Recommendations for community pharmacy

Recommendations for NHS bodies

About this report

This report is intended for:

• community pharmacists, primary care pharmacists and all healthcare staff responsible for prescribing, dispensing or reviewing antibiotic use and providing advice to patients
• NHS leaders responsible for patient safety, medicines optimisation, antimicrobial stewardship (AMS) and primary care contracts
• Community Pharmacy England (CPE) and other national pharmacy bodies.

Purpose

This report has three aims:

• To report key findings of the Pharmacy Quality Scheme’s (PQS) AMS requirements for 2022/23; specifically, to review and evaluate the findings from the implementation of TARGET treating your infection leaflets as a tool to support AMS in community pharmacy.
• To make recommendations to support improving AMS through community pharmacy.
• To highlight the importance of embedding the use of TARGET resources into everyday practice to promote antimicrobial stewardship through community pharmacy supporting readiness for the launch of the Common Conditions Service where AMS will be vitally important in each of the clinical pathways.

Background

Antimicrobial resistance (AMR) is a global problem, impacting people worldwide. The UK’s 2019-2024 national action plan for AMR has three overarching aims:

• Reduce the need for, and the unintentional exposure to antimicrobials.
• Optimise the use of antimicrobials.
• Invest in innovation, supply and access.

In the UK, rising AMR will cause people to suffer longer infectious illnesses as they become more difficult to treat, and the number of human deaths and suffering attributable to infectious disease will increase as will the socio-economic costs associated with treating ill health.

In 2020, 80% of antibiotic prescribing occurred in primary care in England (72% in general practice; 4% dental; 4% other community settings), demonstrating that primary care is still responsible for the majority of antibiotics prescribed to people and therefore a key setting for AMS.

Urinary tract Infections (UTIs) and respiratory tract infections (RTIs) are common, self-limiting infections frequently presenting in primary care. Most resolve spontaneously but patients will often request symptom relief and self-care advice from community pharmacies.

The UK AMR National Action Plan recognises that one of the most successful initiatives to embed AMS into practice has been the use of the TARGET Antibiotic Toolkit. TARGET resources were originally developed by the UKHSA, the Royal College of General Practitioners (RCGP) and the Antimicrobial Stewardship in Primary Care (ASPIC) Group to support GPs, other primary care healthcare professionals and commissioning organisations improve antibiotic prescribing.

Subsequently they have been modified to support their specific use in community pharmacy while ensuring that patients messaging across all resources for all healthcare professionals remains consistent. The toolkit provides a range of resources to support health professionals while educating patients on the appropriate use of antibiotics. Effective use of the TARGET Antibiotic Toolkit supports appropriate antibiotic use as well as reducing the opportunity for resistance to develop.

The use of the TARGET Treating Your Infection (TYI) leaflets for UTIs and RTIs were incentivised as part of the Pharmacy Quality Scheme (PQS) 2022-23, between October 2022 and March 2023.

This work supports the development of a critical foundation for community pharmacy on which to build the sector’s future role described in our delivery plan for improving access to primary care. This includes the launch of the Common Conditions Service, by the end of 2023. The service covers seven conditions:

• uncomplicated UTIs in women
• shingles
• impetigo
• infected insect bites
• sinusitis
• sore throat
• acute otitis media in under 18s.

Pharmacists will be expected to use a clinical pathway to identify patients who are suspected to have one of the seven conditions and offer appropriate management of each of these conditions comprising of self-care, supply of certain over-the-counter (OTC) medicines via protocol or prescription-only medicine (POM), such as antibiotics via patient group directions (PGDs) where clinically appropriate.

Use of TARGET UTI and RTI leaflets in community pharmacy and data collection

TARGET TYI leaflets were used by community pharmacy staff during consultations while responding to UTI symptoms for women under 65 years and RTI symptoms for all patients (no age restriction). The widespread use of these leaflets was incentivised as part of NHS England’s Pharmacy Quality Scheme (PQS) 2022-23 between October 2022 and March 2023.

Participating community pharmacies collected data from walk-in and/or Community Pharmacist Consultation Service (CPCS) patients requesting advice for the management of either urinary symptoms in women aged under 65 years or respiratory symptoms where they utilised the TARGET TYI leaflets to support the patient consultation.

The activity had to be completed by the end of 31 March 2023 and carried out over four weeks with a minimum of 15 patients for each leaflet, or up to eight weeks if the minimum number of patients were not achieved within four weeks for each leaflet. The data from the leaflets was submitted via the NHS Business Services Authority (NHSBSA) Manage Your Service (MYS) portal by the end of 31 March 2023.

Findings

This report summarises the findings from this initiative and includes detailed results in appendices for the use of TARGET UTI and RTI leaflets.

Urinary tract infections

Data was submitted by 8,363 community pharmacies, for 104,142 patients presenting with UTI symptoms.

