Minor Ailment Scheme - Local Enhanced Service

Minor Ailment Scheme - Local Enhanced Service Version 3. revised March 2011

Handbook for Practices and Pharmacies

Contents Section Topic/Content Page 1.1 So what is a minor Ailment Scheme 3 1.2 So why consider a Minor ailments Scheme? 3 2 Minor Ailments Scheme – How does it work? 4 2.1 Conditions Included 5 2.2 Re-consultation 5 3 Service Specification 6 4.1 Introduction 6 4.2 Transfer of Care 6 4.3 Duties of Practices 6 4.4 Pharmacy and Pharmacist requirements to provide local enhanced service 6 and application 4.5 Duties of Participating Community Pharmacies 7 4.6 Duties of non participating Pharmacies 8 5 Service Funding and Payment Mechanism 8 5.1 Funding 8 5.2 Pharmacy payments 8 6 Monitoring and Evaluation 8 6.1 Prescribing data - GPs 8 6.2 Prescribing data – Pharmacy Service 8 6.3 Surveys 9 Appendix 1 Protocols for conditions 10 - Athlete’s Foot 11 - Chicken Pox 12 - Coldsore 13 - Conjunctivitis 14 - Constipation 18 - Contact dermatitis 19 - Cough 20 - Cystitis 21 - Diarrhoea 28 - Hay Fever 29 - Head Lice 30 - Headache / Temperature 32 - Impetigo 34 - Indigestion / Heartburn / Tummy Upset 35 - Insect bites 37 - Mouth ulcers 39 - Nappy rash including PGD for Canesten HC® 41 - Nasal Congestion 46 - Sore Throat 47 - Threadworm 48 - Vaginal Thrush 49 - Warts and verucca 51 Rationale for use of Drugs in minor ailments 53 Appendix 2 Formulary and costs 56 Appendix 3 Minor Ailment Consultation Form 59 Appendix 4 Minor Ailment Referral form 61 Appendix 5 Surgery procedure 63 Appendix 6 Think Minor? Phone poster 64 Appendix 7 Pharmacist’s check list 65 Appendix 8 Community Pharmacists Minor Ailment Scheme Claim form 66 Appendix 9 Pharmacist Minor Ailment s scheme Agreement 68 Appendix 10 Duties of Participating Community Pharmacists 69 Appendix 11 Drugs Supplied Under PGD Fprm 70

2 1.1 So what is a Minor Ailments Scheme (MAS)? Patients are encouraged to consult the Community Pharmacist rather than the GP for a predefined list of minor ailments. Patients are treated from an agreed local formulary. Patients who are exempt from NHS charges receive treatment free of charge. Patients who pay prescription charges pay only the cost and VAT for each treatment. If this amount is more than the prescription charge, they will pay the prescription charge.

1.2 So why consider a minor ailment scheme? General Practice manages a high level of self-limiting conditions. Studies undertaken nationally between 1992 and 1994 estimated that between 100 –150 million GP consultations per year are for conditions that are potentially self-treatable1,2. If self-management was encouraged, 16 appointments per day could reduce each GP’s workload. With the increasing deregulation of prescription-only medicines to Pharmacy medicines, this number can only increase. Nationally, 80% of all prescriptions issued are exempt from prescription charges. There is a financial incentive for people exempt from prescription charges to visit their GP to obtain a prescription. Removing this incentive by pharmacist provision of medication on the NHS has been demonstrated to reduce the workload for a range of minor ailments in one GP practice by a third3. This document outlines the process by which Community Pharmacists within Medway PCT’s boundaries may supply medication, without cost to patients in some instances.

1) Editorial. Over-the-counter drugs. Lancet, 1994;343:1374-5 2) Hoog S The self-medication market – a literature study. J Soc & Admin Pharm, 1992;9:123-137 3) Community pharmacy management of minor conditions – the “Care at the chemist” scheme.

3 2.0 Minor Ailments Scheme – How does it work?

Practice Signposting Pharmacy Other Self referral Pharmacy Patient contacts surgery in person referral Services Patient arrives at Signposting or by ‘phone to make an Pharmacy requesting Patient in signpost Patient presents at appointment with GP or nurse for Pharmacy MAS consultation Pharmacy requesting an included Minor Ailment Patient requesting reports/prese MAS consultation, treatment for an nts with an Pharmacy staff inform included minor included patient who is offering ailment. Staff minor this service. offer use of MAS ailment service Receptionist briefly explains the Health professional Minor Ailments scheme and if the briefly explains the appointment is for one of the Minor Ailments Staff briefly explain the included conditions informs the scheme and if the Minor Ailments scheme patient of participating appointment is for and if the request is for pharmacies one of the included one of the included conditions informs the conditions informs the patient of patient of participating participating pharmacies pharmacies Patient declines signposting option to Community Patient accepts signposting to Pharmacist Community Pharmacist and chooses Patient declines signposting option to Pharmacy to attend Participating Community Pharmacist

Patient offered appointment as usual Patient presents at selected Community Pharmacy. Pharmacy supplies Pharmacist assesses patient. appropriate medicines as normal, but charges patient.

Meets inclusion criteria Does not meet Medicine Supplied as appropriate inclusion criteria: from assessment and formulary Referred to GP Note : Pharmacist should give patient an indication of urgency of appointment i.e. same day within 2-3 days, 7 days etc  Pharmacist completes Note if patient is exempt Medicine Supply form meds provided free. If patient pays for precriptions charge  Declaration of cost of meds (see formulary) receipt/supply signed by if less than prescription patient charge. If more than, charge prescription charge

 Copy sent to PCT for payment at the end of Pharmacist ensures that all the month if not using copies of Medicine Supply Form Webstar are given/sent to correct person

Copy given to patient Copy of form retained by Comm. Pharmacist

4 2.1 Conditions Included

 Athlete’s foot  Chicken Pox (added December 06)  Cold Sore (added December 06)  Conjunctivitis  Constipation  Contact Dermatitis  Cough  Cystitis  Diarrhoea  Headache/temperature  Hay fever  Head lice  Impetigo (added December 06)  Indigestion/heartburn/tummy upset  Insect bite  Mouth Ulcers  Nappy rash  Nasal congestion  Sore throat  Threadworm (added December 06)  Vaginal thrush  Warts and verucca

See appendix 1 for PGDs and protocols. See appendix 2 for formulary

2.2 Re-consultation It is at the professional discretion of the Pharmacist to treat a patient for the same condition twice, e.g. some conditions such as head lice are very likely to re-occur and not require GP intervention, whereas recurrent cystitis is more likely to require a GP opinion. It is acknowledged that patients may present at different Pharmacies for the same conditions. It is imperative that the Pharmacist questions the patient to ascertain this during their consultation. This could be of particular importance with cystitis, thrush and indigestion, for example.

5 3 Service Specification

3.1 Introduction  This service is available to any patient registered with a Medway PCT GP who enters a Pharmacy or contacts a practice requesting treatment for one of the included conditions and meets the inclusion criteria. The patient must be in attendance; the scheme cannot be accessed through a third party. Patients are at liberty to refuse this service.  The service is only available for the minor ailments identified in this service specification.  Only Community Pharmacies who are committed to making staff available to provide the service, and have received the necessary training in the implementation of the Scheme and work in accredited Pharmacies will be included in this service.

3.2 Transfer of Care  Patients presenting with identified symptoms at the GP surgery or a non participating Pharmacy may be signposted into this service.  Patients presenting at a participating Community Pharmacy, will receive the service level of care as laid out in this specification.

3.3 Duties of all Practices  Patients requesting appointments (either immediately or on an appointment basis) for symptoms matching criteria identified in this service can be signposted to a participating Pharmacy if the patient thinks they are suffering with one of the illnesses.  GP surgeries should display official posters and provide leaflets promoting the service.  For patients under the age of 16, the parent/guardian can accept signposting to the scheme on behalf of the patient.  The practice must ensure that they are able to provide urgent appointments for any patients referred back to them within 24 hours.  File all paperwork received from Pharmacies concerning patient consultations and read code it using 8H7t.

3.4 Pharmacy and Pharmacist requirements to provide the local enhanced service and application If a Pharmacy wishes to offer the MAS as a locally enhanced service they must ensure they meet the following inclusion criteria and send a copy of the completed Pharmacist/Pharmacy agreement form (appendix 9) to the Community Pharmacy Team at Medway PCT. The appropriate paperwork will then be issued by the PCT. Pharmacists CANNOT offer the service until they have received confirmation from the PCT.

 The Pharmacy must have a private area for the consultation

 The lead Pharmacist must have completed CPPE MAS modules and PGD training

 The Lead Pharmacist can train any Pharmacist who works in the Pharmacy more than 7 hours a week or who is the regular locum. Both the Lead Pharmacists and regular locum pharmacist must:

 Read the handbook

6  Sign the handbook to confirm that the protocols have been read

 Sign the PGDs to show that they have read and understood them

 Forward signed copies to Medway PCT

 It is the responsibility of the lead Pharmacist to ensure that all Pharmacists who work within the Pharmacy , including locums:

 are aware of the scheme and able to offer the service.

 have signed the Pharmacist agreement form appendix 9) and that the PCT has a copy of these forms.

 In addition they are expected to ensure that there are adequate Standard Operating Procedures in situ that other Pharmacists and Pharmacy staff, working within the Pharmacy, will be able to follow.

