PHARMACEUTICAL SERVICES ADDITIONAL SERVICE

PHARMACY FIRST

Service Overview In order to help alleviate some of the workforce pressures in primary care and to optimise the role of the community pharmacist, two specific common clinical conditions have been chosen to enable patients to access assessment and treatment from community pharmacists :

Assessment and treatment of women aged between 16 and 65 with uncomplicated

urinary tract infection (UTI)

Assessment and treatment of patients aged 2 years and over with impetigo

The objective of the assessment and treatment of UTI or impetigo, by means of patient group directions (PGD), is to provide a timely and appropriate service for patients in the treatment of their condition and to identify patients who need onward referral to other NHS resources. This service will allow NHS treatment to be provided to patients who meet all of the criteria set out in the PGDs and who wish to receive care following assessment by a community pharmacist.

1. Training requirement

1.1 The community pharmacy contractor will ensure that all pharmacists involved in

delivering the scheme complete the NES Pharmacy First training pack, on the Turas Learn platform available at https://learn.nes.nhs.scot/ and participate in any local training programme (including update training) as identified by NHS Lothian in accordance with agreed local standards.

1.2 The community pharmacy contractor has a duty to ensure that pharmacists and staff involved in the provision of the service are aware of and operate within local

guidelines.

2. Claims and Payment

2.1 A £100 registration fee will be paid on the completion and submission of the contract

agreement form for the Pharmacy First service as defined by NHS Lothian (Appendix A).

2.2 Payment for service provision will be £10 per consultation and not per supply. 2.3 Payment for service provision shall be made on the submission of a fully completed

Pharmacy First monthly claim form. (Appendix B).

2.4 Information for audit and evaluation purposes may also be requested and must be completed otherwise payment from NHS Lothian may be withheld.

2.5 The payment terms of this service specification may be revised in line with the roll out of the National service. NHS Lothian shall give the contractor 4 weeks notice of any changes to the payment terms.

3. General Service outline and standard Community pharmacies providing the Pharmacy First service must ensure that they have:

3.1 A standard operating procedure in place in the pharmacy to cover all aspects of

service provision.

3.2 Adequate staff provision to ensure dispensary functions and pharmaceutical services are not compromised due to the service.

3.3 Appropriate administrative support to undertake initial discussions with potential

patients and assist with form filling. 3.4 Indemnity cover for staff involved in the service delivery.

4. Monitoring and evaluation

4.1 It is a requirement of the service that appropriate records are kept and maintained by

the community pharmacy contractor as per the PGDs. This will enable verification of service provision and training requirements and provide information to NHS Lothian for internal and external audit and evaluation purposes.

. 5. Pharmacy premises criteria Community pharmacies providing the Pharmacy First service must have a suitable, private, enclosed consultation area within the community pharmacy. Key requirements are:

Chair(s)

Wheelchair/disabled access

Safe storage of documentation

Background information

a) RPS Medicines, Ethics and Practice (current edition) b) NHS Lothian Data Protection and Confidentiality Policy for personal information c) NES Child Protection Distance Learning Resource Pack d) NHS Lothian Patient Group Direction for Trimethoprim to treat uncomplicated UTI e) NHS Lothian Patient Group Direction for Fusidic acid cream 2% to treat minor

staphylococcal skin infections (Impetigo)

ASSESSMENT AND TREATMENT OF NON-PREGNANT WOMEN

AGED 16-65 YEARS WITH UNCOMPLICATED URINARY TRACT INFECTIONS. 1. Introduction

1.1 The objective of the assessment and treatment of uncomplicated urinary tract

infection (UTI) in women aged between 16 and 65 years, by means of a Patient Group Direction (PGD) for trimethoprim, is to provide a timely and appropriate service for women in the treatment of their condition and to identify patients who need onward referral to other NHS services.

1.2 Treatment on the NHS will be provided to women who meet the criteria set out in the

PGD and who wish to receive care following assessment by a community pharmacist.

