Over the past few years, the NHS has come under increasing pressure to find practical solutions to the workforce and workload crises that are affecting the delivery of primary care (Rosen, 2019). A significant part of the primary care workload relates to the assessment and management of patients with ‘minor illnesses’ (NHS England, 2016). Most minor illnesses resolve spontaneously and the symptoms that patients experience during these episodes can often be managed with over-the-counter rather than prescription medication. As a result, media campaigns are encouraging patients to visit their local pharmacy, rather than attend their local surgery or emergency department. However, this policy brings with it significant risks to both the patient and the community pharmacist (CP), as some of the patients who are being diverted to the pharmacy may either be in the early stages of a serious illness, or at increased risk of developing a serious complication of what is normally a minor illness (Silverston, 2014a). For patient safety not to be compromised by this policy, it is essential that CPs are aware of the serious illnesses that can mimic minor illnesses, as well as those patients who are at increased risk of developing a serious complication of a minor illness. This article describes an online educational programme that has been developed for CPs to increase their awareness of the potential risks involved in the assessment and management of patients with the symptoms of minor illness.
Safer consulting in minor illness
In 2015, Anglia Ruskin University (ARU) was commissioned to develop an educational programme for CPs in Essex, which combined 10 sessions of online learning with one day of face-to-face teaching delivery. The feedback from this programme was positive, with many CPs commenting that the sessions had increased their awareness of serious illnesses and the complications that need to be considered when consulting in the pharmacy. Participants were asked to complete a feedback evaluation of the programme, which cited many examples of changed practice, along with cases of seriously ill and at-risk patients being referred as a result of the increase in the CP's medical knowledge. Following the success of this programme, ARU was approached by the NHS England Local Pharmacy Network Chairpersons for East Anglia and Essex to develop an online programme for CPs from across the region, which was delivered in 2018 as the Safer Consulting in Minor Illness (SCIMI) programme (Anglia Ruskin University and NHS, 2018). The programme is comprised of 18 sessions of online learning, covering some of the most commonly encountered symptoms in primary and pharmacy care, presented as voiced-over slide sets (Box 1). Each session is accompanied by a list of links to the relevant national guidelines, so that participants can refer to these for more detailed information and keep up-to-date with changes to these guidelines. The sessions are also accompanied by a set of reflective practice questions, which are designed to encourage participants to think critically and reflectively about their current practice.
Box 1.Course Content
- Clinical assessment in minor illness
- Assessment of the sick child
- Assessment of the older patient
- Documenting and information transfer
- ‘Is it meningitis?’
- ‘Could it be sepsis?’
- ‘I've got conjunctivitis’
- ‘I've got a headache’
- ‘I've got a sore throat’
- ‘I've got earache’
- ‘I've got sinusitis’
- ‘I've got a cough’
- ‘I've got cystitis’
- ‘I've got a rash’
- ‘I think I've got the flu’
- ‘I've got diarrhoea and vomiting’
- Antibiotics in minor illness
- Analgesics in minor illness
Programme philosophy
In primary care, patients present with symptoms, not diagnoses (Hopcroft and Forte, 2014). This is acknowledged not just in the title of each clinical session but also in the symptom-based approach that is adopted throughout the programme. This is combined with a patient safety-focused approach to the assessment and management of the patient and their symptom.
The relationship between illness, time and clinical assessment is such that a patient presenting to the pharmacy with the symptoms of a minor illness may, be in the early stages of a serious and potentially life-threatening illness (Silverston, 2014b). Therefore, it is important that CPs are aware of the risk factors and early diagnostic markers that can help identify the small number of patients who may present in the early stages of a serious illness. Similarly, there is always the potential for a patient with a minor illness to develop an uncommon but serious complication of that illness, so it is important that CPs are aware of both the possible complications and the risk factors for developing them. Medical knowledge is a fundamental requirement for safe practice because it informs the clinical decisions that are made during the consultation, including the decision as to whether to refer the patient, or send them home with safety-netting advice. Furthermore, medical knowledge is required to determine the medical content of the safety-netting advice that is provided (Silverston, 2014c). Adopting a symptom-based, patient safety-focused approach to minor illness ensures that CPs are given the medical information, clinical assessment and decision-making tools required to assess and manage patients with the symptoms of a minor illness.
Many of the warning signs and risk factors for serious illness can be identified by performing a symptom-based, patient safety-focused symptom and patient history checks. However, some can only be elicited by making a set of observations, or by examining the patient (Silverston, 2019a). Many CPs have not received formal training in clinical assessment, diagnostic reasoning or clinical decision-making, whilst others are unable to perform a comprehensive clinical assessment for logistical reasons. The emphasis in this programme is on taking a systematic, holistic symptom and patient history, combined with a systematic approach to observing the patient. This is combined with a ‘traffic light’ system of patient assessment and clinical decision-making, where the red category comprises those patients who meet the criteria for immediate referral to the emergency department; the amber category features those patients who require referral to a primary care resource for a comprehensive clinical assessment; and patients in the green category can be sent home with advice on self-care and safety-netting. A fundamental principle in this clinical decision-making process is that the patients are not placed in the green category until the criteria for placing them in the red or amber category have been checked first. This places patient safety at the heart of this process.