3.5 Duties of Participating Community Pharmacists  All participating Pharmacists will provide a professional consultation service for patients presenting with one of the specified conditions.  The Pharmacist will assess the patient’s condition. The consultation will consist of:  Patient assessment by Pharmacist.  Provision of advice.  Provision of a medication, only if necessary, from the agreed formulary appropriate to the patient’s condition.  The Pharmacist will complete the Minor Ailment Consultation form (Appendix 3 for all consultations.  The Pharmacist will ensure that the patient has completed and signed the declaration of exemption of Prescription charges (on the consultation form) or pay the prescription charge if exempt.  The pharmacist will ensure that proof of exemption is seen  The Pharmacist will ensure all copies of consultation forms or monthly reports are sent to the relevant people  The Pharmacist will ensure that all patient records are stored adequately.  Normal rules of patient confidentiality apply.  If, in the opinion of the pharmacist, the patient presents with symptoms outside the Scheme, they should be referred back to their GP using the Minor Ailment Referral Form (appendix 4). the patient will need to be seen quickly.  If the patient presents with symptoms indicating the need for an immediate consultation with the GP, they should be referred back to their GP (within surgery hours), to contact NHSDirect or MEDdoc, (as appropriate, outside surgery hours) using the Minor Ailments Referral Form.  Pharmacists should send a list of patients who have used the MAS to each GP practice on a monthly basis. This is generated from the webstar MAS software.  If the pharmacist suspects that the patient and/or parent are abusing the Scheme they should alert the PCT and practice.

7 3.6 Duties of Non- Participating Community Pharmacists Non participating Pharmacists should display information posters and leaflets for patients about the services offered. If requested by patients they must inform them of participating sites. As part of the essential services within the new Pharmacy contract, Pharmacies are expected to signpost to services.

4 Service Funding and Payment Mechanism

4.1 Funding The scheme will be funded from Local Delivery Plan monies.

4.2 Pharmacy Payments The Pharmacy will be paid according to the following schedule:

 Fee: £5.70 per consultation – To be reviewed annually or with legislation changes  Drug Costs: Over the Counter Packs only, to be supplied at cost price plus VAT (see formulary appendix 2) Claims must be submitted to Webstar. This can be done daily, weekly or monthly but must be done by the 5th of the following month. It is not necessary to send a copy of the consultation form to the PCT as Webstar will provide all necessary data and reports directly to the PCT.

5 Monitoring and Evaluation The Community Pharmacy Team will be responsible for monitoring and evaluation of the scheme.

5.1 Prescribing data – GPs  Number of items  Total costs of items An on-going comparison will be made between these parameters for the period the scheme is operating, and with the similar period for the previous year.

5.2 Prescribing data - Pharmacy service  No. of items  Total costs of items  Cost of administering scheme  Indications / actions taken These will be evaluated on an individual Pharmacist basis and in terms of an overall service. The figures will be compared with 5.1

8 5.3 Surveys Satisfaction surveys will be undertaken. The following groups may be sampled:  GPs  Receptionists  Pharmacists  Patients

6.0 Review The scheme will be reviewed annually. Comments about the scheme can be made at any time to the Medicines Management Team at Medway PCT.

9 Appendix 1 :

Protocols

10 ATHLETE’S FOOT

Definition/Criteria Fungal infection of the skin Criteria for INCLUSION Athlete’s foot in adults and in children

Criteria for EXCLUSION

Toe nails becoming black or discoloured. If infection is spreading under the nails. If infection spreads to other parts of the body.

Patients with recurrent athlete’s foot also suffering from loss of weight, thirst, blurred vision, lethargy, polyuria, bladder infections, dizziness or tiredness (diabetic symptoms)

Diabetics, Immunocompromromised.

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

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Clotrimazole Cream 1% 20g P Apply 2-3 times a day Clotrimazole Powder 30g P Apply 2-3 times a day Daktarin Cream 2% 15g P Apply twice a day. Continue for 10 days after lesions have healed Follow-up and advice Powder the feet and the inside of the shoes with an antifungal powder. Continue treatment for two weeks after the symptoms have disappeared to ensure the infection has been treated effectively. Wash the feet every day and allow them to dry properly before putting on shoes and socks. Don’t share towels with anyone else to avoid passing on the infection. Wear cotton or wool socks and change them when they have become damp. Avoid wearing shoes, which are made from synthetic materials.

Side effects and their management

Caution should be taken if the patient is sensitive to Imidazoles.

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

If no response after 2 weeks of treatment.

Widespread infection (possibly immunosupression)

Rapid referral

If there is a suspicion of undiagnosed diabetes (DO NOT DIAGNOSE) Any person suspected of systemic candidiases

CHICKEN POX

11 Definition/Criteria Patient presenting with a red rash which has developed into blisters. Some patients will experience itching and/or run a temperature. Symptoms include fever, aches and headache. Dry cough and sore throat are common in children

Criteria for INCLUSION All patients with a red rash which has developed into blisters. New blisters may appear after 3 to 6 days, some blisters may have turned into scabs already. Patients who may also be running a temperature.

Criteria for EXCLUSION Any patient whose rash is other than that described above Adults usually experience more severe symptoms than children and can feel extremely unwell. They should be advised to consult their GP as they may require anti-viral medication.

Action for excluded patients and non-complying patients Refer to GP

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage

Calamine Lotion topical GSL Apply to affected area(s) when required.

Chlorpheniramine 2mg Syrup po P Take 5ml every 4 to 6 hours Chlorpheniramine 4mg tablets po P Take ONE tablet THREE times DAILY

Follow-up and advice New blisters may appear after 3 to 6 days. A person with choickenpox is infectious for 2 to 4 days before the rash appears and until all the spots have crusted over. This is usually about 5 to 6 days after onset of illness. Patients should stay at home while infectious. Avoid scratching as this can lead to infection. Nails should be cut short or gloves can be worn to help with this. Chickenpox lasts 7 to 10 days in children and longer in adults Keep the patient cool, as being too hot or sweating may make the itching worse. Give plenty of fluids to avoid dehydration. Give paracetamol or ibuprofen to ease fever, headache and aches and pains. Calamine lotion may help with itching. Side effects and their management All antihistamines have the potential to cause some sedation. Chlorpheniramine causes sedation

When to refer to GP: In adult patients where symptoms are severe. Patients whose immune system may be suppressed. In cases where there is severe ulceration in the mouth. Antiviral medication is used in certain circumstances where chickenpox can be more serious eg children with a poor immune system, newborn babies. Some spots may become infected in around 1 in 10 cases, the skin surrounding the crusts becomes red and sore. An ear infection develops in around 1 in 20 cases.

12 COLDSORE

Definition/Criteria Blistered area, usually on or around the mouth, but sometimes can occur on the chin or around the nostrils. A tingling sensation is often felt before the blisters erupt. Once the blisters have burst a crust is formed.

Criteria for INCLUSION Patients who have the tingling sensation Patients with cold sore blisters that may or may not have burst

Criteria for EXCLUSION An known allergy to any of the ingredients Immunocompromised patients

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Aciclovir cream 2g topical GSL Apply to affected area 5 times daily as soon as symptoms occur Blisteze cream 5g topical GSL Apply to affected area every hour as soon as symptoms occur

Follow-up and advice Patients presenting with established cold sores should be treated with Blisteze and not aciclovir. Hands should be washed before and after applying either treatment. Patients should avoid touching or rubbing the affected area with fingers or towels to avoid aggravating the condition or transferring the infection. Treatment should be continued for 5 days. If healing has not occurred, treatment may be continued for an additional 5 days. If lesions are still present after 10 days the patient should consult their doctor

Side effects and their management Transient burning or stinging may follow application. Mild drying or flaking of the skin has occurred in some users.

When to refer to GP: If symptoms persist despite treatment for longer than 10 days.

CONJUNCTIVITIS ------Definition/Criteria Inflammation of the conjunctiva, which becomes red & swollen & produces a watery or pus-containing discharge. Is caused by infection, bacteria or virus, or physical or chemical irritation. ------Criteria for INCLUSION

Adults or children over 2 years presenting with acute infective conjunctivitis ------Criteria for EXCLUSION Pregnancy Breast-feeding Unexplained red eye Under 2 years old Known hypersensitivity to chloramphenicol (or any other ingredient in the product) Disturbances in vision Orbital cellulites Severe pain from within the eye ball ------Action for excluded patients and non-complying patients Refer to an appropriate General Practitioner if further investigation is warranted. Document refusal & action taken in patient records. ------Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage

Chloramphenicol eye drops 0.5% 10ml P

For adults and children: Instil 1 drop in the affected eye(s) every 2 hours for first 12 hours, then four times a day thereafter. Continue for 48 hours after symptoms have resolved.

------

14 Follow-up and Advice . Discuss side effects & administration with the patient & provide a manufacturer’s patient information leaflet. . Advise patient that the infection can spread therefore need to wash hands after touching eyes (personal hygiene) and not to share towels etc. . Do not touch the eye or lashes with the tube or nozzle as this may contaminate the medicine . Continue treatment for 48 hours after symptoms have resolved to prevent re-infection . Seek further medical advice if there is no improvement after 48 hours of treatment . Do not wear contact lenses for the period of treatment . Discard any unused ointment or drops . Discard 28 days after opening or when treatment finishes if less than 28 days ------Side effects and their management Transient stinging, burning or irritation

Potential adverse effects:

Rare reports of aplastic anaemia, sensitivity reactions such as transients irritation, burning, itching and dermatitis.

