Primary care

Managing demand: transfer of management of self limiting conditions from general practice to community pharmacies

Karen Hassell, senior research fellow ^a, Zoe Whittington, research associate ^a, Judy Cantrill, professor of medicines ^a, Fiona Bates, pharmaceutical adviser ^b, Anne Rogers, professor of the sociology of health care ^c, Peter Noyce, professor of pharmacy practice ^a. 

^a School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester M16 9PL, ^b Sefton Health Authority, Burlington House, Waterloo, Merseyside L22 0QB, ^c National Primary Care Research and Development Centre, University of Manchester, Manchester M16 9PL

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

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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

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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 rateshead 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

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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.

	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.

Contributors: KH designed the study, wrote the proposal, made the funding bid , was overall coordinator, and participated in writing the paper. ZW coordinated and conducted the fieldwork, analysed the data, and contributed to writing the paper. PN and JC helped formulate the study, provided pharmaceutical expertise, and contributed to writing the paper. PN was involved in the funding bid. FB helped design the pharmacy formulary and facilitated access to the general practitioners and pharmacists. AR provided input into the formulation of the study. Chris Boyke and Hugh Gravelle of National Primary Care Research and Development Centre and Centre for Health Economics at York University provided statistical advice. Liz Seston, research associate at School of Pharmacy, helped with data collection. KH is guarantor for the paper.

	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.

	References

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1.	Over the counter drugs [editorial]. Lancet 1994; 343: 1374-1375[CrossRef][Medline].
2.	Department of Health. The NHS plan: a plan for investment, a plan for reform. London: HMSO, 2000.
3.	Thomas DHV, Noyce PR. The interface between self medication and the NHS. BMJ 1996; 312: 688-691[Free Full Text].
4.	Hassell K, Rogers A, Noyce PR. Community pharmacy as a primary health care resource: a framework for understanding pharmacy utilisation. Health Soc Care Community 2000; 8: 40-49[Medline].
5.	Whittington Z, Cantrill J, Hassell K, Bates F, Noyce P. Community pharmacy management of minor conditionsthe "care at the chemist" scheme. Pharm J 2001; 266: 425-428.

(Accepted 14 May 2001)