In Wales, people with a sore throat may be offered advice and symptomatic treatment free of charge in community pharmacies through the common ailment service (CAS). However, antibiotics cannot be supplied and this can limit patients’ perceived value of the service. As a result, some patients continue to seek a GP appointment when they have a sore throat.
Sore throat-related antimicrobial prescribing in GP practices in the UK is high, at around 60–78%
, because point-of-care testing (POCT) has not routinely been used to confirm the presence of a viral infection versus a bacterial infection and complications can sometimes arise from the presence of group A streptococci. Throat swabs can guide prescribing, but their use is limited in GP practices because the sample must be sent to a separate laboratory for processing.
Seeking to guide antibiotic provision, NHS Wales Informatics Service (NWIS) secured funding through ‘Efficiency through Technology Funding’ from the Welsh government in 2018, to develop an update to the existing Choose Pharmacy technology — a national IT platform available in 98% of community pharmacies in Wales.
Software was developed and a new sore throat test-and-treat service (STTT) was integrated into the CAS. Under the STTT, patients with acute sore throat can self-present to a participating pharmacy and a pharmacist who has received additional training will complete a clinical assessment using the FeverPAIN or CENTOR clinical scoring criteria, in line with guidance from the National Institute for Health and Care Excellence
The pharmacist undertakes a swab test from patients over a given threshold (FeverPAIN >3 or CENTOR >2) and offers immediate POCT. Pharmacists are able to supply antibiotics to patients with a positive test result, based on predefined dosing schemes agreed in patient group directions. All patients are offered advice and leaflets related to antimicrobial stewardship, especially regarding viral versus bacterial infections, and the self-limiting nature of the latter, regardless of the need and/or results of POCT. All outcomes of the consultations are communicated to the patients’ GP within 24 hours of the consultation. All patients who provide their consent are also followed up via a phone call 10–14 days after their initial consultation.
Since November 2018, two health boards in Wales have been funding pilots of the service in 56 sites — the first NHS-funded STTTs in the UK.
Our long-term aims are to evaluate the impact of STTT on overall antibiotic provision across primary care, GP consultation rates, hospital visits for associated complications, key stakeholder experiences (patient, pharmacist, GPs and practice staff), and to complete a cost–consequence analysis of introducing the new service. The evaluation is a collaborative approach and we have built a team with patients and researchers from Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff Centre for Trials Research and Public Health Wales.
We have completed preliminary evaluation of the first five months of the pilot, from mid-November 2018 to end of March 2019, with more than 1,700 consultations having been conducted.
All STTT consultations are being recorded in the Choose Pharmacy IT application, which allowed us to access routine data and calculate the antibiotic supply rate at around one in five patients. Some six patients decided not to take antibiotics, despite a positive POCT result.
Overall supply of phenoxymethylpenicillin across the two health boards, obtained via dispensing data plus pharmacy provisions, presented a small drop compared with what was expected, when calculating the trend using dispensing data from previous years.
A case study using routine data from a national audit tool revealed that the rate of sore throat-related consultations in one GP surgery in the vicinity of STTT pilot sites has decreased since introduction of the service. At the same time, no unintended harm has come to the patients, as there has been no corresponding spike in number of hospital visits that have been associated with episodes of quinsy. In fact, two episodes of epiglottitis have been successfully diagnosed by pharmacists in the pilot sites and patients urgently referred to the hospital, where both diagnoses were confirmed and immediate treatment was provided.
Patients have overwhelmingly rated the service very highly and there has been a wealth of positive comments also confirming patient education in the satisfaction surveys we have received so far. Interviews with a number of pharmacists are equally encouraging: pharmacists feel empowered to provide this clinical service and they appreciate the opportunity to educate patients in a structured way.
Outcomes of the first five months of evaluation indicate that the service’s potential benefits include providing a more accessible, efficient and high-quality pathway for patients with sore throat, utilising pharmacists’ skills and freeing up GP time for more complex and urgent medical issues, accurately screening for group A streptococci and potentially reducing unnecessary antibiotic prescribing. In line with principles of antimicrobial stewardship outlined in the NICE Innovation briefing, published in May 2018
, the use of POCT in addition to clinical scoring systems increased diagnostic confidence of a suspected group A streptococcus infection as opposed to asymptomatic carriage of the bacteria; without this screening more patients would have ended up with an antibiotic supply. The service also encourages the principles of ‘Prudent Healthcare’ in Wales: patients and professionals as equal partners, shaping the service through providing feedback and co-production; reduced inappropriate variation through evidence-based approaches and no associated cost to the patients; structured approach ensuring that only what is needed is done and no unintended harm has come to the patients.
We are delighted that STTT won the National Antibiotic Guardian award in the Innovation and Technology category on 27 June 2019. The success of STTT has been made possible with the contribution of a wide range of stakeholders, all the way from the Welsh government, Health Education and Improvement Wales, NWIS developers, testers and implementation team, NWIS primary care project team, community pharmacists, GPs, and health boards, to patients.
Efi Mantzourani, senior lecturer in pharmacy practice, School of Pharmacy and Pharmaceutical Sciences, Cardiff University
 Gulliford MC, Dregan A, Moore MV et al. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open 2014;4(10):e006245. doi: 10.1136/bmjopen-2014-006245
 National Institute for Health and Excellence. Sore throat (acute): antimicrobial prescribing. NICE guideline [NG84]. 2018. Available at: https://www.nice.org.uk/guidance/ng84 (accessed August 2019)
 National Institute for Health and Care Excellence. Point-of-care diagnostic testing in primary care for strep A infection in sore throat. 2018. Available at: https://www.nice.org.uk/advice/mib145/resources/pointofcare-diagnostic-testing-in-primary-care-for-strep-a-infection-in-sore-throat-pdf-2285963457844165 (accessed August 2019)