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									                              PRESTON PRIMARY CARE TRUST

                           Pharmacy First
       A Minor Ailments Scheme through Community Pharmacists


Background                                                        2
Service Specification                                             4
Appendix 1 Preston PCT GP Practices Contact Numbers               9
Appendix 2 Pharmacy First Formulary                               10
Appendix 3 Circumstances in which Pharmacy First medicine should
            not be supplied                                       11
Appendix 4 Pharmacy First: Consultation Form                      13
Appendix 5 Pharmacist Rapid Referral Form                         15
Appendix 6 Chorley & South Ribble PCT
             GP practice contact numbers                          17
Appendix 7 Pharmacies Participating in Scheme                     18
Appendix 8 Pharmacy First Patient Passport & Information Leaflet 19
Appendix 9 Pharmacy First Consultation Decision Pathway           23
Appendix 10 Pharmacy First Minor Ailment Protocols                24
Appendix 11 Generic list of competencies for community pharmacies
              involved in providing a minor ailment service       51
Appendix 12 Pharmacy First Locum Guide                            54
Appendix 13 Pharmacy First Common Questions                       56
Appendix 14 Pharmacy First Model Receptionist Protocol            57
Appendix 15 Clinical Governance Implications for pharmacies
              providing a Minor Ailment Service                   58
Appendix 16 List of publications for Patient Information Leaflets 59


                              PRESTON PRIMARY CARE TRUST

                           Pharmacy First
       A Minor Ailments Scheme through Community Pharmacists

1.       Introduction

1.1      A significant amount of a GPs workload is spent dealing with minor ailments.
         A „minor ailment‟ means different things to different people. Some patients
         need a formal GP appointment to be reassured that the symptoms are not
         serious whilst many other patients require convenient and instant access to
         suitable over the counter medicines. Several community pharmacy based
         schemes around the country have allowed this to happen with great success
         thereby relieving pressure on GP appointment times.

2.       Better Management of Minor Ailments

2.1      GPs spend a significant proportion of their working day dealing with minor
         ailments. For some patients this is entirely appropriate, but for many others, it
         is an inconvenient and inefficient way of getting help to look after themselves.
         Many emergency appointments are taken up by people with minor ailments.

2.2      The aim of this scheme is to allow appropriate patients to be referred or to self
         refer to their local community pharmacy. The community pharmacist will be
         able to treat a number of specified minor conditions and supply medicines
         from an agreed local formulary at NHS expense. No payment need be made if
         the patient is exempt from prescription charges. Those patients who pay
         prescription charges will be able to choose either to pay the prescription
         charge due, or purchase the medication at the normal „over the counter‟ price.

2.3      The minor ailments have been selected because of their prevalence, the
         availability of pharmacy medicines for their treatment and the willingness of
         GPs to see their management transferred to pharmacies.

2.4      The scheme was subjected to phased introduction across Preston PCT, which
         commenced in those areas of Preston with high levels of deprivation.

2.5.     Moving minor ailment management into community pharmacy will relieve
         pressure on the GP urgent appointment system. By directing patients with
         minor illnesses to community pharmacies, GPs will potentially have more
         consultation time available for patients with more serious or chronic
         complaints. Relieving capacity and demand pressures will help with
         recruitment and retention initiatives particularly in practices serving areas of
         high deprivation. The scheme will also help to achieve and sustain improved
         access to primary care by helping patients to be seen within 48 hours by a GP
         or another primary health care professional.


2.6      Implementation of the scheme will support the delivery of the NHS plan
         specifically in relation to reshaping care around patients and making better use
         of the skills of pharmacists. Widening the availability of medicines over the
         counter was also identified as a modernisation initiative in the document
         published by the Department of Health „Pharmacy in the Future.‟

         There are many benefits for patients;

             Waiting times are reduced
             Access to advice is improved
             There is an alternative to a GP consultation
             No anxiety about 'bothering the doctor'

         For the Practice and the PCT

          Inappropriate consultations are reduced
          More time for tasks that really need medical input
          It will be easier to achieve access targets

         For the Pharmacist

          Opportunity to work more closely with the primary healthcare team
          Making better use of professional skills

3.       Outline Implementation

3.1      A minor ailments scheme known as “Pharmacy First” has been introduced
         across the whole of Preston PCT.

3.2      It has been introduced in three phases;

          All community pharmacies in Preston PCT have participated in the scheme
           since the launch of phase 1 in March 2004.

          All participating pharmacies undertook an accredited training course prior
           to the launch of phase 1.

          Pharmacists will work within written protocols for each specified minor
           ailment. These protocols will have been developed and approved by the
           PCT Medicines Management Sub Committee.

          Patients managed within these protocols will be given advice and may be
           supplied with the designated medication identified. Some patients may
           require referral.

          Patients registered with the GP practices identified in appendix 1 are
           eligible to participate in the scheme.


                                        Pharmacy First

                                     Service Specification
1        Introduction

1.1      Patients wishing to use the service must be registered with a participating GP
         surgery. See appendix 1.

1.2      The service can only be provided for patients registered with a participating
         GP surgery and presenting with symptoms of a minor ailment listed in
         appendix 2.

1.3      Only the products listed against the specific minor ailment as indicated in
         appendix 2 can be provided as part of the scheme. The licensed medicines
         available within the scheme must not be supplied out with the licensed
         indication for the medicine.

1.4      Eligible patients will only be provided with medicines to manage the minor
         ailment if, in the professional opinion of the pharmacist, the medicine required
         is not contraindicated and that the treatment provided is in accordance with the
         minor ailment protocol.

1.5      Only pharmacies accredited by Preston Primary Care Trust will be included in
         the scheme. See appendix 7.

1.6      Patients under the care of GP practices as identified in appendix 1 will register
         onto the scheme when they visit an accredited pharmacy as a result of
         symptoms associated with one of the minor ailments listed in appendix 2. The
         patient will be encouraged to use the pharmacy that normally dispenses their
         prescriptions. Once registered the patient should normally use that same
         pharmacy for further consultations arising from symptoms associated with one
         of the minor ailments listed in appendix 2. See 1.12 for arrangements
         pertaining to patients registered with GP practices in Chorley & South Ribble

1.7      Registration will take the form of the provision by the pharmacy of a
         Pharmacy First Passport (appendix 8) completed with details of the patient,
         condition treated and medication supplied under the scheme.

1.8      Patients are required to present the Pharmacy First Passport at all subsequent
         pharmacy consultations under the scheme. Ideally this should be at the
         pharmacy that originally issued the Pharmacy First Passport. However
         presentation of the passport in association with a minor ailment consultation at
         another participation pharmacy in Preston PCT is acceptable.


1.9      The top copy of the consultation form (Appendix 4) will be sent to the PCT
         for audit and reimbursement. The second copy should be retained at the
         premises of the pharmacy for at least two years.

1.10     A copy of the patient consultation form (appendix 4) may be faxed to the
         patient‟s GP for information if so requested by the GP.

1.11     Patients are at liberty to decline to participate in the scheme.

1.12     Patients registered with GP practices in Chorley & South Ribble PCT
         (Appendix 6) may receive treatment for the conditions and with the medicines
         listed under the Preston scheme following a consultation in a pharmacy
         within Preston PCT. Documentation and reimbursement requirements are
         identical to that of all other patients managed under the Preston PCT scheme.

2.       Referral into scheme and registration

2.1      Patients presenting at a participating GP surgery or the primary care GP
         deputising service with one of the minor ailments listed in appendix 2 may be
         advised of the scheme and how to access it through their local pharmacy.
         Surgeries should note that patients who are not exempt from prescription
         charges will be required to pay for any medication supplied.

2.2      Patients presenting at a pharmacy by self-referral.

2.3      Pharmacists will only accept a patient into the scheme providing they can
         establish that the patient is registered with a participating GP practice. This
         can be achieved by:

               Evidence produced by the patient of registration with a participating
                GP practice e.g. repeat prescription tear-off slip.
               Pharmacy PMR record showing evidence of a prescription dispensed
                in the last 6 months.

2.4      Once it has been established that the patient is included on the list of a
         participating GP practice, the patient must register with the pharmacy in order
         to participate in the scheme and be provided with a Pharmacy First Passport.
         The patient is required to sign the consultation form (appendix 4) following
         every pharmacy consultation.

2.5      If a patient or pharmacist cannot confirm registration with a participating GP
         practice, the patient cannot access the scheme at that time. The patient should
         be advised of alternative methods of accessing care.


3.       Key points for participating pharmacies

3.1      Core competencies and Clinical Governance issues required of community
         pharmacists participating in a minor ailments scheme are identified in
         appendices 11 and 15

3.2      Once confirmation of patient registration with a participating GP practice has
         been established, the Pharmacist or suitably trained member of the pharmacy
         staff should then carry out a professional consultation with reference to the
         appropriate minor ailment protocol (appendix 10) which should involve:

               Patient assessment
               Provision of advice
               Supply of appropriate medication from the agreed formulary
               Provision of Pharmacy First Passport on initial registration and
                a replacement when the original passport record section is full. All
                fully completed passports should be sent to the PCT at month end
                along with completed consultation forms.
               Completion of „Pharmacy First‟ consultation form. See appendix 4.

3.3      The patient must sign the consultation form if he/she wishes treatment within
         the scope of the scheme. This should occur each time the patient accesses the

3.4      The top copy of each consultation form will be sent to the PCT for audit and
         reimbursement at month end.

3.5      The second copy of the consultation form will be retained at the premises of
         the pharmacy for at least two years.

3.6      A copy of the consultation form may also be sent to the GP for information if
         so requested.

3.7      The pharmacist should ensure that the patient is eligible for treatment within
         the scope of the scheme.

3.8      The pharmacist must ensure that the appropriate medication from the
         formulary (appendix 2) is supplied and that the patient is advised how to
         take/use the medication and is provided with a PIL if appropriate.

3.9      The pharmacist should ensure the patient has completed and signed the
         declaration of exemption of prescription charges on the back of the „Pharmacy
         First‟ consultation form (appendix 4).

3.10     Patients who present with a minor ailment outside the scope of the scheme or
         for whom the listed formulary product/s is/are not appropriate or contra-
         indicated, should be advised of alternative methods of accessing care (e.g.
         OTC sale, routine GP appointment)


3.11     If the patient presents with symptoms causing serious concern to the
         pharmacist e.g. symptoms of meningitis, the pharmacist must use the rapid
         referral form (Appendix 5) which allows patients to see their GP as soon as

3.12     Only the medicines listed in appendix 2 in the quantities stated can be issued
         to an eligible patient following a consultation. Further supplies of this
         medication following a subsequent professional consultation should only be
         supplied if, in the opinion of the pharmacist, it is considered appropriate. A
         patient presenting at the pharmacy more than twice over a short period of time
         with the same minor ailment symptoms should not normally be considered for
         further provision of treatment under the scheme.

3.13     If a pharmacist has any doubt over the appropriateness of the supply of a
         „Pharmacy First‟ formulary medication (see appendix 3) then supply should be
         withheld. The pharmacist must use their professional judgement to decide
         whether rapid referral of the patient to a GP is appropriate or advise the patient
         to see their GP in a normal way. Routine referral should occur if a patient
         repeatedly presents with the same condition or the pharmacist suspects the
         patient is abusing the system.

3.14     The pharmacist should endeavour to keep the consultation process as
         confidential as possible and as such a private consultation area would be
         desirable to achieve this.

3.15     The pharmacy consultation decision pathway is outlined in appendix 9.

3.16     Additional support provided for pharmacists and their staff can be found in
         appendix 12 –(Locum Guide) and appendix 13 – (Common Questions)

4.       Key points for participating Surgeries

4.1      All patients requesting GP consultation for symptoms in keeping with one of
         the minor ailments listed in appendix 2 should be considered for inclusion and,
         if appropriate, directed as to how to access the scheme and provided with an
         information leaflet (appendix 16).

