PHARMACY CARE

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					  PHARMACY CARE




    COMMUNITY PHARMACY

MINOR AILMENTS SCHEME GUIDANCE
         (REVISED APRIL 08)
        ( REVISED PHARMACY LIST 21 APRIL 2008)
                 COMMUNITY PHARMACY

                   MINOR AILMENT SCHEME
Service Specification                          Page

Introduction                                   3

Transfer of Care                               4

Duties of participating Surgeries              4

Duties of participating Pharmacies             5

Referral procedures                            6

Service funding and payment                    7

Monitoring and evaluation                      8

Appendices                                     Page 9

1A. Participating GP Surgeries                 10 -11

1B Self- referral practices                    12 - 14

2. Participating Pharmacies                    15 -18

3. Pharmacist Prescription (FPPharm)           19

4. Patient Referral Form                       20

5. Gillick Competency Test                     21

6. Receptionist Protocol                       22

7. Receptionist Minor Ailment Checklist        23

8. Medicines Formulary, Codes and Conditions   24 - 51

9. Drug and Practice Code Reference Card       52 - 53




                                                         2
 10. Financial Summary Sheet                            54




                           PHARMACY CARE
           COMMUNITY PHARMACY MINOR AILMENT
                        SCHEME

Introduction
This service is available to all patients who are exempt from paying prescription
charges. The patients must be registered with East Riding of Yorkshire PCT Practices,
listed in Appendix 1. Patients are at liberty to refuse this service. Patients can receive
advice and /or treatment on the conditions listed in Appendix 8.

 Patients who pay for their prescriptions should be referred to a pharmacy to purchase
over the counter medicines in the usual way.

Only Community Pharmacies who are committed to making staff available to provide
the service and who have completed the necessary training for the conditions listed in
Appendix 7 will be included in the Pharmacy Care Scheme.

   Criteria for participating within the Minor Ailments Scheme

       •   Participating Pharmacies must provide all Essential Services within the
           Community Pharmacy Contract.
       •   Participating Pharmacies must have a pharmacist on the premises when
           offering the scheme to patients.
       •   Participating pharmacies must have a private consultation room available.
       •   Participating Pharmacies must have a qualified medicines counter assistant
            (Alliance/Boots equivalent Sales of Medicines certificate), or member of staff
           who is qualified to NVQ 2 in Pharmaceutical Services and keeps their CPD up
           to date with regard to minor ailments.
       •   Participating Pharmacies should have a designated, named lead member of
           staff who is responsible for making sure returns are completed, legible,
           accurate and on time.
       •   Participating Pharmacists should keep their CPD on minor ailments up to
           date.
       •   Only Pharmacists who have undertaken PCT accredited training can provide
           Prescription Only Medicines (POMs) under ‘Patient Group Direction’ (PGD).
           Training is specific to individual drugs under PGD.
       •   Pharmacies will be required to submit a summary sheet monthly in paper
           format.




                                                                                             3
Transfer of Care
Patients presenting with one of the conditions, listed in Appendix 1A at a participating
GP surgery can be offered this service. Patients who are registered with any of the GP
practices listed in Appendix 1B will also be able to self refer into the scheme.

Patients presenting at a participating Community Pharmacy confirmed as being
registered with a participating GP Practice (1A or B) will receive the level of care as laid
out in this specification.

Patients wishing to access the service must present their NHS number or reasonable
proof of registration with a participating GP Practice. This could include:

   A. NHS Number and exemptions card
   B. Registration on the pharmacy PMR system and known to the pharmacist.

If the pharmacy is in any doubt of the patient’s eligibility to receive the service they
should advise the patient to seek medical care through normal GP or Pharmacy OTC
routes.


Duties of Participating Surgeries
All patients requesting appointments for symptoms/conditions included in the pharmacy
care scheme can be offered this service using the checklist in Appendix 7.

Participating GP surgeries (Appendix 1A) should display official posters and provide
leaflets promoting the service.

Patients presenting in person accepting the service should be issued a Pharmacy Care
Service information leaflet. These patients should be advised to take their NHS number
and exemptions card to their local participating community pharmacy.

Patients accepting transfer by telephone will be advised to take their NHS number card
and exemptions card to one of the participating pharmacies.

For patients under the age of 16 the parent/guardian can accept transfer into the
scheme.

If a pharmacist thinks that a patient needs to be seen urgently by a GP, then they
should contact the surgery initially via telephone and fax details of the patient
and the condition through to the GP using the referral form in Appendix 4. GP
surgeries are requested to cooperate with the pharmacy to book an appointment
for such patients.




                                                                                           4
Duties of Participating Community Pharmacies
Patients should only be accepted into the service if the pharmacists can confirm the
patients identity and has reasonable proof of registration with a participating GP
Practice. (Appendix 1A or B). (Please do not contact the GP practice to confirm the
NHS number)

Patients should be encouraged to use the same pharmacy but are not obliged to do so.

Pharmacies should keep a detailed record of ‘Pharmacy Care’ treatments on their PMR
system. As part of the registration process patients will be requested to give their NHS
number which can be used as a patient identifier on the payment submission sheet. For
those patients who cannot provide this information on first entering the pharmacy an
identifier code of the patients two initials and date of birth should be used (e.g.
MF16.12. 42).

All participating pharmacies will provide a professional consultation service for patients
registered with participating GP practices who present with one or more of the specified
conditions.

All consultations should take place in the pharmacy and it is expected that the patient
will be present in the pharmacy at the consultation.

The Pharmacist or a suitably trained member of staff e.g medicines counter assistant,
(Alliance/Boots- sales of medicines assistant) or NVQ2 will assess the patient’s
condition. The consultation will consist of:
   •   Patient assessment.
   •   Provision of advice.
   •   Provision of a medication (only if necessary, from the agreed formulary).
   •   Entering details onto the PMR
   •   FPPharm (Pharmacists Prescription Appendix 3). The yellow copy of the
       FPPharm should be retained within the pharmacy and the white copy sent to the
       GP Practice.

Children under 16 years of age who self refer, without parental agreement, should be
Gillick competent to receive this service (Appendix 5).

Normal rules of patient confidentiality apply.

The Pharmacist should ensure that the patient has completed and signed the FPPharm
if they are exempt from paying and confirm this in the usual manner.

Pharmacies will be required to complete and return a monthly summary sheet either
electronically or paper copy to the PCT. This will allow for reimbursement of drug costs,
evaluation of the service and feedback to practices.

Summary sheets must be legible. Please enter one drug per line and indicate all
patients with a suitable ID number. Please check all details prior to submission. Claims
that are not completed correctly will not be processed and this will cause delays in
payments.



                                                                                           5
Referral Procedure

General Referral Procedure - If a patient presents more than twice within any month
with the same symptom/s they should be referred to their surgery if clinically
appropriate. If symptoms do not meet the criteria for a rapid referral the patient should
be advised to make an appointment in the normal manner. The Pharmacy Referral
Form should be completed and faxed to the practice (Appendix 4).

Rapid Referral Procedure – If the patient presents with symptoms indicating the need
for an immediate consultation with the GP, the pharmacist should ring the surgery and
make an appointment for the patient within an appropriate time frame. The pharmacy
should fax a copy of the Referral Form to the GP Practice immediately detailing the
consultation and any treatments that have been prescribed for the patient’s current
condition under the scheme.

If the surgery is closed and/or the symptoms are sufficiently severe the patient should
be advised to contact the on-call doctor on 0845 056 8060.

If the pharmacist suspects that the patient and/or carer is abusing the scheme they
should alert

Jackie Matthews, Head of Medicines Management for Provider Services on 01482
650700 and/or the patient’s GP.




                                                                                            6
Service funding and payment mechanism
Pharmacies will be required to complete and submit a monthly summary sheet to the
PCT. Data submitted will enable reimbursement of drug costs, evaluation of the service
and feedback to practices.

Summary sheets must be legible .Please enter one drug per line and indicate all
patients with a suitable ID number. Please check all details prior to submission. Claims
that are not completed correctly will not be processed and this will cause delays in
payments.

Pharmacies will be paid monthly at a rate of £4.00 per consultation

Drug costs will be reimbursed at drug tariff/agreed cost prices plus VAT monthly. A
summary is included in Appendix 9 (please note drug costs will be reviewed every 6
months and may be subject to change).

The summary record forms (Appendix 10) should be returned to the PCT office by the
5th working day of each month to enable payment for drug costs at the end of the
month. Pharmacists are advised to retain a copy of the summary forms. All payments
will be made through the PPA.