2. Background to the Service

2.1 Unscheduled care services are coming under increasing pressure to deliver timely

and appropriate care to patients. Recent public education programmes have focused on directing patients to the most appropriate route of care to manage their condition

2.2 A significant percentage of GP practice consultations concern patients with genito-

urinary symptoms and of those, a large percentage are related to lower urinary tract infections and result in a LUCS consultation or advice from a GP.

2.3 A recent study in the British Journal of General Practice1 detailing a project run in

Greater Glasgow and Clyde compared the care pathway of patients with UTI symptoms attending GP services with those receiving management, including trimethoprim supply under PGD, via community pharmacies. The study concluded that, “Operating within PGD controls, antibiotic treatments for UTIs could be provided via community pharmacy to improve patient access to treatment which may also maintain antibiotic stewardship and reduce GP workload”.

3. Service aims

3.1 To provide timely and appropriate access to treatment for uncomplicated lower urinary

infections in adult women between 16 and 65 years of age.

3.2 To provide triage and onward professional to professional referral of women with symptoms outside of the criteria for treatment of uncomplicated lower urinary infections in adult women as defined in the PGD.

3.3 To provide services with the appropriate assurances of antibiotic stewardship.

4. Service outline and standard 4.1 An uncomplicated UTI treatment service is available on the basis of assessment and

locally agreed criteria. 4.2 The client’s eligibility for UTI treatment will be assessed in accordance with national

and local guidance. (Appendix 1) 4.3 The community pharmacy contractor will be responsible for the provision of advice

(both written and verbal) to the patient as appropriate.(Appendix 3) 4.4 A three day course of trimethoprim will be available, as required, to any women who

meet the inclusion criteria contained within the PGD and the local protocol on eligible client groups.

4.5 The community pharmacy contractor will be responsible for writing a suitable prescription to allow supply.

4.5.1 Universal Claim Framework (UCF) The GP practice code should be used

which, if not known, can be found at http://www.communitypharmacy.scot.nhs.uk/unscheduled_care.html

4.5.2 CPUS For patients registered with a GP in Scotland the GP reference code of

the patients GP should be used which, if not known, can be found at http://www.communitypharmacy.scot.nhs.uk/unscheduled_care.html .

For patients from elsewhere in the UK code 99996 should be used. 4.6 The community pharmacy contractor will be responsible for referring women who are

excluded from treatment under the PGD and local protocol to other service providers where appropriate, e.g. GP or LUCS.

4.7 The community pharmacy contractor will maintain patient medication records of the

episodes of care. 4.8 The community pharmacy contractor will be responsible for the provision of a user-

friendly, client-centred, non-judgemental and confidential service. 4.9 The community pharmacy contractor providing the service will ensure that the

premises used for the patient consultation meet the standards agreed with NHS Lothian.

4.10 The Pharmacy Contractor will inform the patient’s General Practitioner following an

assessment of their patient, by means of a notification form (Appendix 2) or using the

SBAR tool on PCR 4.11 The community pharmacy contractor will display NHS Lothian approved and supplied

material within the pharmacy advertising the service. 4.12 The community pharmacist should ensure that the patient is aware that they must

inform any other health professional they consult for this condition, that they have already accessed this service.

Reference

1. Antibiotic treatment of urinary tract infection by community pharmacists: a cross-

sectional study. Booth, Jill L; Mullen, Alexander B; Thomson, David AM; Johnstone, Christopher; Galbraith, Susan J; Bryson, Scott M; McGovern, Elizabeth M. British Journal of General Practice, Volume 63, Number 609, April 2013, pp. e244-e249(6)

Acknowledgement

Adapted by NHS Lothian based on documents produced by NHS Grampian and NHS Borders.

Appendix 1 (1/2) Patient Group Direction for the supply of trimethoprim for the treatment of Uncomplicated UTI by Pharmacists working within NHS Lothian. Management of suspected UTI in non-pregnant females aged 16-65 years

NB: Only proceed if patient has no exclusions under PGD Yes No Yes No Yes No References:

Sign88 Management of suspected bacterial urinary tract infection in adults July 2012

HPA/RCGP Diagnosis of UTI quick reference guide for primary care April 2011

Diabetic

Refer to GP or LUCS

(Professional to Professional)

Haematuria

Signs and symptoms of UTI?