4.2      Patients presenting in person to the GP surgery should be provided with the
         patient information leaflet stamped by the practice and advised to use the
         pharmacy where they normally obtain their prescriptions. Patients resident in
         Chorley & South Ribble PCT but registered with a Preston PCT GP practice
         may normally have their prescriptions dispensed at a pharmacy in Chorley &
         South Ribble PCT. They should use that pharmacy to access treatment under
         the minor ailments scheme operational across Chorley & South Ribble PCT.

4.3      Surgeries should liase with pharmacists to allow the rapid referral procedure
         from the pharmacy to the GP to operate effectively (appendix 5).

4.4      GP surgeries should endeavour to advertise the scheme using posters and
         leaflets provided by Preston PCT.


4.5      If GP surgeries request a copy of the pharmacy consultation form they should
         record the medication supplied by the pharmacist on the GP electronic patient
         record or in the patient notes stating the name of the pharmacy providing the

4.6      Practices may find the model Receptionist Protocol (appendix 14) helpful in
         supporting the scheme.

5.     Service funding

5.1      The Pharmacy payment structure paid by the Preston PCT will consist of:

               Consultation fee £3.00
               Medication cost based on the drug tariff price or Chemist and Druggist
                cost price plus VAT (currently 17.5%).

6.       Claims for payments

6.1      Claims for payment should be made by the 5th working day of the following
         month by submission to the PCT of the top copy of each consultation form.
         Late submission may delay payments. The monthly claim summary form
         introduced at the launch of the scheme is no longer required although
         pharmacies may wish to complete this form for their own internal records.

6.2      The pharmacy should retain the second copy of the „Pharmacy First‟
         consultation form at the pharmacy premises for at least two years and as such
         should allow Preston PCT access to these documents as and when required.
         Breach of this may result in termination of the service.

6.3      Payments will be made at the end of the 2nd month following that to which
         the payment relates and can be identified from the pharmacy contractors PPA

6.4      Incomplete consultation forms will be deemed invalid and as such will be
         returned to the contractor for resubmission, which will delay payments.

6.5      Where a formulary item supplied is not done so in accordance with the minor
         ailments protocols, no reimbursement for the formulary item supplied will
         occur and no consultation fee will be paid.

7.       Termination of service

7.1      The pharmacy contractor or Preston PCT may terminate this agreement by
         providing written notice of their intention to do so. A period of 28 days should
         be                     given                       as                     notice.


    Appendix 1

             GP                   Practice Manager           Telephone          Fax                  Address 1                            Address 2                         Postcode
Baroudi G                    Pat Baroudi              01772 792864       01772 705251   Ribble Village Surgery       200 Miller Road, Preston                             PR2 6NH
Chakrabarti HP               Pam Allen                01772 884308       01772 887735   110 Deepdale Rd              Preston                                              PR1 5AR
Chesworth RJH & Ptnrs        Harry Williamson         01772 716033       01772 715445   Lytham Road Surgery          2a Lytham Road, Fulwood,Preston                      PR2 8JE
Conway HP                    Louise Fowler            01772 726389       01772 768138   Ashton Health Centre         Pedders Lane, Ashton, Preston                        PR2 1HR
Craig M & Partners           Sangeeta Chikhalikar     01772 723222       01772 726619   Docland Medical Centre       Blanche Street, Preston                              PR2 2RL
Das BT                       Karen Baron              01772 726588       01772 726613   34-35 Ashton St              Preston                                              PR2 2PP
Fletcher DJ & Ptnrs          Alison Ashworth          01772 792512       01772 693521   Ribbleton Medical Centre     243 Ribbleton Avenue, Preston                        PR2 6RD
Forrester & Partners         Helen Stammers           01772 783021       01772 785809   Berry Lane Medical Centre    Berry Lane, Longridge, Preston                       PR3 3JT
Ghori SS                     Margaret Ghori           01772 729756       01772 760862   104 Woodplumpton Rd          Fulwood, Preston                                     PR2 2LR
Hann JC & Partners           Ann Fadden               01772 258474       01772 884200   Park View Surgery            23 Ribblesdale Place, Preston                        PR1 3NA
Jandu MS & Partners          Cathy Jandu              01772 726186       01772 768823   Briarwood Medical Centre     514 Blackpool Rd, Ashton, Preston                    PR2 1HY
Jha JN                       Asha Jha                 01772 254546       01772 254984   310 St George's Rd           Deepdale, Preston                                    PR1 6NR
Khan QO & Partners           Glenda Sandham           01772 252414       01772 254101   57 – 59 Meadow St            Preston                                              PR1 1TS
Kumar B                      Val Wiles                01772 252409       01772 885509   St Paul's Surgery            36-38 East St, Preston                               PR1 1UU
Mawson AC & Partners         Pam Grogan               01772 655533       01772 653414   The Health Care Centre       Flintoff Way, Preston                                PR1 5AF
Naik RK                      Carol Molyneux           01772 863033       01772 865492   The Surgery                  17-19 Beech Drive, Fulwood                           PR2 3NB
Nath K                       Louise Fowler            01772 726169       01772 768138   Ashton Health Centre         Pedders Lane, Ashton, Preston                        PR2 1HR
O'Donnell EI & Ptnrs         Louise Fowler            01772 726500       01772 768138   The Park Medical Practice    Peddars Lane, Ashton, Preston                        PR2 1HR
Patel DC & Partners          Anne Fairclough          01772 717261       01772 769733   Broadway Surgery             2 Broadway, Fulwood, Preston                         PR2 9TH
Pavey K & Partners           Lynda Williams           01772 783271       01772 782836   Stonebridge Surgery          Preston Road, Longridge, Preston                     PR3 3AP
Pritchett AHJ & Ptnrs        Gill Fraser              01772 401730       01772 401731   The New Hall Lane Practice   Geoffrey Street Health Centre Geoffrey St, Preston   PR1 5NE
Robb GA & Partners           Joanne Nicholas          01772 253554       01772 256679   The Surgery                  63-65 Garstang Rd, Preston                           PR1 1LB
Rossall CJ                   Rossall CJ               01772 655599       01772 909080   The Health Centre            Flintoff Way, Preston                                PR1 5AF
Shahid SZ                    Patricia Bracken         01772 555733       01772 885406   228-232 Deepdale Rd          Deepdale, Preston                                    PR1 6QB
Shaw S                       Kath Wild                01772 401760       01772 401950   The Geoffrey St Surgery      Geoffrey Street Health Centre Geoffrey St, Preston   PR1 5NE
Singh B                      Sharon Riley             01772 821069       01772 556778   98 Deepdale Rd               Deepdale, Preston                                    PR1 5AR
Singh H & Partners           Wendy Sutton             01772 254484       01772 881835   Fishergate Hill Surgery      50 Fishergate Hill, Preston                          PR1 8DN
Smith EM & Partners          Gwen Davy                01772 252077       01772 885451   Moor Park Surgery            49 Garstang Road, Preston                            PR1 1LB
Thanda KM                    Kath Wild                01772 401931       01772 886567   Avenham Lane Practice        Avenham Lane H C, Avenham Lane, Preston              PR1 3RG
Webster M                    Jane Mills               01772 254173       01772 563669   49 Frenchwood Ave            Frenchwood,Preston                                   PR1 4ND

Preston Primary Care
Centre                       Jim Braithwaite          01772 788058       01772 713016   Royal Preston Hospital       Sharoe Green Lane, Fulwood, Preston                  PR2 9HT

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                                            Appendix 2
                                     Pharmacy First – Formulary

MINOR                                                             MEDICINE
Athletes foot                    Clotrimazole cream 20g, Miconazole Cream 30g
Constipation                     Ispaghula Sachets (10), Lactulose Soln. (300mL), Senna Tabs (20)
Cold sores                       Aciclovir 5% Cream 2g,
Cough, cold and Flu like         Ibuprofen 200mg Tabs (24), Paracetamol 500mg Tabs (32)
symptoms including               Ibuprofen Suspension 100mg/5mL (100mL)
Fever                            Paracetamol Suspension 120mg/5mL (100mL/200mL)
                                 Paracetamol Suspension 250mg/5mL (100mL), Menthol and
                                 Eucalyptus Inhalation (100mL), Pholcodine Linctus adult (200mL)
                                 and paediatric (90/100mL), Pseudoephedrine Linctus (100mL) or
                                 Tabs (24)
                                 Xylometazoline adult and paediatric Nasal Drops (10mL), Normal
                                 Saline Nose Drops (10mL).
Cystitis                         Potassium Citrate Mixture (200mL), Paracetamol 500mgTabs (32)
Diarrhoea                        Dioralyte (6 Sachets)
Earache                          Ibuprofen 200mg Tabs (24), Paracetamol 500mg Tabs (32)
                                 Ibuprofen Suspension 100mg/5mL (100mL)
                                 Paracetamol Suspension 120mg/5mL (100mL/200mL)
                                 Paracetamol suspension 250mg/5mL (100mL) Pseudoephedrine
                                 Linctus (100mL) or Tabs (24)
Eczema                           Emulsifying Ointment (500g), Aqueous Cream (500g),
                                 Hydrocortisone Cream 1% (15g)
Hay fever (Allergic              Chlorphenamine 4mg Tablets (30), Chlorphenamine 2mg/5mL Syrup
Rhinitis)                        (150mL), Sodium Cromoglycate 2% Eye Drops (10mL), Cetirizine
                                 10mg Tablets (30). Cetirizine Oral Soln 5mg/5mL (150mL)
Headache                         Ibuprofen 200mg Tabs (24), Paracetamol 500mg Tabs(32)
                                 Ibuprofen Suspension 100mg/5mL (100mL)
                                 Paracetamol Suspension 120mg/5mL (100mL/200mL)
                                 Paracetamol Suspension 250mg/5mL (100mL)
Head Lice                        Phenothrin 0.2% Lotion (50mL x 1 or 2 bottles)
                                 Malathion 0.5% Aqueous Liquid or Lotion (50mL x 1 or 2 bottles)
Indigestion                      Gaviscon Liquid (150mL)
Mouth ulcers                     Hydrocortisone Lozenges (20)
                                 Bonjela Gel (15g)
Nappy rash                       Sudocrem Cream (60g)
Scabies                          Permethrin Dermal Cream (30g), Malathion 0.5% Aqueous Liquid
                                 (50mL), Chlorphenamine 4mg Tablets (30), Chlorphenamine
                                 2mg/5mL Syrup (150mL), Cetirizine 10mg Tablets (7). Cetirizine
                                 Oral Soln 5mg/5mL (75mL)
Sore Throat                      AAA Spray (60 sprays), Difflam Spray (30mL), Ibuprofen 200mg
                                 Tabs (24), Paracetamol 500mg Tabs (32)
                                 Ibuprofen Suspension 100mg/5mL (100mL)
                                 Paracetamol Suspension 120mg/5mL (100mL/200mL)
                                 Paracetamol Suspension 250mg/5mL (100mL)
                                 Aspirin Sol Tabs 300mg (24)
Teething                         Bonjela Gel (15g)
Threadworm                       Mebendazole 100mg Tabs (1) x 2
Oral thrush                      Miconazole Oral Gel (15g)
Vaginal thrush                   Clotrimazole 500mg Pessary (1), or 1% Cream (20g) or
                                 Clotrimazole Combi Pack (1)
Verrucas                         Cuplex Gel 5g

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Appendix 3

    Circumstances in which a Pharmacy First medicine should not be supplied

    Patients presents with symptoms not indicative of any of the minor ailments included in the

    Patient or parent cannot demonstrate that the patient is on the list of a participating
     GP practice.(PMRs, repeat prescription tear off slip, Pharmacy First Passport)

    The patient normally pays a prescription charge. (these patients whilst not excluded from the
     scheme, may choose to purchase OTC medicines rather than pay the prescription charge for a
     medicine supplied under the Pharmacy First scheme)

    Patient or parent unwilling to complete Pharmacy First documentation

    Pharmacy First medicine is contraindicated

    Recent supply of the Pharmacy First medicine

    Lost medicine

    Patient or parent unwilling to accept medication or quantity of medication available
     from within the Pharmacy First Formulary

    Medicine requested „just in case‟

    Medicine requested to take abroad

    Medicine requested in lieu of uncollected repeat prescription

    Medicine requested to stock up medicine cabinet

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                             Preston Primary Care Trust
                                        Pharmacy First: Consultation Form

1. Patient Details.                                                                    Date of Consultation……………………………..
Patient Name…………………………………………….……                                                       Date of Birth………………………………………
Patient address……………………………………………….                                                     GP Practice* (Senior Partner Name)
…..………………………………………………………………                                                              ……………………………………………………..
…….…………………………………….………………………                                                             *Specify PCT if not Preston……………………………..