Most (non-pregnant) women (77% – 75,071) presented with none or only one of the three strongly predictive symptoms of dysuria, new nocturia, cloudy urine; and/or vaginal discharge and therefore were less likely to have an UTI, as outlined in UTI diagnostic guidance.

Conversely, 22,381 (23%) of women presented with two or more symptoms of dysuria, new nocturia, cloudy urine and with no vaginal discharge and therefore they were more likely to have an UTI.

The TARGET UTI leaflets were designed to support community pharmacy teams to differentiate between symptoms more likely to be associated with UTIs and those that could be managed with self-care. The findings suggest that most women presenting to community pharmacy with urinary symptoms were less likely to have an UTI, and could be suitably managed with self-care, pain relief and appropriate safety netting.

Around a third of patients were managed by community pharmacy team members without the need for escalation to a pharmacist and 78% (80,791) patients were managed within the pharmacy, by the pharmacist and pharmacy team without the need to escalate to another healthcare setting. Most women (94%; 97,452) received self-care advice, of whom 37,565 (36%) were also provided with patient information leaflets.

Complete results from the use of TARGET treating your infection leaflets for UTIs are in Appendix 1. Full details of the UTI results have been published here: Responding to Urinary Tract Infection Symptoms in England’s Community Pharmacies (mdpi.com).

Respiratory tract infections

Data was submitted by 8,221 community pharmacies for 115,094 RTI leaflets. Of patients with suspected RTIs, 43% (49,813) were managed by the pharmacy team without the need to escalate to the pharmacist.

Most (88%; 101,846) patients were managed within the pharmacy, by the pharmacist and pharmacy team without the need to escalate to another healthcare setting.

The other 12% of patients (13,248) presented with symptoms suggesting that urgent medical advice was required. Of these, 6,859 (6% of all patients) were signposted to other healthcare services, with most (5,507 – 5% of all patients) referred to their GP. Of these patients, 6,011 were advised to seek medical advice if symptoms did not improve within 48 hours or got worse.

Most patients (95%; 109,474) were provided with self-care advice, of whom 31% (35,624) were also provided with patient information leaflets to support the verbal advice provided.

The use of the TARGET TYI leaflets has supported community pharmacy teams to respond to RTI symptoms in a structured way. The leaflets help to reassure patients when symptoms are mild, providing safety netting advice to these patients as well as promoting self-care while supporting the identification of patients who require escalation and signposting to other healthcare settings.

Complete results from the use of TARGET treating your infection leaflets for RTIs are in Appendix 2.

Conclusion

This PQS AMS criterion of using the TARGET TYI leaflets has continued to develop the clinical role of pharmacy teams by embedding shared decision-making tools to support consultations for patients with respiratory and urinary symptoms.

This criterion has effectively promoted AMS activities in community pharmacy which has had consistently high engagement since first being introduced in the PQS 2020/21 and in subsequent schemes in 2021/22 and 2022/23.

Together, these demonstrate how community pharmacy teams are supporting wider primary care objectives and managing patients with common infections using a variety of resources from the TARGET Toolkit. These findings have demonstrated that the TARGET TYI leaflets can support community pharmacy teams to play a crucial role in AMS, by providing a structured approach to the patient consultation to tailor patient education and advice to address symptoms often associated with common infections such as UTIs and RTIs.

The TARGET TYI leaflets have assisted community pharmacy teams to differentiate between symptoms more likely to be associated with infections requiring antibiotic treatment and/or signposting to other healthcare settings and those that could be managed with self-care.

The findings suggest that most patients presenting to community pharmacy with urinary or respiratory symptoms are less likely to have an UTI or RTI requiring antibiotic treatment. More than three-quarters of patients with symptoms of UTI (women aged under 65) and RTI were effectively supported using the structured pathways detailed in the TARGET TYI leaflets.

The data shows how the use of the TARGET TYI leaflets has facilitated the provision of self-care advice, appropriate safety-netting to help manage symptoms and OTC medication purchases to provide symptomatic relief when appropriate for most patients. This may further reduce patient expectation to receive antibiotics for self-limiting infections and reduce pressure on prescribers in primary care to prescribe antibiotics.

OTC medicines are useful in managing mild to moderate symptoms and were frequently recommended by pharmacy teams in response to patients’ requests and presenting symptoms. NICE and other evidence-based guidance should be used by pharmacy teams to refresh their knowledge of hierarchy of evidence for OTC product recommendations.

By using the TARGET TYI leaflets, at least 30% of patients were able to be managed by pharmacy staff without escalation to the pharmacist, enabling pharmacist time to be effectively deployed for other responsibilities and making optimal use of pharmacy team resource.

The TARGET AMS resources are already embedded in general practice in England. By incentivising use of these resources via the PQS, most community pharmacy teams in England are now also familiar with TARGET Toolkit resources therefore patients are provided with consistent evidence-based AMS messaging across the primary care pathway.

Community pharmacy teams escalated 100% of the 15% of women identified with symptoms requiring escalation (as detailed in the TARGET TYI UTI leaflet) and 97% of the 6% of RTI patients with symptoms identified as requiring urgent medical advice to appropriate healthcare settings highlighting good awareness of warning signs and appropriate action taken.