Another important principle is that the clinical content of the educational programme is linked to national guidelines, which relate to the assessment and management of each symptom and each disease. The symptom and disease-specific red flags and risk factors, as well as the scoring systems to identify the presence and severity of specific medical conditions and illnesses are drawn from these guidelines and embedded in each session. This information also formed the basis of the criteria that are incorporated into the traffic light assessment and clinical decision-making system that is used. Linking the medical content of the programme to guidelines that have been developed and validated at a national level not only encourages evidence-based, best practice in the care of patients but it also facilitates the development of a more integrated and collaborative approach to patient care between CPs and other members of the primary care team.
Programme content
The first session of the programme discusses the principles and practices of safer consulting in minor illness. The use of a systematic observational approach to clinical assessment is advocated, using the mnemonic ABCDEFS (Box 2) to identify the red flags that would mandate an immediate referral for emergency care. A ‘wagon wheel’ assessment tool is used to facilitate the development of a systematic, holistic approach to clinical assessment (Silverston, 2013). The traffic light system for clinical assessment and clinical decision-making is introduced as a template, which is applied throughout the programme, to identify those patients who need to be referred for emergency care, or a more comprehensive clinical assessment.
Box 2.ABCDEF'S Assessment
- A = Activity
- B = Behaviour
- C = Colour
- D = Dehydration
- E = Effort of breathing
- F = Fever
- S = Symptom-specific symptoms & signs
The next two sessions cover the clinical assessment and management of both younger and older patients, as these age groups are at an increased risk of developing serious illnesses that may initially mimic a minor illness, as well as the serious complications of minor illness. In addition, patients from within these age groups require a modified clinical assessment that takes account of the age-specific medical conditions that may be present and the differences in the way that the clinical assessment is performed. The age-related medical conditions that can present with each symptom and the changes to the way that clinical assessment is performed are discussed, as well as the need to assess the additional medical and social vulnerabilities that may be present, including pre-existing illness, multimorbidity and polypharmacy, all of which increase the risk of serious illness and serious complications in minor illness. The session on documenting and information transfer discusses the medical, medico-legal and inter-professional relationship benefits of documenting consultations appropriately and of writing good referral letters.
Sessions on sepsis and invasive meningococcal disease are included because it is essential that CPs can recognise the early symptoms and signs of these two life-threatening conditions. These can both present during their early stages as minor illnesses (UK Sepsis Trust 2006; Thompson, 2006). Knowledge of the risk factors and the earliest symptoms and signs of these serious illnesses is essential for CPs, not only because this information is required to identify patients who have these serious illnesses, but also so that appropriate safety-netting advice for the development of these illnesses can be provided to patients and relatives. This is followed by sessions covering ten of the most frequently encountered symptoms in pharmacy practice, in which a symptom-based, patient safety-focused approach is applied to the assessment and management of patients with each symptom. Accompanying each session is a set of questions encouraging participants to think critically and reflectively about their current practice and how information from that session can be incorporated into the way that the CP assesses and manages patients presenting with that symptom. At its best, medical education involves not just an increase in knowledge but a change in practice to incorporate the application of that knowledge, which is what this programme aims to encourage. The final two sessions cover the use of antibiotics and analgesics in minor illness, discussing concepts such as antibiotic stewardship, targeted antibiotics and risk/benefit analysis in minor illness, along with a discussion regarding the latest concerns on the use of non-steroidal anti-inflammatory drugs in minor illness (Royal College of General Practitioners, 2019; National Institute for Health and Care Excellence, 2019).
Feedback
The programme was developed on the Learnworld (2019) learning platform, and, as part of the requirement for issuing a certificate of continuing professional development, participants were required to complete a feedback evaluation form (Box 3). The first cohort of 68 CPs completed a tick-box questionnaire and 39 participants contributed additional written comments. Evaluation of the responses to the questionnaire are provided in Box 3.
Box 3.SCIMI survey
- Q1: Did this educational programme meet your expectations?
Yes: 65 (95.6%) No: 3 (4.4%)Sample of comments: ‘At first I thought that it was not going to be helpful and seemed too basic but on listening-on after the introduction I found it to be very insightful and very useful to community pharmacy so it exceeded my expectations.’
- Q2. Was the medical content of the programme set at the right level?
Just right: 63 (92.6%). Too advanced: 4 (5.9%). Too basic: 2 (2.9%)Sample of comments: ‘I was initially sceptical about the course and its contents. On having completed it, I was pleasantly surprised by all the helpful tools which will allow me to help identify patients requiring referring and safety-netting advice that I could provide.’
- Q3: Would you recommend this programme to others?
