its merits.
“Pharmacists see its value in legitimising what they already do,” says Alison Strath, principal pharmaceutical officer at the Scottish Executive.
The top three most common ailments that pharmacists are dealing with are pain, headlice and coughs and colds. 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 says. On average, pharmacists are seeing five to 10 patients a day.
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.
“Patients think the service is great,” says Neil Campbell, pharmacist at Boots in central Dundee. “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.”
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. “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. “There is potential for a much bigger workload if there is a flu outbreak,” he comments.
John Carracher, a pharmacist in the village of Muirhead, north of Dundee, says: “Patients are saying it is great — why couldn’t it have been done years ago?” 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.
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.
Remuneration
The payment pharmacists in the project receive for the minor ailments service comes in two parts.
Payment for the service
Pharmacists are paid a capitation fee for participating in the minor ailments service pilot project. This fee is banded according to the number of patients they have registered. The current fees* are:
| Number of patients |
Annual capitation fee |
| 0—250 |
£3,910 |
| 251—500 |
£5,863 |
| 501—750 |
£7,817 |
| Over 750 |
£7,817 plus £8.04 per patient |
* A new fee structure will be introduced with the new contract in April 2006 |
First, there is a fee to provide the service which is banded according to the number of patients they have registered, termed a “capitation fee” (see Panel). 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,” explains Ms Strath.
The cost of drugs is covered by top-slicing the prescribing budget. The average cost per item in the project is around about £2. “It is cost-effective,” Ms Strath says. “Pharmacists are prescribing generic medicines.”
The details of the new pharmacy contract in Scotland have not yet been agreed so whether this payment model will continue is unknown. However, it looks likely that the service will be funded through a capitation payment.
In England, it is understood that the reason the Department of Health did not want to include a minor ailments service within pharmacists’ core contract came 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.
This article is based on one published in The Pharmaceutical Journal (31 January 2004, p115).
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