Dysuria* Urgency

Frequency* Polyuria

Suprapubic tenderness

MILD or < 2 symptoms

SEVERE symptoms of BOTH

dysuria*+ frequency*

OR

>3 symptoms

Symptoms include – vaginal

itch or discharge?

Provide reassurance and give advice

on management of symptoms. Advise

patient to seek further advice from

Community Pharmacist/GP/LUCS if

condition deteriorates or symptoms fail

to improve within 48h.

If unsure, refer to GP or LUCS

Signs &Symptoms of upper UTI:

Loin pain

Flank tenderness

Fever/rigors

Nausea/vomiting/diarrhoea

Rapid onset

systemically unwell

Refer to GP or

LUCS

(Professional to

professional)

Supply

Trimethoprim

according to

PGD

Explore alternative

diagnoses.

If unsure, refer to GP or

LUCS

Refer to GP or LUCS

(Professional to Professional)

Appendix 1 (2/2) PATIENT ASSESSMENT PROFORMA UTI – to be completed by the pharmacist

Date of Assessment:

Time of Assessment:

Name of Patient: Date of Birth:

Details of presenting symptoms are shown below:

SYMPTOMS YES NO

Haematuria (PGD exclusion refer to GP)

Severe dysuria

Severe frequency

Urgency

Polyuria

Suprapubic tenderness

Other symptoms

YES NO

Symptoms related to UTI?

(if NO use comments/notes below)

*Severe Dysuria & Frequency or ≥ 3

symptoms?

≤2 symptoms?

Suitable for Trimethoprim x 3 days?

Advised to return/seek medical advice if symptoms worsen?

Information leaflet given?

Contra-indications to treatment of UTI by Pharmacist: YES NO Age <16 or ≥65

Haematuria

Pregnant (confirmed or possible) UTI Prophylaxis

Catheter in situ Confused/dehydrated

Previous antibiotic treatment for UTI In last 28 days

More than 2 episodes of UTI in 6 months or 3 episodes in 12 months

Vaginal itch/discharge

Allergy to trimethroprim, co-trimoxazole or any of the components of the medication

Symptoms of upper UTI any of the following: Loin pain, flank tenderness, fever/rigor,nausea/vomiting/diarrhoea, rapid onset, or systematically unwell

Taking interacting medications: Check current BNF for interactions but including: Azathioprine,ciclosporin, mercaptopurine,methotrexate, phenytoin, warfarin, digoxin, pyrimethamine, rifampicin

Medical conditions – any of the following: Renal impairment, hyperkalaemia, diabetes, severe hepatic insufficiency, megaloblastic anaemia, other blood dyscrasias, folate deficiency, porphyria, galactose intolerance, the Lapp lactose deficiency, glucose-galactose malabsorption, immunosuppressed, urinary tract abnormality, on antibiotic prophylaxis for recurrent UTI

Patients answering any questions Yes in this column are excluded from the PGD and must be managed as appropriate.

Treated by Pharmacy YES / NO Referred for treatment to:

*Comments/Notes

(tick box if supplied) Cystitis information leaflet Trimethoprim 200mg twice daily for 3 days (6 tablets) Pharmacist Name (print) Pharmacist signature Date

Appendix 2

NHS Lothian Treatment of Uncomplicated Urinary Tract Infections (UTI’s)

in non-pregnant adult females Notification of Assessment through Community Pharmacy

Date and Time: Name of Pharmacist:

CONFIDENTIAL WHEN COMPLETED: Data protection confidentiality note: This message is intended only for the use of the individual or entity to whom it is add ressed and may contain information that is privileged, confidential and exempt from disclosure under law. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. GP name:

GP practice address:

The following patient has attended this pharmacy for assessment and treatment of an uncomplicated urinary tract infection. Patient name:

Date of Birth: CHI: (If available)

Patient address:

Following assessment your patient has: Been given advice on management of symptoms Been supplied a 3 day course of trimethoprim 200mg twice daily Been referred for treatment to Your patient has been advised to contact the practice if symptoms fail to resolve following treatment. You may wish to include this information in your patient records. Patient consent: I can confirm that the information provided is a true reflection of my individual circumstances and I give m y consent to allow an NHS Lothian Pharmacist to provide the most appropriate advice and/or treatment for me. I also give my permission to allow the pharmacist to pass, to my own GP, details of this consultation and any advice given or treatment provided. I have been advised that some of the information may be used to assess the uptake of the service but that this will be totally anonymous and not be attributable to any individual patient. Patient signature:

Date:

DD/ MM/ YYYY Time: 00:00

Postcode:

DD/ MM/ YYYY

Pharmacy Name & Address

DD/ MM/ YYYY

Appendix 3

Patient Information: Urinary Tract Infection (UTI)

Preventing Future episodes Drink plenty of water every day (at least six to eight glasses). Go to the toilet when you need – do not hold it in. Avoid nylon underwear and feminine hygiene sprays. Avoid the use of tampons.

Keep yourself extra clean ‘down below’ by using a separate flannel to wash yourself night and morning.

Use plain water for washing; always wipe from ‘front to back’ Avoid bubble baths, talcum powder, all personal (vaginal) deodorants & feminine

wipes A bath every day is not necessary and may, in fact, be harmful – a shallow bath is

better than a deep one and a shower is better still.

If you are prone to getting UTIs after sex: Cleanse the genital area with water before intercourse (but do not douche). Pass urine as soon as possible afterwards. If you are a female using a diaphgram or spermicidal creams, you may wish to

choose a different form of contraception, as these can increase the risk of UTIs. Use enough lubrication (eg KY jelly) during sex, if you are prone to dryness.

There is some evidence that drinking cranberry juice (one glass per day) can help prevent UTIs coming back. However, this is not advised if you take warfarin to thin the blood or have a personal family history of kidney stones. If you find the drink bitter, try mixing it with another fruit juice or you may prefer to take cranberry tablets, which are available to buy. If symptoms do return

As soon as you feel the first twinges of an infection, start drinking a lot of water or another bland liquid such as milk or weak tea. Avoid strong coffee, tea or alcohol. For the first 3 hours, drink at least half a pint every 20 minutes to flush out the infection before it gets a grip.

NOTE: If you need to consult another healthcare professional about this condition please let them know you have already seen the pharmacist.

PHARMACEUTICAL SERVICES

ADDITIONAL SERVICE PHARMACY FIRST

ASSESSMENT AND TREATMENT OF IMPETIGO WITH FUSIDIC ACID CREAM 2%.

IN PATIENTS OVER 2 YEARS OF AGE 5. Introduction

5.1 The objective of the assessment and treatment of Impetigo in adults and children aged

over 2 years, by means of a patient group direction (PGD) for fusidic acid cream 2%, is to provide a timely and appropriate service for patients in the treatment of their condition and to identify patients who need onward referral to other NHS services.

5.2 Treatment on the NHS will be provided to patients who meet the criteria set out in the

PGD and who wish to receive care following assessment by a community pharmacist.

6. Background to the Service

6.1 Unscheduled care services are coming under increasing pressure to deliver timely

and appropriate care to patients. Recent public education programmes have focused on directing patients to the most appropriate route of care to manage their condition

6.2 A notable percentage of GP practice consultations concern patients presenting with

impetigo.

7. Service aims

7.1 To provide timely and appropriate access to treatment for minor staphylococcal skin

infection (Impetigo) in patients over the age of 2 years.

7.2 To provide triage and onward professional to professional referral of patients with symptoms outside of the criteria for treatment of impetigo in patients over the age of 2 as defined in the PGD.

