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1. Introduction

Minor Ailment Schemes are a key component of community pharmacy development under the NHS Plan initiatives. Community Pharmacists already advise patients on a wide range of minor ailments and either recommend treatment or refer on to another healthcare professional. The management of patients with minor self-limiting conditions, impacts significantly upon GP workload
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. The situation is most acute where patients do not pay prescription charges and may not have the resources or the motivation to seek alternatives to a prescription from their GP.
Access is a key feature of the Government’s modernisation plans for the NHS, with the promise that by 2004 all patients will be able to see a primary care professional within 24 hours and a GP within 48 hours.
The pilot project in Sheffield was developed under the auspices of the Pharmacy
Joint
Planning Group (JPG). The aim of the project was to manage a number of minor selflimiting conditions within community pharmacy, thus reducing the demands these patients make of their GPs. In addition the effective management of patients in this way should be helpful in assisting GPs to meet access targets
With the continued de-regulation of prescription only medicines (POM) to pharmacy (P) status means that community pharmacy is well equipped to deal effectively with selflimiting conditions. Recent published work
2 has indicated that the management of such patients can be successfully moved from general practice to community pharmacy and a number of pilot projects are in progress across the country.
2. Conditions Covered
A service specification was developed for the management within community pharmacy of the following conditions:
- Cough
- Sore Throat
- Headache / Earache / Temperature
- Nasal Congestion
- Hay Fever
- Head Lice
- Indigestion / Heartburn / Tummy Upset
- Diarrhoea
- Constipation
- Thrush

1
Over the counter drugs (editorial) Lancet 1994;343:1374-5
2
Managing demand: transfer of management of self-limiting conditions from general practice to community pharmacy. Hassell K et al. BMJ 2001; 323 :146-7
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3. Formulary
A formulary was developed containing the following items:
Simple Linctus (200 ml)
Simple Linctus Paediatric (200 ml)
Aspirin 300 mg – Soluble Tablets (32)
Paracetamol 500 mg Tablets (32)
Paracetamol Suspension SF 250 mg / 5 ml (100 ml)
Paracetamol Suspension SF 120 mg / 5 ml (100 ml)
Ibuprofen 200 mg (48) Ibuprofen Suspension 100 mg / 5 ml (100 ml)
Menthol and Eucalyptus Inhalation (100 ml)
Sodium Chloride Nasal Drops (OP)
Xylometazoline 0.1% Nasal Spray
Xylometazoline 0.05% Nasal Drops
Pseudoephedrine (Galpseud) Tablets 60 mg (24)
Pseudoephedrine Hydrochloride (Galpseud) Linctus (140 ml)
Chlorphenamine Tablets 4 mg (30)
Cetirizine Tablets 10 mg (7)
Sodium Cromoglicate Eye Drops (10 ml)
Beclometasone Nasal Spray (180 sprays)
Chlorphenamine Syrup (150 ml)
Malathion Alcoholic Lotion (50 ml / treatment)
Malathion Aqueous Liquid (50 ml / treatment)
Malathion Alcoholic Lotion (200ml / treatment)
Malathion Aqueous Liquid (200ml / treatment)
Non-insecticidal head lice treatment / plastic comb
Non-insecticidal head lice treatment / metal comb)
Permethrin Crème Rinse (59 ml)
Magnesium Trisilicate Mixture (200 ml)
Gaviscon Liquid (200 ml)
Gaviscon 500 Tablets (12)
Loperamide Capsules (12)
Dioralyte Sachets
Senna Tablets (20)
Fybogel (10)
Clotrimazole Cream 1% (20 g)
Clotrimazole Pessary (500 mg)
4. Recruitment of GP Practices and Pharmacies
Initially the Prescribing Advisers from each of the four Sheffield PCTs recruited a total of
13 GP practices across the City.
Following identification of participating GP practices an open meeting was held for
Sheffield pharmacy contractors and 29 pharmacy practices were recruited across the City.
As the project became established the Pharmacy Joint Planning Group agreed to extend participation to further GP and pharmacy practices. The position in February
2002 and