Refer to SPC and current BNF for full details

Use the Yellow Card System to report adverse drug reactions directly to the CSM. Yellow Cards and guidance on its use are available at the back of the BNF ------When to refer to GP:

Refer to PGD below

Rapid referral:

Patients showing signs of anaphylaxis Any suspected penetrating trauma to the globe of the eye Unexplained decrease in visual acuity Open eye injuries

15 Additional information for treatment of conjunctivitis with

Chloramphenicol 0.5% eye drops

1. Clinical Condition Treatment Objective Topical treatment of infective conjunctivitis Inclusion Criteria Bilateral red discharging eyes in adults and children over 2 years Exclusion Criteria 1. Hypersensitivity to any components 2. Pregnancy and Breastfeeding 3. Patients with previous eye disease, eye surgery, glaucoma, 'dry eyes' 4. Any unusual symptoms e.g. visual disturbance, bulging eye, nystagmus. Action If Patient Excluded 1. - 4. Refer to GP Action If Patient Declines Explain possible consequences Treatment Advise patient to contact own GP.

2. Description of Treatment Name of Medicine / Chloramphenicol 0.5% eye drops Formulation Dose / Frequency For adults and children: Instil 1 drop in the affected eye(s) every 2 hours for first 12 hours, then four times a day thereafter. Continue for 48 hours after symptoms have resolved. Route / Method Squeeze into lower fornix with eyelid pulled down gently Total Quantity to Supply 10ml bottle Adverse Effects Blurred vision, local transient irritation, burning, stinging, itching, dermatitis can occur Rare side effects: Aplastic Anaemia If irritation, pain, swelling laceration or photophobia occur after undesired eye contact, the exposed eye(s) should be irrigated for at least 15 minutes. Advice to Patient Avoid contamination of the eye drops – Encourage hand washing, non- sharing of towels. Discard 28 days after opening or when treatment finishes if less than 28 days If vision is blurred do not drive or operate machinery Do not wear contact lenses during treatment Ensure Patient Information Leaflet is received Treatment should be continued for at least 48 hours after the eye appears normal. Follow Up Advise patient to seek medical advice if symptoms worsen or fail to improve after 48 hours Further Information BNF, Summary of Product Characteristics, Patient Information Leaflet

Legal Category Pharmacy medicine

16 CONSTIPATION

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

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

Criteria for conditional EXCLUSION Patients currently receiving laxatives as part of their regular medication. Pharmacists should exercise their professional judgement to implement dosage alteration to existing laxative regime Children and Babies

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

Senna tabs (20) po P 2 on Fybogel sachets (10) po P 1 bd

Lactulose Solution 300ml P 15ml bd (or depending on age)

Follow-up and advice Regular doses of laxatives are rarely required and can cause a “lazy” bowel. Consider alteration to diet to prevent the occurrence of further events e.g. increased fibre and fluid intake and increased physical activity if appropriate AVOID Senna during pregnancy Senna not for long-term use.

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

When and how to refer to GP Conditional referral: If constipation persists beyond one week, consult the GP

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

Patients taking medication with recognised constipating effects (Drugs which commonly cause constipation include: Antacids, Amiodarone, Anticholinergics, Antidiarrhoeal agents, Antiparkinson agents, Calcium -channel blockers, Calcium supplements, Clonidine, Disopyramide, Diuretics, Iron, Lithium and NSAIDS, opioid analgesics.

17 CONTACT DERMATITIS

Definition/Criteria External precipitating factor is responsible for the symptoms e.g. nickel, cheap jewellery, chemical-containing products.

Criteria for INCLUSION Contact dermatitis occurring in adults and children over 10

Criteria for EXCLUSION Patients under 10, patients with symptoms on the face, neck, genitalia

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

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Hydrocortisone cream 1% 15g Apply once or twice a day Topical P Eumovate cream 15g (12 years and above) Apply once or twice a day Topical P

Follow-up and advice Avoid contact with irritant/allergen or use of barrier between the skin and irritant e.g. cotton lined rubber gloves. Avoid scratching. The creams should be used sparingly and only until symptoms have resolved. Advise if symptoms do not resolve within 7 days to make an appointment to see a GP. Side effects and their management Side effects are unlikely. When and how to refer to GP

Second Course of therapy.

Rapid referral:

Extensive areas of the body affected. Suspected infection. Severe condition of the area: badly fissured/cracked skin/bleeding skin. No identifiable cause. Duration of longer than 2 weeks

18 COUGH

Definition/Criteria Coughing arises as a defensive reflex mechanism

Criteria for INCLUSION Troublesome cough requiring soothing

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

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

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage It must be remembered that Simple Linctus is a drug with limited clinical value and is symptomatic treatment. Patients should be reassured that a cough is self limiting and does not need an antibiotic.

Pholcodine Linctus , 5-10ml tds – qid P

Simple Linctus 200ml, 5ml tds – qid P

Simple Linctus, Peadiatric 200ml 5-10ml tds – qid P

Follow-up and Advice Maintain fluid intake with chesty cough

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

Consider supply, but patient should be advised to make an appointment to see the GP:  A persistent, dry, night time cough in children  A dry cough in a patient prescribed an ACE inhibitor

Rapid referral:  Constant chest pain or chest pain on normal inspiration  Difficulty breathing  Green or rusty sputum  If pain related to exertion

19 CYSTITIS

Definition/Criteria Inflammation of bladder and urethra, usually caused by a bladder infection

Signs and Symptoms

A sharp burning, stinging sensation when passing water An urge to pass water more frequently, even though there may be very little to pass A feeling of not emptying the bladder completely Darker urine than normal, possibly streaked with blood and pains in lower abdomen and back and accompanied by fever

Criteria for INCLUSION For trimethoprim refer to PGD inclusion criteria For Canestan Oasis or cystopurin adult women presenting with signs and symptoms of cystitis

Criteria for EXCLUSION Trimethoprim – refer to PGD exclusion criteria

For Canestan Oasis or cystopurin Men Children under 12 years Women presenting with recurrent cystitis Patients with heart or kidney problems Patients with high blood pressure Patients with kidney problems Patients with diabetes or on a low sodium diet Any patients taking an ACE inhibitor, diuretics or cyclosporin Breastfeeding and pregnancy Elderly Excess fluid retention in the extremities causing swelling, for example of the ankles (peripheral oedema)

Action for excluded patients and non-complying patients Refer to General Practitioner - Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage

Potassium and sodium citrate containing preparations: Canestan Oasis®, Cystapurin® GSL

 Contents of one sachet in water 3 times daily over 48 hours  Six sachets to be taken for treatment

Trimethoprim 200mg tablets 1 bd for 3 days POM

PLEASE NOTE: When a supply of a drug using a PGD is made the patients GP must be informed. Please use the Drugs supplied under PGD through the MAS form (Appendix 11) to do so.

20 Advice . Empty bladder as completely as possible after urinating . Avoid delay in emptying the bladder . Importance of perianal hygiene, wiping from fron to back after passing stools . Avoid tight underclothes made of synthetic material . If symptoms are related to sexual intercourse, perianal skin should be washed beforehand; bladder should be emptied before and after intercourse . Drink large quantities of fluids, e.g. barley water, cranberry juice and water. . Avoid drinks such as alcohol, coffee, strong tea and fruit juices . Drink as much water as possible, to help flush bacteria out of the bladder . A hot water bottle can help alleviate the pain . Do not use perfumes, deodorants and perfumed soaps around the vaginal area . Women prone to cystitis should not use spermicides and/or diaphragm for contraception

Side effects and their management Sodium and Potassium citrate is not known to have any side-effects, but mild diuresis is possible

Trimethoprim refer to PGD cautions / need for further advice and Adverse Effects

When to refer to GP

Trimethoprim - refer to PGD action if patient excluded.

Canestan Oasis or Cystapurin

Men presenting with symptoms Pregnancy Associated with fever, nausea and/or vomiting Loin pain or tenderness Haematuria Vaginal discharge Associated with increased thirst Recurrent cystitis No response after 3 days

Conditional referral:

If symptoms persist after three days of treatment, patient should consult the GP

Consider supply, of Canestan Oasis or Cystapurin but patient should be advised to make an appointment to see the GP if:

Cloudy urine or presence of blood A Temperature is present Severe loin or stomach pains Unusual heavy vaginal discharge

Rapid referral:

Recurrent symptoms of cystitis

21 DIARRHOEA

Definition/Criteria Increased frequency and fluidity of defecation.

Criteria for INCLUSION

Patients experiencing the above symptoms

Criteria for EXCLUSION Patients with chronic diarrhoea problems Children under the age of 1year Pregnancy

Loperamide caps(6) po P 2 stat then 1 after every loose motion Dioralyte sachets (20) po P According to fluid loss, usually 200ml-400ml solution after each loose motion.

Criteria Loperamide for adults only

Advice Patient should only be given clear fluids for 24-48 hours until the symptom resolves. AVOID Solid foods, avoid dairy products. Take soups.

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

When and how to refer to GP

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

Consider supply, but patient should be advised to make an appointment to see the GP:  Patients taking medication with recognised diarrhoea effect

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

22 HAY FEVER

Definition/Criteria Seasonal allergy to plant pollen

Criteria for INCLUSION Patients with previously diagnosed hay fever requiring symptomatic treatment

Criteria for EXCLUSION Refer to relevant patient information leaflets

Chlorpheniramine tabs 4mg (28) po P 1 tds Cetirizine tabs 10mg (7) or (30) po P 1 od Sodium Cromoglycate eye drops (10ml) topical P 1 drop qds Beclomethasone nasal spray(100 sprays) (over 18) topical P 2 sprays each nostril bd Fluticasone nasal spray (60 dose) topical P 2 sprays each nostril bd Chlorpheniramine syrup (150ml) po P 5ml (2mg) 4-6 hourly Loratadine syrup (60ml) po P age dependent Loratadine tablets (7) po P 1 od

Follow-up and advice Pollen avoidance measures Not to exceed maximum doses Possible interactions with Loratidine - Patient must inform GP if prescribed further medication

Side effects and their management All antihistamines have the potential to cause some sedation. Chlorpheniramine causes sedation

When and how to refer to GP

 Patient should consult the GP if treatment is ineffective or persists after the end of September

 Pregnancy

Special considerations/Concurrent medication Glaucoma (antihistamines contra-indicated) Patients on anti-arrhythmic drugs (antihistamines contra-indicated)

23 HEAD LICE

Definition/Criteria Infestation with head lice Treatment is not necessary unless a live louse is found.