2. Referral Method
GP Surgery.                  Pharmacist                    Patient self referral               Out of Hours                   Other

3. Minor Ailment
Athletes Foot                            Diarrhoea                         Head Lice                               Scabies
Constipation                             Earache                           Indigestion                             Sore Throat
Cold Sores                               Eczema                            Mouth Ulcers                            Teething
Cough,Cold, Flu–like symptoms, Fever     Hay Fever (Allergic Rhinitis)     Nappy Rash                              Threadworm
Cystitis (in women)                      Headache                          Oral Thrush                             Vaginal Thrush
                                                                                                                   Verrucas

4. Formulary Item Supplied
 AAA Spray x1                                                                 Malathion 0.5% Aqueous liquid(50mL)
 Aciclovir 5% cream (2g)                                                      Malathion 0.5% lotion (50mL)
 Aqueous cream (500g)                                                         Mebendazole 100mg tabs (1)x2
 Aspirin Sol tabs 300mg (32)                                                  Menthol and Eucalyptus inhalation (100mL)
 Bonjela gel (15g)                                                            Miconazole cream (30g)
 Cetirizine 10mg tabs (30)                                                    Miconazole oral gel (15g)
 Cetirizine oral solution 5mg/5ml (150ml)                                     Normal saline nose drops (10mL)
 Chlorphenamine 2mg/5mL syrup (150mL)                                         Paracetamol 500mg tabs (32)
 Chlorphenamine 4mg tabs (30)                                                 Paracetamol suspension 120mg/5mL (100mL)
 Clotrimazole 500mg pessary x 1                                               Paracetamol suspension 120mg/5mL (200mL)
 Clotrimazole combi pack x 1                                                  Paracetamol suspension 250mg/5mL (100mL)
 Clotrimazole cream 20g                                                       Permethrin dermal cream (30g)
 Cuplex gel 5g                                                                Phenothrin 0.5% liquid (50ml)
 Difflam spray (30mL)                                                         Phenothrin 0.2% lotion (50mL)
 Dioralyte sachets (6 sachets)                                                Pholcodine linctus adult (200mL)
 Emulsifying ointment (500g)                                                  Pholcodine Paediatric linctus (90/100mL)
 Gaviscon liquid (150mL)                                                      Potassium citrate mixture (200mL)
 Hydrocortisone cream 1% (15g)                                                Pseudoephedrine linctus (100mL)
 Hydrocortisone lozenges (20)                                                 Pseudoephedrine tablets 60mg (24)
 Ibuprofen 200mg tabs (24)                                                    Senna tabs (20)
 Ibuprofen suspension 100mg/5mL (100mL)                                       Sodium cromoglycate 2% eye drops (10mL)
 Ispaghula sachets (10)                                                       Sudocrem cream (60g)
 Lactulose soln (300mL)                                                       Xylometolazone adult nasal drops (10mL)
                                                                              Xylometolazone paediatric nasal drops (10mL)
                                                                           
                                                                           
                                                                           

Pharmacist Signature………………………….                                                                         Pharmacy Stamp


Please ensure exemption declaration overleaf is signed

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                                        DECLARATION OF EXEMPTION

                               To be completed by the patient or the patient‟s representative.

The patient doesn‟t have to pay because he/she:

A          is under 16 years of age                                 Pharmacy use only

B           is 16, 17 or 18 and in full-time education
C           is 60 years of age or over
D          has a current maternity exemption certificate
E          has a current medical exemption certificate               Evidence not seen

F          has a current prescription pre-payment certificate
G          has a 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 named on a Working Families‟ Tax Credit NHS Exemption Certificate
N          *is named on a Disabled Person‟s Tax Credit NHS Exemption Certificate
*Name:                                     Date of birth:                              NI no:

* for boxes H, K, M and N. print the name of the person getting benefit or Credit. This may be you or
  your partner. Checks may be made with the Department for Work and Pensions (previously DSS) or
  the Inland Revenue.

I am the patient.                                                 I am the patient‟s representative

Declaration: I declare that the information I have given is correct and understand that if it is not, action
may be taken against me. For the purposes of audit and for verifying entitlement to exemption from
prescription charges (where appropriate) I consent to the disclosure of relevant information about
myself/the patient, including to and by the Inland Revenue and the local Primary Care Trust. I
understand that this information may be communicated to my GP or healthcare professionals directly
involved in my care. I have been counselled on the use of the medicine supplied and understand the
advice given by the pharmacist.

To the Patient – Please complete either declaration (1) or (2) below:-

     1.    I have received the above medicine(s) indicated on this form and am exempt from charges for
           the reason specified above.

Signed (Patient)…………………………………Date………………………………..

     2.    I have received the above medicine(s) indicated on this form, I am not exempt from
           prescriptions charges and I have paid £…………….

Signed (Patient)………………………………….Date……………………………….
Print name and address (if different from overleaf):

IMPORTANT – Your Pharmacist is providing treatment and/or advice under the Minor Ailments Scheme
in line with the symptoms you have described. If your symptoms persist you should seek further advice
from your doctor. Use the information given in your „Pharmacy First‟ passport provided by the pharmacist
to advise your doctor which pharmacy you have attended and what advice and treatment you have already

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      Appendix 5.

  Care in the Pharmacy                                                 Pharmacy First

                                     Minor Ailments Scheme
                              Pharmacist Rapid Referral form

Patient Name:

Patient Address:

GP Name:

Please make an appointment ASAP for this patient.


Pharmacists Name, Address and Telephone Number:

Date and Time:

     Please Fax this form to GP surgery or give to the patient to take to surgery.

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Appendix 6
          PRACTICE                        SURGERY NAME                  STREET              REGION      POSTCODE       PRACTICE MANAGER         No                 FAX No
DR A B PHILLIPS & PARTNERS      RIVERSIDE MEDICAL CENTRE          194 VICTORIA ROAD    WALTON LE DALE   PR5 4AY    JAYNE SAYNER             01772 556703 01772 880861
DR A K TANDON                   THE BEECHES MEDICAL CENTRE        LIVERPOOL ROAD       LONGTON          PR4 5AB    BARRBARA NORRIS          01772 613123 01772 616311
DR A SERVICE & PARTERS          WHITTLE SURGERY                   199 PRESTON ROAD     WHITTLE LE WOODS PR6 7PS    SALLY COOKE              01257 262383 01257 261019
DR D R BALL & PARTNERS          ROSLEA SURGERY                    51 STATION ROAD      BAMBER BRIDGE    PR5 6PE    MARGARET/VAL CALLAGHAN   01772 335128 01772 492248
DR D W YOUNG & PARTNERS         THE RYAN MEDICAL CENTRE           St MARY'S ROAD       BAMBER BRIDGE    PR5 6TE    JULIE HOWARTH            01772 335136 01772 626701
DR E M H DAWOUD & PARTNER 652 PRESTON ROAD                        CLAYTON LE WOODS     CHORLEY          PR6 7EH    LORRAINE PARKINSON       01772 323021 01772 620078
DR G G K WIJETHILEKE            MEDICARE UNIT                     1 CROSTON ROAD       LOSTOCK HALL     PR5 5RS    JANET GALLAGHER          01772 330724 01772 620160
DR G W AHAD                     STATION SURGERY                   8 GOLDEN HILL LANE   LEYLAND          PR25 3NP   CAROL DONNAN             01772 622505 01772 457718
DR H D SULE & PARTNER           MOSS SIDE MEDICAL CENTRE          16 MOSS SIDE WAY     LEYLAND          PR26 7XL   JANET McGRATH            01772 623954 01772 622897
DR I H JONES                    THE HEALTH CENTRE                 COLLISON AVENUE      CHORLEY          PR7 2TH    JAYNE PRESTON            01257 268955 01257 241870
DR J PARKER & PARTNERS          WORDEN MEDICAL CENTRE             WEST PADDOCK         LEYLAND          PR25 1HW   TRACY WILLIAMS           01772 423555 01772 623878
DR K BROWN & PARTNERS           ACRESWOOD SURGERY                 5 ACRESWOOD CLOSE    COPPULL          PR7 5EJ    LYNDA KEELEY             01257 793578 01257 794005
DR K K GARG & PARTNER           CROSTON MEDICAL CENTRE            30 BROOKFIELD        CROSTON          PR26 9HY   GLENNYS PARR             01772 600081 01772 601612
DR K MASHAYEKHY                 VILLAGE SURGERY                   WILLIAM STREET       LOSTOCK HALL     PR5 5RZ    BEVERLEY MASHAYEKHY      01772 697666 01772 697888
DR K PATEL & PARTNERS           CENTRAL PARK SURGERY              BALFOUR STREET       LEYLAND          PR25 2TD   ANNE-MARIE MILLER        01772 623110 01772 623885
DR LYONS & PARTNER              THE HEALTH CENTRE                 COLLISON AVENUE      CHORLEY          PR7 2TH    JACCI ROWLEY             01772 644186 01257 232285
DR M FRANCE & PARTNERS          WITHNELL HEALTH CENTRE            RAILWAY ROAD         WITHNELL         PR6 8UA    MARYLIN CLOWES           01254 830311 01254 832337
DR M S J GALE & PARTNER         THE HEALTH CENTRE                 COLLISON AVENUE      CHORLEY          PR7 2TH    PAT STRINGER             01257 262104 01257 232285
DR N S McCRAITH & PARTNERS St MARY'S HEALTH CENTRE                COP LANE             PENWORTHAM       PR1 0SR    GWEN ADAMS               01772 744404 01772 752967
DR O A ELHALHULI                ADLINGTON MEDICAL CENTRE          22-24 BABYLON LANE   ADLINGTON        PR6 9NW    JUNE FERNANDE            01257 482076 01257 474770
DR P BAMFORD & PARTNER          THE HEALTH CENTRE                 COLLISON AVENUE      CHORLEY          PR7 2TH    SUSAN HARTLEY            01772 644184 01257 235585
DR P R CURTIS & PARTNERS        SANDY LANE SURGERY                SANDY LANE           LEYLAND          PR25 2EB   CHRISTINE KERBER         01772 909917 01772 909911
DR Q AHMAD                      CROSTON VILLAGE SURGERY           OUT LANE             CROSTON          PR26 9HJ   DIANA HEATON             01772 600722 01772 600448
DR R A EVISON & PARTNERS        REGENT HOUSE SURGERY              21 REGENT ROAD       CHORLEY          PR7 2DH    SUE JEZZARD              01257 264842 01257 231387
DR R DASGUPTA & PARTNER         KINGSFOLD MEDICAL CENTRE          WOODCROFT CLOSE      PENWORTHAM       PR1 9BX    WENDY BATE               01772 746492 01772 909141
DR R J C BENNETT & PARTNER THE SURGERY                            20 DOCTORS LANE      ECCLESTON        PR7 5RA    ANNE SINGLETON           01257 451221 01257 450911
                                                                                                                   PAT COOK -
DR S D MOSS & PARTNERS          LONGTON HEALTH CENTRE             LIVERPOOL ROAD       LONGTON          PR4 5HA    KATH SWAIN               01772 615429 01772 611094
DR S E LEWIS & PARTNER          VILLAGE SURGERY                   2 CHURCHSIDE         NEW LONGTON      PR4 4LU    KAREN RIMMER             01772 613804 01772 617812
DR S N HILTON & PARTNER         CUNLIFFE MEDICAL CENTRE           41 CUNLIFFE STREET   CHORLEY          PR7 2BA    SHIELA ECKERSLEY         01257 267127 01257 234665
DR S R LORD & PARTNER           EUXTON MEDICAL CENTRE             St MARY'S GATE       EUXTON           PR7 6AH    CHRISTINE MEREDITH       01257 267402 01257 271501
DR T LEELAKUMARI                STATION SURGERY                   8 GOLDEN HILL LANE   LEYLAND          PR25 3NP   GLENNYS PARR             01772 622808 Fax not working at present
DR THORNLEY PCT LOCUM           EAVES LANE SURGERY                311 EAVES LANE       CHORLEY          PR6 0DR    GILLIE BUCK              01257 272904 01257 266821
DR V K KHANNA & PARTNER         CLAYTON BROOK SURGERY             62 TUNLEY HOLME      BAMBER BRIDGE    PR5 8ES    JANICE FISHWICK          01772 313950 01772 620467
DR W R ALMOND & PARTNERS        LIBRARY HOUSE SURGERY             AVONDALE ROAD        CHORLEY          PR7 2AD    JENNY PARRY              01257 262081 01257 232114