March 2003 is set out in Tables 1 and 2.
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Table 1. Participating GP Practices by PCT (February 2002 & March 2003)
North* South East** South West*** West****
February 2002 2 5 2 4
March 2003 5 8 3 6
* North Sheffield Primary Care Trust
** South East Sheffield Primary Care Trust
*** Sheffield South West Primary Care Trust
****Sheffield West Primary Care Trust
Table 2. Participating Pharmacy Practices by PCT (February 2002 & March
2003)
North South East South West West
February 2002 7 9 6 7
March 2003 8 12 6 9
5. Training and Support to Practices
A detailed protocol for the scheme was developed, together with all the relevant documentation and sufficient copies were printed to equip all participating practices. In addition information leaflets and A3 sized posters to inform patients about the scheme were designed and printed.
Each practice was visited by the Pharmacy Development Manager who ensured that staff were trained in the operation of the scheme, and were clear about how they would implement it at the practice level. With these arrangements in place the pilot project commenced at the start of February 2002.
Further support to practices, after commencement was provided in the form of follow up visits by the Pharmacy Development Manager or the Community Pharmacy
Facilitator. In addition phone support was provided on an ongoing basis.
6. Results
Analysis of the first 14 month’s experience with the minor ailments pilot has yielded the information detailed below in Table 3.
Table 3. Patients Treated & Items Prescribed - by PCT (February
– March 2003)
PCT
No of Patients
No of Items
West
1092 1289
South West
774 1019
South East
592 690

North
615 784
Totals 3073 3782
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As can be seen from the table above, 3073 patients were dealt with by this service, and had one or more medicine prescribed (mean 1.23) between 1 st
February and 31st
March
2003.
Table 4. Patients not prescribed any Items - by PCT (February 2002
– March
2003)
PCT Consultation Only
West 9
South West 16
South East 2
North 18
Totals 45
In addition over the same period a total of 45 patients (~ 1.5%) accessed the service but were not prescribed any medicines by the pharmacist. This was because the pharmacist either considered t hat the patient’s condition fell outside the minor ailments service and referred them to their GP, or that the condition required advice only.
7. Medicines Prescribed
The medicines prescribed by the community pharmacists for the period 1
February 2002
–
31 March 2003 are as shown in Table 5.
Table 5. No of Packs of Each Formulary Item Prescribed (February 2002 –
March 2003)
Formulary Item No. of packs prescribed
Paracetamol Suspension 120mg 682
Permethrin Crème Rinse (59ml) 648
Malathion Alcoholic Lotion (50ml) 465
Malathion Aqueous Liquid (50ml) 281
Simple Linctus Paediatric (200ml) 258
Paracetamol Suspension 250mg 223
Simple Linctus (200ml) 221
Clotrimazole Pessary (500mg) 173
Paracetamol 500mg (32) 167
Clotrimazole Cream 1% (20g) 162
Cetirizine 10mg (7) 111
Pseudoephedrine Linctus (140ml) 78
Dioralyte Sachets (6) 75
Pseudoephedrine 60mg (24) 58
Sodium Cromoglicate Eye Drops (10ml) 54
Gaviscon Liquid (200ml) 50
Senna Tablets (20) 47
Aspirin 300mg Soluble (32) 45
Loperamide Capsules (12) 41