Criteria for INCLUSION Patients who are proven to be infested with live head lice, and their sleeping contacts Patients with severe eczema, scalp dermatitis, asthma and small children should be treated with the aqueous rather than the alcoholic liquid. If one member of the family has head lice, detection combing of all members should be undertaken, and only those to be found to be infected should be treated Families are treated as a single consultation. Complete one consultation under the name of the person who has attended the pharmacy and specify the number of bottles provided to treat the family.

Criteria for EXCLUSION Family / siblings of patient, who are not proven to be infested (note: infestation is not indicated by the presence of nits [hatched and empty egg shells]) Children under the age of six months A second request within one week

Recommended Treatments, Route and Legal status In order to avoid unnecessary treatment and to prevent insecticide resistance, the Kent Three Step Approach should be followed

In most cases only Step 1 is required

Step 1 Treat with aqueous malathion 0.5% product – leave on for 12 hours before washing off. Allow hair to dry naturally. Comb hair every day with grooming comb, remove dead and remaining live lice out of the hair. Check the head seven days after treatment and if live lice are still present, repeat with the same lotion. Do not use lotion more than once a week or for more than three consecutive weeks. Seven days after second treatment repeat step 1. If lice are still present, proceed to Step 2.

Step 2 Seven days after Step 1, if live lice are still present, Step 2 should be followed. A permethrin 1% product, or a phenotrin 0.5% (Full Marks) preparation in aqueous base should be used. Apply to clean dry hair, allow to dry naturally, shampoo after a minimum of 12 hours. Use two treatments seven days apart, if necessary. After 7 days following second treatment, if live lice are still found, proceed to Step 3

Step 3 If live lice are still present seven days after completion of Step 1 and 2, then head should be examined by a health professional (practice nurse, school nurse, health visitor or GP). If live lice are detected , Step 3 should be implemented. An Aqueous based carbaryl 1% product (carylderm) should be used in the same manner as Step 1. Carbaryl is only available on prescription. Two applications, seven days apart, can be used.

24 Head Lice comb Malathion alcoholic lotion (50ml/ treatment) topically P Malathion aqueous liquid (50ml / treatment) topically P Permethrin crème rinse (59ml) topically P Phenothrin 0.5% liquid or lotion or mousse topically P

Dosage and Criteria To be administered to washed and towel dried hair and left on for 12 hours (pack inserts specify less time) Patients need to be counselled and issued with a patient information leaflet.

Follow-up and advice Hair should be allowed to dry naturally – avoid flames. Do not use hair dryers Broad comb, then wet comb well conditioned hair to remove dead lice & eggs Regular detection combing as treatment will not prevent re-infection from classmates Not suitable for prophylaxis Transmission of head lice requires close head-to-head contact (lice cannot jump, fly, or swim). There is no need to wash clothing or bedding that has been in contact with lice; head lice that fall off the head or clamber onto hats or pillows are likely to die quite soon because they need a host for warmth and to feed. Shampoos should not be used – they are diluted too much in use to be effective. Parents should be encouraged to inform staff at school if their child has head lice. Tie hair back, tight, plait long hair. Avoid direct contact where possible after treatment.

Side effects and their management Side effects are experienced rarely. Possible skin irritation

25 Headache / Temperature

Definition/Criteria Pain is a subjective experience, the nature and location of which may vary considerably. This guidance only covers the management of tension-type headache and non-specific headache.

Criteria for INCLUSION Patients requiring relief of pain / fever associated with upper respiratory tract infections.

Criteria for EXCLUSION Children under the age of three months

Recommended Treatments, Route and Legal status Paracetamol Tablets 500mg(32) po P 1 -2 qds Paracetamol soluble tablets (24) po GSL 1-2 qds Paracetamol suspension SF 250mg / 5ml(100ml) po P 5-10ml qds Paracetamol susp SF 120mg / 5ml(100ml) po P 5ml qds Ibuprofen Tablets 200mg (48) po P 1-2 tds Ibuprofen susp 100mg/5ml (100ml) po P 2.5ml 3-4 times/day (1-2 years) 5ml 3-4 times /day (3-7 years) 10ml 3-4 times/day (8-12 years)

Criteria Ibuprofen where asthma and GI problems have been excluded. Not for treatment of fever

Follow-up and advice Enquire about concurrent analgesic usage:  Paracetamol daily dose - other products containing Paracetamol  Other NSAIDs – prescribed or OTC Rest, warming, cooling or changing position, may obtain relief from pain. Patients should be advised to avoid any aggravating factors. Fever should also be treated with temperature reducing methods such as tepid bathing NB overuse of analgesics can cause headaches A headache diary has been found to be effective in identifying possible aetiological factors, assessing frequency of headache, and response to treatment

Side effects and their management Side effects are rare with occasional use of Paracetamol Ibuprofen should be taken after food to avoid GI side effects

26 When and how to refer to GP Conditional referral:

If headache persists beyond one week, consult the GP

In chronic tension-type headache

Rapid referral

Headache associated with raised cerebrospinal fluid pressure is often intermittent at first, but becomes constant and more severe as the cause of the raised pressure progresses. The pain is characteristically worse in the morning, and the person may be woken by it. It is worsened by changes in posture, particularly bending, and is improved by rest. Coughing, sneezing, straining, or vomiting exacerbates it.

27 IMPETIGO

Definition/Criteria Impetigo is a common contagious skin infection caused by bacteria. Primary impetigo: Infection of previously healthy skin. Usually caused by a small cut to the skin that has allowed bacteria to get under the skin. Secondary impetigo: Infection of skin already ‘broken’ by another skin condition, such as eczema.

The rash usually appears 4-10 days after infection. Small blisters develop first, however as these usually burst to leave scabby patches they are not always noticed. Typically lesions are:  Crusted  Yellow, with a red base under the crusts  Painless but occasionally itchy  Commonly found on the face  Surrounded by satellite lesions

The sufferer does not usually feel unwell.

Criteria for INCLUSION Patients with a rash as described above. Criteria for EXCLUSION Patients with severe infection that may require antibiotics A known allergy to any of the ingredients.

Crystacide cream 1% topical P Apply to affected area 2 or 3 times a day or when required. For 5-7 days.

Follow-up and advice Before applying the cream the affected area should be cleansed using warm water and a mild soap. Impetigo is contagious steps should be taken to reduce the risk of passing the infection on:  Avoid touching patches of impetigo and do not allow others to touch them  After applying cream or washing the affected area wash hands thoroughly  Do not share towels, flannels or wash water whilst infected with impetigo  Children should be kept off school or nursery until there is no more blistering or crusting.

Side effects and their management Burning or stinging may follow for a short time after application.

When to refer to GP: If symptoms persist, despite treatment, for 5 to 7 days. If the infection is very severe.

28 INDIGESTION / HEARTBURN

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

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

Criteria for EXCLUSION

Patients over the age of 40 experiencing first episode Patients bleeding PR (excluding haemorrhoids) Unexplained weight loss Vomiting of significant amounts of blood Patients experiencing difficulty-swallowing food. Pregnant patients and patients with porphyria should not be offered Zantac 75mg

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Magnesium Trisilicate Mixture (200ml) po GSL 10ml tds in water Gaviscon advance tablets ( 20) po P 1-2 qds Peptac Liquid (500ml) po P 10-20ml qds Zantac 75 mg (14 tablets) po P 1 bd

29 Follow-up and advice Symptoms can be aggravated by stress and anxiety. Advise patients to stop smoking, moderate alcohol intake and lose weight Eat small meals slowly and regularly and avoid foods which aggravate the problem Not to take products at the same time as other medication Gaviscon or Peptac should be taken 20min – 1 hr after meals and at bedtime The sodium content of some antacids may be important when a highly restricted salt diet is required in some renal and cardiovascular diseases Avoid any nonsteroidal anti-inflammatory drugs, which is a common cause for dyspepsia

Side effects and their management Magnesium trisilcate may occasionally cause minor diarrhoea Zantac may darken tongue or blacken faeces. When and how to refer to GP

 If symptoms persist beyond one week the patient should consult the GP  If symptoms not relieved by medication – especially patients with history of IHD

 Patients taking NSAIDs including aspirin  Recent / recurrent peptic ulcer disease  Second request within a month

Rapid referral:

 Bleeding PR (excluding haemorrhoids) i.e. dark blood  Unexplained recent weight loss  Vomiting significant amounts of blood

30 INSECT BITES

Definition/Criteria Trauma produced by a biting insect seldom causes serious problems, however, the biting insect deposits salivary gland secretions, which contain various antigenic substances that may provoke a reaction in the person who has been bitten Stinging insects commonly encountered in the UK include: honeybees, bumblebees, wasps, and hornets. Biting insects commonly encountered in the UK include: midges, gnats and mosquitoes; flies; fleas; mites; ticks; and bedbugs

Signs and Symptoms  Itch  Rash/raised papules on the affected areas  large local reactions to an insect bite may occasionally be confused with cellulitis. The presence of ascending lymphangitis and lymphadenopathy suggest an infectious cause.