7.3 To provide services with the appropriate assurances of antibiotic stewardship.

8. Service outline and standard 8.1 An impetigo treatment service is available on the basis of assessment and locally

agreed criteria. 8.2 The client’s eligibility for impetigo treatment will be assessed in accordance with

national and local guidance. (Appendix 4 and 5) 8.3 The community pharmacy contractor will be responsible for the provision of advice

(both written and verbal) to the patient as appropriate (Appendix 6).

8.4 A seven day course of fusidic acid cream 2% will be available, as required, to any patient who meets the inclusion criteria contained within the Patient Group Direction (PGD)

8.5 The community pharmacy contractor will be responsible for writing a suitable prescription to allow supply. 8.5.1 Universal Claim Framework (UCF) The GP practice code should be used

which, if not known, can be found at http://www.communitypharmacy.scot.nhs.uk/unscheduled_care.html 8.5.2 CPUS. For patients registered with a GP in Scotland: the GP reference number should be used which, if not known, can be found at http://www.communitypharmacy.scot.nhs.uk/unscheduled_care.html. For patients from elsewhere in the UK the code 99996 should be used.

8.6 The community pharmacy contractor will be responsible for referring patients who are

excluded from treatment under the PGD and local protocol to other service providers where appropriate, e.g. GP or LUCS.

8.7 The community pharmacy contractor will maintain patient medication records of the

episodes of care. 8.8 The community pharmacy contractor will be responsible for the provision of a user-

friendly, client-centred, non-judgemental and confidential service. 8.9 The community pharmacy contractor providing the service will ensure that the

premises used for the patient consultation meet the standards agreed with NHS Lothian.

8.10 The Pharmacy Contractor will notify the patient’s General Practitioner where they

have assessed their patient, by means of a notification form (Appendix 7) or using

SBAR tool on PCR. 8.11 The community pharmacy contractor will display NHS Lothian approved and supplied

material within the pharmacy advertising the service.

Acknowledgement Adapted by NHS Lothian based on documents produced by NHS Forth Valley

Appendix 4 IMPETIGO- Supporting information for Pharmacists

NON-BULLOUS IMPETIGO

Usually occurs around the nose and mouth

Appears as red sores which burst leaving behind golden crusts typically 2cm across.

Sores are not usually painful but can be itchy BULLOUS IMPETIGO

Begins with appearance of fluid filled blisters which usually occur on the central part of body between waist and neck.

Blisters are usually 1-2 cm across

Once burst they leave a yellow crust

Blister may be painful and the area of skin may be itchy WHAT THE PGD STATES

Minor skin infection limited to a few lesions in one area of body.

The rash consists of vesicles that weep and then dry to form yellow-brown crusts.

See PGD for all exclusion criteria WHAT ELSE COULD IT BE?

Chicken pox Allergic reaction

Cold sores WHAT YOU NEED TO KNOW

Age

Exact symptoms, how long, severity?

Have they had this before and when? Recent treatment? Medication(s) being taken

Problems with ANY medication

Are they generally well otherwise WHAT YOU NEED TO DO IF IMPETIGO IS CONFIRMED BY PRESENTATION OF SYMPTOMS

Ask if okay to use Fusidic Acid cream Remind them to read the leaflet

Dose reminder

Advice regarding good hygiene measure to prevent spread.

Complete notification of treatment form or SBAR for supply

Send copy of notification of treatment form/ SBAR to GP

Write CPUS CP4/3 for supply WHAT ADVICE YOU NEED TO GIVE

Wash hands before and after applying cream

Where possible remove scabs by bathing in warm water before applying the cream

Impetigo is very infectious, prevent spread by using own flannels and towels(hot wash after use)

Do not scratch or pick spots

Contact GP or NHS 24 if symptoms do not improve after 5 days or spread

Appendix 5 PATIENT ASSESSMENT PROFORMA IMPETIGO – to be completed by the pharmacist

PATIENT NAME:

PATIENT ADDRESS:

DATE OF BIRTH/CHI NUMBER:

DATE OF CONSULTATION:

PATIENT’S GP PRACTICE:

Yes No Notes

Is patient aged 2 or older?