                                                                                      7
Monitoring and Evaluation
Pharmacies and GP Practices will be expected to participate in regular monitoring and
evaluation of the scheme to show:
   •   Changes to GP prescribing data for cost and volume.
   •   Cost and volume of pharmacy prescribing and indications treated.
   •   Impact on GP appointments and time.
   •   Attitudinal surveys of GPs, Receptionists, Pharmacists and Patients




                                                                                        8
        COMMUNITY PHARMACY MINOR
             AILMENT SCHEME


APPENDICES

1A. Participating GP Practices                   10 -11

1B. Self- referral practices                     12 -14

2. Participating Pharmacies                      15 -18

3. Pharmacist Prescription (FPPharm)             19

4. Patient Referral Form                         20

5. Gillick Competence Test                       21

6. Receptionist Protocol                         22

7. Receptionist Pharmacy Care Scheme Card        23

8. Medicines Formulary and Conditions Guidance   24 -51

9. Drug and Practice Codes Reference Card        52 - 53

10. Financial Summary Sheet                      54




                                                           9
Appendix 1A


     East Riding of Yorkshire Participating Surgeries

              Practice Name & Address   Telephone & Fax     Code
                                            Numbers


                       BEVERLEY
  Dr G Clayton                          Tel: 01482 888690   CLAY
  Beverley and Molescroft Surgery       Fax: 01482 888689
  30 Lockwood Rd
  Beverley
  HU17 9GQ
  Dr A M Harley                         Tel: 01482 881298   WALK
  Walkergate Surgery                    Fax : 01482
  117-119 Walkergate                    861791
  Beverley
  HU17 9BP
  Dr P G Jones                          Tel: 01482 862733   MAN
  The Health Centre                     Fax: 01482 864958
  Manor Rd
  Beverley
  HU17 7BZ
  Drs Kelly and Bawn                    Tel: 01482 862474   SAM
  The Surgery                           Fax: 01482 880495
  Samman Rd
  Beverley
  HU17 OBS
  Dr P R Mixers                         Tel: 01482 863326   FIRE
  The Old Fire Station                  Fax: 01482 861863
  Albert Terrace
  Beverley
  HU17 8JW
  Dr R L Pearson                        Tel: 01482 882546   NORT
  North Beverley Medical Centre         Fax: 01482 886295
  Pighill Lane off Woodhall way
  Beverley
  HU17 7JY
  Dr H S Suri                           Tel: 01482 881517   SURI
  The Surgery                           Fax: 01482 887022
  25 Greenwood Ave
  Beverley
  HU17 OHB
                      BRIDLINGTON
  Dr D F Bowden                         Tel: 01262 673362   FIELD
  Field House Surgery                   Fax: 01262 400218
  18 Victoria Rd
  Bridlington
  YO15 2AT




                                                                    10
                GOOLE and HOWDEN
Dr R W Harrison                             Tel: 01430 430318   HOW
The Medical Centre,                         Fax: 01430 432050
Pinfold St,
Howden,
 DN14 7DD
Dr M S Patel                                Tel: 08444 772596   MONT
Montague Medical Centre, Fifth Ave, Goole   Fax: 01405 726126
DN14 6JD
Dr L Wrightson                              Tel: 01405 767711   BART
The Health Centre, Bartholomew Ave, Goole   Fax: 01405 768212
DN14 6AW
                   HALTEMPRICE
Dr Y Adhami                                 Tel: 01482 646581   ADH
80 Hull Rd                                  Fax: 01482 645509
Hessle
HU13 9LU
Dr J G Best                                 Tel: 01482 658918   BEST
7 Weeton Way                                Fax: 01482 655205
Anlaby
HU10 6QH
Dr M E Hancocks                             Tel: 01482 845832   HAN
123 Hallgate                                Fax: 01482 841662
Cottingham
HU16 4DA
Dr A C Robertson                            Tel: 01482 645295   HESS
The Hessle Health Centre                    Fax: 01482 649513
11 Hull Rd
Hessle
HU13 9LZ
Dr J Robson                                 Tel: 01482 847250   ROBS
The Chestnuts                               Fax: 01482 848173
45 Thwaite St
Corttingham
HU16 4QX
                       HEDON
Dr C J Lambert                              Tel: 01482 899348   LAMB
Church View Surgery                         Fax: 01482 890715
Market Hill
Hedon
HU12 8JE
                     HORNSEA
Dr P I Collingwood                          Tel: 01964 532212   EAST
Eastgate Medical Group                      Fax: 01964 535007
37 Eastgate
Hornsea
HU18 1LP
                    WITHERNSEA
Dr R D Fouracre                             Tel: 08444 773562   NICH
St Nicholas Surgery                         Fax: 01964 613960
Queen St
Withernsea
HU19 2PZ




                                                                       11
Appendix 1B


               East Riding of Yorkshire Surgeries
               PATIENTS REGISTERED WITH THE
              SURGERIES BELOW CAN SELF-REFER

                        Practice Name & Address     Code

     BEVERLEY Locality
     Dr A J Sykes                                   LEVEN
     Leven and Beeford Medical Practice
     29 High Stile
     Leven
     HU17 5NL
     Hedon
     Dr P English                                    ENG
     Market Hill House
     4 Market Hill
     Hedon
     HU12 8JD
     BRIDLINGTON Locality
     Dr K T Farley                                  MANOR
     Manor House Surgery
     Providence Place
     Bridlington
     YO15 2QW
     Dr P A Harris                                  THREE
     Practice 3
     The Medical Centre
     Station Ave
     Bridlington
     YO16 4LZ
     Dr H R P Meldrum                                ONE
     Practice 1
     The Medical Centre
     Station Ave
     Bridlington
     YO16 4LZ
     Dr H K McNab                                   TWO
     Practice 2
     The Medical Centre
     Station Ave
     Bridlington
     YO16 4LZ
     Driffield
     Dr A D Clarke                                  CRAN
     The Medical Centre
     Cranwell Rd
     Driffield
     Y025 7UH




                                                            12
Dr D F Wigglesworth                      BRIDG
The Bridge Street Practice
21 Bridge St
Driffield
Y025 6DB
GOOLE, HOWDEN and WEST WOLDS Locality
Dr J P Brooke                           BARMBY
The Surgery
7 Barmby Rd
Pocklington
YO42 2DL
Dr J E Clark                            MARSH
The Marshes
Butt Lane
Snaith
DN14 9DY
Dr R A Ferguson                          GILB
The Health Centre
Thornton Dam Lane
Gilberdyke
HU15 2UL
Dr JR Moore                             HOLME
The Surgery
Rush View
Holme-on Spalding Moor
York
YO43 4BJ
Dr J C Keel                             BROUGH
Brough Medical Practice
4 Centurion Way
Brough
HU15 1AY
Dr R W Webster                          MARKET
Market Weighton Surgery
4 Londesborough Rd
Market Weighton
YO43 3AY
HALTEMPRICE Locality
Dr R G Clarke                            SWAN
The Old Pump House
West End
Swanland
HU14 3PE
Dr J S Howard                            HESS
87 Beverley Rd
Hessle
HU13 9AJ
Dr J C Keel                              KEEL
4 Centurion Way
Brough
HU15 1AY
Dr R G Mitchell                          MITCH
15 School Lane
North Ferriby
HU14 3DG




                                                 13
Dr M E A Moody              MOOD
45 Main St
Willerby
Hull
HU10 6BP
Dr J C Wilson               WILL
Cottingham Medical Centre
17-19 South St
Cottingham
HU16 4AJ




                                   14
Appendix 2


   Participating East Riding of Yorkshire Community
                      Pharmacies



             Pharmacy Name & Address           Telephone & Fax     Start date
                                                   Numbers

                BEVERLEY LOCALITY

  Alliance Pharmacy                            Tel: 01482 870357   Dec 07
  119 Walkergate                               Fax:01482 870357
  Beverley
  HU17 9AJ
  Boots the Chemist                            Tel: 01482 881583   May 08
  17 Toll Gavel                                Fax: 01482 867082
  Beverley
  HU17 9AA
  Hengate Pharmacy                             Tel: 01482 868208   Dec 07
  Manor Rd Health Centre                       Fax:01482 868208
  Manor Rd
  Beverley
  HU17 7BZ
  Lloyds Pharmacy                              Tel: 01482 868317   Dec 07
  Samman Rd                                    Fax:01482 868317
  Beverley
  HU17 0BS

  Molescroft Pharmacy                          Tel: 01482 886294   Dec 07
  Pighill Lane                                 Fax:01482 886294
  Off Woodhall Way
  Beverley
  HU17 7JY
  Spinks the Chemist                           Tel: 01482 882562   Dec 07
  Old Fire Station                             Fax: 01482 882562
  Albert Terrace
   Beverley
  HU17 8JU
  Superdrug Pharmacy                           Tel: 01482 881344   Dec 07
  23-25 Toll Gavel                             Fax: 01482 881344
  Beverley
  HU17 9AA
          BRIDLINGTON and Driffield LOCALITY

  Alliance Pharmacy                            Tel: 01262 672706   April 08
  41 Promenade                                 Fax:01262 672706
  Bridlington
  YO15 2FY
  Alliance Pharmacy                            Tel: 01262 672127   April 08
  7 Quay Rd                                    Fax:01262 672127
  Bridlington
  YO15 2AB


                                                                                15
Alliance Pharmacy                        Tel: 01262 606746   June 08
18 Victoria Rd                           Fax: 01262 606746
Bridlington
YO15 2AT
Boots the Chemist                        Tel: 01262 673202   April 08
9-13 Promenade                           Fax: 01262 401265
Bridlington
YO15 2PY
Lloyds Pharmacy                          Tel: 01262 850020   April 08
High St                                  Fax: 01262 850111
Flamborough
YO15 1JX
Lloyds Pharmacy                          Tel: 01262 676847   April 08
1-5 Westgate                             Fax: 01262 604090
Old Town Bridlington
YO16 4QF
Bridlington Late Night Pharmacy          Tel: 01262 400070   April 08
86 The Promenade
Bridlington
YO15 2QL
Superdrug Pharmacy                       Tel: 01262 672229   May 08
22-24 King St                            Fax: 01262 672229
Bridlington
YO15 2DQ
Station Ave Pharmacy                     Tel: 01262 604494   April 08
Station Ave                              Fax:01262 677726
Bridlington
YO16 4LZ
                           Driffield
Boots the Chemist                        Tel: 01377 252067   March 08
55 Middle St South                       Fax: 01377 241407
Driffield
Y025 6PS
Lloyds Pharmacy                          Tel: 01377 257471   March 08
Unit 3 The Viking Centre                 Fax: 01377 257471
Middle St North
Driffield
Y025 6ST
Tesco In-Store Pharmacy                  Tel: 01377 297449   March 08
George St                                Fax: 01377 297449
Driffield
Y025 7RA
 GOOLE, HOWDEN and WEST WOLDS LOCALITY
Boots the Chemist                        Tel: 01405 764118   Sept 07
Units 9 & 10 Wesley Square               Fax: 01405 769915
Goole
DN14 5EZ
N & J Drummond                           Tel: 01405 765673   Sept 07
Alfred’s Place                           Fax: 01405 765673
Swinefleet Rd
Goole
DN14 5RN
Lloyds Pharmacy Ltd                      Tel: 01405 667371   May 08
Unit 6                                   Fax: 01482 667371
Welton Rd
Brough
HU15 1LZ
Lloyds Pharmacy Ltd                      Tel: 01405 763074   Sept 07
110-112 Boothferry Rd                    Fax: 01405 763074
Goole
DN14 6AG




