Description of the service initiative intervention
The Pharmacy First Extended Care Service for ENT & Eye conditions aimed to provide eligible patients registered with a GP practice contracted to NHS England, Staffordshire and Shropshire Area (NHSE S&S) with access to medication via community pharmacies for the treatment of specified ENT conditions and for acute bacterial conjunctivitis not suitable for treatment under the Pharmacy First Common Ailments Service (PFCAS). The specific ENT conditions included were acute otitis externa, acute otitis media, acute bacterial sinusitis, chronic sinusitis, seasonal allergic rhinitis, and sore throat. These ENT conditions were chosen on the basis of being among the most common category of presenting conditions to the local A&E departments and the specific conditions being commonly occurring within the category. Acute bacterial conjunctivitis was included because analysis of PFCAS data indicated that it was a common reason for GP referral by community pharmacists.
Consenting patients had a consultation with a pharmacist where their symptoms and their medical and medication history were assessed (with reference to their Summary Care Record wherever possible). The pharmacist examined the patient, assessed their treatment needs and determined whether they met specific inclusion criteria to be managed under the extended care service. For patients who were included, pharmacists gave self-care advice (including what to do if their symptoms did not resolve or their condition worsened) and, where clinically appropriate, supplied non-prescription medicines either purchased by the patient or through the PFCAS. Where antibiotic treatment or other POMs appeared to be necessary the pharmacist supplied these under Patient Group Directions (PGDs) specific to each condition and the GP practice was informed. The antibiotic that could be supplied was specified in each PGD (with an alternative in case of allergy or other contraindication) at a fixed dose, frequency and duration of treatment. Antibiotic choices in PGDs complied with local antibiotic formularies to take account of local antibiotic resistance patterns. The service also allowed deferring antibiotic treatment, which meant that if the patient returned after waiting a pre-defined number of days, the antibiotic could be supplied without repeating the consultation.
As part of accessing the service, all patients agreed to be contacted by the pharmacist approximately 5 days after their consultation for a short telephone interview to follow up on how successful the treatment had been and whether they had since seen another health professional for the same condition.
The service started in late November 2017 and was provided through ten community pharmacies contracted to NHSE S&S that had signed the Service Level Agreement (SLA). These pharmacies were selected for the service on the basis of having responded to a call for expressions of interest and meeting pre-defined criteria. These included that the pharmacies had to have an accredited consultation area approved for delivery of advanced services (i.e. clearly signed as a private consultation area, where the patient and pharmacist can sit down together and talk at normal speaking volume without being overheard by staff or customers) and that two pharmacists from each pharmacy had completed bespoke, online and face-to-face training on diagnosis and management of the ENT and eye conditions. The training was developed and delivered by a team that included two GP trainers in examination skills and pharmacist facilitators. This included training pharmacists on recognising ‘red flag’ signs and symptoms potentially indicative of a more serious condition, diagnosis in vulnerable groups and how to use diagnostic equipment (otoscope, torch and digital ear thermometer). Participating pharmacies were supplied with the additional equipment necessary (e.g. an otoscope) and were able to provide the service to a limited number of patients each, based on the funding secured. The service was funded by the North West Midlands Urgent and Emergency Care Network, which included the training and supply of additional equipment, and project managed by Local Pharmaceutical Committees (LPCs). Additional top-up funding was awarded to the project by NHSE S&S Local Professional Network for pharmacy.
Data collection and analysis
The evaluation used two methods of data collection: PharmOutcomes to record service access data and a questionnaire survey as a means of collecting patient satisfaction data. PharmOutcomes was used as a means of collecting data about patient uptake and outcomes of the service because it is already used by community pharmacies in the study location to record and be remunerated for delivery of commissioned services. Recording modules can be written for this web-based system to match service specifications and PGDs, resources and links can be embedded into the system to allow the pharmacy team easy access to local documents and any relevant national guidance. Recording service delivery data on the system allows local and national level analysis on the effectiveness of commissioned services. All personally identifiable information was removed from the data downloaded from PharmOutcomes for the evaluation, but patient age, gender, ethnicity and the first part of their postcode were included. Anonymous patient satisfaction data were collected using a questionnaire because community pharmacy customers tend to be familiar with the format as it is commonly used by pharmacies and GP surgeries for gaining patient feedback. As a service evaluation, ethical approval was not required.
Questions were set up in PharmOutcomes for pharmacists to answer as consultations progressed to guide the consultation and ensure that standardised information was recorded. These questions were mapped to the SLA and PGDs. This included the outcome of pharmacists’ consultations with patients in terms of supply of non-prescription medicine (either purchased or supplied under the PFCAS), as well as the diagnosis made and the numbers of those who were supplied with a POM, not supplied with any treatment or were referred.
For the follow up telephone interviews, pharmacists attempted to contact all patients who had received the extended care service to determine whether they had subsequently seen another health professional about the same condition within 5 days of seeing the pharmacist and, if so, which professional they had seen. This data was recorded in PharmOutcomes. Where patients had seen another health professional they were asked why and a free text response was recorded in PharmOutcomes. This data was thematically categorised and frequency counted.
Patients who received the extended care service were also given a pack containing an invitation letter, a patient satisfaction questionnaire and a pre-paid envelope. They were invited to complete the questionnaire anonymously and post it back to the pharmacy, or anonymously complete an online version. The questions were designed as fixed response rather than free text and were developed from standard questions used in numerous other evaluations according to the aims of the evaluation of the extended care service. These included whether patients would use the service again, or recommend the service to others, reasons for using the service, and how they found out about the service, as well as asking them to rate their satisfaction with the service they had received on a 5 point Likert scale.
Data recorded in PharmOutcomes were downloaded into a Microsoft Excel spreadsheet and anonymised before being sent to a researcher (SW) who was independent of the service delivery and administration. Questionnaire data was manually inputted into Excel. These data were subjected to descriptive statistical analysis.