If No, refer

Does the rash consist of vesicles which weep and

form yellow / brown crusts?

If No, consider other diagnosis and refer if appropriate

Is the rash limited to a few lesions on one area of the

body?

If No, refer

Has the patient been treated for impetigo within the

last 3 months?

If Yes, refer

Are there other skin conditions in the same area?

If Yes, refer

Is the patient taking any other medication? See

current BNF for interactions

If Yes, review potential interactions and clinical significance.

Refer if necessary

Is there a known hypersensitivity to any component of

the medicine

If Yes, refer

For female patients of child bearing age (> 13); is

patient pregnant or breastfeeding?

If Yes, refer

Any other exclusion criteria – see PGD

If Yes, refer

Does the patient appear systemically unwell? If Yes, refer

Advice checklist

Advice on potential transmission and hygiene measures

Advice on method and frequency of application including need to avoid

contact with eyes

Advice on side effects of fusidic acid

Advice on seeking medical advice if uncontrolled or if worsening

symptoms

The above information is correct to the best of my knowledge. I have

been counselled on the use of fusidic acid cream and understand the

advice given to me by the pharmacist.

Patient signature:

Treatment

A supply should only be made if you are certain that to the best of your knowledge, it is appropriate.

Fusidic acid cream

2%

Advice

only

Refer Give details:

The action specified was based on the information given to me by the

patient/parent/guardian, which to the best of my knowledge is correct.

Pharmacist signature:

Appendix 6 Patient Information for Impetigo

During treatment, it is important to take precautions to minimise the risk of impetigo spreading to other people or to other areas of the body.

Most people are no longer contagious after 48 hours of treatment or once their sores have dried and healed. It is important to stay away from work, school, nursery or playgroup until this point.

The advice below can also help to prevent the spread of the infection:

Do not share flannels, sheets or towels with anyone who has impetigo – wash them at a high temperature after use

Wash the sores with soap and water to remove the crusts Avoid touching or scratching the sores, or letting others touch them – it may help to

ensure your nails are kept clean and short Avoid contact with newborn babies, preparing food, playing contact sports, or going to

the gym – until the risk of infection has passed Wash your hands frequently – particularly after touching infected skin Washable toys should also be washed – wipe non-washable soft toys thoroughly with

a cloth that has been wrung out in detergent and warm water and allowed to dry completely

To reduce the risk of impetigo returning, make sure any cuts, scratches or bites are kept clean.

In very rare cases, impetigo may lead to some scarring particularly if you scratch at the blisters, crusts or sores.

NOTE: If you need to consult another healthcare professional about this condition please let them know you have already seen the pharmacist.

Appendix 7

Notification of Assessment of Impetigo Infection with

Fusidic Acid 2% Cream through Community Pharmacy

Date and time: Tim Name of Pharmacist:

CONFIDENTIAL WHEN COMPLETED: Data protection confidentiality note: This message is intended only for the use of the individual or entity to whom it is addressed and may contain information that is privileged, confidential and exempt from disclosure under law. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. GP name:

GP practice address:

The following patient has attended this pharmacy for assessment and treatment of an impetigo infection. Patient name:

Date of Birth: CHI: (If available)

Patient address:

Following assessment your patient has: Been given advice on management of symptoms Been supplied a 15g tube fusidic acid 2% cream, apply 3-4 times daily Been referred for treatment to You may wish to include this information in your patient records. Patient consent: I can confirm that the information provided is a true reflection of my individual circumstances and I give m y consent to allow an NHS Lothian Pharmacist to provide the most appropriate advice and/or treatment for me. I also give my permission to allow the pharmacist to pass, to my own GP, details of this consultation and any advice given or treatment provided. I have been advised that some of the information may be used to assess the uptake of the service but that this will be totally anonymous and not be attributable to any individual patient. Patient signature: Date:

DD/ MM/ YYYY

Postcode:

DD/ MM/ YYYY

Pharmacy Name & Address

DD/ MM/ YYYY