                                                                        16
Lloyds Pharmacy Ltd                  Tel: 01405 764177   Sept 07
Fifth Ave                            Fax: 01405 764177
Goole
DN14 6JD

Alliance Pharmacy                    Tel: 01430 430297   Sept 07
27 Bridgegate                        Fax: 01430 430297
Howden
DN14 7AA
Alliance Pharmacy                    Tel: 01430 441442   May 08
Unit 2                               Fax: 01430 441442
Scalby Lane
Gilberdyke
HU15 2UJ
Alliance Pharmacy                    Tel: 01759 302829   May 08
The Pavement                         Fax: 01759 302829
Pocklington
YO 42 2AX

              HALTEMPRICE LOCALITY
Alliance Pharmacy                    Tel: 01482 653031   Jan 08
28 Hull Rd                           Fax: 01482 653031
Anlaby
HU10 6UA
Alliance                             Tel: 01482 847772   Jan 08
42-44 King St                        Fax: 01482 847772
Cottingham
HU16 5QE
Alliance Pharmacy                    Tel: 01482 847663   Jan 08
156 Hallgate                         Fax: 01482 847663
Cottingham
HU16 4BD
Alliance Pharmacy                    Tel: 01482 649290   Jan 08
19-21                                Fax: 01482 649290
The Square
Hessle
HU13 0AE
Boots the Chemist Ltd                Tel: 01482 648512   April 08
2 The Square                         Fax: 01482 642672
Hessle
HU13 OAA
Lloyds Pharmacy                      Tel: 01482 847112   Jan 08
Unit 1 Kings Parade                  Tel: 01482 847112
Kings St
Cottingham
HU16 5QQ
Hessle Pharmacy                      Tel: 01482 642226   Jan 08
225 Boothferry Rd                    Fax: 01482 642226
Hessle
HU13 9BB
Alliance Pharmacy                    Tel: 01482 631435   Jan 08
44 Church Rd                         Fax: 01482 631435
North Ferriby
HU14 3BU




                                                                    17
Alliance Pharmacy                 Tel: 01482 653118   Jan 08
5-7 Kingston Rd                   Fax: 01482 653118
Willerby
HU10 6AD
Willerby Pharmacy                 Tel: 01482 659058   Jan 08
145 Kingston Rd                   Fax: 01482 650807
Willerby
HU10 6AL
                       Hedon
Alliance Pharmacy                 Tel: 01964 624768   Feb 08
Unit 1                            Fax: 01964 624768
Church Lane
Thorngumbald
HU12 9PD
Alliance Pharmacy                 Tel: 01482 898311   Feb 08
15 Market Place                   Fax: 01482 898311
Hedon
HU12 8JA
East Riding Pharmacy              Tel: 01482 898973   Feb 08
16-20 St Augustines Gate          Fax: 01482 898962
Hedon
HU12 8EX
                      Hornsea
Bowling Pharmacy Ltd              Tel: 01964 532066   Oct 08
85 Newbegin                       Fax: 01964 532066
Hornsea
HU18 1PA
B A Whittle Chemists              Tel: 01964 533242   Oct 08
130 Newbegin                      Fax:01964 537879
Hornsea
HU18 1PB
Lloyds Pharmacy                   Tel: 01964 532967   Oct 08
4 Market Place                    Fax: 01964 536153
Hornsea
HU18 1AW
                     Withernsea
Alliance Pharmacy                 Tel: 01964 612217   Nov 08
94-96 Queen Street                Fax: 01964 612217
Withernsea
HU19 2HB




                                                               18
    Appendix 3

                    Pharmacy Prescription (FPPharm)
Name                                                Surgery
Address                                             Practice Name


DOB                                                 Practice Code

NHS/ID Number

 Symptoms reported


Please tick one box only
  Advice and Counselling only                           Referral to GP                                       Medicine supplied
Medicine and quantity supplied




Pharmacist Name (Block Capitals)                    Pharmacist signature


Pharmacy Stamp                                      Date supplied

                                                    Details of this prescription will be shared with your Doctor and the
                                                    Local Primary Healthcare Trust for audit purposes. All information
                                                    will be treated with the strictest confidence and held in accordance
                                                    with the Data Protection Act.

NOTE                 You will be asked to show proof that you do not have to pay prescription charges. If you do not have proof, you
                     will still get your free medicine supply but checks will be made later to confirm your eligibility

Part 1               The patient doesn’t have to pay because he/she:
A                    Is under 16 years of age
B                    Is 16,17 or 18 and in full-time education
C                    Is 60 years of age or over
D                    Has a valid maternity exemption certificate
E                    Has a valid medical exemption certificate
F                    Has a valid prescription prepayment certificate
G                    Has a valid War Pension exemption certificate
L                    Is named on a current HC2 charges certificate
H                    Gets Income Support
K                    Gets Income-based Jobseeker’s Allowance
M                    is entitled to, or named on a valid NHS Tax Credit Exemption Certificate
N                    Has a partner who gets pension credit guarantee credit (PCGC).
Declaration          I declare that the information I have given on this form is correct and complete and I understand that
                     if it is not, appropriate action may be taken against me. I confirm proper entitlement to exemption
                     and for the purposes of checking this, I consent to the disclosure of relevant information, including to
                     and by the Inland Revenue and Local Authorities.

Patient Signature    Patients signature to confirm exemption and receipt of medication




                                                                                                                              19
Appendix 4


                 Community Pharmacy Care Scheme
                          Referral Form

                       (Please indicate urgent or non urgent referrals)

             Urgent Referral


             Non Urgent Referral




   Patient’s [Full] Name
   & Address:


   Patient’s GP:

   Date of Referral:

   Reason for Referral:




   Relevant History and
   Interventions:




   Pharmacy Name &
   Address:


   Pharmacist Name:
   Signature:




                                                                          20
Appendix 5


                         Gillick Competence


For clients who are believed to be under 16 years of age. Discussion with the
young person should explore the following issues at each consultation. This
should be fully documented and should include an assessment of the young
person’s maturity.


     Assessment of Gillick Competence            YES            NO


     Understanding of advice given.


     Encouraged to involve parents


     The effect on the physical or mental
     healthof young person if advice/
     treatment withheld


     Action in the best interest of the young
     person



Pharmacist’s signature………………………………              Date……………….

Clients signature …………………………………….               Date………………..


Comments by the pharmacist:

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………
………………………………………………………………………………………


                                                                          21
Appendix 6


                          Receptionists Protocol


This protocol is for use by all persons dealing with requests for appointments and/or
prescriptions either by the patient in person or by telephone.
For patients making an appointment by telephone or in person
1. If the patient contacts the GP practice by telephone then ask them if they are
   suffering from one of the conditions included in the pharmacy care scheme.
2. If the patient is presenting in person show them the list of conditions included in the
   pharmacy care scheme.
3. Inform them that there is a pharmacy care scheme in operation for patients who are
   exempt from prescription charges. Patients can be referred to a local pharmacy for
   advice and a medicine rather than waiting for an appointment.
4. If the patient is present and accepts transfer into the scheme, please give the patient
   a Pharmacy Care Service information leaflet, provide them with details of their NHS
   number if they do not already know it and provide details of all local participating
   pharmacies. All patients who go to the pharmacy should provide some form of
   identification e.g NHS number and exemption card.
5. If a patient refuses transfer into the scheme an appointment should be made for
   them with the Doctor in the usual manner.


For patients self-referring at the Pharmacy
The pharmacist is required to confirm a patient’s identification by their NHS number and
exemption card and is required to check with the patients that they are registered at a
participating ERYPCT GP Practice. If the pharmacist does not know the patient or have
a previous prescription record for them then the pharmacist should allocate each new
patient with an individual patient I.D. This should be either their NHS Number or a
number generated using initials and DOB.


Rapid Referral
On some occasions the Pharmacist may consider that the patient needs to be seen by a
doctor. The urgency will depend on the symptoms. In these circumstances the
Pharmacist will send a fax and ring to make an appointment on the patient’s behalf or
advise the patient to make an appointment. Sometimes if the surgery is closed the
Pharmacist will have to signpost the patient to the Out of Hours Service on 0845 056
8060.




                                                                                         22
Appendix 7


   Do you think you maybe suffering from one of the
                 following conditions?
    •   Acne                •   Dry/Infected Eyes           •       Nasal Congestion
    •   Allergic/contact    •   Eczema, Dry or Itchy Skin   •       Nappy Rash
        dermatitis


    •   Athletes Foot       •   Ear Wax                     •       Oral Thrush


    •   Cold Sores          •   Haemorrhoids                •       Pain, including
                                                                    dental, period,
                                                                    back, head, ear
                                                                    and soft tissue.
    •   Cough/Cold/Flu/     •   Hay Fever                   •       Sore Throat
        High temperature


    •   Constipation        •   Head lice                   •       Teething


    •   Cystitis in adult   •   Indigestion/Heart           •       Threadworms
        females                 Burn/Tummy upset/
                                Vomiting
    •   Dandruff            •   Insect bites and stings
                                                                •    Vaginal Thrush


    •   Diarrhoea           •   Mouth Ulcers                •       Warts / Verrucae




 If you are requesting an appointment or prescription for any of the
conditions listed above the reception staff will be able to refer you to
                   a local pharmacy for free advice.

     If you don’t pay for prescriptions you will not have to pay for
  treatment under the scheme if you bring proof of your exemption.

   Remember advice is always free. Ask at you GP Practice or local
                       Pharmacy for details.




                                                                                       23
Appendix 8


 Medicine Formulary, Codes and Conditions Guidance
Patients with symptoms of the following conditions may be referred in to this scheme.
Pharmacists should provide advice and treatment appropriate to the presenting condition.
Products should be supplied for licensed indications according to the Summary of Product
Characteristics (SPC).

