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Pharmacy First Patient Group Directions
Update October 2020
Paul Humphriss, Medicines Optimisation Pharmacist, Devon CGG
Devon Pharmacy First Services
Due for relaunch on
Monday 2nd November 2020
Background and review of Pharmacy First PGDs
▪ Service Level Agreement – 2-year cycle: Review due by April 2020
▪ PGD Review – 2-year cycle: due by April 2021(Nitrofurantoin, Chloramphenicol,
Sodium Fusidate, Timodine). Timetabled to start late 2020 to ensure could be
completed by April 2021
▪ COVID-19 stalled SLA review in March 2020
▪ Pharmacy First Services suspended in March 2020
▪ Need to review PGDs prior to reintroduction to ‘future proof’ services
▪ Agreed to prioritise review of Nitrofurantoin PGD based on:
• PGD usage data across Devon and support relaunch
• Feedback from LPC and Community Pharmacists
• Requirement to align with PHE guidelines
• Eliminate urinalysis, reduce infection control concerns
• Consider remote PGD use (‘future proof’)
Process of review of Nitrofurantoin PGD review
▪ Review of existing PGD e.g. PHE evidence, PGD legislation,
Special Pharmacy Services website, other similar services
▪ Rewrite using resources and expert opinion
▪ Consultation of PGD draft – Devon wide Antimicrobial Steering
Group, LPC
▪ Consultation feedback review, PGD revision and agreement
▪ PGD panel presentation and approval
▪ PharmOutcome updating
▪ Sharing information / training
Nitrofurantoin PGD – what’s changed?
▪ Inclusion – principle change in the PGD
▪ Women aged 16 years and over and under 65 presenting with two or more of the
following symptoms:
• Dysuria
• New Nocturia
• Urine which is cloudy to the naked eye
▪ PHE referencehttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/
829721/Diagnosis_of_urinary_tract_infections_UTI_diagnostic_flowchart.pdf
▪ Eliminates urinalysis and allows remote use
▪ Where remote consultation is considered clinically appropriate, the Pharmacist must ensure that
an adequate clinical assessment can be conducted to positively identify the condition
▪ Remote SPS PGD reference https://www.sps.nhs.uk/articles/can-a-medicine-be-supplied-under-a-
pgd-in-the-absence-of-the-patient/
Nitrofurantoin PGD – what’s changed?
▪ Exclusion changes includes
• Women who have had 2 or more urinary tract infections within the past 6 months or more
than 3 during the previous 12 months (PHE)
• Expansion of definition of pyelonephritis and sepsis (PHE)
▪ Supply section:
• Supply and receipt of the medication to the patient must be made on the day of the PGD
consultation
▪ Advice section includes:
• Updated risks / symptoms associated with bladder cancer and menopause
• Provide PIL from the TARGET toolkit https://www.rcgp.org.uk/clinical-and-
research/resources/toolkits/amr/target-antibiotics-toolkit/uti-resource-suite.aspx
Relaunch and the future
▪ Pharmacy First planned to restart Monday 2nd November 2020
▪ PGDs for Chloramphenicol eye drops, Sodium fusidate cream and Timodine cream
are unchanged - not yet been considered for remote use
▪ GPs will be informed of relaunch
▪ Community Pharmacists invited to advise to GP colleagues when they are able to
reoffer the service
▪ PGD review for the remaining 3 Pharmacy First PGDs to commence in November
2020
• Consider inclusion of new CPPE Remote Consultations package as an educational
requirement https://www.cppe.ac.uk/programmes/l/consultrem-e-01
• Consider NICE guideline NG153 Impetigo: antimicrobial prescribing
• Consider implications of extending remote use of PGDs
Pharmacy First: Working with Primary Care PartnersTOM KALLIS
PROJECT PHARMACIST, DEVON LPC
TK DEVON LPC 2020
Patient Pathways
Pharmacy First builds capacity in the management of acute conditions in the health system
How do patients access Pharmacy First currently?
Push/Pull aspects of the service
Could you consider a referral pathway from your local practices?