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Appendix 7                   Preston PCT Pharmacies Participating in the Pharmacy First Scheme

         Pharmacy Name                                                                  Address                           Telephone              Fax
Alliance Pharmacy.                   Unit 5, Kwik Save Development, Ribble Village Local Centre, 198 Miller Rd, PR2 6NH       01772 654139   01772 654139
Alliance Pharmacy.                   76, Pedders Lane, Ashton, Preston, PR2 1HN                                               01772 726149   01772 726149
Asda Pharmacy                        Asda Superstore, Eastway, Fulwood, Preston, PR2 5SP                                      01772 703174   01772 703174
Ashton Pharmacy                      33 Ashton Street, Preston, PR2 2PP                                                       01772 726383   01772 426383
Avenham Pharmacy.                    42, Avenham Lane, Preston, PR1 3TS                                                       01772 259915   01772 259915
Boots The Chemist                    Unit C2, Deepdale Retail Park, Blackpool Rd, Preston, PR1 6QY                            01772 792265   01772 703813
Boots The Chemist                    10 - 13 Fishergate, Preston, PR1 3QA                                                     01772 254517   01772 880079
Boots The Chemist                    440 Blackpool Road, Ashton on Ribble, Preston, PR2 2LP                                   01772 726602   01772 768613
Broadway Pharmacy                    331 Garstang Road, Preston, PR2 4UP                                                      01772 717574   01772 717574
D.D.L Davies                         59-61 Plungington Road, Preston, PR1 7EN                                                 01772 556030   01772 562067
Frenchwood Pharmacy                  1 Ruskin Street,Preston, PR1 4NA                                                         01772 491185   01772 252469
Gamull Pharmacy                      Ribbleton Medical Centre, 245 Ribbleton Avenue, Preston, PR2 6RD                         01772 796142   01772 796518
Goosnargh Pharmacy                   6, Church Lane, Goosnargh, PR3 2BE                                                       01772 865238   01772 865238
Ingol Pharmacy                       86, Village Green Lane, Ingol, Preston, PR2 7DS                                          01772 726955   01772 726955
Kadri Pharmacy                       87-89 Meadow Street, Preston, PR1 1TS                                                    01772 823751   01772 467467
Knights Pharmacy                     14 Elswick Road, Larches Estates, Ashton Preston, PR2 1NT                                01772 728111   01772 728111
Lloyds Pharmacy                      112 Deepdale Road, Preston, PR1 5AR                                                      01772 254937   01772 203205
Lloyds Pharmacy                      3,Lytham Road, Fulwood, Preston, PR2 2JE                                                 01772 718022   01772 716083
Lloyds Pharmacy                      258, New Hall Lane, Preston, PR1 4ST                                                     01772 493257   01772 493258
Lloyds Pharmacy                      Geoffrey Street Health Centre, Geoffrey Street, Preston, PR1 5NE                         01772 493224   01772 493224
Lloyds Pharmacy                      234-236 Deepdale Road, Preston, PR1 6QB                                                  01772 493234   01772 493235
Lloyds Pharmacy Ltd                  40 Berry Lane, Longridge, Longridge, Preston, PR3 3JJ                                    01772 782643   01772 782643
Lloyds Pharmacy Ltd                  78-80 Lancaster Road, Fulwood, Preston, PR1 1DD                                          01772 250486   01772 250486
Lloyds Pharmacy Ltd                  Longsands Lane, Preston, PR2 9PS                                                         01772 653031   01772 653031
Moor Park Pharmacy                   32, Garstang Road, Preston, PR1 1NA                                                      01772 555150   01772 555150
Morrisons Pharmacy                   Wm Morrison Supermarket, Mariners Way, Ashton on Ribble, Preston, PR2 2YN.               01772 732925   01772 732925
Pomfrets Chemist                     22 Lancaster Road, Preston, PR1 1DA                                                      01772 252468   01772 562116
Ribbleton Pharmacy                   182 Ribbleton Avenue, Ribbleton, Preston, PR2 6QN                                        01772 796131   01772 702145
Rowland‟s Pharmacy                   Blanche Street, Preston, PR2 2RC                                                         01772 721893   01772 736489
Sainsburys Pharmacy                  Sainsburys Store, Flintoff Way, Off Deepdale Road, Preston, PR1 6PJ                      01772 651374   01772 651374
Sharoe Green Pharmacy                Unit 9, Booths Shopping Complex, Sharoe Green Lane, Fulwood, Preston, PR2 9HD            01772 712244   01772 712288
Smithson‟s Pharmacy                  51 Fishergate Hill, Preston, PR1 8DN                                                     01772 252033   01772 251020
Stonebridge Pharmacy                 Units 2&3, Stonebridge Pde, Preston Rd, Longridge, Preston, PR3 3AN                      01772 784700   01772 784700
Superdrug Pharmacy                   43 Friargate, St.Georges's Centre, Preston, PR1 2NQ                                      01772 253752   01772 253752

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Appendix 8

 Appendix 9

                                                                                            PATIENT ADVICE
         Is the patient presenting with symptoms that may                            Suggest (as appropriate)
          be related to any of the minor ailments included
                                                                       NO               OTC Sale.
                  in the „Pharmacy First‟ Scheme?                                       Routine GP appointment.
                                                                                        Urgent doctor‟s appointment
                                  YES                                       NO

          Is the patient registered with a participating GP

                                                                                 Suggest (as appropriate)
          Is the patient exempt from paying a prescription                                OTC Sale.
          charge?                                                                         Routine GP appointment.
                                    YES                                NO                Urgent doctor‟s appointment
                                                                                         Pharmacy First supply
      Has the patient already registered with the
      scheme and has been previously supplied with
      a Pharmacy First Passport?

      Has the patient presented the Passport at the              NO                  Request patient to return with Pharmacy
      pharmacy?                                                                       First Passport.

NO                             YES
                                                                                 Suggest (as appropriate)
      Is there any reason why any a Formulary                                       OTC Sale.
      medicine identified in the Minor Ailment                   YES                Routine GP appointment.
      Protocol should not be supplied following                                     Urgent doctor‟s appointment
      reference to the Passport?

                                                                                 Suggest (as appropriate)
     Is the patient excluded from treatment from
                                                                  YES               OTC Sale.
     within the scheme according to Pharmacy First                                  Routine GP appointment.
     Minor Ailment Protocol?                                                        Urgent doctor‟s appointment

     Is the particular medication to be supplied from
     the Pharmacy First Formulary normally routinely                                 Request patient to order routine repeat
     prescribed for the patient on repeat prescription                                prescription.
     by their doctor (See PMR‟s)?

     Does the patient refuse the appropriate medicine            YES             Suggest (as appropriate)
     as identified in the Pharmacy First Formulary?                                 OTC Sale.
                                                                                    Routine GP appointment.
                                                                                    Urgent doctor‟s appointment
     Document refusal by the patient.                            YES             Suggest (as appropriate)
                                                                                    OTC Sale.
                                                                                    Routine GP appointment.
                           NO                                                       Urgent doctor‟s appointment
      Supply if appropriate medicine from Pharmacy First Formulary.
     Counsel patient on appropriate management of symptoms and the use
     of medicines if supplied. Provide PIL if appropriate.
     Issue or update Pharmacy First passport – instruct patient of
     importance of producing passport for any future consultations with
     any pharmacy across the PCT.
     Complete documentation with patient. and collect prescription charge
     if appropriate.,                                                                                                 23
     Explain that the consultation document may be shared with Preston
     PCT for audit and may be provided to the patient‟s GP.
Appendix 10

              Minor Ailment Protocols

         Allergic Rhinitis (including hayfever) Protocol
         Definition                  Allergic hypersensitivity reaction of the nose with or without conjunctiva of the eyes caused by pollen or other allergen
         Symptoms                    Rhinorrhoea (nasal discharge)
                                     sneezing,
                                     nasal congestion
                                     nasal itching
                                     red, watery and/or itchy eyes
         Common allergens            Pollen, house dust mite droppings, pet hairs, mould spores
Advice                              Hay fever
                                     Remain indoors with windows closed esp. mid-morning and early evening
                                     Avoid fields, newly mown grass, fruit picking and touching outdoor animals
                                     Wear close fitting sunglasses
                                     Choose an air-conditioned car
                                     Follow pollen counts (e.g.
                                    Perennial rhinitis
                                     Dust using sprays and vacuum twice weekly
                                     Wash all bedding at 60oC weekly
                                     Cover pillows and mattresses with plastic (use non-allergenic pillows)
                                     Remove anything that collect dust from the bedroom e.g. rugs, stuffed toys, open cupboards
                                     Treat furniture and carpets with ascaricides (e.g. benzyl benzoate) to control dust mites and fungicide
                                     Pets should be kept out of the bedroom (or house if possible)
                                     Use vacuum cleaners with high-efficiency particulate air cleaner (HEPA) filters
         Pharmacy First Formulary    Chlorpheniramine Tabs 4mg (30)
                                     Chlorpheniramine Syrup 2mg/5ml (150ml)
                                     Cetirizine 10mg tablets (30)
                                     Cetirizine Oral Solution 5mg/5ml (150ml)
                                     Sodium cromoglycate 2% eye drops (10ml)
                                    Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations
                                    and/or the BNF/Mims.
         When to refer               Children under 12 years old
                                     Pregnant and breastfeeding women
                                     Symptoms unresponsive to treatment
                                     Severe persistent symptoms (provide initial treatment)
                                     Patient is wheezing and/or short of breath
                                     Rhinitis accompanied by:
                                          Earache or facial pain (sinusitis/otitis media)
                                          Purulent (green/yellow) discharge from the eyes
         Review Date                April 2006

Athlete‟s Foot Protocol
Definition                    Fungal infection of the feet, which is otherwise known as Tinea pedis.

Description of symptoms       The fungus is most often confined to the skin between the toes but it can also affect other nearby areas of the foot.
                              The most common symptom is a persistent itching of the skin.
                              As the infection progresses, the centre of the infection becomes inflamed and sensitive to the touch.
                              Gradually, the edges of the infected area become milky white and the skin begins to peel.
                              In some patients the area becomes very sore and cracks develop in the skin, making the patient susceptible to secondary
                                bacterial infection.

Pharmacy First Formulary           Miconazole cream (30g)
                                   Clotrimazole cream (20g)
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                           the BNF/Mims.

Other advice to be given      Continue using the cream for two weeks after the infection appears to have cleared to eradicate all remaining fungal spores.
                              Anti-fungal sprays and powder may be purchased for direct application to shoes and hosiery.
                              Wash and dry feet thoroughly, especially between the toes.
                              Wearing clean wool or cotton socks allows the skin to breath.
                              Athlete‟s foot is more common in people that wear artificial soles and especially trainers and sports shoes.
                              It can help to expose feet to the air where possible.
                              Avoid walking barefoot in public areas.

When to refer                 Treatment failures. The diagnosis may need to be confirmed with a lab test.
                              If the infection spreads to the toenails. Here it causes the nail to become thick, discoloured and crumbly.
                              If the fungal infection spreads to other areas of the body.
                              If the condition is complicated with a secondary bacterial infection which takes advantage of the damaged skin. Any
                               patient presenting with symptoms of cellulitis (e.g. spreading redness, pain and tenderness) should be referred immediately.