When a patient who is under 16 years presents for treatment, the pharmacist must be satisfied
the child understands the nature of the condition and the correct use of the medication before a
product is supplied.

Pharmacists should supply original packs except in exceptional circumstances where this may
not be possible. The medication must not be a POM (unless it is a POM supplied under a PGD)
and the labelling of such products must comply with EC labelling requirements. This includes
(amongst other things) the BN, PL and expiry date. For full details of labelling requirements
please refer to the Medicines Ethics and Practice section on labelling of relevant medicinal
products.

The following pages provide guidance for the treatment of conditions include in the minor
ailments scheme. However it is recognised that pharmacists will use their clinical judgement
when deciding on the best treatment for individual patients.




                                                                                             24
                                              ACNE
Definition/Criteria
Acne is a skin condition that affects the hair follicles and the sebaceous glands in the skin, which
secrete an oily substance called sebum. It most commonly occurs in adolescents and young
adults, but can occur for the first time later in life.

Criteria for INCLUSION
Patient presenting with mild acne – a history of troublesome spots, most commonly affecting the
face, shoulders, back and/or chest.

Criteria for conditional EXCLUSION
Hyperandrogenism – clinical features such as irregular periods, alopecia, hirsutism
Patients with a previous history of contact dermatitis caused by benzoyl peroxide.

Action for excluded patients
Referral to General Practitioner

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Benzoyl Peroxide 2.5% aquagel topical         P       apply sparingly once daily at first; increase to
                                                      twice daily when you get used to using it.
Benzoyl Peroxide 5% aquagel topical           P       apply sparingly once daily at first; increase to
                                                      twice daily when you get used to using it.
Benzoyl Peroxide 10% aquagel topical P                apply sparingly once daily at first; increase to
                                                      twice daily when you get used to using it.
Follow-up & advice
• Wash the skin 20-30 minutes before using.
• May bleach hair, bed-linen or clothes that come into contact with it.
• Use the lowest strength first. If you wish to increase the strength do it gradually.
• Apply aquagel to the affected area, not just to each spot.
• Most common reason for treatment failure is because people don’t use it regularly for long
   enough. It can take up to 6 weeks for any noticeable improvement in skin.
• It is not caused by poor hygiene – excessive washing can aggravate it.
• Do not wash more than twice a day and use a mild soap and lukewarm water.
• Picking spots does not improve it and can cause scarring.
• Diet has no effect on acne – no evidence that chocolate or fatty food aggravates it.

Side effects and their management
• Commonly causes mild skin irritation. If skin becomes irritated stop using it until irritation goes.
   Then try again either reducing the strength of preparation or reduce the time it is left on.

Conditional referral to GP:
• Moderate or severe acne.
• If Benzoyl Peroxide has been used correctly for >8 weeks without improvement.

References
http://cks.library.nhs.uk/acne_vulgaris/view_whole_guidance (2006)




                                                                                                 25
                                    ATHLETE’S FOOT
Definition/Criteria
A fungal infection of the foot which tends to occur between the toes.

Criteria for INCLUSION
Patient presenting with itching, flaking and peeling of the skin between the toes. The skin may be
soggy, cracked, red and inflamed or present as small blisters between the toes.

Criteria for conditional EXCLUSION
    • Circulatory disorders.
    • Diabetes mellitus.
    • Severe and/or extensive infection.
    • Evidence of bacterial infection requiring treatment.
    • Immunocompromised patients.

Action for excluded patients & non-complying patients
Referral to General Practitioner

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Clotrimazole Cream 1% (20g)          top    P      apply 2-3 times daily and continue for 7 days
                                                   after all signs of infection have cleared.
Terbinafine Cream 7.5g               top    P      (for 12 yrs and over) apply thinly twice daily for
                                                   1 week.
Follow-up & advice
• Athlete’s foot is highly contagious and can be easily contracted whilst walking barefoot around
   swimming pools and in changing rooms.

To prevent re-infection:
• Dry feet carefully after washing, especially between the toes.
• Use a separate foot towel. Do not share towels. Wash towels frequently.
• Cotton socks and leather shoes are preferable as they allow the feet to breathe.
• Socks should be changed daily and washed before use.
• Flip-flops can be worn near swimming pools and in communal changing rooms.

N.B. Terbinafine cannot be used in pregnant and breastfeeding patients

Conditional referral:
•  Uncertain diagnosis.
•  Treatment used correctly but condition not cleared up.

References
http://www.cks.library.nhs.uk/fungal_skin_infections/view_whole_guidance (2006)




                                                                                                26
                 COLD SORES AND GINGIVOSTOMATITIS
Definition/Criteria
Infection with herpes simplex virus (HSV) causing pain and blistering on or around the lips (cold
sores) or within the mouth (gingivostomatitis). After primary infection, the virus lies dormant until
triggered by a stimulus such as the common cold, sunlight or impaired immunity.

Criteria for INCLUSION
Patients who present with pain or tingling on or around the lips with a previous history of HSV.

Topical aciclovir offers very limited benefits and should only be supplied to patients who respond
to this treatment. Treatment should only be supplied when the patient is experiencing prodromal
symptoms. It should not be supplied to treat lesions inside the mouth.

Criteria for EXCLUSION
    • Immunocompromised individuals.
    • Children under 8 years of age.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Chlorhexidine 0.2%      top  GSL Rinse mouth with 10ml for about 1 minute twice a day
Mouthwash 300ml
Aciclovir 5% Cream (2g)  top   P   Apply to the effected area.

Follow-up & advice
Gingivostomatitis
• Good oral hygiene important to avoid the risk of secondary infection.
• Limit the use of sharp foods (e.g. crisps), spicy foods, hot fluids and carbonated drinks.
• Rinse mouth with salt water solution.
Cold Sores
•   If triggered by sun exposure use a sunscreen on the lips with an SPF of 15 or more.

Side effects and their management
• Aciclovir: Transient stinging or burning; occasional erythema, itching or drying of the skin.
• Chlorhexidine: mucosal irritation; reversible brown staining of teeth.

When & how to refer to GP

Rapid referral
• Immunocompromised individuals: seek specialist advice promptly when treating these patients.

References
CKS: http://www.cks.library.nhs.uk/herpes_simplex_oral/view_whole_guidance (2007)




                                                                                                  27
                  CONJUNCTIVITIS (ACUTE BACTERIAL)
Definition/Criteria
Acute inflammation of the conjunctiva of the eye.

Criteria for INCLUSION
Conjunctivitis, where a bacterial infection is suspected.

Criteria for EXCLUSION
Children under 2
Contact lens wearers (without approval of an optometrist)
Users of other eye drops regularly prescribed
Atypical symptoms of conjunctivitis
Suspected foreign body in the eye
Eye injury
Photophobia
Where vision has been affected
Severe pain within the eye
Unusual looking pupils or cloudy cornea
Feels generally unwell
Glaucoma
Eye surgery/laser treatment in last 6 months
Pregnancy and breastfeeding
Recent trip abroad

Action for excluded patients & non-complying patients
Referral to General Practitioner
Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Chloramphenicol 0.5% Eye Drops    eye         P One drop to the affected eye every 2
                                                   hours for the first 48 hours then four
                                                   hourly for 72 hours
Chloramphenicol 1% Eye ointment eye           P Apply four times a day for the first 48
                                                   hours then twice a day for 72 hours

Follow-up & advice
   • See GP if no improvement or condition worsens over 48 hours.
   • Correct administration of eye drops.
   • Avoid sharing towels and facecloths.

Side effects and their management
Transient burning or stinging sensation. Hypersensitivity reactions possible though very rare.
When & how to refer to GP
Immediate referral:
If symptoms become worse or patient presents with any of the criteria for exclusion.


References
RPSGB Practice Guidance (June 2005) OTC Chloramphenicol Eye Drops.
CKS: http://www.cks.library.nhs.uk/conjunctivitis_infective/view_whole_guidance (2007)




                                                                                                 28
                                      CONSTIPATION
Definition/Criteria
Increased difficulty and reduced frequency of bowel evacuation compared to normal.

Criteria for INCLUSION
Adults with significant variation from normal bowel evacuation, which has not improved following
adjustments to diet and other lifestyle activities (see below).


Criteria for EXCLUSION
Patients currently receiving laxatives as part of their regular medication.
N.B. it is not recommended that laxatives are given for children in the scheme.

Action for excluded patients & non-complying patients
Referral to General Practitioner.
Referral to Health Visitor for Children and Babies.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Ispaghula Sachets (10)         po     GSL 1 morning and evening mixed in a glass of water
Lactulose Solution (300ml)     po     GSL Take three 5ml spoonfuls twice a day
Senna tabs (20)                po     GSL 2 at night initially. Consider increasing if no response
Glycerin Suppositories 4g (12) rectal GSL Insert 1 into the rectum when required
Senna Syrup 150ml              po     GSL 10 – 20ml at bedtime

Follow-up & advice
• Start treatment if appropriate with a bulk forming laxative
• If stools remain hard add or switch to an osmotic laxative
• If stools are soft but patient finds them difficult to pass use a stimulant laxative
• Laxatives should be stopped once the stools become soft and easily passed again.
• Regular doses of laxatives are rarely required and can cause a “lazy” bowel.
• Consider alteration to diet to prevent the occurrence of further events eg. increased fibre and
   fluid intake and increased physical activity if appropriate.
• Rectal laxatives should be used if an oral preparation hasn’t worked.
• Senna should not be used in pregnancy.

Side effects and their management
If dosage is too large, griping and diarrhoea may result.
Senna may colour the urine yellow or red.

When & how to refer to GP
Conditional referral:
• If constipation persists beyond one week, consult the GP.
• If more than one request per month.
Consider supply, but patient should be advised to make an appointment to see the GP:
   • Patients taking medication with recognised constipating effects.
Rapid referral
• Sickness associated with constipation.
• Constipation and diarrhoea.
• Severe abdominal pain.

