The management of patients who visit general practitioners for acute, self limiting, health problems is a widespread concern for the workload of general practitioners.1 Although nurses and pharmacists receive government support for providing treatment for self limiting conditions,2 patients exempt from prescription charges are not necessarily motivated, or do not have the resources, to obtain care from other sources.3,4 This increases the workload for general practitioners in areas with high percentages of exempt patients. We examined how referring patients with self limiting conditions directly to a community pharmacist would affect general practitioners' workload.
Participants and methods
All patients seeking general practice appointments or telephone prescriptions for 12 conditions at one general medical practice were offered a consultation with a community pharmacist at one of eight community pharmacies serving that practice.5 The pharmacists prescribed treatments from a limited formulary. Patients exempt from NHS prescription charges received medicines free of charge through one pharmacy, which they chose from the eight included in the trial. Participants were patients who obtained general practice care over a four month baseline period and those who used general practice or pharmacy services during a six month intervention period.
Once we had removed the financial disincentive to use alternative sources of primary care, we were able to assess the extent to which patients would transfer from general practice care to community pharmacy management. We measured transfer rates and reductions in general practice consultations for the 12 conditions together and individually. We also examined prescribing outcomes and reconsultation rates.
Results
Over the six months of the trial, the overall workload of the general practitioners was unaffected, but the workload for the 12 study conditions decreased (P=0.001, 95% confidence interval 0.397 to −0.108). Overall, 37.8% of the combined consultations for the 12 conditions were transferred, but specific conditions had higher transfer rates—head lice, indigestion, thrush, and constipation. Patients that presented with earache, cough, and sore throat (or any combination of these) were more likely to want to consult a general practitioner (table).
Most patients (88.7%) who transferred to the pharmacy were prescribed a formulary product (table). Almost half (49.0%) of the patients who consulted a general practitioner were prescribed a drug that could have been provided from the pharmacies' limited formulary, and an eighth received prescriptions for products that could be purchased over the counter. Almost a quarter (22.6%) of general practice consultations resulted in a prescription for an antibiotic, while 10.4% patients received a prescription for a condition unrelated to the reason for the consultation. Reconsultation rates did not differ significantly between patients who consulted a general practitioner and those who consulted a pharmacist. Both groups of patients were comparable with respect to age, sex, and the number of consultations with a general practitioner in the previous six months.
Comment
Management of some self limiting conditions by community pharmacists is feasible, satisfactory, and acceptable to patients. For the 12 self limiting conditions studied, the trial resulted in the transfer of 37.8% of the general practice workload to the community pharmacy. However, the total workload of the general practitioners did not fall, since the number of appointments during the trial was similar to that at baseline and during the same period in the previous year. Further work is required to fully understand the different levels of transfer achieved with different conditions.
Table.
Transfer rates for presenting conditions, and intervention outcomes, in patients who were offered management by community pharmacy. Values are numbers (percentage) unless otherwise specified
| Total number of consultations | Treatment provider
|
Transfer rate (%) | ||
|---|---|---|---|---|
| General practitioner or nurse practitioner* | Community pharmacist† | |||
| Presenting condition | ||||
| All conditions | 1522 | 946 | 576 | 37.8 |
| Constipation | 19 | 9 (1.0) | 10 (1.7) | 52.6 |
| Cough | 268 | 235 (24.8) | 33 (5.7) | 12.3 |
| Diarrhoea | 48 | 33 (3.5) | 15 (2.6) | 31.3 |
| Earache (plus other symptom) | 118 | 104 (11.0) | 14 (2.4) | 11.9 |
| Hay fever | 4 | 3 (0.3) | 1 (0.2) | 25.0 |
| Head lice | 395 | 67 (7.1) | 328 (56.9) | 83.0 |
| Headache | 8 | 6 (0.6) | 2 (0.3) | 25.0 |
| Indigestion | 5 | 1 (0.1) | 4 (0.7) | 80.0 |
| Nasal symptoms | 15 | 9 (1.0) | 6 (1.0) | 40.0 |
| Sore throat | 120 | 96 (10.1) | 24 (4.2) | 20.0 |
| Temperature | 20 | 12 (1.3) | 8 (1.4) | 40.0 |
| Thrush | 66 | 16 (1.7) | 50 (8.7) | 75.8 |
| Upper respiratory tract infection symptoms (plus other symptom) | 419 | 342 (36.2) | 77 (13.4) | 18.4 |
| Other symptom combinations | 17 | 13 (1.4) | 4 (0.7) | 23.5 |
| Intervention outcomes | ||||
| Received formulary product for study condition‡ | 464 (49.0) | 511 (88.7) | ||
| Received (non-formulary) antibiotic | 214 (22.6) | NA | ||
| Received other non-formulary prescription only medicine | 56 (5.9) | NA | ||
| Received other non-formulary over the counter medicine | 115 (12.2) | NA | ||
| Bought over the counter medicine (non-exempt patients) | NA | 8 (1.4) | ||
| Received pharmacy advice only | NA | 9 (1.6) | ||
| Received treatment for non-study condition | 98 (10.4) | NA | ||
| Failed to show following referral to trial | NA | 27 (4.7) | ||
| Referred back to general practitioner | NA | 21 (3.6) | ||
| Reconsultation with general practitioner or pharmacist (within 14 days) for same condition | 38 (4.0) | 33 (5.7) | ||
NA=not applicable. *Median age of patients 21.8 years, 382 (40.4%) male patients. †Median age of patients 17.8 years, 153 (26.6%) male patients. ‡Formulary was limited to over the counter drugs prescribable by general practitioners.5
Acknowledgments
Various staff from the Health Authority provided invaluable support throughout the study, in particular Fiona Bates, pharmaceutical adviser, and Peter Johnson, consultant pharmacist, who acted as a facilitator in the early stages of the study. We thank the pharmacists, general practitioners, surgery staff, and patients who took part in the research.
Footnotes
Funding: Community Pharmacy Research Consortium, which includes Company Chemist Association, National Pharmaceutical Association, Pharmaceutical Services Negotiating Committee, Scottish Pharmaceutical General Council, Department of Health, and Royal Pharmaceutical Society of Great Britain.
Competing interests: None declared.
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