Review Date                April 2006

Cold Sores Protocol
                              Cold sores are very common caused by the herpes simplex virus
Definition                    They are characterised by fluid blisters which appear on red swollen areas of the skin or on the mucous membranes.
                              The blisters heal without scarring but tend to reoccur.

Precipitating factors         The virus can only be transmitted by close personal contact such as kissing.
                              Most people will have come into contact at an early age but generally do not show symptoms until after puberty usually when the immune
                               system becomes comprised eg due to a heavy cold.

Advice to be given            Early recognition of symptoms may be a tingling sensation after which scabs appear and typically fall off after 8 to 10 days.
                              Treatment should begin as soon as possible.
                              In children, the virus can infect the mouth and throat and can be accompanied by fever, aches and pains.
                               Cold sores should not be touched as this can spread infection therefore hands should be washed before and after each application of
                               the cream.

Pharmacy First Formulary    Aciclovir 5% cream (2g)
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                           the BNF/Mims.

Side effects                  Transient stinging or burning, occasional erythema, itching or drying of the skin.
                              Avoid contact with eyes and mucous membranes.

When to refer                 Patient is immunocompromised eg AIDS
                              Infection of mucous membranes, eye or vagina
                              Pregnancy
                              Children under 12 should be referred automatically if intra oral and not just the lips.

Review Date                April 2006

Constipation Protocol
                             Constipation can be a reduced frequency of stools compared to the patient‟s normal bowel habits, difficulty in passing stools or a sense of
 Definition                 incomplete emptying after a bowel movement.
Precipitating factors           Diet (poor or low-fibre diet)
                                Inadequate fluid intake
                                Lack of physical activity
                                Other medication – if appropriate, medication may need to be reviewed.
                                Regularly suppressing the urge to defecate
                                Stress and travel
                                Certain conditions and diseases (e.g. IBS, pregnancy, hypothyroid or neurological diseases)
 Pharmacy First Formulary       Immediate relief
                                 Senna tablets (20) – for acute simple constipation.
                             Medium-term treatment
                                 Ispaghula sachets (10) – useful where dietary intake of bulk is low.
                                 Lactulose solution (300mL) – valuable when the major problem is the passing of hard, painful stools.
                            Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                            the BNF/Mims.
 Advice to be given         Regular doses of laxative are rarely required.
                            Give advice on changes that can help prevent re-occurrence
                                 Increase dietary fibre (e.g. fruits, vegetables and whole grains)
                                 Increase fluid intake
                                 Increase physical activity
 When to refer               If the constipation persists beyond one week.
                             If an infant or child has not had a bowel movement in 3 days OR any infant younger than 2 months.
                             Nausea and vomiting are also present.
                             Sharp or severe abdominal pain, especially if also bloated.
                             Sudden constipation with abdominal cramps and an inability to pass gas or stool.
                             Unexplained weight loss.
                             Blood in the stool.
                             Rectal pain.
                             Constipation alternating with diarrhoea.
                             If patient is regularly requesting laxatives.
 Review Date                April 2006

Cough, Cold and Flu-like Illnesses (Viral URT infections )
including Fever Protocol
                                  Cough, Cold and Flu-like Illness (Viral URT infections) including Fever
How common is it?                 Very Common. Children are more at risk to developing upper respiratory tract infections.
                                  There are over 1000 types of cold virus1.
Description of symptoms           Cold symptoms include - cough (dry or productive), mild fever, runny or blocked nasal cavity, sneezing and watery eyes, sore throat
                                  Flu-like symptoms include - feeling hot or cold or shivering, high temperature, headache, muscle and bone aches, dry cough. Runny nose
                                   and sneezing may also occur
                                  A cough is the body‟s way of removing mucus or dust from the lungs 2.
                                  A productive cough (chesty cough) is associated with phlegm or mucus, may be accompanied by earache and can occur if there is a chest or
                                   ear infection possibly of viral origin.
                                  A dry cough is a tickly feeling in the back of the throat that is not associated with production of mucus.
                                  Cold and Flu symptoms are similar but Flu is more severe and last longer
                                  General feeling of being unwell.
Precipitating factors             Infection.
                                  Drug therapy on rare occasions ( ACE inhibitors may induce cough).
Advice to be given                Give palliative treatment for symptoms.
                                  Rest and avoid strenuous exercise if symptoms are severe.
                                  Drink plenty of non-alcoholic fluids particularly hot water with honey and lemon have a soothing effect
                                  In patients aged 65years and over, those with chronic illnesses such as asthma, emphysema, heart disease, kidney disease and diabetes or
                                   those living in residential care should be advised to on the benefits of annual influenza vaccination each October/November.
                                  Normal body temperature is 37oC
                                  Fever is a natural defence mechanism to infection
                                  Advice on the appropriate dose of medicine supplied for children and the maximum daily dose of Paracetamol if supplied
                                  Smoking cessation advice if appropriate

Pharmacy First Formulary           Paracetamol tabs (32) or suspension (100mL/200mL) for analgesia or for pyrexia. Choose Paracetamol as the analgesic and/or antipyretic of
                                Ibuprofen tablets 200mg (24) for analgesia or for pyrexia,
                                Xylometazoline nasal drops (10mL) (<7 days treatment), Pseudoephedrine tabs (24) or linctus (100ml), Normal saline (0.9%) nasal drops
                                    (10mL) or menthol and eucalyptus inhalation (100mL) as decongestants (care in patients with high BP)
                                Pholcodine linctus (200mL) and Pholcodine Paediatric linctus (90mL/100mL) as suppressant for dry cough.
                                Patients should be referred to the GP if repeated requests are made for Pholcodine and the GP informed.
                               Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                               the BNF/Mims.

Non pharmaceutical treatment      Hot water inhalations (for chesty / productive coughs)
                                    Hot shower or bath before bedtime.
                                    Keep room warm but airy, don‟t wrap children up too warmly
                                    Sponge children with lukewarm water if temperature is high
                                    Drinking plenty of non-alcoholic fluids can help to thin the mucus with chesty cough.
                                    Avoid smoking and smoky rooms.
    When to refer                   Suspected meningitis – vomiting, fever, stiff neck, light aversion, drowsiness, joint pain, fitting and rash
                                    In the very young (children under 1 year) when the child is unwell and associated with either:

                                    High temperature (above 40oC)

                                    Poor feeding
                                     Abnormal breathing.
                                    If child acts oddly i.e. changes in speaking, walking, unable to sit up, drowsy all the time
                                    Severe earache2.
                                    In the elderly (over 75) who are of poor health (heart or lung disease).
                                    Persistent fever more than 4 days and cough for more than 5 days or if symptoms are worsening and not responding to adequate treatment.
                                    Chest pain.
                                    Worsening asthma with no self-management plan.
                                    If there is wheezing with breathing or shortness of breath Dyspnoea/wheeze asthma (especially night cough) of longer than 2 weeks
                                    Blood in phlegm or phlegm/sputum is green
                                    Unexpected loss in weight (associated with cough)
                                    Check if patient is on drug therapy (ACE inhibitor) – advise patient to discuss with GP at next routine appointment
                                    Temperatures regularly over 41C..
                                    Patients recently returned from foreign travel (particularly in malarious areas).
                                    Patients that appear to be very unwell or have symptoms that suggest an infection that may need other GP input
                                    Any other reason which makes you professionally wary of making a supply.

    Review Date                  April 2006

  E Van der Does & R.G. Metz What should I do? Do I go to the doctors?
  The NHS Home Healthcare Guide 1998
  A. Blenkinsopp et al. Symptoms in the Pharmacy 1995

Cystitis Protocol
Description                    Inflammation of the bladder lining due to infection (most commonly bacterial), irritation or damage.
How common is it?              Common in young women in particular.
Description of symptoms        Increase in frequency and urgency of urination. However, only small amounts of urine are excreted. Patient may feel that they are unable to
                                empty the bladder.
                            Burning, stinging or pain on urination.
                            Urine may be dark, have a strong odour, be cloudy and on occasion contain traces of blood.
                            Pain in the lower back or abdomen.
                            Malaise, fever, nausea and vomiting.
                            The only symptoms with which elderly patients may present are confusion, weakness, falls or a general feeling of being unwell.
                            Children may be irritable, have a reduced appetite, may be vomiting or may display signs of discomfort during urination.
  Advice to be given        Drink at least eight glasses of water each day.
                            Wipe bottom from front to back after going to the toilet.
                            Use a hot-water bottle to alleviate abdominal pain.
                            Drinking plenty of cranberry juice may prevent bacteria from adhering to the bladder wall and thus reduce the duration of the infection.
                            Avoid alcohol and caffeine as these may dehydrate the patient further.
                            Wear cotton underwear.
                            Try to completely empty the bladder when urinating.
                            If symptoms are related to sexual intercourse, advise patient to empty bladder within an hour after intercourse.
                            Alkalising agents, for example, potassium citrate, sodium bicarbonate and sodium citrate may ease the discomfort of urination.         N.B.
                                Exercise caution when recommending sodium based agents to patients with cardiac disease or hypertension and when recommending
                                potassium based agent to patients who are already taking potassium-sparing diuretics, aldesterone antagonists and ACE inhibitors, as
                                hyperkalaemia may occur
Pharmacy First Formulary    Paracetamol tabs (32) may ease abdominal pain
                            Potassium Citrate Mixture (200ml).
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                           the BNF/Mims.
When to refer               Male patients.
                            Children under 12
                            Pregnant women.
                            Vaginal discharge
                            Diabetics.
                            Blood in the urine.
                            Symptoms unresolved after 2-4 days, with or without treatment using alkalising agents.
                            Recurrent attacks.
                            Fever or vomiting.
Review Date                April 2006

Diarrhoea Protocol
                                  An increase in the normal frequency of bowel movements with the passage of abnormally soft or watery faeces
Description of symptoms         Sudden onset (acute diarrhoea)
                                5 or more watery or loose stools
                                Abdominal cramps, flatulence, weakness and malaise may be present
Precipitating factors           Ingestion of contaminated food or water, medicines, poor personal hygiene
Advice to be given              Self-limiting condition
                                Recommend „wait and see‟ for the first 24 hours
                                Replacement of lost fluids is normally the only treatment required.
Pharmacy First Formulary        Oral re-hydration therapy (ORT)With Dioralyte Sachets (6)
                               Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                               the BNF/Mims.
Non pharmaceutical treatment    Drink plenty of fluids (at least 1.5 litres daily)
                                Adults and older children should avoid dairy products and fruit juice for the duration of symptoms
When to refer                   Young children
                                     Symptoms for more than 24 hours if under 1 years old
                                     Symptoms for more than 2 days if under 3 years old
                                Elderly (symptoms for more than 2 days if over 70 years old
                                Apparently anorexic patients
                                Symptoms present for more than 3 days with colic symptoms and generally unwell
                                Diarrhoea accompanied by:
                                     Fever
                                     Severe vomiting
                                     Weight loss
                                     Blood or mucus in stools.
                                     Signs of dehydration
                                Persistent change of bowel habit
                                Recent travel to a foreign country
                                Patient is taking/recently finished a course of antibiotics
Review Date                    April 2006

Earache Protocol
Definition                  Earache is caused by the build-up of fluid and pressure in the middle ear.
                            The middle ear is drained by the Eustachian tube into the nasal passages. A cold or allergy can cause this tube to become blocked leading to
                           a build up of pressure in the middle ear.
                            Earache is more common in young children where the Eustachian tube is smaller and more easily blocked.

Description of symptoms     An earache can be a sharp, dull or burning pain.
                            The pain may be transient or constant
                            Stuffiness and there may be some hearing loss
                           When dealing with infants signs often include:
                            Increased irritability and crying
                            Pulling at the ears
                            If the symptoms are caused by an infection then high temperature and flu- like symptoms may also occur

Patient History             When taking a history it is important to ask about provoking factors such as:
                              A cold
                              Hay fever
                              Where water might get in the ear (e.g. swimming) and sudden changes in pressure (especially children).
                            Treat only when it is a simple case of earache. All infections of the ear need to be referred.
                            Other infections and problems of the nose, mouth, throat and jaw can also cause pain in the ear.

Pharmacy First Formulary    Paracetamol tablets (32) or suspension (100mL/200mL).
                            Ibuprofen tablets 200mg (24) or suspension (100mL)
                            Pseudoephedrine tabs (24) or linctus (100mL)
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                           the BNF/Mims.

Advice to be given          Decongestants can help open the Eustachian tubes. Decongestants are for short-term use only (rebound congestion with long-term use) N.B.
                           Caution in hypertension & diabetes.
                            Apply a cold wet washcloth to the outer ear to reduce discomfort.
                            Steam could help keep mucous thin and clear the Eustachian tubes.

                 Children under 3 months old
When to refer    Earache continues for more than 12 hours after taking painkiller
                 Symptoms have been present for longer than 3 days.
                 Rapid noticeable hearing loss
                 Constant ringing,buzzing or hissing in ears
                 All ear infections need to be referred. The following all suggest an ear infection.
                   Presence of severe pain
                   Continuous pain
                   Presence of discharge from the ear
                 Fever or raised temperature, nausea, vomiting, dizziness or loss of balance.
                 Symptoms have been present in the previous 3 months

Review Date     April 2006

Eczema Protocol (N.B. The terms eczema and dermatitis may be used interchangeably.)
                           Three main types:
Definition                     Atopic – an inherited condition. This may occur in conjunction with asthma, hayfever or rhinitis.
                               Irritant – occurs due to lack of natural oil in the skin caused by soaps, disinfectants, detergents or chemicals at work or at home.
                               Allergic – mediated by an immune reaction to a substance which has made contact with the skin. The reaction occurs on subsequent exposures after the
                                initial exposure. Examples of allergens include cosmetics, hair dyes, nickel, chromium and some plants.
How common is it?                  It occurs in up to 20% of children and up to 10% of adults.
Description of symptoms        Extremely itchy, red, inflamed and/or dry skin.
                               New areas may weep or become crusted.
                               Chronic atopic eczema may lead to thickened and scaly (lichenified) skin.
The “Itch-Scratch” cycle       Eczematous skin is very itchy scratching temporarily relieves the itching but also releases inflammatory mediators which cause further itching and
                           scratching skin becomes more damaged allowing penetration of Staphylococcus aureus toxins which dry out the skin and cause more itchiness.
Goals of treatment             Maintaining healthy skin.
                               Treating damaged skin as soon as symptoms occur.
                               Preventing further “flare-ups”.
Pharmacy First Formulary       Aqueous Cream (500g), Emulsifying Ointment (500g), Hydrocortisone Cream 1% (15g)
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or the
General Information            Emollients – moisturisers replace lost moisture in the skin, prevent further loss of moisture, help restore the “epidermal barrier”, may act as anti-
                                inflammatory agents and finally, allow smaller doses of steroids to be used without lowering their potency if used regularly and frequently. Emollients
                                should continue to be used during treatment with steroid creams but at a different time of day.
                               Topical steroids – used to treat “flare-ups” by reducing skin inflammation and itching. Overuse may lead to skin-thinning and steroid-induced rosacea on
                                the face. In order to avoid these side-effects there are important rules to follow:
                            Apply steroids sparingly. The fingertip unit may be used as a rough guide. This is the amount of cream needed to cover the area between the first crease
                                of the index finger to the tip. Half a finger-tip unit of steroid cream should cover an area the size of the flat of the hand.
                            As soon as a clinically-acceptable effect has been achieved, stop using the topical steroid. As a general rule, OTC steroid creams should be used for no
                                longer than a week. If flare-ups require treatment with a steroid cream for longer than this, it should be under medical supervision only.

Points to remember            Try to identify the cause of irritant or allergic eczema and advise the patient to avoid further contact with the substance.
                              Steroid creams are open to potential misuse as skin-lighteners. Be aware of this and exercise caution where appropriate.

When to refer                  If you are unsure of the diagnosis.
                               If there is little or no response to a moderately potent steroid cream after one week.
                               If the face, genitals or armpits are severely affected by eczema.
                               If a diagnosis of seborrhoeic eczema or psoriasis is suspected or confirmed.
                               In cases of severe eczema in children under 12 years of age or pregnant women.
                               If the eczema is crusty, weeping, has pustules, is unusually inflamed or has suddenly worsened. This would indicate a bacterial infection of the eczema.
                                If viral or fungal infections are suspected, these should also be referred to the G.P.
Review Date                April 2006

Headache Protocol
    Description            Tension headache
                                Usually bilateral, non-pulsating, does not affect normal routine. Described as tightness or squeezing around
                                the head
                           Ice-cream/ice-pick” headache
                                Short piercing pain usually behind one eye for periods up to several minutes, several times a day. Can be triggered by cold food.
                                Described as “like a flash of lighting”
                                Usually unilateral, pulsating, moderate to severe in severity for periods of 4-72 hours. Patient may also have photophobia, aura (e.g.
                                visual disturbance) and/or nausea and vomiting. Normally affects ability to perform normal activity during headache but patients are
                                symptom free between attacks
                           Chronic daily headache
                                Headache often with neck stiffness for more than 4 hours a day for more than 15 days a month. Can be caused by analgesic dependence
                           Cluster headache
                                 Severe sudden onset unilateral headache around the eyes, often with red, watery or swollen eye(s), droopy eyelid, stuffy or runny nose or
                                 sweating. Normally lasts between 15-180 minutes with varying frequency
Pharmacy First Formulary    Paracetamol 500mg tablets (32), 120mg/5ml or 250mg/5ml suspensions (100mL/200mL) (liquid preparations have rapid onset of action)
                            Ibuprofen 200mg tablets (24), or 100mg/5ml suspension (100mL)
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations
                           and/or the BNF/Mims.
Non pharmaceutical          Stress management
management                  Avoiding tyramine containing food (e.g. cheese, red wine, chocolate) may be helpful for migraine sufferers
                            Neck exercises may be helpful to patients who suffer from chronic daily headaches
                            Eye test
When to refer               Undiagnosed migraine - Check if taking the oral contraceptive pill, cluster or chronic daily headache
                            Recent head injury within the last 14 days.
                            Sudden onset described as “sudden blow to the head” (subarachnoid haemorrhage)
                            Headache associated with:

                                   High temp, stiff neck, photophobia, drowsiness, vomiting, anorexia, rash, unequal pupils, symptoms of meningitis- bulging
                                    fontanelle in babies, rash or seizures.

                                   Jaw pain, scalp or muscle tenderness, , general malaise esp. if over 50 years of age (cranial arteritis)
Review Date                April 2006

Headlice Protocol
Definition                         Infestation of scalp by live head lice
Diagnosis                          The only way to confirm an infection is by seeing a live louse.
                                    Hatched lice and eggs are difficult to see on the hair.
                                    Use a detection comb over white paper to confirm diagnosis. The combing should begin at the top of the head with the comb touching
                                       the scalp, then draw the comb slowly through the hair to the ends.
                                    Lice are about 2 - 3mm long and vary from grey to brown in colour. The eggs (nits) are attached to the hair shaft close to the scalp;
                                       they are white to grey in colour and approximately 2mm long.
                                Itchiness of the scalp can occur but this usually happens several weeks after infestation.
Pharmacy First Formulary        Phenothrin 0.2% lotion (1st choice) (50mL x 1 or 2 bottles)
                                Malathion 0.5% aqueous liquid and lotion (50mL x 1 or 2 bottles)
                               Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations
                               and/or the BNF/Mims. Normally supply 50mL for each application (2 applications are required 7 days apart)
General Information             Only treat if live lice are located.
                                All infected members of the household should be treated at the same time ie within 24hours. The patient will have to confirm that live lice
                               have been identified in other close members of the family before product is supplied for each infected member. Each family member will have
                               to be registered into the scheme and be under the care of one of the participating GP practices.
                                Alcoholic lotions are suitable for people with normal healthy skin.
                                Aqueous lotions are the treatment choice for small children, asthmatics and patients with eczema or other skin disorders.
                                In general, a course of treatment for head lice should be 2 applications of product 7 days apart to prevent lice emerging from any eggs that
                               survive the first application.
                                Not using products properly accounts for about a third of all treatment failures.
                                Head-lice repellent is on sale to the public but its effectiveness is uncertain.
Advice to be given              Ensure that a patient information sheet is given.
                                Contact tracing – Contacts include anyone who is likely to have had head-to-head contact with the infected individual in the last month.
                               They should be advised to have their hair checked for live lice.
                                „Wet combing‟ is a good way to keep an eye out for the first signs of infection and it is recommended that parents wet comb their
                               children‟s hair once a week.
                                Provide a patient information leaflet
Non pharmaceutical treatment    Wet combing methods. This typically involves meticulous combing (for about 30 minutes each time) with a detection comb and hair
                               conditioner over the whole scalp at 4-day intervals for a minimum of 2 weeks. The evidence to show this method works is lacking. Several
                               products are available to the public.
When to refer                   Treatment failures with Malathion and Phenothrin.
                                Children under 6 months
                                Pregnant or breastfeeding women.
Review Date                    April 2006

Indigestion Protocol
Definition                         Upper abdominal discomfort, pain associated with food/hunger relieved by antacids, symptoms causing sleep disturbance, nausea and
                           Gastro-oesophageal reflux
                                   Heartburn, acid regurgitation, epigastric pain, belching, waterbrash

Advice                        Eat small regular meals, avoid eating on the go or rushing meals
                              Avoid foods which may aggravate symptoms e.g. spicy or fatty foods
                              Lifestyle management e.g. smoking cessation, alcohol consumption, weight loss
                              Elevating the head position during sleep for relieving nocturnal heartburn
                              Stress management

Pharmacy First Formulary   Gaviscon liquid (150mL)
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations
                           and/or the BNF/Mims.

When to refer                 First symptoms of indigestion at 55 years old or over
                              Patients who:
                                Received abdominal surgery
                                Have a history of gastric ulceration
                                Receiving NSAIDs or other medicines known to cause gastric irritation
                                Pain in the chest indicative of another aetiology
                              Indigestion accompanied by:
                                Unexplained weight loss
                                Blood in stool (fresh blood or black and tarry stools)
                                Difficulty in swallowing, food „sticking‟ in the throat
                                Lump in the throat
                                Severe epigastric pain
                                Persistent vomiting
                              Symptoms for more than 2 weeks

Review Date                April 2006

Mouth Ulcers Protocol
Definition                  A mouth ulcer is any ulcerative lesion affecting the oral mucosa.
                            The term aphthous stomatitis refers to the condition of recurrent mouth ulcers.
Description                 Minor aphthous ulcers are the most common (8 in 10 cases). Usually, there is only one ulcer but up to 5 may develop at the same time.
                           They are small (less than 10mm across) with a depressed round grey area surrounded by a red erythomatous edge. Each ulcer heals
                           spontaneously after 7-10 days without leaving a scar. They are usually not very painful.

                              Major aphthous ulcers (1 in 10 cases) are larger (greater than 10mm across) and usually only one or two appear at a time. Each ulcer
                               lasts 2 weeks to several months and then resolves leaving a scar. They can be very painful.
                              Pinpoint aphthous ulcers (1 in 10 cases) are tiny (1-2mm across) and many occur at the same time. Some may join together to form
                              irregular shapes. Each ulcer may last 1 week to 2 months.
Precipitating factors       In most cases, the ulcers develop for no apparent reason in healthy individuals.
                            Single isolated traumatic ulcers are often due to catching the gum with the toothbrush or badly fitting dentures.
                            More females than males are affected.
                            Stress or anxiety
                            Changes in hormone levels (e.g. just before their menstrual period or after the menopause).
                            A lack of certain vitamins (such as vitamin B12 or folic acid) or iron may be a factor.
                            There may be a genetic factor
                            Aphthous ulcers are common in people with crohn‟s disease, coeliac disease, HIV infection and Bechet‟s disease.
Advice to be given          Suggest the patient limits the use of sharp foods (e.g. crisps), spicy foods, hot fluids and carbonated drinks
Pharmacy First Formulary    Bonjela gel (15g)
                            Hydrocortisone lozenges (20)
                           Give clear instructions on appropriate dosage based on the manufacturers recommendations and/or the BNF/Mims.
Other advice to be given    Maintain good oral hygiene
                            Antiseptic mouthwash (e.g. Chlorhexidine) may reduce the pain, prevent the ulcer from becoming infected and may also help ulcers to
                               heal more quickly.
When to refer               If ulcer persists for more than 3 weeks then 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
                            Difficulty in swallowing or chewing not associated with a sore lesion
                            Any sore that bleeds easily
                            If there are any other symptoms other than the mouth ulcers.
Review Date                April 2006

Nappy Rash Protocol
Description                   Nappy rash is a red rash, or sore area, that affects skin under or around a baby‟s nappy.
                              The main cause is a wet or dirty nappy being in contact with the skin for too long a period of time. Human waste contains ammonia by-
                               products which also damage baby‟s skin.

Pharmacy First Formulary       Barrier creams and ointments are used for protection against nappy rash. Their ingredients act as water-repellent substances.
                            Sudocrem cream (60g)
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations
                           and/or the BNF/Mims.

General advice                When possible, leave the nappy off allowing air to get to the skin
                              If barrier cream is to be used only apply small amount.
                              Change the baby‟s nappy as soon as possible after it becomes wet or soiled
                              Clean the nappy area thoroughly after each bowel movement, and allow it to dry
                              If baby has sensitive skin or nappy rash then it is a good idea to apply a small amount of barrier cream after every wash.
                              Avoid plastic pants as these will trap moisture. Try woollen or cotton underwear on top of the nappy, which allows the skin to breathe.

When to refer                 If nappy rash is a bright shade of red, very warm or swollen. This may indicate the presence of a bacterial or fungal infection.
                              If rash continues for longer than a few days or becomes worse, even after allowing the skin to breathe and using a barrier cream.
                              In addition to the nappy rash, baby has a high temperature or seems distressed.
                              If rash does not match the description of typical nappy rash, skin is flaky or there are blisters.

Review Date                April 2006

   Oral Thrush
Definition                    Oral thrush is an infection of yeast fungus, Candida albicans, in the mucous membranes of the mouth.
Description of symptoms        Presence of sore, creamy/yellow coloured patches in the mouth
                               The patches are slightly raised
                               Scraping off the spots leaves raw areas which may bleed slightly
Who is at special risk?        Infants and elderly
                               Denture users
                               People whose immune system is suppressed by disease or medical treatments
                                Steroids and steroid inhalers
                                Immuno-suppressants or chemotherapy
                                HIV infection
                            Antibiotics may upset the normal balance of micro-organisms in the mouth
                            Adults with uncontrolled diabetes or other metabolic disturbances
                            People with poor nutrition
                            Elicit drug users
Pharmacy First Formulary    Miconazole oral gel (15g)
                                A treatment course is usually 7 – 14 days so ensure a minimum of 7 days supply is given (max 2 x 15g per consultation).
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                           the BNF/Mims.
Other advice to be given    Maintain good oral hygiene
                            If possible, address the cause of the thrush
                                Invest in better fitting dentures
                                Adjust diabetes control
                                Rinse the mouth out after using steroid inhaler
                            In breast-fed infants, the mother should also use the oral gel on her nipples to prevent continuous spread to the infant. Ensure enough gel is
                            In bottle-fed infants, the teats should be discarded once the infection begins to clear because fungus may get into the teat and cannot be
                               easily eradicated.
When to refer               Thrush that resists treatment.
                            Thrush in infants is very common but if it recurs frequently, it should raise suspicions for an underlying disorder.
                            Thrush in apparently healthy adolescents and young-middle aged adults is rare and should always be viewed as a possible symptom of an
                                 underlying medical problem
                            Sudden and intense thrush
Review Date                April 2006

Scabies Protocol
Definition                        Scabies is an allergic irritant condition resulting from the burrowing of the human scabies mite.
Description of symptoms      Intense itching and/or rash
                              Generally symmetrical on the body
                              Itching is worse when the body is hot, for example, when in bed.
                              It is most common for itching to begin on the hands and wrists.
                            A definitive diagnosis can be made on finding burrows in the skin, usually on the hands. However, these are not often seen. Burrows are
                              very small (0.5cm or less) curving white lines, sometimes with a vesicle at one end
                            People with impaired immune systems may show a different reaction to scabies
                            The skin develops thick crusts which are highly contagious (Crusted scabies)
General information         Infection only spreads through direct skin-to-skin contact with another human being.
                            The most common way to catch scabies is through hand-holding
                            Incubation is usually 4-6 weeks in patients without previous exposure
                            It is still contagious in the weeks before the symptoms appear making spread difficult to contain
                            Itching may persist for 2-3 weeks after successful treatment. During this time no new lesions should develop.
Pharmacy First Formulary    Malathion 0.5% aqueous liquid (50mL)
                            Permethrin dermal cream (30g)
                            Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations
                              and/or the BNF/Mims. Normally supply 2 units for each application. (2 applications are required 7 days apart)
                            Cetirizine 10mg tablets (7) and oral solution 5mg/5mL (75mL) (for itching).
Other advice                All members of the household should be treated at the same time even in the absence of symptoms ie within 24 hours. Each family member
                              will have to be registered with one of the participating GP practices.
                            Remember to supply a suitable quantity for each person.
                            Follow instructions in the patient information leaflet
                            Alternative symptomatic treatment of itching that may be purchased
                            Ensure a patient information sheet is given.
                            Contact tracing is the responsibility of the patient to alert anyone who may be infected.
When to refer               Children under 2 years, pregnant and lactating women should be referred to the G.P.
                            Treatment failure
                            Signs of bacterial infection
Review Date                April 2006

Sore Throat Protocol
Definition                        Sore Throat

How common is it?                 It is estimated that 90% of pharmacy consultations for sore throats are viral in origin1. This leaves 10% to be of bacterial origin. Group A
                                   beta-haemolytic streptococcus (GABHS) is the most common bacterial cause and can be isolated from up to 30% of patients presenting at
                                   the GP‟s2.

Description of symptoms           Sore throat and / or ear
                                  Pain on swallowing.
                                  Difficulty in swallowing
                                  Fever, headache and malaise.
                                  Laryngitis (infection of the voice box) can also cause a sore throat.
                                  Redness of pharynx and tonsils, presence of exudate, enlarged tonsils, swollen tender neck glands.
                                  Not all of these symptoms may be present at any one time.

Precipitating factors             Poor immune response (illness or drug related).

Advice to be given                Sore throats are usually a self-limiting illness (whether caused by viral or bacterial infection) and will resolve in 7 – 10 days
                                  Explanation, reassurance and advice on condition are all that is required.
                                  Avoid talking, smoking and alcohol

Pharmacy First Formulary           Paracetamol 500mg tablets (32) and suspension (100mL/200mL)
                                   Ibuprofen 200mg tablets (24) and suspension (100mL)
                                   Adult and children over 16 years can gargle with Soluble Aspirin 300mg (32) dissolved in a glass of water then swallowed. Repeat every
                                   four hours as necessary (avoid in patients with history of stomach ulcer or asthma)
                                Difflam spray (30mL)
                                AAA spray (1)
                               Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                               the BNF/Mims.

Non pharmaceutical treatment      Taking regular sips of warm drinks, like honey and lemon, can help to relieve the symptoms.
                                  Sucking sugar free lozenges can help.

                   Patient taking other medication e.g. carbimazole, methotrexate etc that may cause neutropenia (alterations in the white blood cell counts).
When to refer      Patients, especially young children, presenting with severe symptoms (not able to swallow, acute onset and high temperature over 39°C,
                    drooling and seems unable to swallow their saliva).
                   Sore throat with no improvement after 5 days.
                   Swallowing drinks is not possible
                   Difficulty in breathing
                   Repeated tonsil infections or abcesses
                   Severe Earache
                   Hoarseness for more than 3 weeks1.

Review Date     April 2006

Teething Protocol
Definition                     The emergence of teeth through the gums of the mouth usually begins between the 6 th and 8th month of life and all deciduous teeth are normally
                               in place by the time they are around three years old. Some children can go through teething much earlier or later.
Description of symptoms               Symptoms are very varied with most babies suffering little pain but some have symptoms for several weeks and can include:
                                Irritability caused by the pain and discomfort of the tooth rising to the surface of the gum.
                                Excess salivation and drooling.
                                Gum swelling, redness and sensitivity.
                                Wakefulness at night
                                Refusing food/ demanding more feeding than normal
                                Biting and gnawing. This helps relieve the pressure from under the gums.
                                Temperature a little higher than normal
                                Bowel movements slightly looser than normal
                                Flushed cheeks
                                Cheek rubbing and ear pulling
Advice to be given              Extra comforting can often be the only intervention required
                                Gently wipe the baby‟s face often to remove saliva to prevent rashes from developing.
                                Recommend registration with an NHS dentist if the child is not already registered.
OTC medication                 Bonjela gel (15g)
Non pharmaceutical treatment    Give the baby something cool to chew on. This can ease the pain. For example:
                                    Teething rings, which can be cooled in the fridge.
                                    A clean wet washcloth placed in the freezer for 30 minutes.
                                May like to try hard foods e.g. sugar-free biscuits, frozen bread, chilled carrot sticks
                                They may get some relief form eating cold foods such as: Yoghurt or applesauce.
                                Rubbing the baby‟s gums with a clean finger can also soothe the ache.
When to refer                   If the child has a temperature over 38oC (100oF) or diarrhoea
                                If symptoms and pain (if the baby is crying inconsolably) are excessive. Teething shouldn‟t be excruciating
Review Date                     April 2006

Threadworm Protocol
Definition                       A parasitic worm which is caught after swallowing the eggs

Description of symptoms          Anal Pruritus mainly at night is quite often the only symptom
                                 Sometimes worms can be seen around the anus or in the stools

How common is it?                Threadworms are extremely common. Infection can spread rapidly between family members by direct transfer of eggs.

Pharmacy First Formulary       Mebendazole 100mg Tablets (2) (patients over 2 years old).
                              Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                              the BNF/Mims

General Information              All members of the family should be treated at the same time
                                 Mebendazole should not be used in pregnancy or if potentially pregnant.
                                 It is not advisable to breast-feed following administration of Mebendazole

Non pharmaceutical measures      Use of Anthelmintics needs to be combined with hygiene measures to be prevent ova being transferred form the anus to the mouth
                                   Washing hands and scrubbing nails before each meal and after going to the toilet
                                   Bathing immediately after rising will remove eggs laid during the night
                                   Keeping nails short
                                   Prevent nail biting and thumb sucking

When to refer                    Children under 2 years
                                 Pregnant or potentially pregnant women.
                                 Signs of bacterial infection
                                   Day and night time irritation
                                   Red and inflamed skin around the anus
                                   Purulent mucus discharge from the anal canal

Review Date                   April 2006

Vaginal Thrush Protocol
Definition                    Fungal infection of the lower female genital tract.