References
CKS: http://www.cks.library.nhs.uk/constipation/view_whole_guidance (2008)




                                                                                              29
        CONTACT DERMATITIS / URTICARIA / PRURITUS / ECZEMA

Definition/Criteria
• Itchy, red, dry, cracked or flaking, scaly skin precipitated by products such as nickel, cheap
    jewellery, chemical containing products.
• Itchy sensation of skin evoked by physical or chemical stimuli.
• Inflammation of the skin.
Criteria for INCLUSION
Evidence of contact dermatitis (commonly on the hands) following exposure to irritant.
Troublesome itching and / or urticaria with no specific underlying abnormality that requires short-
term symptomatic treatment.
Superficial inflammation of the skin, causing itching, with a red rash often accompanied by small
blisters that weep and become crusted.
Criteria for EXCLUSION
Signs and / or symptoms of infection or infected rash.
Action for excluded patients & non-complying patients: Referral to General Practitioner.
Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Oilatum emollient 250ml
Balneum Bath Additive 200ml
Hydrocortisone 1% cream 15g            top    P       Age 10 years and over, apply once daily
                                                      sparingly for max 7 days
Aqueous cream 500g                     top    GSL apply liberally when required
Crotamiton cream 10% 30g               top    P       Apply 2-3 times daily (under 3 yrs apply daily)
Crotamiton lotion 10%100ml             top    P       Apply 2-3 times daily (under 3 yrs apply daily)
Chlorphenamine tabs 4mg (30)           po     P       1 tds prn
Chlorphenamine 2mg/5ml (150ml) po             P       according to age of patient
Loratidine tabs 10mg (7)               po     P       1 od
Follow-up & advice
    • Avoid scratching.
    • Avoid further contact with the irritant or potential stimuli.
    • Use of a barrier between the skin and the irritant e.g. cotton lined rubber gloves when in
        contact with chemicals.
    • Use of an emollient and/or soap substitute products.
Side effects and their management
Chlorphenamine can cause drowsiness.
When & how to refer to GP
    • Conditional referral: If the area is not healing or symptoms have not resolved after 5-7
        days using an appropriate product.
Consider supply, but patient should be advised to make an appointment to see the GP:
        • No identifiable cause; Duration of longer than 2 weeks; Pregnancy; Epilepsy.
Rapid referral - Evidence of infection or angio-oedema: Severe condition of the area: badly
fissured / cracked skin and/or bleeding : Weight loss: History of liver / kidney disease.
Special considerations - Glaucoma, patients on anti-arrhythmic drugs.
References
http://www.cks.library.nhs.uk/dermatitis_contact/view_whole_guidance (2005)
http://www.cks.library.nhs.uk/urticaria/view_whole_guidance (2007)
http://www.cks.library.nhs.uk/eczema_atopic/view_whole_guidance (2004)




                                                                                                 30
                                               COUGH

Definition/Criteria
Coughing arises as a defensive reflex mechanism.

Criteria for INCLUSION
Troublesome cough requiring soothing.

Criteria for EXCLUSION
Patients under one year
Chronic Bronchitis
Cough productive of blood stained sputum
Asthmatics presenting with wheeze or reduced peak-flow

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Simple Linctus S.F. (200ml)           po   GSL          5-10ml qds
Simple Linctus Paediatric S.F (200ml) po   GSL          5-10ml qds


Follow-up & advice
• There is no good evidence for or against the effectiveness of cough preparations.
• Maintain fluid intake with chesty cough.
• Smoking cessation advice where appropriate.

When & how to refer to GP
Conditional referral:
• If cough and other symptoms persist beyond two weeks the patient should consult the GP.

Consider supply, but patient should be advised to make an appointment to see the GP:
• A persistent, dry, night time cough in children.

Rapid referral:
• Constant chest pain or chest pain on normal inspiration.
• Difficulty breathing.
• Pain related to exertion.

References
http://www.cks.library.nhs.uk/patient_information_leaflet/cough
http://www.cks.library.nhs.uk/patient_information_leaflet/respiratory_tract_infection
http:/www3.interscience.wiley.com/homepages/106568753/CD001831.pdf




                                                                                        31
             CYSTITIS (MILD URINE INFECTION IN WOMEN)
Definition/Criteria
 Inflammation of the bladder often caused by infection and usually accompanied by the desire to
pass urine frequently and with a degree of burning.

Criteria for INCLUSION
Adult females presenting with burning sensation and a desire to pass urine frequently or a
previous diagnosis of cystitis who are confident it is a recurrence of the same condition.

Criteria for EXCLUSION
Pregnancy or breast feeding.
Women under 16 and over 50 years.
Urinary tract infection in people with indwelling urinary catheters.
High blood pressure, heart disease, some medications.
Recurrent cystitis despite prophylactic treatment.
Males.
Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Potassium citrate     po      P      10ml 3 times daily well diluted with water for 2 days
solution 200ml
Follow-up & advice
• Increase fluid intake but the increased urine flow may be uncomfortable.
• Pass water regularly and do not “hang on” if needing to go to the toilet.
• When cleaning, wipe from front to back to avoid transferring germs.
• Paracetamol or ibuprofen may help with the pain or discomfort.
• Consider chlamydia screening in sexually active women.

Side effects and their management
Hyperkalaemia on prolonged high dosage, mild diuresis.
When & how to refer to GP
Conditional referral:
• If symptoms do not resolve after 2 days.
• If cystitis becomes a recurring problem consult a doctor.
Consider supply, but patient should be advised to make an appointment to see the GP:
• Concurrent constipation.
Rapid referral
• Suspected diabetes.
• Presence of blood in the urine.
• Cramp like pain in lower abdomen / loin pain persisting after the bladder has been emptied.
• Immunocompromised patients.

References
http://www.cks.library.nhs.uk/uti_lower_women/view_whole_guidance (2006)




                                                                                             32
                                         DANDRUFF
Definition/Criteria
Greyish white flakes or scales on the scalp.

Criteria for INCLUSION
Troublesome severe dandruff with/without itching scalp that requires treatment.

Criteria for EXCLUSION
Pregnant women.
Patients showing hypersensitivity to any of the ingredients.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Ketoconazole 2% shampoo (60ml) top  GSL apply twice/week for 2-4 weeks, then use
                                           minimum of every 2 weeks

Follow up & advice
• Apply to damp hair, massage well into scalp and leave for 5 mins before rinsing.
• It is the scalp that needs treatment rather than the hair.
• Need to continue treatment on a less frequent basis to prevent recurrence.
• Continue normal shampoo between applications / before application of treatment.
• Hair dyes and perms can irritate the scalp.

Side effects and their management
Allergic reactions – stop use of product and consult GP.

When & how to refer to GP
Conditional referral:
• Patient should consult GP if symptoms have not resolved within 4 weeks.

Consider supply, but the patient should be advised to make an appointment to see the GP:
• Suspected psoriasis.

Rapid referral:
• Broken and/or weeping scalp.

Special considerations / Concurrent medication
Use of other scalp or skin products.

References
http://www.cks.library.nhs.uk/seborrhoeic_dermatitis/view_whole_guidance (2004)




                                                                                     33
                                          DIARRHOEA
Definition/Criteria
Increased frequency and fluidity of defecation.

Criteria for INCLUSION
Patients experiencing the above symptoms.

Criteria for EXCLUSION
Patients with chronic diarrhoea.
Children under the age of 1 year.
Patients recently returned from abroad.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Loperamide caps (10)   po    P      2 stat then 1 after every loose motion
Dioralyte sachets (6)  po     GSL follow instructions on packet

Follow up & advice
• Standard dietary advice for the treatment of diarrhoea should be given
      o Resume normal feeding as soon as possible (fasting is of no benefit)
      o Increase fluid intake
• Rehydration sachets help if there are signs of dehydration present.
• Loperamide is only useful if patients need to reduce the number of trips to the toilet.

Side effects and their management
Loperamide can cause abdominal pain and bloating.


When & how to refer to GP

Conditional referral:
• If symptoms persist beyond 48 hours, consult the GP.

Consider supply, but patient should be advised to make an appointment to see the GP:
• Patients taking medication with recognised diarrhoeal effect.
• Patients with insulin dependent diabetes mellitus.

Rapid referral:
• Adults, where symptoms have lasted more than 5 days.
•
  Children who look ill or dehydrated or where symptoms have lasted more than 48 hours.
• Pregnancy.

References
http://www.cks.library.nhs.uk/gastroenteritis/view_whole_guidance (2007)




                                                                                            34
                                        DRY EYES
Definition/Criteria
Chronic soreness of the eyes associated with reduced or abnormal tear secretion.

Criteria for INCLUSION
Tear deficiency.

Criteria for EXCLUSION
Unknown cause of dry eyes in younger people.
Associated disease e.g. Sjogren’s syndrome.
Children under 10 years.
Diabetes mellitus.
History of trauma to eyes.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Hypromellose 0.3% 10ml eye    P     instil as required

Follow-up & advice
• Drops should be used regularly to keep symptoms away.
• Advice on wearing contact lenses.
• Counselling on medication causing dry eyes.
• Avoidance of trigger factors e.g. windy conditions, tobacco smoke, air-conditioning, low
   humidity.

When & how to refer to GP

Conditional referral:
• If symptoms do not respond to hypromellose.

Consider supply, but patient should be advised to make an appointment to see the GP:
• Impaired or deteriorating vision.
• Ulcers appear on the cornea.
• Related to medication.


References
http://www.cks.library.nhs.uk/dry_eye_syndrome/view_whole_guidance (2008)




                                                                                             35
                                 EAR WAX (CERUMEN)
Definition/Criteria
 The waxy material that is secreted by the sebaceous glands in the external auditory meatus of the
outer ear.

Criteria for INCLUSION
Presence of earwax which is causing discomfort, hearing loss, or if a proper view of the eardrum is
needed.