Chlorphenamine Syrup (150ml) 39
Ibuprofen 200mg (48) 37
Ibuprofen Suspension (100ml) 32
Menthol & Eucalyptus Inh (100ml) 23
Fybogel (10) 23
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Sodium Chloride Nasal Drops 22
Beclometasone Nasal Spray (180 sprays) 20
Chlorphenamine 4mg (30) 20
Magnesium Trisilicate Mixture (200ml) 15
Gaviscon 500 Tablets (12) 12
Non insecticidal head lice / Plastic Comb 12
Xylometazoline 0.1% Nasal Spray 9
Xylometazoline 0.05% Nasal Drops 8
Malathion Alcoholic Lotion (200ml) 6
Malathion Aqueous Liquid (200ml) 5
Non insecticidal head lice / Metal Comb 3
8. Conditions Treated
Under the protocol the pharmacist records the condition that the patient presents with, this together with the medication prescribed enables a record to be built up of the indications treated. This information is as shown in Table 6.
Table 6. Packs Prescribed by Indication (February 2002 – March 2003)
Indication Packs Prescribed Packs as Percentage of
Total
Head Lice 1420 34.4%
Analgesics 1186 28.8%
Cough 479 11.6%
Thrush 335 8.1%
Hay Fever 244 5.9%
Nasal Congestion 198 4.8%
Diarrhoea 116 2.8%
Indigestion 77 1.9%
Constipation 70 1.7%
This information is displayed graphically in Figure 1 shown over the page.
Figure 1. Packs Prescribed by Indication (February 2002 – March 2003)

9. Referral into the Scheme
It was envisaged from the outset that patients would be referred into the scheme primarily via surgery staff, however a number of other possible routes were identified, for example by seeing and acting on publicity material or being informed by a participating pharmacist.
The results depicted below were obtained from the patient survey conducted by telephone interview.
As anticipated referral via the surgery was the most common route with 52% of patients indicating this was how they had heard about the scheme. This was followed by being informed by the pharmacist or their staff (40%) by other sources (6%) including
Health
Visitors and family members and by posters and leaflets (2%).
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The data is represented graphically below in Figure 2.
Figure 2. Sources of Referral (February 2002
– March 2003) n = 50
10. Cost of Service
The service costs comprise two elements:
Professional fee paid to community pharmacists, currently £2.50 per patient
Payment for the medicines prescribed, reimbursed at trade price of medicines
(as listed in Chemist & Druggist Price List) & VAT.
The costs are as shown in Table 7.

Table 7. Cost of Service (February 2002
– March 2003)
PCT
Professional Fees
Cost of Medicines
Totals
£ £ £
West 2261 3270 5531
South West 1597 2810 4407
South East 1192 1754 2946
North 1421.50 1709.50 3131
Totals 6471.5 9543.5 16015
As can be seen the costs of the scheme are extremely modest, with 3073 patients being treated for £16,015 (mean £5.21).
11. Attitudinal Surveys
Users and providers of the service were contacted and asked if they would participate in the evaluation. Those that responded positively were asked about their experiences of the scheme. In addition information was gathered from surgeries about the impact of the scheme on appointments.
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Patient Survey: Fifty patients who had participated in the scheme were contacted by telephone and asked a series of 5 questions:
1. Did you find the minor ailments scheme easy to use ? Forty-seven patients
(94%) responded positively. Of those who responded negatively one patient found that the pharmacist was unwilling to prescribe for the minor ailment because of concern about the patient’s hypertension which was being concurrently treated with prescribed medication. One patient considered that there was too much “form filling” and one indicated that they wanted “a more in depth consultation”.
2. Would you have had to go to the GP otherwise ? Forty-one patients (82%) said yes.
Of those that said they wouldn’t have gone to the GP one indicated that they it was dental problem.
3. Did you find the scheme saved time compared to a GP consultation ? Forty-six patients
(92%) said yes to this question. One patient who replied negatively said that the form filling should be streamlined and commented that the GP had already had all their

details on computer.
4. Was it still necessary for you to see your GP for the same condition after receiving treatment at the pharmacy ? Six patients (12%) replied yes. Forty-four patients
(88%) replied no i.e. they did not require a subsequent GP consultation for this condition.
One patient who did need to see their GP revealed that both she and her daughter required treatment; the daughter’s condition resolved following treatment however the mother subsequently needed to see her GP. Another patient commented that they needed to see their GP because their symptoms persisted..
5. Would you be like to see the scheme continue ? All patients apart from one answered yes to this and a number made additional comments, eg one patient thought more publicity should be employed to bring the benefits of the scheme to more people.
The patient who was not in favour of the schemes continuance commented that they
“only went as the GPs was full and didn’t find it helpful”.
Figure 3. Minor Ailments
– Patient Survey (n = 50)
70%
75%
80%
85%
90%
95%
100% Was the scheme easy to use
Would patient otherwise have visited GP
Saved time compared to GP visit
Didn't subsequently need GP visit
Want scheme to continue