Criteria for INCLUSION Patients presenting with above symptoms indicating an insect bite

Criteria for EXCLUSION Patients with eczema or areas of extensively broken skin Patients presenting with cut or grazed skin, sunburnt skin or large areas of skin Children under 10 years of age (when treating with Hydrocortisone 1% cream) Pregnancy or breastfeeding NOT to be used on face/neck/anogenital region/broken or infected skin (including cold sores, acne, and athletes foot)

Action for excluded patients and non-complying patients Refer to General Practitioner

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Hydrocortisone cream 1% topical P apply SPARINGLY over a small area 1-2 times a day for ONE week only. Mepyramine 2% (Anthisan) cream topical GSL apply directly to the affected parts two or three times a day for up to three days. Chlorpheniramine tabs 4mg (28) po P 1 tds Chlorpheniramine syrup (150ml) po P 5ml (2mg) 4-6 hourly

31 Advice Avoid scratching If the sting is still in the wound, pluck it out firmly with fine tweezers. Apply a cold compress to relieve pain and minimise swelling.

Bee stings should be scraped away rather than "plucked" in order to avoid squeezing the contents of the venom sac into the wound.

For a sting in the mouth, give the patient ice to suck or cold water to sip to minimise the swelling. Dial 999 for an ambulance

Do not store the cream above 30 C

Side effects and their management Occasionally a skin rash or skin sensitisation – stop using the cream if that occurs

When to refer to GP

 If the patients shows sign of anaphylaxis (become anxious, develop red, blotchy skin, the face and neck start swelling, there is difficulty in breathing or the pulse is rapid), dial 999 for an ambulance  If bite shows signs of infection e.g. red, hot, swollen, tender

Rapid referral:

Patients showing signs of anaphylaxis

32 MOUTH ULCERS

Definition/Criteria Apthous ulceration of the oral mucosa

Signs and Symptoms  Soreness of the mouth  Lesions up to 5mm diameter  Lesions appear as a white or yellowish centre with an inflamed red outer edge  Common sites are the tongue margin and inside the lips and cheeks

Criteria for INCLUSION

Patients presenting with mouth ulcers in the above-mentioned nature, which could be caused by trauma (biting the cheek, ill-fitting dentures), dietary deficiency of iron, folate, zinc and vitamin B12.

Criteria for EXCLUSION Patients on Methotrexate, Carbimazole who has developed mouth ulcers Ulcer that fails to heal could be a sign of oral cancer Patients presenting with major aphthous ulcers

Paracetamol 120mg/5ml suspension(Sugar Free)/Paracetamol 120mg/5ml sus po P 5ml qds

Paracetamol 250mg/5ml suspension(Sugar Free)/Paracetamol 250mg/5ml sus po P 5-10ml qds

Ibuprofen susp 100mg/5ml (100ml) po P 2.5ml 3-4 times/day (1-2 years) 5ml 3-4 times /day (3-7 years) 10ml 3-4 times/day (8-12 years)

Chlorhexidine 0.2% mouthwash topical / po P rinse mouth with 10ml for about 1 minute twice a day

Benzydamine 0.15% mouthwash topical / po P rinse mouth with 15ml every 1½ - 3 hours as required, usually not for more than 7 days.

Choline salicylate compound gel topical / po GSL apply ½ inch of gel with gentle massage not more than every three hours.

Adcortyl in Orabase for mouth ulcers topical / po P apply a thin layer 2-4 times a day, do not rub. Max use is 5 days

33 Advice . Minor mouth ulcers are self-limiting. Pain will be reduced after three to four days and the ulcer will heal within one to two weeks . NRT given by mouth (e.g. gum, microtabs) may cause mouth ulcers. It maybe helpful to use a different type of NRT (patches or nasal spray) instead. . Avoid spicy foods, acidic fruit drinks and very salty foods which can make the pain worse . Use a straw to drink to by-pass ulcers in the front of the mouth (not hot drinks, they can burn the throat) . Use a very soft toothbrush or see a dentist if dentures are badly fitting

Side effects and their management Most of the drugs indicated have no side-effects

When to refer to GP

If patients has blistering or ulcers on the lips and inside the mouth If accompanied by diarrhoea If no improvement after a week of treatment or presence of multiple ulcers (Herpes Simplex) Where there is evidence of contributing systemic condition

Mouth ulcers that appear larger than 5mm in diameter

Rapid referral:

If oral neoplasia is suspected, refer urgently.

34 NAPPY RASH

Definition/Criteria Contact dermatitis on prominent parts e.g. buttocks and thighs. It can become infected with Candida. Folds are often spared. The skin will have clusters of erythematous papules, which can form a livid red rash with sharp borders.

Criteria for INCLUSION Babies with soreness in nappy area.

Criteria for conditional EXCLUSION Evidence of systemic infection or infection with yellow crusting areas. Use of Clotrimazole HC cream in infants less than one year old.

. White soft paraffin 100g apply after nappy change GSL, External use . Clotrimazole-HC cream 30g – for severe nappy rash where there is an indication of Candida infection. Apply sparingly twice a day after nappy change. Cover Clotrimazole HC cream with, but do not mix with, white soft paraffin or zinc and castor oil cream to act as a barrier. POM (see patient group direction). External Use.

Follow-up and advice  Seek advice from General Practitioner if no improvement after 2 days  Regular nappy changes  Clean the skin with warm water, harsh soaps or detergents should be avoided  Nappy wipes may be irritant  Allow air to nappy rash for as long as possible Side effects and their management Unlikely if use is appropriate (and limited in the case of Clotrimazole HC cream to 5 days treatment)

When and how to refer to GP Referral to GP:

 Where there is evidence of systemic infection or yellow crusting areas.

35 NASAL CONGESTION

Definition/Criteria Blocked nose associated with colds and upper respiratory tract infections

Criteria for INCLUSION Congestion where seasonal allergy has been excluded

Criteria for EXCLUSION Diabetes or hyperthyroidism Recurrent nose bleeds Prostatic hypertrophy Hepatic or renal impairment Avoid in people taking monoamine oxidase inhibitors due to the possibility of hypertensive crisis

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Sodium chloride nasal drops (OP) nasal GSL bd Xylometazoline 0.1%nasal spray nasal GSL bd Xylometazoline 0.05% nasal drops (over 2 years) nasal GSL bd Pseudoephedrine tabs 60mg (over 12 years) (24) po P 1tds-qds Pseudoephedrine Hydrochloride Linctus (140ml) po P 5ml qds (6-12 years) 2.5ml qds (2-5 years)

Criteria Systemic products should be supplied when topical products tried without success Pseudoephedrine excluded for patients on anti-hypertensive therapy, or with heart disease, Pseudoephedrine tablets are contra-indicated for children under 12 years

Follow-up and advice Patients should be advised to put 1 tsp. of menthol & eucalyptus in a pint of hot (not boiling) water and use a cloth / towel over the head to trap the steam Maximum use of topical decongestants is seven days

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

36 SORE THROAT

Definition/Criteria A painful throat which is often accompanied by viral symptoms Signs are commonly redness of the pharynx and tonsils, presence of exudate, enlarged tonsils, and swollen tender neck glands.

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

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Aspirin 300mg soluble tablets (32) gargle P (over 16 years only) 1 qds Paracetamol 500mg tabs (32) po P 1-2 qds Paracetamol susp SF 120mg / 5ml (100ml) po P 5ml qds Paracetamol susp SF 250mg / 5ml (100ml) po P 5-10ml qds Paracetamol soluble tablets (24) po GSL 1-2 qds

Follow-up and advice Patients should be advised to swallow the aspirin suspension after gargling (unless aspirin causes dyspepsia) Patients should avoid smoky or dusty atmospheres and reduce or stop smoking. Patients who find swallowing painful should take a light fluid diet. Paracetamol daily dose - other products containing Paracetamol Sore throat symptoms resolve within 3 days in 40% of people and within 1 week in 85% of people, irrespective of whether they are streptococcal-positive or not Prescription of an antibiotic increases re-attendance rates for further episodes of sore throat . There is also the risk of adverse effects, and there is concern that indiscriminate prescribing increases bacterial resistance in the community

Side effects and their management There are unlikely to be any side effects.

When and how to refer to GP Conditional referrals:  If symptoms persist for more than one week, the patient should consult the GP

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

Rapid referral:

 Patients known to be immunosuppressed (accompanied by other clinical symptoms of blood disorders  People with breathing difficulty or stridor, as epiglottitis may be present (urgent admission indicated)

37 THREADWORM Definition/Criteria Evidence of threadworms in stools or anus. Threadworms are common but not usually serious. They infect the gut and lay eggs around the anus which cause itching. Medication kills the worms but not their eggs which can survive for two weeks. The hygiene measure below prevent the eggs being swallowed and therefore causing re-infection.

Criteria for INCLUSION All family members should be treated at the same time, regardless of whether there is evidence of threadworms in the stools or anus. All family members should follow the hygiene rules, as stated below.

Criteria for conditional EXCLUSION Patients under 2 years of age Pregnant or breastfeeding women Patients currently taking either cimetidine or metronidazole

These patients should be referred to their GP.

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

Mebendazole 100mg tablets po P 1 tablet followed by 1 tablet 14 days later if infection nor cleared.

Follow-up and advice

The following hygiene precautions are recommended, to be followed by each member of the family, to prevent re- infection with threadworms:

1. Keep nails short. Wash hands and scrub nails each morning.

2. Avoid nail biting or finger sucking.

3. Wash hands before meals or snacks.

4. Wear pyjamas or underpants in bed and wash them daily.

5. Bath every morning, washing thoroughly around the bottom.

6. Provide a towel for the exclusive use of each member of the family.

7. Change clothes and bed linen regularly.

8. Keep toothbrush in a closed cupboard. Rinse well before use. Since the life cycle of an adult worm can be as long as six weeks, it is advisable to continue with these general hygiene measures for six weeks.