Criteria for EXCLUSION
Recent ear surgery.
Perforated eardrum or history of perforation.
Use of a hearing aid.
History of chronic middle ear disease, recurrent otitis externa or tinnitus.
Unilateral deafness.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Sodium bicarbonate             ear   P       Put 3-4 drops into the affected ear(s) four times a day
5% ear drops 10ml                            for 3 - 5 days.
Follow-up & advice
• The patient should lie with the affected ear uppermost for 5 to 10 minutes following the
   instillation of a generous amount of the softening agent.
• Earwax is normal but may build up. Do not poke or clean the ears with cotton buds or similar
   objects.
• A week or so of drops, twice a day, often causes wax to break up and come out of the ear by
   itself.

Side effects and their management
Irritation to the ear canal.

When & how to refer to GP

Conditional referral:
• There is no improvement after 7 days.

Consider supply, but patient should be advised to make an appointment to see the GP:

References
http://www.cks.library.nhs.uk/earwax/view_whole_guidance (2007)




                                                                                               36
                             HAEMORRHOIDS (PILES)
Definition/Criteria
Swollen veins which protrude into the anal canal (may swell and hang down outside the anus).

Criteria for INCLUSION
Presence of haemorrhoids requiring soothing relief of itching, burning, pain, swelling and/or
discomfort in the perianal area and anal canal.

Criteria for EXCLUSION
Pregnant women.
Children under the age of 18 years.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Anusol Plus HC Ointment (15g)         top     P     apply bd & after bowel movement for up to 7
                                                    days
Anusol Plus HC Suppositories (12) pr          P     insert 1 bd & after bowel movement for up to 7
                                                    days
Anusol Ointment (25g)                 top     P     apply bd & after bowel movements for up to 7
                                                     days
Anusol Suppositories (12)            pr     P      insert 1 bd & after bowel movements for up to
                                                     7 days
Follow up & advice
• Correct insertion / application of product.
• Cleansing of anal area with soap and warm water will give relief from pruritus ani.
• Advise high fibre diet or adopt regular bulk forming laxative.
• Maintain fluid intake.

Side effects and their management
Allergic reactions – stop use of product and consult GP.

When & how to refer to GP
Conditional referral:
• Patient should consult GP if symptoms have not resolved within 7 days.
Consider supply, but the patient should be advised to make an appointment to see the GP:
• Haemorrhoids of more than 3 weeks duration.
• Suspect drug induced constipation.
• Small amount of fresh blood in stool.
Rapid referral:
• Associated abdominal pain / vomiting.
• Marked change in bowel habit.
• Weight loss.

References
http://www.cks.library.nhs.uk/haemorrhoids/view_whole_guidance (2005)




                                                                                                37
                                        HAY FEVER
Definition/Criteria
Seasonal allergy to pollen.

Criteria for INCLUSION
Patients with symptoms of hay fever requiring treatment.

Criteria for EXCLUSION
Patients under the age of 6.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Chlorphenamine tabs 4mg (30)               po     p     1 tds
Chlorphenamine syrup (150ml)               po     P      5ml (2mg) 4-6 hourly
Loratadine tabs 10mg (7 or 30)             po     P     1 od
Loratidine syrup (100ml)                   po     P     10ml daily (over 6 years)
Cetirizine 10mg tabs (7 or 30)             po     P     1 od (over 6 years)
Sodium Cromoglycate eye drops 2% (10ml)    eye    P     1 drop qds
Beclomethasone nasal spray (100 sprays)    nasal P      2 sprays each nostril bd
Otrivine Antisitin Eye Drops (10ml)         eye P      1 drop each eye 2-3 times a day

Follow-up & advice
• Pollen avoidance measures.
• Not to exceed maximum doses.

Side effects and their management
Chlorphenamine causes sedation.

When & how to refer to GP

Conditional referral:
• Patient should consult the GP if treatment is ineffective or persists after the end of September.

Consider supply, but patient should be advised to make an appointment to see the GP:
• Pregnancy.

Special considerations/Concurrent medication
Glaucoma.
Patients on anti-arrhythmic drugs.

References
http://www.cks.library.nhs.uk/allergic_rhinitis/view_whole_guidance (2008)
http://www.cks.library.nhs.uk/conjunctivitis_allergic (2007)




                                                                                              38
                                          HEAD LICE
Definition/Criteria
Infestation with head lice.

Criteria for INCLUSION
Patients who are proven to be infested with live head lice. Confirmed evidence of live lice is a
requirement prior to treatment.

Criteria for EXCLUSION
Family / siblings of patient, who are not proven to be infested.
Children under the age of six months.
No evidence of live lice found on head.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Detector comb
Bug Buster Kit
Hedrin Lotion (50ml x 2)                           topically   P
Malathion alcoholic liquid (50ml / treatment) x 2 topically    P
Malathion aqueous liquid (50ml / treatment) x 2   topically    P

NB: Insecticides should not be considered for first line treatment of head lice.

Follow up and advice
• Patients may be issued with a lice detector comb.
• Advise to wet comb thoroughly for at least 30 minutes every 4 days for two weeks.
• Advice for close contacts.
• Treatment to be repeated in seven days.
• Alcoholic preparations should not be used in severe eczema, asthmatic patients and small
   children. The same chemical should not be used for the next re-infestation (i.e. alternate
   treatments).
• Avoid smoking and naked flames with alcoholic preparations.
• Hair should be allowed to dry naturally – avoid flames. Do not use hair dryers.
• Not suitable for prophylaxis.
• Patients should be encouraged to regularly comb with a detector comb.
• Failure of treatment is indicated by the presence of live lice one week after the second
   application.
Side effects and their management
Side effects are experienced rarely.

References
http://www.cks.library.nhs.uk/head_lice/view_whole_guidance (2007)




                                                                                                   39
             INDIGESTION / HEARTBURN / TUMMY UPSET
Definition/Criteria
A collection of symptoms (including stomach discomfort, chest pain, a feeling of fullness,
flatulence, nausea and vomiting) which usually occur shortly after eating or drinking.

Criteria for INCLUSION
Patients who require relief from some of the above symptoms.
Previous diagnosis of minor GI problem.
A new GI problem that has lasted less than 10 days.

Criteria for EXCLUSION
Patients over the age of 40 experiencing first episode with persistent symptoms
Child under 12 years.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Gaviscon Advance Liquid (250ml)           po      GSL 10-20ml qds / 1-2 qds
Domperidone tabs 10mg (10)                po      P      1 qds
Ranitidine tabs 75mg (12)                 po      P      1 bd
Co-magaldrox SF Suspension 500mls         po      GSL 10 – 20ml qds
Follow-up & advice
• Symptoms can be aggravated by stress and anxiety.
• Advise patients to stop smoking, moderate alcohol intake and lose weight, where appropriate.
• Eat small meals slowly and regularly and avoid foods which aggravate the problem.

Side effects and their management


When & how to refer to GP

Conditional referral:
•       If symptoms persist beyond one week the patient should consult the GP.
•       If symptoms not relieved by medication – especially patients with history of IHD
Consider supply, but patient should be advised to make an appointment to see the GP:
•       Patients taking NSAIDs.
•       History of recent / recurrent peptic ulcer disease.
•       Second request within a month.
Rapid referral:
•       Bleeding P.R (excluding haemorrhoids) i.e. dark blood.
•       Unexplained recent weight loss.
•       Vomiting.
Special consideration
The sodium content of some antacids may be important when a restricted salt diet is required in
some people with renal or cardiovascular disease.
References
http://www.cks.library.nhs.uk/dyspepsia_symptoms/view_whole_guidance (2005)




                                                                                             40
                             INSECT BITES AND STINGS
Definition/Criteria
Itching, inflammation or irritation around the site of a bite requiring symptomatic treatment.

Criteria for INCLUSION
Evidence of itching, inflammation or irritation.

Criteria for EXCLUSION
Child under 1 year.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Crotamiton 10% cream (30g)           top    GSL Apply to the affected area 2 to 3 times a day
Hydrocortisone 1% cream 15g         top     P       Age 10 years and over, apply sparingly 1-2
                                                    times daily for max 7 days
Chlorphenamine tabs 4mg (30)        po      P       1 tds prn
Chlorphenamine syrup (150ml)        po      P       according to age of patient
Plus other non-sedating antihistamines
Follow-up & advice
• Apply a cold compress.
• Use of insect repellent products for future potential exposure.
• If any of the following symptoms occur seek medical advice: swollen lips and eyelids, difficulty
   breathing, becoming pale and faint, increased generalised itchiness, aches/pains and feeling
   unwell.
• Treatment of some stings may require the use of a pain reliever.

Side effects and their management
Chlorphenamine causes drowsiness.

When & how to refer to GP

Conditional referral:
  • Medical attention should be sought if the bite becomes larger in size and redness spreads.

Consider supply, but patient should be advised to make an appointment to see the GP:
  • If have known allergy to bites and stings seek medical attention.

Rapid referral
   • If the patient experiences shortness of breath or fever or symptoms of shock.
   • If stung in the mouth, suck an ice cube, or sip cold water and seek medical attention.
   • If any of the following symptoms are felt the patient may be having a severe allergic
       reaction and an ambulance should be called: swollen lips and eyelids, difficulty breathing,
       becoming pale and faint, increased generalised itchiness, aches/pains and feeling unwell.

References
http://www.cks.library.nhs.uk/insect_bites_and_stings/view_whole_guidance (2007)




                                                                                                 41
                                     MOUTH ULCERS
Definition/Criteria
Ulceration of the oral mucosa occurring in any area of the mouth.

Criteria for INCLUSION
Mouth ulcers requiring symptomatic treatment to alleviate pain and discomfort.