GP Surgery Survey: Twenty-one one of the participating surgeries, were contacted by telephone and the practice manager was asked a series of 8 questions:
1. Were you satisfied with the instruction pack and the back-up provided with the scheme ? All practices answered yes to this question with no reservations, there was one nonrespondent.
2. How did you promote use of the scheme to patients ? All surgeries made use of the posters and leaflets provided. Fifteen surgeries (71%) reported that they promoted the scheme via direct contact with the patient by reception staff, 12 surgeries (57%) promoted the scheme when patients telephoned to request appointments. Ten surgeries (48%) reported that
GPs suggested the service to patients following consultation for a minor ailment.
3. Did you find patients were willing to use the scheme as an alternative ? Seventeen surgeries
(81%) answered yes to this question. One practice answered no to this and flagged up that their patient list was comprised of a high proportion from ethnic minorities who insisted on seeing a doctor. Four practices were unable to comment on this question..
4. Overall how acceptable was the scheme to patients ? Twenty practices (95%) in total replied that it was either very acceptable once patients understood what was involved or that patients were willing to try the service. One practice replied that mothers seeking consultations for young children were unwilling to use the service.
5. Did the use of the scheme have an impact on GP consultations ? Four practices (19%) answered yes. One commented that it had an impact on nurse triage resulting in freed up appointments. The remainder answered no but several commented that the demand for appointments was too variable to discern any impact from the scheme.
6. Do you consider wider promotion/use of the scheme would help GP access targets ?
Nineteen practices (90%) answered yes to this question. One practice said that for their particular practice it would not help. Two practices did not respond to this question.
8. Are there any other conditions that should be included within the scheme? Three practices
(14%) answered yes to this and cited cold sores, acne, and mouth-ulcers as possible additions. The majority of practices (86%) answered no.
7. Would you be like to see this scheme continue? All practices answered yes to this question without reservation.
The key results from the GP surgery survey are depicted below in Figure 4.
Figure 4. Minor Ailments - GP Surgery Survey (n=2 1)

0%
20%
40%
60%
80%
100%
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Pharmacy Survey: The top twenty-two (by patient consultations) of the 35 participating pharmacies were contacted by telephone and the following information was elicited from the pharmacist:
There was general satisfaction with the instruction pack and the back-up provided with the scheme – 21 pharmacists (95%) responded positively, 1 non-respondent.
Patients were referred onto the scheme primarily by surgeries but also self-referred after seeing publicity material – posters and leaflets
The scheme was considered easy to use by sixteen of the pharmacists (73%), one considered it was easy to use with practice and assistance from pharmacy staff. Five respondents considered that it was time consuming and onerous.
Seventeen respondents (77%) considered the formulary acceptable and appropriate.
Four pharmacists considered it would benefit from being amended or extended, and there was 1 non-respondent.
With regard to the remuneration offered seventeen respondents (77%) considered that the

current level of £2.50 per patient was acceptable and appropriate. Five pharmacists considered it was inadequate and suggested a ra nge of options from £3.50 to £10.00.
Twenty-one respondents (95%) considered that extending the coverage of the scheme to involve more surgeries and pharmacies would be appropriate.
Twelve respondents (55%) needed to refer patients back to their GP. Nine pharmacists reported that this had not been necessary.
Twenty-one respondents (95%) indicated that they would wish to see the scheme continue.
One negative response was received, in which the pharmacist commented that the pharmacy was very busy and suggested a scheme in which patients could be seen at a specific time of the day would be better.
The key results from the pharmacy survey are depicted below in Figure 5
Figure 5. Minor Ailments – Pharmacist Survey
Minor Ailments:
Pharmacist Survey
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Satisfied with the back-up provided
Had patients referred by surgery
Found scheme easy to use
Found formulary acceptable
Found remuneration adequate
Favour expansion of scheme
Had referred patients back to GP
Wished scheme to continue
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12. Summary
In the first fourteen months of operation, the scheme has been used by more than 3000 patients across Sheffield for a range of minor ailments. Whilst it is not known for certain that all of these patients would otherwise have consulted a GP the likelihood – given the protocol of the scheme – is that in many cases they would have done so.
In the case of those patients referred by the surgery (52%) we can be fairly confident that a GP consultation would have otherwise ensued. This confidence is enhanced by the