Side effects and their management Side effects following the use of mebendazole occur only in very rare instances and are usually minor, such as mild, short-lived stomach ache or diarrhoea, or possibly an allergic reaction such as rash, shortness of breath, itching etc.

Other much rarer side effects have been reported, please refer to the Patient Information Leaflet for further information.

38 VAGINAL THRUSH

Definition/Criteria Vaginal candidiasis (Thrush).

Criteria for INCLUSION Vaginal candidiasis (thrush) occurring in adult females with a previous diagnosis of thrush who are confident it is a recurrence of the same condition.

Criteria for EXCLUSION Elderly patients Pregnancy Patients under 16 years Patients unsure if it is thrush. More than 2 infections of candidal vaginitis in the last 6 months Patients with recurrent thrush also suffering from loss of weight, thirst, blurred vision, lethargy, lower abdominal pain or dysuria, polyuria, bladder infections, dizziness or tiredness (suspicion of diabetes?) Diabetes, imminucompromised.

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Canesten Combi P Cream applied bd and pessary insert nocte Clotrimazole 500mg pessary P Insert pessary nocte Clotrimazole 2% cream P Apply 2-3 times daily Fluconazole 150mg capsule P Take as single dose

39 Follow-up and advice Make aware sexual partners should be treated concurrently. Advise if symptoms do not resolve within 7 days to make an appointment to see a GP. Make aware of problems with vaginal deodorants scented soap etc Clean “wiping” using the front to front-to-back action. Side effects and their management Precaution to use if patient is sensitive to Imidazoles. Occasional local irritation

When and how to refer to GP Conditional referral:

 On 3rd occurrence  Has symptoms that are not entirely consistent with a previous episode

 Post-menopausal women

Rapid referral: Presence of loin pain.

Fever.

If blood present in discharge

If there is a suspicion of undiagnosed diabetes (DO NOT DIAGNOSE)

Recurrent infection, defined as four episodes or more in one year.

Severe infection, which has additional complications and often responds poorly to short courses of treatment.

Infection in pregnant women, who may require different treatment.

Other forms of complicated vulvovaginal candidiasis, such as infection in immunocompromised women, infection in women with uncontrolled diabetes mellitus, and infection in women who are debilitated.

40 WARTS & VERRUCA

Definition/Criteria Viral infection caused by wart virus (human papilloma virus)

Signs and Symptoms  Well defined, raised lesions with a roughened surface  Lesions are usually flesh-coloured  May appear singly or as several lesions  Palms or backs of the hands are common sites for warts  Usually painless  Common warts have thick cauliflower like surface  Verrucae occur on the side of the foot and may be covered in hard skin

Criteria for INCLUSION Children over 1 month and adults presenting with signs and symptoms of warts or verruca

Criteria for EXCLUSION Known hypersensitivity to salicylic acid Patients who are diabetic Moles, birth marks, genital or facial warts Any change in shape, size, and colour Any discharge or pain Children under 1 month Peripheral neuropathy Patients at risk of neuropathic ulcers

Recommended Treatments, Route and Legal status. Frequency of administration and maximum dosage Topical preparations containing Salicylic acid (11-50%) - Cuplex gel P Apply bd Duofilm P Apply once daily Salactol paint P Apply once daily Bazuka gel P Apply once daily Salatac gel P Apply once daily

41 Advice  Continuous application of the preparation for several weeks or months may be needed  Treatment should be applied daily and is helped by prior soaking of the foot in warm water for 5-10 minutes to soften and hydrate the skin  Removal of dead skin from the surface, if verruca, by gentle rubbing with a pumice stone or emery board ensures that the next application reaches the surface of the lesion  Occlusion using an adhesive plaster helps to keep the skin macerated, maximising the effectiveness of salicylic acid  Protection of the surrounding skin is important and can be achieved by applying a layer of petroleum jelly to prevent the treatment from making contact with healthy skin  Application of the product using an orange stick will help limit the substance to the lesion itself. Most warts will disappear spontaneously between 6 months and 2 years  Do not apply to healthy skin or skin which is inflamed or broken  Warts of the skin can be transmitted from person to person by direct contact, indirectly from contaminated surfaces, and from one body location to another in the same person by auto-inoculation

Side effects and their management Skin irritation

When to refer to GP  Anogenital or Facial warts  Diabetics  History of vascular disease  Elderly  Bleeding  Itching  Any change in appearance of the wart – especially size, colour  Persistent infection following 3 months of treatment

Conditional referral: If symptoms persist after three months of treatment, patient should consult the GP

42 Rationale for use of Drugs in minor ailments

Candida/Athletes foot

 Imidazoles are effective against both Candida and tinea, and may be preferred if diagnostic doubt exists. Chicken pox  It is well documented that antihistamines are effective in relieving itchy symptoms caused by chicken pox Cold sores  Herpes infection of the mouth and lips is generally associated with Herpes Simplex virus serotype 1 (HSV-). Treatment of Herpes simplex infection should start as early as possible and usually within 5 days of the appearance of the infection. In individuals with good immune function, mild infection is treated with a topical antiviral drug and Aciclovir is active against herpes simplex infections Conjunctivitis  Chloramphenicol has a broad spectrum of activity and is the drug of choice for superficial eye infections Constipation

 There is no conclusive evidence that one form of laxative is more effective than another in the elderly, therefore the appropriate drug should be chosen according to the individual person's circumstances.

 There is insufficient evidence to decide which is the most appropriate laxative for use in childhood.

 Laxatives such as bulk-forming agents, stool softeners, or a combination of a stimulant laxative and a softener should be tried if increasing fibre and fluids fails. Contact Dermatitis  Results from an experimentally induced skin inflammation study indicated that Eumovate 0.05% cream has both more effective anti-inflammatory activity and better moisturising properties than hydrocortisone 1% cream and that these effects are in part due to its efficient emollient base. Cough

 Cough due to viral upper respiratory tract infection is extremely common in primary care.

 at present, there is no evidence that brand name cough medicines are any more effective in the management of cough in children than placebo. Cystitis  When there is an infection in the urinary tract, the bacteria in the bladder create an acidic environment that helps them to grow and multiply rapidly. As a result, the urine becomes more acidic, making it very painful to pass urine.  Sodium citrate, after conversion to bicarbonate, neutralises the acid present and makes the urine alkaline. This relieves the discomfort of passing urine and also makes the environment less suitable for the growth of the infecting bacteria.  Cochrane review states that short-course antimicrobial (3-day course) of Trimethoprim appears to be an effective alternative to the standard course of therapy Head Lice Most studies of treatments for head lice are of poor quality. This was highlighted by a recent Cochrane review where, out of 71 trials identified, only four were considered suitable for inclusion

 The studies included in the Cochrane review evaluated malathion, permethrin, and wet combing using the 'Bug Busting' method. Permethrin and malathion, but not wet combing, were effective for the treatment of head lice in these studies.

43 Headache/Temperature

 Paracetamol or NSAIDs are effective in the treatment of headache

 Codeine should be used with caution because of the increased risk of causing medication overuse headache Low-dose combination codeine preparations (e.g. co-codamol) have been shown to be of no greater efficacy than paracetamol alone. High-dose codeine (30 mg) may be used for people with severe headache but this must be short term (less than one week) only

 In episodic tension-type headache the treatment of choice is paracetamol or NSAIDs. Impetigo  Hydrogen Peroxide cream has shown to be as effective as Benzoyl peroxide in reducing both inflammatory and non-inflammatory AV lesions in patients with mild-to-moderate impetigo. In comparison with BP 4% gel, HPS cream shows a better local tolerability profile. Indigestion/Heartburn  There is limited evidence on the efficacy of antacids in the management of dyspepsia; however; symptomatic relief is often reported with the use of an antacid.  Histamine H2-receptor antagonists (H2RAs) are effective in the treatment of acute peptic ulceration, with 95% of duodenal ulcers healed in 6 weeks. Cimetidine, famotidine, nizatidine, and ranitidine appear to be equally effective. Insect bites and stings

 Symptomatic treatments recommended for itching include:

Antihistamines - these are of minimal help in treating pruritus. However, a short course of a sedative oral antihistamine at night may be useful to break the itch-scratch cycle and help with sleep.

If there is local inflammation, consider using a topical corticosteroid. This may also help to relieve itching, although there is little objective evidence to support this Mouth ulcers

 Chlorhexidine gluconate 0.2% mouthwash is used for aphthous ulcers. There is some evidence that it reduces duration and severity of ulceration. Recurrence of ulceration is not prevented but it may help to prevent secondary bacterial infection. It can also provide oral hygiene when people are unable to brush their teeth. However regular use causes tooth staining, which may not be acceptable to some people

 Corticosteroids: hydrocortisone lozenges or triamcinolone oral paste is probably most useful when applied early, before the ulcer develops. The limited evidence available suggests that corticosteroids do not cause adrenal suppression when used in this way. Triamcinolone oral paste may be difficult to apply to some parts of the mouth.

 Choline salicylate dental gel (Bonjela or Dinnefords Teejel) may provide analgesia for some people, but excessive application can cause further ulceration [BNF 42, 2001].

 Benzydamine mouthwash or spray may be considered for some people. Although they have not been shown to affect the course of an ulcerative episode, they may be useful when analgesia is required. The spray is more convenient to carry for frequent applications [BNF 42, 2001]. The mouthwash is not licensed for use in children aged 12 years and under.

44 Nappy Rash

 General measures related to medicine to be taken as soon as nappy rash develops include:

Application of a barrier cream (e.g. zinc and castor oil) after every change.

Topical anticandidal therapy (an imidazole or nystatin) should be applied, as Candida albicans is isolated from most children with nappy rash. This therapy is often combined with 1% hydrocortisone to reduce the associated inflammation.