Conversation at both a practice and a PCN level
TK DEVON LPC 2020
GP CPCSExample of established referral pathway
Pilot service in Devon across a handful of GP/Pharmacy sites across Devon
Direct referral from GP practice into a pharmacy consultation ‘CPCS style’
Via PharmRefer
For minor ailments, can encompass conditions not to be routinely prescribed for
TK DEVON LPC 2020
GP CPCS Patient Journey
TK DEVON LPC 2020
Patient contacts GP
Patient is assessed and low acuity condition (see following page for
list) identified for potential referral
Patient advised that a referral to the local community pharmacist
who will contact them today about their condition
With patient consent, pharmacy is selected and referral sent via
PharmRefer
The patient is advised that the pharmacist will contact them by phone in the first instance. They
may need to attend the pharmacy for a further consultation if
necessary
Patient has consultation with Pharmacist & is given appropriate
advice around self-care and prevention. Patient possibly
directed to medicines which will help their condition, or have
referral escalated
GP to Pharmacy Referral sheetE X C L U S I O N C R I T E R I A : P R E G N A N T W O M E N , C H I L D R E N < 1 Y E A R
CONDITIONS What conditions are SUITABLE for referral to pharmacists? Do Not refer in these circumstances
BITES / STINGS • Cold Sores
Coughs• Flu-like symptoms • Sore throat • Drowsy/fever
Fast heart rate• Swelling or cramps
Red, inflamed or hot to touch
COLDS • Cold Sores
Coughs• Flu-like symptoms • Sore throat • Lasted +3 weeks • Unable to swallow
CONGESTION • Blocked or runny nose • Constant need to clear
their throat• Excess mucus • Lasted +3 weeks • 1 side obstruction or facial swelling
EYE • Conjunctivitis
Eye,red or irritable• Eye, sticky
Eyelid problems• Watery / runny eyes • Severe pain
Reduced vision• Light sensitivity
GENERAL • Constipation
Diarrhoea• Sleep difficulties
Tiredness• Vomiting or nausea • Severe / on going • Blood loss
Weight loss
FAILED
CONTRACEPTION• Morning after pill • Known or suspected
pregnancy• Under 13
PAIN • Acute pain
Ankle or foot pain
Haemorrhoids/Piles
Headache
Heatburn or indigestion
Hip pain or swelling
Infant colic
• Knee or lower leg pain
Lower back pain
Lower limb pain
Mouth ulcers
Rectal pain
Shoulder pain
Sore throat
• Sprains and strains
Teething
Thigh or buttock pain
Toothache
Wrist, hand or finger pain
• Condition described as
severe or urgent
Conditions have been on going
for +3 weeks
• Pharmacy treatment not worked
SKIN • Acne, spots and pimples
Athlete’s Foot
Blisters on foot
Cold sores
Dermatitis
• Dry skin
Hair loss
Hayfever
Mouth ulcers
Nappy rash
Oral thrush
• Rash – allergic
reaction
Scabies
Skin dressings
Skin rash
Wound problems
• Condition described as
severe or urgent
Conditions have been on going
for +3 weeks
• Pharmacy treatment not worked
Bites
Nappy rash over 3 years old or children already
using a prescribed nappy rash cream
SORE THROAT • Adults and children over
12 months• Flu-like symptoms • Hoarseness • Lasted +3 weeks
Voice change• Unable to swallow
SWELLING • Ankle or foot swelling
Lower limb swelling• Thigh or buttock swelling
Toe pain or swelling• Wrist, hand or finger
swelling• Condition described as
severe or urgent• Pharmacy treatment not worked
GYNAE THRUSH • Vaginal discharge• Vaginal itch or soreness • Diabetic/Pregnant
Under 16/over 60• Pharmacy treatment not worked
TK DEVON LPC 2020
But what does this mean for me and my pharmacy?
TK DEVON LPC 2020
Consider…
What next steps might you take for your pharmacy and these PGDs linking in with local practices?
-Local conversations on a practice by practice basis
-Linking in with pharmacy PCN lead
-What capacity might you have?
-Ad hoc referrals?
-When does your business have best capacity?
TK DEVON LPC 2020
TK DEVON LPC 2020
TK DEVON LPC 2020
PCN Mandate to collaborate with Community Pharmacies
5.7.1. A PCN must agree with local community services providers, mental health providers and community pharmacy providers how they will work together
5.7.4. A PCN must detail its arrangements with community mental health providers, and community pharmacy (via the community pharmacy nominated Pharmacy PCN Lead) in Schedule 7 of the Network Agreement by 31 March 2021.
Also a role for community pharmacy in the SMR DES spec…
TK DEVON LPC 2020
SMR Service Requirements
Identification of Patients
Prioritisation and Capacity
Invitations
Qualifications and Training
Recording of SMRs on GP IT Systems
Collaboration on Meds Optimisation
New Medicines Service
TK DEVON LPC 2020
Summary of Key Points
Opportunity for Push and Pull pathways into Pharmacy First
Local conversations at Practice Level
PCN lead conversations
Resources available with exclusion criteria
Several areas of collaboration, including in PCN specification
Support available via Devon LPC