patient survey, which indicated that 82% of participants would have otherwise consulted their GP.
With regard to the treatment provided by the pharmacy, it appears that in the majority of cases (88%) the patient did not subsequently need to consult their GP. This indicates that the treatment provided a successful outcome in terms of managing the minor ailment. The scheme has therefore demonstrated considerable potential for moving the treatment of minor ailments from GP practice to community pharmacy.
Patients reported that the scheme was easy to use, that it was convenient and saved them time compared with seeing their GP. They also reported that the treatment provided by the pharmacist was such that they did not, in the majority of cases (88%) need to subsequently consult their GP for the condition. All of the patients surveyed indicated that they would like to see the scheme continue, and a number commented that they wished to see it extended to cover additional conditions.
From the perspective of the GP surgery there was general satisfaction with the instruction pack and the back up provided under the scheme. Practices promoted the scheme via a variety of methods including direct contact with patients, and making use of posters and displays. The scheme was considered acceptable to patients once they understood what was involved, and no adverse reaction was reported. A minority of the practices surveyed
(19%) indicated an impact on GP consultations, and further practice reported a positive effect upon nurse triage capacity.
Information gathered from the pharmacy survey indicated that the scheme was in general straight forward to operate and that the materials and the back –up provided were satisfactory. The formulary was considered adequate but could benefit from being amended and extended. There was less satisfaction with the remuneration offered as it was not considered adequate to reflect the time required to provide the service.
Pharmacists also indicated that they wished to see the scheme continue and for coverage

to be extended.
In conclusion the scheme appears to be cost effective and offer good value for money, pharmacists appear to have been conservative and responsible in terms of their prescribing with the majority of patients receiving one item (mean 1.23) and the cost per patient treated inclusive of medicine costs and professional fee averaged £5.21
The scheme has proved popular with patients, who found it convenient and satisfactory. It is endorsed by practices with some reporting a positive impact on GP consultations for minor ailments and all indicating that it is helpful in meeting GP access targets.
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13. Recommendations
The following comprise a number of recommendations drawn from experience of the scheme and comments received after distribution of the first draft of this evaluation:
The Formulary : Whilst the formulary was considered adequate a number of practitioners suggested the inclusion of some additional items would strengthen the scheme. It is therefore recommended that the formulary be subject to regular review to ensure that it continues to meet the needs of patients.
Access to the Service : Currently the service is available to patients of 22 medical practices throughout the city. Whilst this distribution may be appropriate for working up a pilot scheme it may now be considered inequitable that patients of participating surgeries can access this service and patients of other surgeries cannot. It is therefore recommended that each PCT considers the place of the scheme within their overall strategies and decides on the appropriate level of coverage.
Publicising the Service : During the initial phase of this scheme publicity has been limited to posters and leaflets placed within participating practices. This has been necessary in order to avoid generating demand in places where the service is not available.
Because of this however many potential users of the service do not know of its existence. It is therefore recommended that greater efforts be made to increase awareness of the service to patients who are eligible to use it.

New Community Pharmacy Contract : Coinciding with the finalisation of this evaluation report the Department of Health have published the framework for a new community pharmacy contract. This framework envisages a number of additional services, to be commissioned locally by PCTs. One example of such a service is a minor ailment scheme.
This endorsement of the value of minor ailment schemes is heartening for health communities that have pioneered developments in this area. Efforts must now be made to ensure a smooth transition to providing this service under the new contracting arrangements.
Peter Magirr
Community Pharmacy Facilitator
August 2003