Criteria for EXCLUSION
Evidence of systemic symptoms.
Patients taking immunosuppressant drugs or who are known to be immunosuppressed.
Ulcer present for more than 3 weeks.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Adcortyl in orabase (5g)     oral   P      apply thin layer to ulcer 2-4 times daily,
                                            do not rub in

Chlorhexidine 0.2% (300ml) M/wash            GSL    rinse mouth with 10mls for about 1 minute
                                                    twice daily

Choline Salicylate gel (15g)         oral     P     apply to the ulcer no more than every 3 hours

Hydrocortisone 2.5mg pellets (20)    oral     P     suck 1 four times a day

*Chlorhexidine should only be supplied for gingivostomatitis when tooth brushing is
painful.

Follow-up & advice
• Good oral hygiene to avoid the risk of secondary infection.
• Suggest the patient limits the use of sharp foods (e.g. crisps), spicy foods, hot fluids and
   carbonated drinks.
• Rinsing mouth with salt water solution.
When & how to refer to GP

Conditional referral:
• Symptoms persist or ulcer(s) return.

Consider supply, but patient should be advised to make an appointment to see the GP:

Rapid referral
• If ulcer persists for more than 3 weeks the patient should be referred to their doctor or dentist
   for further investigation.
• Non painful lesions including any lump, thickening or red or white patches.
• Any sore that bleeds easily.

References
http://www.cks.library.nhs.uk/aphthous_ulcer/view_whole_guidance (2007)




                                                                                                 42
                                       NAPPY RASH
Definition/Criteria
 A painful raw area of skin around the anus and buttocks due to contact with frequent irritant
stools, or reddening over the genitals and napkin area due to urine soaked napkins.

Criteria for INCLUSION
Painful raw area of skin around the anus and buttocks.
Reddening over the genitals.
Red raised areas of skin in the napkin region due to candidiasis.

Criteria for EXCLUSION
Ulceration of affected area.
Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Conotrane® cream 100g     top     P      apply a small amount over the sore area and repeat at
                                         nappy change
Clotrimazole 1% cream 20g top     P      apply 2-3 times daily rubbing gently
Follow-up & advice
• Nappies should be changed frequently and tightly fitting water-proof pants avoided.
• The rash may clear when left exposed to the air.
• Avoid using baby wipes.

Side effects and their management
Local irritation.
Sensitivity to imidazoles or Conotrane® cream.

When & how to refer to GP

Conditional referral:
• If no improvement in 48 hours or the rash worsens.

Consider supply, but patient should be advised to make an appointment to see the GP:

Rapid referral

References
http://www.cks.library.nhs.uk/nappy_rash/view_whole_guidance (2007)




                                                                                                 43
                                NASAL CONGESTION
Definition/Criteria
Blocked nose associated with colds and upper respiratory tract infections.

Criteria for INCLUSION
Congestion where seasonal allergy has been excluded.

Criteria for EXCLUSION
Recurrent nose bleeds.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Pseudoephedrine tabs 60mg (12)    po       P      1 tds-qds (over 12 years)
Normal Saline Nasal Drops (10ml)  nasal    GSL bd
Ephedrine Nasal Drops 0.5% (10ml) nasal           1 – 2 drops, 3 – 4 times a day

N.B. Pseudoephedrine tablets must only be provided to patients who have supplied their NHS
number.
Follow-up & advice
• Correct administration of nasal drops

Side effects and their management
Sympathomimetics may keep the patient awake if taken at night.

When & how to refer to GP

Conditional referral:
If symptoms become worse and / or sinus pain develops refer to GP.


References
http://www.rpsgb.org/pdfs/LEBupdatepsephmeds.pdf




                                                                                             44
                                       SORE THROAT
Definition/Criteria
A painful throat which is often accompanied by viral symptoms.

Criteria for INCLUSION
Sore throat which requires soothing.

Criteria for EXCLUSION
Patients on diseased modifying drugs or other immunosuppressant drugs.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Paracetamol 500mg tabs (32)             po        P     1-2 qds
Paracetamol susp SF 120mg / 5ml (100ml) po        P     2.5-5ml qds (3mths-1yr)
                                                        5-10ml qds (1-5yrs)
Paracetamol susp SF 250mg / 5ml (200ml) po        P     5-10ml qds
Tyrozets lozenges (24)                  po        P     follow instructions on packet

Follow-up & advice
Patients should avoid smoky or dusty atmospheres and reduce or stop smoking.
Patients who find swallowing painful should take a light fluid diet.
Paracetamol daily dose - other products containing paracetamol.

When & how to refer to GP
Conditional referral:
• If symptoms persist for more than one week, the patient should consult the GP.

Consider supply, but patient should be advised to make an appointment to see the GP:
• Symptoms suggesting oral candidiasis / tonsillitis.
• Patients on oral steroids.
• The condition has persisted more than one week.
• A second request within one month.

Rapid referral:
• Patients known to be immunosuppressed (accompanied by other clinical symptoms of blood
   disorders).
References
www.cks.library.nhs.uk/sore_throat_acute/view_whole_guidance (2004)




                                                                                       45
                                        TEETHING
Definition/Criteria
A selection of symptoms, which can include pain and redness of gums, excess salivation, dribbling
and restlessness in children aged up to 30 months old.

Criteria for INCLUSION
Children less than 30 months old.

Criteria for EXCLUSION
Over 30 months.

Action for excluded patients & non-complying patients B
Referral to General practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Anbesol liquid 6.5ml                    top P     apply to affected area up to 8
                                                  times a day
Paracetamol susp SF 120mg / 5ml (100ml) po  P     2.5-5ml qds (3mths-1yr)
                                                  5-10ml qds (1-5yrs)

Follow-up & advice
• The use of teething rings, which can be cooled in the fridge, can help to reduce the sensation
   of pain and give the baby something to chew on.
• Recommend registration with an NHS dentist if the child is not already registered.

When & how to refer to GP

Conditional referral:

Consider supply, but patient should be advised to make an appointment to see the GP:
  • Child with fever, digestive tract disorders or rash.

Rapid referral
• Fever unresponsive to paracetamol.
• Presence of a rash.




                                                                                            46
                     TEMPERATURE, ACHES AND PAINS
Definition/Criteria
Pain is a subjective experience, the nature and location of which may vary considerably.

Criteria for INCLUSION
Patients requiring relief of pain and / or fever, including headache, earache and soft tissue injuries.

Criteria for EXCLUSION
Children under the age of three months.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Paracetamol tablets 500mg (32)                      po     P    1 -2 qds
Paracetamol suspension SF 250mg / 5ml (200ml) po           P    5-10ml qds
Paracetamol susp SF 120mg / 5ml(100ml)              po     P    2.5-5ml qds (3mths-1yr)
                                                                5-10ml qds (1-5yrs)
Ibuprofen tablets 200mg (24)                         po    P    1-2 tds
Ibuprofen susp 100mg/5ml (100ml)                    po     P    2.5ml 3-4 times/day (1-2 years)
                                                                5ml 3-4 times/day (3-7 years)
                                                                5-10ml 3-4 times/day (8-12 yrs)
Ibuprofen tablets 400mg (24)                        po     P     three times a day
Follow-up & advice
• Take product at full recommended dose.
• If symptoms are relieved but return, repeat at full recommended dose.
• Advise about concurrent analgesic use.
• Drink plenty fluids.
• Consider rest, elevation, compression and elevation (RICE) in soft tissue injuries.
• Fever can also be treated with temperature reducing methods such as tepid bathing.
• Overuse of analgesics can cause headaches.

Side effects and their management
Dyspepsia with ibuprofen.
When & how to refer to GP

Conditional referral:
If pain worsens or symptoms persist for more than 5 days see GP.

Consider supply, but patient should be advised to make an appointment to see the GP:
Suspected bacterial infection requiring appropriate treatment.

Rapid referral:
Child under 2 years with fever unresponsive to paracetamol.
Suspected meningitis.
References
http://guidance.nice.org.uk/CG47 Feverish illness in children (May 07)
http://www.cks.library.nhs.uk/common_cold/view_whole_guidance (2007)




                                                                                                  47
                                     THREADWORMS
Definition/Criteria
Intestinal helminth infection (pin-shaped, white/cream coloured, approx. 100mm long and less than
0.5mm wide).

Criteria for INCLUSION
Appearance of threadworm in faeces with/without presence of perianal itching (worse at night).

Criteria for EXCLUSION
Pregnant women.
Children under the age of 1 year.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Mebendazole tabs (Ovex) 100mg (1)   po     P      100mg stat dose (adult & child >2yr)
Piperazine powder 4g sachet (2)     po     P      follow instruction on packet

Follow up & advice
• All family members should be treated at the same time.
• Hygiene advice to prevent re-infection and transmission.
• Mebendazole can be repeated if necessary after 2-3 weeks.

Side effects and their management
Evidence of hypersensitivity reaction (urticaria, angio-oedema etc.) – urgent medical attention.
Treatment can cause nausea, vomiting, diarrhoea and abdominal pain.

When & how to refer to GP
Conditional referral:
• patient should consult GP if symptoms have not resolved within 4 weeks.

Consider supply, but the patient should be advised to make an appointment to see the GP:
• presence of diarrhoea.
• broken skin near anus / possible secondary bacterial infection.
• vaginal itch in females.
Rapid referral
• Abdominal pain, nausea, vomiting or diarrhoea.
• Recent travel abroad.
• Suspect infection other than threadworm.
• Bleeding pr.
• Fever / muscle pain.
• Perianal itch with no sighting of threadworms in faeces.

Special considerations / Concurrent medication
Epilepsy / history of neurological abnormality (avoid use of piperazine).

References
http://www.cks.library.nhs.uk/threadworm/view_whole_guidance (2007)




                                                                                               48
                                      THRUSH (ORAL)
Definition/Criteria
 Fungal infection appearing as white patches on the tongue or inside of the cheeks. May be
associated with the use of broad spectrum antibiotics.