 If the nappy rash does not improve rapidly with the above management: The most likely causative factors are still a combination of Candida albicans and physical irritants (faeces and urine). Continue with the general measures outlined above in combination with topical anticandidal therapy (with or without a mild corticosteroid) [Even though candidal resistance is not thought to be a problem in this situation, many health professionals would consider changing from an imidazole to nystatin (or vice versa) due to the possibility of infection with a less susceptible organism Nasal Congestion

 Oral decongestants (e.g. pseudoephedrine) or topically administered nasal decongestants (e.g. ephedrine, oxymetazoline, xylometazoline): there is no evidence to support regular use of any of these. Topical nasal decongestants have an immediate beneficial effect on reducing nasal stuffiness, but prolonged regular use may cause rebound congestion on withdrawal (rhinitis medicamentosa), resulting in continued inappropriate use. Although oral preparations are not as immediately effective as topical preparations, they do not cause rebound congestion on withdrawal. Adverse effects of systemic decongestants result from unwanted sympathomimetic effects, and they should be used with caution in people with diabetes, hypertension, hyperthyroidism, raised intraocular pressure, prostatic hypertrophy, hepatic or renal impairment, or ischaemic heart disease. Avoid in people taking monoamine oxidase inhibitors due to the possibility of hypertensive crisis. There is no evidence to support the use of oral or topical decongestants in children less than 12 years old with the common cold

 Steam inhalation has been used for the symptomatic relief of the common cold for decades. Although there does not appear to be any clear evidence of benefit (e.g. objective evidence of decreased viral shedding), neither is there a worsening of clinical symptom scores Sore throat

 Paracetamol is the analgesic drug of choice in sore throat. Ibuprofen is an alternative. There is little evidence to suggest that the addition of a weak opioid such as codeine phosphate offers any additional advantage, and adverse effects are more likely.

 Gargles have been poorly researched and no specific recommendations can be made regarding their use. Anecdotally, gargling with salt water or aspirin is reported to relieve pain in some people. One small study found that benzydamine as a gargle for sore throat resulted in significantly greater relief of pain and dysphagia at 24 hours than placebo, but this requires confirmation [SIGN, 1999]. Threadworm

 Antihelmintics are effective in threadworm infections, but their use needs to be combined with hygienic measures to break the cycle of aust-infection. Mebendazole is the drug of choice for treating threadworm infection in patients of all ages over the age of 2 years Vaginal Thrush

 Topical imidazoles are an effective cure for uncomplicated vulvovaginal candidiasis. A systematic review found that for every three women treated with topical imidazoles, one extra had resolution of symptoms compared to placebo in the short term (NNT=3). No particular topical imidazole was found to be superior to any other

 The efficacy of topical imidazoles is not dependent on the length of the course of treatment, but is related to the total dose of drug received. A single high dose is as effective as a lower divided dose over several days 45  To be effective, intravaginal application is required. However, women should apply cream to the vulva as well as inserting a pessary or intravaginal cream where possible, as this area is also commonly affected. Application of topical treatment can be painful in some instances where there is particularly bad inflammation Warts and Verrucae

 Although most studies of topical treatments for cutaneous warts are of poor quality, a recent Cochrane review found that topical treatments containing salicylic acid compared to placebo are effective and safe

46 Appendix 2: Minor Ailment Scheme Formulary March 2011 Condition Treatment Cost £ (ex VAT) Clotrimazole Cream 1% 20g 1.68 Athlete’s Foot Clotrimazole Powder 30g 1.52 Daktarin Cream 2% 15g 1.93 Calamine Lotion 200ml 0.54 Chicken Pox Chlorpheniramine Syrup – 150ml 2.23 Aciclovir Cream – 2g 1.96 Cold Sores Blisteze cream – 5g 1.40 Conjunctivitis Chloramphenicol eye drops 0.5% 10ml 2.01 Fybogel Sachets – 10 2.12 Constipation Lactulose Solution – 300ml 2.61 Senna Tablets - 20 1.43 Contact Eumovate Cream – 15g 3.31 Dermatitis Hydrocortisone Cream 1% - 15g 0.75 Pholcodine Linctus – 200ml 0.80 Cough Simple Linctus – 200ml 0.66 Simple Linctus Paediatric – 200ml 0.33 Canestan Oasis – 6 2.71 Cystitis Cystopurin – 6 2.59 Trimethoprim 200mg Tablets - 6 0.50 Dioralyte Sachets – 20 6.99 Diarrhoea Loperamide – 6 1.70 Beclomethasone Nasal Spray 180dose 5.36 Cetirizine Tablets 10mg – 7 2.28 Cetirizine Tablets 10mg -30 5.02 Chlorpheniramine syrup – 150ml 2.23 Hayfever Chlorpheniramine tablets 4mg – 28 1.80 Fluticasone Nasal Spray – 60dose 4.16 Loratadine Syrup - 100ml 2.85 Loratadine Tablets 10mg - 7 0.85 Sodium Cromoglycate eyedrops 10ml 2.46 Ibuprofen Tablets 200mg – 48 1.32 Ibuprofen Suspension 100mg/5ml -100ml 1.59 Paracetamol Suspension 120mg/5ml 1.64 -100ml Headache Paracetamol Suspension 250mg/5ml – 2.00 100ml Paracetamol Soluble tablets 500mg -24 2.48 Paracetamol Tablets 500mg – 32 0.23 Headlice comb – 1 1.69 Malathion Alcoholic Lotion – 1 x 50ml 2.23 Malathion Alcoholic Lotion family 2x50ml 4.46 Headlice Malathion Alcoholic Lotion family 3x50ml 6.69 Malathion Alcoholic Lotion family 4x50ml 9.02 Malation Aqueous lotion – 1x50ml 2.28 Malation Aqueous lotion -family 2x50ml 4.56

47 Malation Aqueous lotion family 3x50ml 6.84

Malation Aqueous lotion family –4x50ml 9.12

Condition Treatment Cost £ (ex VAT) Permethrin Crème Rinse – 1x59ml 2.38 Permethrin crème Rinse family 2x59ml 4.76 Permethrin crème Rinse family 3x59ml 7.14 Permethrin crème Rinse family 4x59ml 9.52 Phenothrin 0.5% liquid -1x50ml 2.23 Phenothrin 0.5% liquid family 2x50ml 4.46 Headlice Phenothrin 0.5% liquid family 3x50ml 6.69 Phenothrin 0.5% liquid family 4x50ml 9.02 Phenothrin 0.5% lotion 1 x 50ml 2.23 Phenothrin 0.5% lotion family 2 x 50ml 4.46 Phenothrin 0.5% lotion family 3 x 50ml 6.69 Phenothrin 0.5% lotion family 4 x 50ml 9.02 Phenothrin 0.5% mousse 1 x 50ml 2.54

48 Phenothrin 0.5% mousse family 2 x 50ml 5.08 Phenothrin 0.5% mousse family 3 x 50ml 7.58 Phenothrin 0.5% mousse family 4 x 50ml 10.12 Gaviscon Advance Tablets -20 3.24 Magnesium Trisilicate Mixture – 200ml 1.68 Heartburn/Indigestion Peptac Liquid – 500ml 1.95 Zantac Tablets 75mg - 24 4.16 Impetigo Crystacide Cream 1% - 10g 4.82 Chlorpheniramine Syrup – 150ml 2.23 Chlorpheniramine tablets 4mg – 30 1.80 Insect Bite Hydrocortisone cream 1% - 15g 3.20 Mepyramine Cream 2% - 25g 2.14 Adcortyl in Orabase – 5g 2.25 Benzydamine Mouthwash – 200ml 2.02 Chlorhexidine Mouthwash 0.2% - 300ml 1.90 Choline salicylate Gel – 15g 1.79 Mouth ulcer Ibuprofen Susp 100mg/5ml – 100ml 1.59 Paracetamol S/F Susp 120mg/5ml – 1.64 100ml Paracetamol S/F Susp 250mg/5ml – 2.00 100ml Canestan HC cream -30g 2.15 Nappy rash White Soft Paraffin – 50g 0.99 Pseudoephedrine Linctus – 100ml 2.12 Pseudoephedrine Tablets 60mg – 24 2.12 Sodium chloride Nasal drops -10ml 0.83 Nasal Congestion Xylometazoline Nasal drops 0.05% – 1.59 10ml Xylometazoline Nasal spray 0.1% - 10ml 1.91 Aspirin soluble Tablets 300mg – 32 0.96 Paracetamol S/F Susp 120mg/5ml -100ml 1.64 Sore Throat Paracetamol S/F Susp 250mg/5ml -100ml 2.00 Paracetamol Tablets 500mg – 32 0.23 Paracetamol soluble Tablets 500mg - 24 2.48 Ibuprofen suspension 100mg/5ml – 1.32 100ml Ibuprofen tablets 200mg – 48 1.59 Temperature Paracetamol S/F Susp 120mg/5ml -100ml 1.64 Paracetamol S/F Susp 250mg/5ml -100ml 2.00 Paracetamol Tablets 500mg – 32 0.23 Paracetamol soluble Tablets 500mg - 24 2.48 Threadworm Mebendazole Tablets 100mg – 8 3.42 Canestan Combi – 1/10g 5.70 Clotrimazole Cream 2% -20g 3.70 Vaginal Thrush Clotrimazole pessary 500mg – 1 4.15 Fluconazole capsule 150mg - 1 1.44 Verruca Bazuka 12% - 5g 3.39 Bazuka 26% - 5g 3.95 Cuplex gel -5g 2.23 Duofilm Paint -15ml 2.25 Salactac gel – 8g 3.12 49 Salactol paint – 10ml 1.79 Bazuka 12% - 5g 3.39 Bazuka 26% - 5g 3.95 Cuplex gel -5g 2.23 Warts Duofilm Paint -15ml 2.25 Salactac gel – 8g 3.12 Salactol paint – 10ml 1.79

50 Appendix 3:

Minor Ailment Consultation form

Pharmacy holds these forms for completion during consultation

It has 2 copies

1. Pharmacist 2. Patient

51 Minor Ailments Consultation Form (Pharmacist Copy)

Date______Consultation No. ………….