Description of symptoms       Presenting symptoms include thick, white vaginal discharge, pain or burning on urination, soreness and itching

 Advice to be given           Maintain good hygiene
                              Avoid highly perfumed soaps, bubble baths and vaginal deodorants if they know they are prone to thrush.
                              Remind the doctor that they are prone to thrush if they are prescribed antibiotics or other medication.
                              Try to keep the genital area cool, thrush thrives in warm moist conditions.
                              Wear loose fitting cotton underwear.
                              Partner will need treating
                              Symptoms may take up to 7 days to resolve, if this fails to happen then the patient should be advised to make an appointment with their
                              Pessaries best used at night to aid retention

Pharmacy First Formulary                   Clotrimazole 500mg pessary (1), Clotrimazole 1% cream (20g), Clotrimazole combi pack (1)
                               Patients should be given clear instructions on appropriate dosage of the preparation supplied
                                           based on the manufacturers recommendations and/or the BNF/Mims.
Which product                 If the patient describes symptoms that are mainly external, Clotrimazole Cream should be supplied
                              If the patient describes symptoms that are mainly internal, Clotrimazole One should be supplied
                              If the patient describes symptoms that are both internal and external, Clotrimazole Combi should be supplied

When to refer                 First time sufferer
                              Blood staining within the discharge, abnormal or irregular vaginal bleeding
                              Presence of sores or blisters in vaginal area
                              Patient is pregnant or likely to be pregnant
                              Patient is under 16 or over 60 years of age.
                              Diabetic
                              Unresolved symptoms 7 days after treatment
                              Personal history of or recent exposure to STI
                              Any other reason which makes you professionally wary of making the supply

Where to refer                GP, Family Planning Clinic or GUM

Review Date                April 2006

Verrucas Protocol
Description                   Verrucas or plantar warts are those found on the feet, especially the soles.
                              All warts are caused by various types of the human papillomavirus
                              A verruca typically presents as a flat skin coloured lesion with a black dot at its centre
                              Friction wears away the dead cells of the wart which exposes thrombosed blood vessels giving the verruca its typical appearance

Pharmacy First Formulary    Cuplex gel (5g) – follow instructions in patient information leaflet
                           Patients should be given clear instructions on appropriate dosage of the preparation supplied based on the manufacturers recommendations and/or
                           the BNF/Mims.

Other advice                  Treatment is not always necessary as many verrucas remit without any intervention but this can often take months or even years
                              Avoid applying keratolytic to healthy skin – can use vaseline to protect healthy skin
                              Avoid spreading the verruca
                                    Maintain scrupulous cleanliness
                                    Use a separate towel
                                    Avoid walking around in barefoot
                                    Cover verruca with a plaster

When to refer                 Painful verrucas
                              Suspect skin cancer
                              Diabetic patient
                              Pregnancy
                              immuno-compromised – check medication

Review Date                April 2006

Appendix 11
 Generic list of competencies for community pharmacies involved in
                   providing a minor ailment service.
This is an example of a core competency framework which defines in generic terms
the competencies that community pharmacists have, or need to develop, to offer a
minor ailment scheme.

Competency frameworks can be used to assist in recruiting community pharmacies to
provide extended services, for performance review, and to identify training and
development needs of community pharmacy staff providing extended services.

Core Competency framework for community pharmacists providing
extended services
Adapted from:
Anon.    Community pharmacy medicines management: a resource pack for
community pharmacists. The community pharmacy medicines management project
2003. Available at

Competence in information management
The pharmacy will:

 establish and maintain appropriate sources of information about minor ailments
  and their treatment.
 operate a protocol(s) for the sale of non-prescription medicines.
 establish and maintain information on other local services relevant to the
  treatment of minor ailments.
 make a written record of the minor ailment consultation.
 record the outcome of the minor ailment consultation in the PMR, as appropriate.
 correctly process documentation of the minor ailment scheme.
 provide appropriate records for audit and evaluation purposes.

Competence in communication
The pharmacy will:

 elicit key information for the treatment of minor ailments by the use of appropriate
 provide information and advice in a manner appropriate to the needs of the patient.

Competence in problem-solving
The pharmacy will:
 recognise and define actual or potential problems in the patient‟s drug therapy,
  life style or quality of life related to the treatment of that minor ailment.
 identify the best option for the treatment of the minor ailment based on
  appropriate evidence and sound analysis, and taking account of the patient‟s

 when necessary refer the patient to a more appropriate source of help or
 take responsibility for, and accept the outcome of, own proffered advice or
  decisions for minor ailments.

Competence in working with others
The pharmacy will:

 contribute to the scheme in accordance with the law, with the RPSGB Code of
  Ethics and with other relevant codes of conduct or practice, including systems for
  clinical governance.
 respect and observe patient confidentiality.
 negotiate successfully with GP‟s and their staff if any problems arise.
 operate across the community pharmacy: primary care interface in support of the
  management of minor ailments
 behave in a manner which instils confidence of others involved in the treatment of
  minor ailments, especially the patient.
 support, collaborate with, delegate to, and supervise other team members in an
  appropriate manner for the treatment of minor ailments.
 use knowledge and skills effectively to help the learning of other team members
  about the treatment of minor ailments

Competence in personal skills development
The pharmacy will:

 recognise personal and professional limitations in respect of minor ailments
 identify and priorities the pharmacy staffs‟ learning and development needs for
  minor ailments management.
 develop plans with learning objectives to meet identified needs for the treatment
  of minor ailments.
 use learning and development opportunities, including those of and from work-
  based experience, in support of minor ailments management.
 records learning activities relevant to minor ailments management
 evaluate if learning objectives were met and identify further learning needs for
  minor ailments management
 apply learning to practice of minor ailments management.

Competence in achieving concordance in drug therapy
The pharmacy will:

 elicit, listen to, respect and reflect the patient‟s perceptions of his/her condition
  and addressed his/her concerns about his/her medicines or about taking them.
 encourage the patient to ask questions about his/her condition and treatment.
 explain clearly to the patient the benefits of and rationale for his/her proposed
 identify factors which might discourage or prevent the patient from taking the
  medication regimen and seek to remove or ameliorate those factors by simple
  practical measures or suggestions of a clinical or no-clinical nature.

Competence in achieving a healthier lifestyle and higher quality of
The pharmacy will:

 help the patient to recognise any clear need for change in his/her lifestyle for
  reduced risk of ill-health
 use opportunities to promote and support the patient‟s healthier lifestyle.

   Appendix 12

     Pharmacy First – Minor Ailment Scheme

                             Locum Guide

 The Pharmacy First Scheme allows participating pharmacies to supply certain
medication on a pharmacy prescription form to patients registered with a Preston

The Pharmacy may supply any of the medication listed in the formulary for those
 stated conditions. The medication may only be supplied in accordance with its
                            OTC product licence.

 Medication may not be supplied for any other condition other than those listed
              even though the product is licensed for such use.

Normal Prescription Charges and Exemptions Apply

                Please ensure that

               The patient has a Pharmacy First Passport or is issued with one
              once Registration with a participating Preston GP has been confirmed.

               The consultation form is completed on BOTH sides.

               An entry is made onto the Pharmacy First Passport

               Any prescription levy is collected

               Any medication supplied is labelled in the normal way.

                            For further information contact
                            Malcolm Phillips on 01772 645586

What is it?      The scheme provides treatment for certain ailments from   See Appendix 2
                 pharmacies as if they were on an FP10.
Who?             Any patient registered with a participating Preston PCT   A list has been
                 practice                                                  faxed to the
Where?      Any participating pharmacy                                     You‟re in one
When?       Any time the pharmacy is open. No need to see a GP first
Passports?  To use the scheme the patient must have a passport, or be The yellow/blue
            issued with one. It acts as a record card and lists the    book, PCT headed
            medication supplied through the scheme                     cards held in the
How?        You can supply any of the medication listed for any of the Normal
            conditions. Label medication as if it were being supplied prescription
            on FP10 is good practice and will ensure a record is made exemptions and
            in the PMR                                                 charges apply
When not to There are no real limits on the frequency of supply,       Don‟t supply
supply      serious consideration should be given to repeat provision through the
            of Pholcodine Linctus (see Cough/Cold/Flu protocol).       scheme if you
            Use your professional judgement but refer to the minor     wouldn‟t sell the
            ailments protocols. Generally if the medication has been product!
            supplied on two previous occasions in the last month,
            referral may be required. Obvious exemptions include
            hay fever medicines.
Paperwork?? Each patient should have a passport.                       It looks like a lot
            At each supply make an entry on the PMR and in the         but it‟s quite
            Passport.                                                  simple. Please
                                                                       ensure it is
                                                                       completed or
                                                                       payment will not
                                                                       be made.
               Complete the Patient Consultation Form (Both sides)

Appendix 13

               Pharmacy First – Minor Ailment Scheme
Common Questions

   Q. Who can use the service?
   A. Any patient registered with any Preston PCT GP or Chorley & South Ribble PCT
      GP. This includes children and the elderly. Children under 16 must be issued with
      their own passport and the parent/guardian must sign on their behalf. The parent or
      guardian should normally accompany the child on each occasion they wish to
      access the scheme.

   Q. What medicines can I use to treat which ailments?
   A. The list of medicines and ailments will change from time to time. These are
      detailed on appendix II with reference to the specific condition requiring treatment.
      No other ailment is treatable through the scheme even if a suitable medicine is
      available for another condition.

   Q. Can patients demand the medicines available for the conditions treatable?
   A. No. You are under no obligation to supply any of the products available if you feel
      they are inappropriate for a particular patient or you think a referral is required.

   Q How much will I be paid?
   A. Payments will be £3.00 per consultation that results in the supply of a pharmacy
      first medicine/s. You will be reimbursed your drug costs at the agreed price.

Appendix 14

                              Model Receptionist 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:

   a. Patients exempt from prescription charges, where considered appropriate and
      practical, may be informed that there is a new scheme in operation where patients
      can be referred to a local pharmacist for advice and medicine rather than waiting for
      an appointment. Normal exemptions from prescription charges will apply.

   b. If the patient is present then they should be given a Pharmacy First information
      leaflet to take to one of the participating pharmacies.

   c. If a patient refuses transfer an appointment should be made for them with the
      Doctor in the usual manner.

   For Patients Self Referring at the Pharmacy

   Some patients will go straight to the Pharmacy to join the Scheme. The Pharmacist is
   required to be satisfied of the patient‟s registration with a participating surgery. If the
   patient does not have evidence with them of registration with a participating practice,
   the pharmacist should not consider the patient for treatment within the scheme.
   Therefore where confirmation cannot be provided, the patient will not be entitled to use
   the scheme.

   Referral from Pharmacy

   On some occasions the Pharmacists may consider that the patient needs to be seen by a
   doctor. In most cases patients should be requested to make a routine appointment with
   their GP. If the patients presents at the pharmacy with similar symptom however the
   Pharmacist will refer the patient back to the surgery using the urgent referral form
   (appendix 5) which will be given to the patient and a copy faxed to the GP practice,
   together with the advice to seek an appointment at the surgery. Sometimes if the
   surgery is closed the Pharmacist may advise the patient to call the emergency number
   or go straight to A & E

Appendix 15

                          Clinical Governance Implications
                  for pharmacies providing a Minor Ailment Service.

  The pharmacist and the pharmacy staff should be clinically competent in the treatment
  of the minor ailments included in the scheme. It is through continuing education and
  CPD that this competency can be maintained.

  As the pharmacy manager/owner may not be present at the pharmacy every day, they
  must ensure that all support staff, including part-time and locum pharmacies are fully
  briefed on the services being provided. Staff appraisals should be conducted regularly
  to ensure personal development for the staff and adequate training should be provided
  to them. An induction period for locum pharmacists would be advisable.

  Pharmacist should have relevant sources of references in the pharmacy which should be
  available to all appropriate staff. The pharmacy should be equipped with up to date
  computerised PMR facilities. A facility to record interventions, conversations with
  prescribers, carers and patients should ideally be available on the PMR. All support
  staff should be familiar with the PMR and associated programmes.

  Standard operating procedures related to the safe operation of the pharmacy should be
  written so that support staff, particularly part-time and locum pharmacists, are aware of
  the standards to which they are expected to perform. The procedures should include
  error and near miss reporting.

  The staff and responsible pharmacist should be able to reflect on their practice, and
  continually endeavour to improve their practice. The pharmacist should regularly
  perform an audit cycle on procedures to ensure robustness and enable continuous

  The practice in the pharmacy should reflect the safety, confidentiality and views of

  Adapted from:

   Anon. Community pharmacy medicines management: a resource pack for
    community pharmacists. The community pharmacy medicines management project
    2003. Available at

Appendix 16

Department of Health Publications
PO Box 777

Tel: 08701 555 455

Fax: 01623 724 524


Text phone: 08700 102870
All of these publications are free of charge. When asking for specific guides the DOH person will
confirm availability and cost implications where necessary.

Current Publications available in conjunction with Minor Ailments Scheme

Head Lice
Influenza 2004
Pubic Lice/Scabies (Sexual Health)
The NHS self-help guide
Vaginal Thrush

Discontinued publications not being updated



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