Yes: 61 (89.7%). No: 2 (2.9%). Not sure: 5 (7.4%)Sample of comments: ‘I think this course should be compulsory for every pharmacy undergraduate, or pre-reg pharmacist.’‘I feel that this course should be rolled out to as many community pharmacists as possible. This course has helped and will help all who participate.’
- Q4: Has this programme helped you to decide which patients should be referred?
Yes: 66 (97.1%) No: 1 (1.5%) Not sure: 1 (1.5%)Sample of comments: Besides the increased number of consultations who come to see the pharmacist in the community pharmacy, I am having to deal with more complicated cases, making this programme relevant & important. As a direct consequence of learning from this programme, my consultations are more structured and I am more likely to recognise a red flag, make a meaningful referral or better safety-net.
- Q5: Have you been able to identify any seriously ill patients that you would not have identified before?
Yes: 35 (51.5%). No: 14 (20.6%) Not Sure: 9 (27.9%)Sample of comments: ‘I have a much more heightened awareness for possible ‘Big Sick’ scenarios and am frequently asking myself ‘could this be sepsis?’
- Q6: Has this programme improved your clinical practice?
Yes: 64 (94.1%). No: 2 (2.9%). Not sure: 2 (2.9%)Sample of comments: ‘It has already radically changed my approach to the way I advise my patients/customers’‘I have already made some significant changes to my consultations. I have shared my learnings with members of staff and have noticed them using a different approach too. We have all become more thorough in our methods.’‘This programme has definitely made me think more of the whole situation when advising and consulting with patients, which has made me ask more questions and look more closely at the patient as a whole.’
Conclusion
The policy of diverting patients away from both general practice and the emergency department to CPs is likely to have profound implications, in terms of an increase in the number of patients visiting the pharmacy and in the range of medical conditions that will present to the CP. In addition, the relationship between the CP and the public will also change, as people will expect to have a consultation with the CP in which a serious cause for their symptoms is excluded and a risk assessment for serious complications is performed, before advice on the self-management of their symptoms and safety-netting advice are provided. Although some CPs have the training, equipment, availability and the facilities to assess patients, many do not at present. This educational programme is the first step in a process of helping CPs to develop the medical knowledge and skills to be able to assess and manage patients with the symptoms of minor illness and to enable CPs to work in an integrated and collaborative way with other members of the primary care team.
This programme should also be of benefit to those community pharmacists who can prescribe to patients. In minor illness, it is important that the prescriber can identify two groups of patients. The first group comprises of those patients for whom a prescription is not indicated, either because an emergency referral is required instead, or because the risks of side-effects from treatment outweigh the potential benefits. The other group represents those patients who are at increased risk of developing a serious complication of a minor illness, for whom the benefits of treatment far exceed the potential risks. This programme can help prescribers in their clinical decision-making with regard to when and when not to prescribe in minor illness.
The majority of participants from the first cohort of CPs found the programme to be of value, and, based on the feedback received, it appears to have achieved its primary purpose of increasing medical knowledge and changing practice. CPs are an important health care resource not just for patients but also in terms of reducing the workload in other parts of the health care system (MINA Study, 2014). However, it is essential for the safety of patients that CPs are appropriately trained and equipped and are also provided with the facilities and logistical support to be able to work competently and safely in this role. In addition, CPs are in an excellent position to be able to work in advanced practitioner roles in primary care. An advanced practitioner in primary care qualification would provide CPs with an educational pathway to develop their knowledge, skills and clinical role even further (Silverston, 2019b). The SCIMI programme is an opportunity for CPs to take the first step along that exciting new pathway, which will include the opportunity to undertake further training in clinical assessment as part of the NHS Community Pharmacist Consultation Service (NHS England, 2019) and a Postgraduate Certificate in Advanced Clinical Assessment Skills and Non-Medical Prescribing, which is being offered at a number of different universities. The assessment and management of patients with the symptoms of a minor illness forms a significant part of the primary care workload and CPs can play an important role in both reducing this workload and in caring for patients competently, safely and locally.
Key Points
- In order to reduce the workload in primary and urgent care, patients with the symptoms of minor illness are being directed to community pharmacies
- Illness is a dynamic process, so patients in the early stages of a serious illness may present initially with the symptoms of a minor illness
- Although most patients with a minor illness will not develop a serious complication of that illness, some will
- It is important that community pharmacists are capable of identifying patients in the early stages of a serious illness, or at increased risk of a serious complication of a minor illness
- This article describes an on-line educational programme for community pharmacists, which has received positive feedback evaluation from its participants.
CPD reflective questions
- Why is it important to adopt a symptom-based, patient safety-focused approach to minor illness?
- What is the potential benefit of using reflective practice questions over a self-assessment MCQ in continuing professional development?
- How does critical thinking and reflective practice encourage a change in clinical practice?
- Why is it important that all clinicians who are involved in the assessment and management of patients with minor illness know about serious illnesses such as sepsis and meningitis?