Embedding the use of TARGET resources into everyday practice within community pharmacy will support pharmacy teams in their readiness for the launch of the Common Conditions Service where AMS will be vitally important in each of the clinical pathways. Pharmacists will be expected to use a clinical pathway to identify symptoms associated with the seven conditions and offer management comprising of self-care, supply of certain OTC medicines via protocol or prescription-only medicine (POM) via PGDs where clinically appropriate.

All AMS initiatives have been renewed for the 2023/24 PQS with the addition of advice on safe disposal of unused or expired antibiotics.

Appendix 1: Results from TARGET treating your infection leaflets for UTIs

PQS Uptake

Data were collected between 14 October 2022 and 31 March 2023 with 8,363 community pharmacies submitting data for 104,142 TARGET TYI UTI leaflets.

6,101 (73%) submitted data for the required 15 patients, with the remainder submitting data for fewer than 15 patients.

Staff member and patients leaflets

Table 1: Staff member use of TARGET UTI leaflet

Patient characteristics and symptoms

Table 2: Patient pregnancy status

Table 3: Presenting symptoms

*multiple symptoms could be ticked simultaneously.
**other symptoms mainly comprising of back pain, itching or smelly urine.

Table 4: Number of patients escalated to the pharmacist

*These are non-pregnant women with symptoms strongly predictive of a UTI (presenting with two or more symptoms of dysuria, new nocturia, cloudy urine and with no vaginal discharge.)

Table 5: Number of patients with possible symptoms for escalation

*These are non-pregnant women with symptoms strongly predictive of an UTI (presenting with two or more symptoms of dysuria, new nocturia, cloudy urine and with no vaginal discharge)
**Symptoms include worsening symptoms; they have blood in their urine; kidney pain in their back just below the ribs; patient is pregnant; shivering chills and muscle pain; temperature is above 38.C or less than 36.C; symptoms are not starting to improve within 48 hours of taking antibiotics; confusion or very drowsy; not passed urine all day; vomiting, as defined on the TARGET leaflet

Table 6: Signposting timescales to other healthcare services

*These are non-pregnant women with symptoms strongly predictive of an UTI (presenting with two or more symptoms of dysuria, new nocturia, cloudy urine and with no vaginal discharge).
**TARGET checklist advises pharmacy teams to recommend immediate GP / NHS111 escalation for urgent assessment when the patient has signs of a serious infection, detailed in Table 10.

Table 7: Patients who were signposted with urgent escalation symptoms requiring assessment and their destination

*These are non-pregnant women with symptoms strongly predictive of an UTI (presenting with two or more symptoms of dysuria, new nocturia, cloudy urine and with no vaginal discharge).
** Other destinations included regional/local services where patients could be assessed and supplied a prescription-only medication (POM) using a Patient Group Direction (PGD).

Table 8: Signposting for symptoms requiring urgent escalation

*These are non-pregnant women with symptoms strongly predictive of an UTI (presenting with two or more symptoms of dysuria, new nocturia, cloudy urine and with no vaginal discharge)

Table 9: Over-the-counter treatment offered to the patient

*These are non-pregnant women with symptoms strongly predictive of an UTI (presenting with two or more symptoms of dysuria, new nocturia, cloudy urine and with no vaginal discharge)
**Multiple medicines could be supplied simultaneously

Table 10: The provision of self-care advice

*These are non-pregnant women with symptoms strongly predictive of an UTI (presenting with two or more symptoms of dysuria, new nocturia, cloudy urine and with no vaginal discharge)

Appendix 2: Results from TARGET treating your infection leaflets for RTIs

PQS uptake

Data were collected between 14 October 2022 and 31 March 2023 with 8,221 community pharmacies submitting data for 115,094 TARGET TYI RTI leaflets. 7,050 (86%) pharmacies submitted data for the required 15 patients, with the remainder submitting data for fewer than 15 patients.

Staff member and patient leaflets

Table 11: Staff member use of TARGET RTI leaflet

Patient characteristics and symptoms

Table 12: Patient age

Table 13: Number of patients reporting each of the suspected infections

*Some patients presented with multiple suspected infections – 137,656 suspected infections were presented by 115,094 patients

Table 14: Patients presenting multiple suspected infections

Patient management and escalation

Table 15: Number of patients escalated to the pharmacist

Table 16: Number of patients with symptoms requiring escalation to another healthcare setting

Table 17: Signposting timescales to other healthcare setting

Table 18: Patients who were signposted due to symptoms requiring escalation and destination

Table 19: Symptoms requiring escalation identified for immediate signposting

Patient treatment

Table 20: Over-the-counter (OTC) remedies/treatment offered to patients

Table 21: OTC remedies purchased by patients

*Some patients were recommended more than one OTC medicine

Table 22: Self-care advice provided

Publication reference: PRN00612