Criteria for INCLUSION
Patients presenting with symptoms suggestive of oral thrush.
No history of recurrent infection.
Criteria for EXCLUSION
Pregnancy and breast feeding.
Infants under 1 month of age.
People undergoing chemotherapy.
Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Nystatin oral suspension (30ml) po POM Adults and children 1 month and over; 1ml 4 times a
                                                day held in the mouth for as long as possible before
                                                swallowing.
Miconazole Oral Gel 2% (15g)        topical P Adults: 5 – 10 ml 4 times a day held in the mouth for
                                                as long as possible. See BNF / product literature for
                                                dose in children.
N.B. In adults nystatin should be the first line treatment but it is only available from pharmacists
accredited to supply uder the PGD.

In children under 2 miconazole oral gel is the first line treatment


Follow-up & advice
• Advice on good oral hygiene.
• Dental prostheses should be removed at night and brushed with gel.
• If symptoms persist beyond 1 week contact GP.
• Counselling on potential drug interactions.

Side effects and their management
Nausea, oral irritation and sensitisation.

When & how to refer to GP

Conditional referral:
• If symptoms persist beyond 1 week.
• Consider potentially hazardous drug interactions.
Consider supply, but patient should be advised to make an appointment to see the GP:
• Immunocompromised individuals but see under rapid referral.
• Known diabetes.
Rapid referral
• Immunocompromised individuals: seek specialist advice promptly when treating these patients.
• Suspected diabetes.
References
http://www.cks.library.nhs.uk/candida_oral/view_whole_guidance (2007)




                                                                                               49
                                  THRUSH (VAGINAL)
Definition/Criteria
Itching / irritation to vaginal area with or without a creamy white non-odorous discharge.

Criteria for INCLUSION
Adult females with a previous diagnosis of thrush who are confident it is a recurrence of the same
condition.
Symptomatic male partners of an infected female.

Criteria for conditional EXCLUSION
Patients under 16 and over 60 years.

Action for excluded patients & non-complying patients
Referral to general practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Clotrimazole cream 2% (20g)         top P       apply 2-3 times daily
Fluconazole cap 150mg (1)           po  P       1 stat
Clotrimazole vaginal pessary (500mg) pv P      insert at night

Follow up and advice
• If symptoms do not resolve within 7 days to make an appointment to see GP.
• Make aware of problems with vaginal deodorants, scented soaps etc.

Side effects and their management
Sensitivity to Imidazoles.

When & how to refer to GP

Conditional referral:
• On 3rd occurrence within 6 months.

Consider supply, but patient should be advised to make an appointment to see the GP:
• Known diabetes mellitus.

Rapid referral:
   • Presence of loin pain.
   • Fever.
   • If blood present in discharge.
   • Foul smelling discharge.
   • Suspicion of diabetes.
   • Post menopausal.

References
http://www.cks.library.nhs.uk/candida_female_genital/view_whole_guidance (2007)




                                                                                              50
                            WARTS AND VERRUCAS
Definition/Criteria
 A wart is a small (often hard) benign growth on the skin caused by a virus, usually occurring on
the face, hands, fingers, elbows and knees. Verrucas (Plantar warts) occur on the sole of the
foot, usually painful and may be covered by a thick callus.

Criteria for INCLUSION
Symptoms and signs suggestive of a wart or verruca.

Criteria for EXCLUSION
Warts on face, anogenital region or large areas.
Diabetes mellitus.
Impaired peripheral blood circulation.
Broken skin around area of wart / verruca.

Action for excluded patients & non-complying patients
Referral to General Practitioner.

Recommended Treatments, Route and Legal status. Frequency of administration &
maximum dosage
Cuplex ® gel 5g      top     P      apply twice daily
Salatec ®      8g     top    P      apply twice daily
Follow-up & advice
• Advice on hygiene, for example not sharing towels, as warts spread rapidly in communities,
   especially schools.
• Rub wart surface with file or pumice stone once weekly.
• Removal can take several weeks and treatment may need to be continued for up to 12
   weeks.
• Warts usually disappear spontaneously in time.

Side effects and their management
Stinging, dryness and peeling.

When & how to refer to GP

Conditional referral:

Consider supply, but patient should be advised to make an appointment to see the GP:

Rapid referral

References
http://www.cks.library.nhs.uk/warts_including_verrucas (2007)




                                                                                               51
Appendix 9

                Drug Code Reference Card (revised Apr 08)

Drug Codes
    Item                        Code      Cost Per        Item                           Code           Cost Per
                                          Item (£)                                                      Item (£)
    Aciclovir 5% Cream             ACIC            2.56   Hydrocortisone 1% Cream               HYDC            1.65
    (2g)                                                  (15g)
    Adcortyl in Orabase           ADOR            2.25    Hydrocortisone 2.5mg Pellets          HYDP           2.54
    (5g)                                                  (20)
    Anbesol Liquid                ABES            1.59    Hypromellose 0.3% Eye                 HYPE           1.52
    (6.5ml)                                               Drops (10ml)
    Anusol Ointment               ANUO            1.96    Ibuprofen 200mg Tablets (24)           IBTL          0.75
    (25g)
    Anusol Plus HC Ointment       AHCO            2.39    Ibuprofen 400mg Tablets (24)          IBTH           1.30
    (15g)
    Anusol Plus HC                AHCS            2.48    Ibuprofen Suspension                  IBUS           1.59
    Suppositories (12)                                    (100ml)

    Anusol Suppositories (12)     ANUS            1.85    Ketoconazole 2% Shampoo               KETS           3.42
                                                          (60ml)

    Aqueous Cream (500g)          AQUC            1.51    Lactulose Solution (300ml)            LACT           2.62


    Balneum Bath Additive         BALN            2.48    Loperamide 2mg Capsules               LOPC           1.20
    (200ml)                                               (10)

    Beclometasone Nasal           BECN            3.56    Loratidine Syrup (100ml)              LORS           2.85
    Spray (100 sprays)
    Benzoyl Peroxide              BENZ            1.76    Loratidine tablets 10mg (30)          LORA           1.01
    Aquagel 2.5% (40g)
    Benzoyl Peroxide              BEPE            1.92    Loratidine tablets 10mg (7)           LOTB          0.85
    Aquagel 5% (40g)
    Benzoyl Peroxide              BPAG            2.07    Malathion Alcoholic Liquid            MALA    2.22 (each)
    Aquagel 10% (40g)                                     50ml (2)                                             4.44

    Bug Buster Kit (1)            BUGK            4.55    Malathion Aqueous Liquid          MAQU        2.27 (each)
                                                          50ml (2)                                             4.54
    Cetirizine 10mg Tablets       CETT            0.82    Mebendazole Tablets (Ovex)            MEBT           1.17
    generic (7)                                           100mg (1)
    Cetirizine 10mg Tablets       CEGN            0.50    Normal Saline Nasal Drops             NORS           0.99
    generic (30)                                          (10ml)

    Chloramphenicol eye           CHLO            2.75    Nystatin Oral Suspension              NYST           1.91
    drops (10ml)                                          (30ml)

    Chloramphenical eye          CHLO2            3.39    Oilatum Emollient (250ml)             OILE           2.75
    ointment (4g)

    Chlorhexidine 0.2%           CHMW             2.00    Otrivine Antistin Eye Drops           OTRD           2.36
    Mouthwash (300ml)                                     (10ml)

    Chlorphenamine 4mg            CHLT            0.90    Paracetamol 500mg Tablets             PART           0.52
    Tablets (28)                                          (32)

    Chlorphenamine Syrup          CHLS            2.28    Paracetamol SF 120mg/5ml              PARA           0.44
    (150ml)                                               Suspension (100ml)
    Choline Salicylate Gel        CHOL                    Paracetamol SF 250mg/5ml              PARS           1.13
    (15g)                                         1.79    Suspension (200ml)

    Clotrimazole 1% Cream        CLOT1            1.71    Piperazine 4g Powder                  PIPE           1.47
    (20g)                                                 Sachets (2)

    Clotrimazole 2% Cream        CLOT2            3.99    Potassium Citrate solution            POTC           0.88
    (20g)                                                 (200ml)




                                                                                                                       52
Clotrimazole Vaginal        CLVP         3.80      Pseudoephedrine 60mg           PSET   1.24
Pessary 500mg (1)                                  Tablets (12)
Co-magaldrox SF             MUCO           1.71    Ranitidine Tablets 75mg (12)   RANI    1.99
Suspension 195/220
(Mucogel) (500ml)
Conotrane Cream (100g)      CONO           0.74.   Salatac Gel (8g)               SALG    3.12

Crotamiton Cream 10%        CROC           2.27    Senna Syrup 7.5mg/5ml          SENS    3.20
(30g)                                              (Senokot) (150ml)

Crotamiton Lotion 10%       CROL           2.99    Senna Tabs 7.5mg (20)          SENT    0.89
(100ml)
Cuplex Gel (5g)             CUPG           2.23    Senokot (Ispaghula) Sachets    SENA    1.79
                                                   (10)
Daktarin Oral Gel 2%        DAKG           2.45    Simple Linctus SF (200ml)      SIML    0.68
(15g)
Detector Comb (1)           DETE           0.99    Simple Paediatric SF Linctus   SPLN    0.69
                                                   (200ml)
Dioralyte Sachets (6)        DIOR          2.11    Sodium Bicarbonate Ear         SODB    1.25
                                                   Drops 5% (10ml)
Domperidone Tablets         DOMP           2.39    Sodium Cromoglycate 2%         SODC    3.19
10mg (10)                                          Eye Drops (10ml)

Ephedrine Nasal Drops       EPHE           1.25    Terbinafine Cream 7.5g (1)     TERB    2.28
0.5% (10ml)

Fluconazole 150mg           FLUC           1.52    Tyrozets (24)                  TYRO    1.43
Capsules (1)



Gaviscon Advance Liquid     GAAL           2.70
(250mls)
Glycerin 4g Suppositories   GLYC           1.44
(Adult) (12)
                            HEDR    (2.98 each )
Hedrin Lotion 50ml (2)                      5.96




                                                                                                 53
Appendix 10
Financial Summary sheet




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