Diverted traffic

1 A variety of management strategies have been introduced to deal with the tide of inappropriate consultations in primary care: prescription charges, the use of practice nurses and, more recently , the nurse-led telephone helpline NHS Direct.

Prescription charges may be of limited use. A patient s exemption from prescription charges will mean that a visit to the GP is a matter of necessity, not choice, for those whose income cannot stretch to the cost of over the counter medicines.

2 New ways of working which consider these financial constraints are needed if the health service is to respond adequately to the concerns of doctors and the patients they serve.

Recent government policy advocated more extensive use of community pharmacists as the first port of call for treatment of self-limiting conditions.

3 Despite this, few studies have examined whether community pharmacists can alleviate some of the workload pressure encountered by GPs from patients consulting with self limiting ailments. Earlier work of ours had revealed the extent to which patients currently use pharmacies for the treatment of self limiting illnesses, but also showed that prescription exemption status was a major barrier to this.

4 A trial scheme, Care at the Chemist, went into operation in August last year in Bootle, Merseyside. Patients consulting at one practice for 12 self-limiting conditions (see box, right) are offered a visit to a pharmacist instead.

The four-doctor practice has a list of about 8,000 patients and employs a nurse practitioner , a practice manager , a secretary, a computer support assistant and five reception staff. A pharmacy consultant employed by Sefton health authority also works part-time at the practice.

The eight pharmacies in the scheme are a mixture of small independently owned pharmacies, and small and large multiples, staffed by either self-employed owners or managers. HA data suggests they serve a population of 5,000 each.

The pharmacists role

The pharmacists involved in the project remain in their pharmacies, rather than being based in the GP practice.

This gives patients a choice about where to go, and when (so no waiting for appointments), opening up different access routes to primary care.

Patients get medicines from the pharmacy under the same financial conditions as if they were getting a prescription directly from the GP. The pharmacists prescribe from a formulary, based on the current prescribing patterns of the four GPs and the pharmacies over-the-counter drugs-use data.

They can offer advice if medicines are not considered appropriate and can redivert patients back to the GP if necessary . The HA reimburses the pharmacists for their professional input by paying for each consultation, irrespective of whether a medicine is provided or not, while the usual reimbursement of drug costs, discounts, and container allowances also apply .

Data collection

Baseline data was collected for four months before the study began. During this phase the GPs and practice nurse had to record consultation and management outcome data - whether a prescription was given and what was prescribed - for all patients requesting appointments or prescriptions for any of the 12 conditions.

This allows us to quantify the potential shift from general practice to community pharmacy . The eight community pharmacists also collected similar baseline data for the same period.

How the project works

Patients arriving at the surgery are presented with a laminated sheet listing the 12 conditions and are discreetly asked by the receptionist whether they want to see the doctor for any of the conditions or symptoms listed. If the patient says yes, they are told about the scheme and asked if they would prefer to see the pharmacist rather than wait to see the GP . People who phone the surgery for repeat prescriptions which can be easily identified as being for one of the 12 conditions are asked the same thing. Leaflets and posters in the surgery encourage patients to seek referral to the scheme, as do the GP's.

Analysing the data

During the four months before the project went into operation, 798 consultations for the 12 conditions were recorded, representing approximately 9 per cent of the total practice workload, although this varied week by week, and for the different practitioners (see table 1).

Unsurprisingly , the 12 self-limiting conditions formed a much larger proportion of the nurse practitioner s caseload. Of the total practice workload for these 12 conditions, 20 per cent were prescription requests, suggesting that a reasonable proportion of patients are not necessarily seeking clinical advice, but simply access to medicines.

During the same period, to treat the same illnesses, 5,419 sales were recorded for over-the-counter products in the eight study pharmacies. Two-fifths of these sales were made after the patient presented to pharmacy staff with symptoms, rather than demanding named products.

Among those consulting for one of the 12 conditions during the baseline period, children under 16 comprised 55 per cent of patients, while patients aged over 45 made up only 11 per cent of the caseload (see table 2).

Of the 12 study conditions, cough, sore throat and hay fever presentations accounted for 60 per cent of actual GP consultations, while head lice, hay fever and thrush accounted for more than 84 per cent of prescription requests. Consultations in the community pharmacies were more diverse, with the top three conditions out of 12 accounting for 43 per cent of pharmacy consultations (see table 3).

By the end of October 1999, 251 patients had used the scheme, representing 35 per cent of those eligible. Most of these (88 per cent) accessed the scheme by phoning the surgery and asking for a direct referral. Of those who insisted on seeing their GP , 31 per cent were subsequently prescribed antibiotics or other non formulary medicines, which suggests that these patients did need to see the GP . But the rest could have seen a pharmacist, suggesting that a much larger shift from GPs to community pharmacy is possible.

GPs are pleased with the early results of the scheme and patients are also responding positively to it. Patients who saw the GP through the open ccess route no longer have lengthy waits, and those who phone for routine appointments or prescription requests no longer have the extra burden of visiting the surgery and go straight to the pharmacy .

Early results indicate that it is mothers with young children, consulting for head lice treatments, who make most use of the new scheme. Given the age of the patients for whom the consultation is requested and the type of prescription request, this is perhaps not too surprising.

The pilot scheme will run until the end of this month, when the HA will decide whether to continue with it. A cost-benefit analysis is planned and interviews will be conducted with all practitioners, in particular with the GPs, to discover how they make use of any freed time. A sample of patients will be interviewed about their use and views of the scheme.

This evaluation and dissemination of the findings will be vital if lessons are to be learned and further schemes of this sort are to be developed to suit different local circumstances. At the moment, this method of patient management, which builds on the available expertise of health practitioners, rather than establishing new systems of care, appears to offer exciting demand management opportunities.