Please write clearly using a BALL POINT PEN on a SOLID surface. Please press firmly Patients details:

First Name………………………………. .Surname……………………………………………………….

House Number………………… Post Code……………………………………. Date of birth………………..

GP practice Pharmacy PATIENT CONSENT – to be completed by ALL patients

I am happy for my doctor to receive details of my visit to the pharmacist yes no

Please indicate ONLY the statement below which applies to you. A x is under 16 years of age G x has a war pension exemption certificate B x is 16,17,18 and in full time education L x is named on a current HC2 charges certificate C x is 60 years of age or over H x gets income support D x has a maternity exemption certificate K x gets income-based jobseekers allowance E x has a medical exemption certificate M x is named on a working families Tax Credit NHS exemption certificate F x has a prescription prepayment certificate N x Is named on a disabled persons Tax Credit NHS exemption certificate x no medication was supplied x I have paid £ for the medicine(s) supplied I am the patient Pharmacy use: I am the childs parent or guardian Evidence of exemption seen yes no

Patient’s (or parent’s/guardian’s) signature …………………………………………………………. Date …………………….

Minor Ailments Consultation Form (Patient Copy)

Date______Consultation No. ………….

Condition …….…………………………………………………………………………………..

Treatment Supplied ………………………………………………………………………………………..

Pharmacist’s signature ……………………………………………. If your symptoms do not improve and it is necessary to visit your Doctor please take this form with you. Top half of page to be kept by Pharmacy – Second half of page to be kept by patient

Appendix 4:

Minor Ailment Referral Request

52 Pharmacies hold these forms to refer patients for a medical opinion

This document appears on the following page. This has 2 copies

1. Pharmacist 2. Patient (To take to GP)

53 Appendix 4

Minor Ailments Referral Request

Name GP Surgery

Address

Referring Person

DoB Date of Referral Symptoms Reported

Reason for referral

How soon does the patient require the appointment and to whom were they referred (please delete option not applicable)?

Immediately, (Pharmacist to refer patient to GP)

Routine to GP

Name of Pharmacist doing referral (Block Capitals)

Pharmacy Stamp Pharmacists signature

Date referred

White copy – Pharmacist Yellow copy - Patient

54 Appendix 5: Surgery Procedure for signposting to the Minor Ailment Scheme

Patients included in the scheme who are exempt from prescription charges will continue to have their medicines supplied free of charge.

If the patient presents with one of the following symptoms they will be provided with the opportunity of seeing a participating pharmacist instead of waiting to see a GP.

Make sure that this presentation is recent and that the patient has NOT been self medicating. This will avoid the Pharmacist having to refer the patient back to the practice.

 Athlete’s foot  Blocked nose  Chickenpox  Cold sore  Conjunctivitis (excluding children under 2 years)  Constipation (excluding children and babies)  Contact dermatitis (excluding patients under 10 and those with problems on their neck, face or genitalia)  Cough ( excluding patients under 1 year)  Cystitis  Diarrhoea (excluding patients under 1 year),  Headache  Head lice ( excluding children under the age of 6 months).  Heartburn  Hay fever  Impetigo  Indigestion  Insect bite  Mouth ulcers  Nappy rash (excluding patients under 1 year),  Sore throat,  Temperature,(excluding children under 3 months  Threadworm  Vaginal thrush ( excluding patients under 16)  Warts or verucca

Practices will need to provided patient with the list of participating Pharmacies DO NOT FORGET when you receive a Minor Ailment Consultation report to input it in the patient’s notes using Read code 8H7t.

Appendix 6: Think Minor? Think offer Minor Ailment referral to Pharmacist?

‘If you think you are suffering with x, you can go to a local Pharmacy for advice and appropriate treatment.’

Patient complaining of one of these???

 Athlete’s foot  Blocked nose  Chickenpox  Coldsore  Conjunctivitis (excluding children under 2)  Constipation (excluding children and babies)  Contact dermatitis (excluding patients under 10 and those with problems on their neck, face or genitalia) Remember they don’t need to pay for  Cough ( excluding patients under medicines if they don’t pay for 1 year) prescriptions.  Cystitis  Diarrhoea (excluding patients Your nearest participating Pharmacies under 1 year), are:  Headache  Head lice ( excluding children under the age of 6 months).  Heartburn  Hay fever Other participating Pharmacies are:  Impetigo  Indigestion  Insect bite  Mouth ulcers  Nappy rash (excluding patients under 1 year),  Sore throat,  Temperature,(excluding children Any queries speak to: under 3 months  Threadworm  Vaginal thrush (excluding patients under 16,pregnant women, elderly) If the patient still wishes to see GP  Warts or verucca after explanation, make them an appointment, but record in notes, so GP can discuss their decline with them.

56 Appendix 7: Minor Ailment consultation checklist If you can answer YES to each question you have done everything!

 Completed consultation?  Patient understands scheme?  Pharmacist happy that patient understands treatment/advice?  Pharmacist completed Minor Ailment Consultation form?  Pharmacist filed Pharmacist copies of all paperwork in safe and secure place?

Patient intervention complete!

Reimbursement:

All consultations are to be submitted to Webstar by the 5th working day of each month for the previous month’s consultations. Submissions will be accepted no later than 3 months from the consultation date.

Any queries please contact the community pharmacy on 01634 335083

57 Appendix 9: Pharmacist/Pharmacy agreement form

Please find below the minor illnesses that will be covered within the minor ailments scheme. Please read the protocols, tick the relevant box and sign the form. Keep a copy for your Pharmacy records and send a copy to the Medicines Management team at the PCT. Minor Illness Protocol Read and Agreed Athlete’s Foot Chickenpox Cold sore Conjunctivitis Constipation Contact Dermatitis Cough Cystitis Diarrhoea Hay Fever Head Lice Headache/Temperature Impetigo Insect bite Indigestion Mouth Ulcers Nappy Rash Nasal Congestion Sore Throat Threadworm Vaginal Thrush Warts and Verucca

I have read the handbook and the protocols and agree to abide by them for the purpose of the minor ailments scheme. I have read the PGDs on Clotrimazole HC cream, and trimethoprim and agree to supply/administer this medicine only in accordance with this PGD. PGDs do not remove inherent professional obligations or accountability. It is the responsibility of each professional to practice only within the bounds of their own competence and in accordance with their own code of professional conduct.

Pharmacy accreditation: Essential service and consultation area

Pharmacist training: I have attended

PCT MAS training Other (Please specify) ……………………………………..

Pharmacist’s Signature ------Name------

Pharmacy Address ------

Pharmacy Tel. No. ------

Date ------Please return to: Minor Ailment Co-ordinator, Medicines Management Team, 2 Ambley Green, Bailey Drive, Gillingham Business Park, Gillingham ME8 0NJ

58 Appendix 10: Duties of Participating Community Pharmacists

1) The lead participating pharmacist will complete the Pharmacist’s Agreement and send it to the address at the bottom of the form.

2) All participating Pharmacists will provide a professional consultation service for patients presenting with one of the specified conditions. a) The Pharmacist will ensure the patient has been supplied with, and reads, a leaflet of the scheme.The pharmacist will then:

1) Assess the patient (use of supplied protocols). 2) Provide advice. 3) Provide medication, if necessary, from the agreed formulary appropriate to the patient’s condition. 4) Complete, in full, the Minor Ailment Consultation Form. RUINED FORMS SHOULD BE SENT TO THE PCT AT THE END OF EACH MONTH. 5) Distribute Minor Ailment Consultation Forms, as directed on the forms.

3) Normal rules of patient confidentiality apply. 4) The Pharmacist should ensure that the patient has completed and signed the declaration of exemption of prescription charges on Minor Ailment Consultation Form.

5) If, in the opinion of the pharmacist, the patient presents with symptoms outside the Pilot Scheme, they should be referred back to their GP.

6) If a patient presents more than once within any month with the same symptoms and there is no indication for urgent referral, the patient should be referred to their surgery for a routine appointment.

7) If the patient presents with symptoms indicating the need for an immediate consultation with the GP they are outside the realms of the Scheme and should be advised to refer back to their GP (within surgery hours) or to contact the on-call doctor, or to attend A & E immediately (as appropriate, outside surgery hours). You must complete the Minor Ailments Referral Request giving the yellow copy to the paitent.

8) If the pharmacist suspects that the patient and/or parent is abusing the scheme they should alert the PCT Medicines Management team on 01634 335083 and the patient’s GP.

9) The pharmacist will provide feedback to the GP with the patient’s consent, as they deem appropriate. The procedure for this to be decided by participating pharmacist and GP.

10) All consultations should be entered onto the computer and submitted to Webstar by the 5th of the following month.

11) All forms should be stored in a secure place for 2 years after the consultation before being disposed of confidentially.

59 Appendix 11: Supply information to practices

Drugs supplied under PGD (Trimethoprim tablets/Canesten HC) through Minor ailment scheme

The following patients have been supplied a drug under PGD for your records.

Name of patient, Drug supplied under PGD Signature of Pharmacists address, DOB and Manufacturer of product, Authorising name and registered GP batch number and expiry Manager or GP RPSGB with number date responsibility for PGDs

Pharmacy Stamp: