Referral of clients by community pharmacists: views of general medical practitioners FELICITY SMITH

Community pharmacists have been shown to advise approximately 15 per cent of clients who present to them with minor ailments to consult another health professional, usually their general medical practitioner. The clients that pharmacists refer may or may not be those that GPs most wish to see. There may be other clients or symptoms that GPs believe sho d be referred to them. This study investigated GPs’ views on community pharmacists’ referral practices, looking at which symptoms they believed should be referred, the level of agreement between them and how their recommendations compared with the referral practices of community pharmacists established by the author in an earlier study. Questionnaires were posted to a random sample of GPs in Greater London, asking them to indicate the referral advice they felt appropriate for each of 62 symptom groups, recommending either direct referral, no referral or referral only in some cases. The symptom groups were derived from the symptoms presented to the pharmacists in the earlier study.

Respondents were generally positive about the pharmacist’s role, indicating that for many symptom groups they felt it appropriate for the pharmacist to be a first port of call. Although the variation between responses suggested that there should be local liaison regarding practice, on the whole the GPs’ recommendations were in line with the pharmacists’ existing practices.

P

IT is now widely recognised that pharmacists undertake an important primary care role in advising the public on the management of common ailments and health problems.’-3 Com- munity pharmacists are frequently the first and often the only health professionals who are con- sulted by the public on what are often perceived as minor symptom^.^.^ They, therefore, have an important role in identifying and referring cases that may require particular management or fur- ther investigation to the appropriate agencies.

A study in which community pharmacists issued referral cards to clients when referring them to their general medical practitioners found that nearly three-quarters of clients advised by the pharmacist to see their GP did SO.^ This supports the view that by providing sound refer- ral advice, pharmacists are in a position to operate as a filter, promoting the appropriate use of primary care services. However, a number of studies of advice given by pharmacists have claimed that they do not reliably refer potential serious symptoms that warrant further investiga- t i ~ n . ~ , ~

In a previous study by the author, community pharmacists were found to refer around 15 per cent of clients whom they advised on minor ailments to another health care professional, usually their GP.’ Over half (57 per cent) of these referrals were direct, where the client was advised to see another health care professional immedi-

ately or as soon as possible. The remainder were conditional referrals, where the client was ad- vised to seek further advice if the symptoms had not subsided or cleared within a given time period or with a particular medication. The referral patterns of these community pharmacists were also found to be symptom-related rather than pharmacist-related, ie, a situation where some pharmacists referred a high proportion of clients irrespective of the nature of the symptoms, while others referred few, was not apparent.

Community pharmacists along with other health professionals, in particular GPs, are con- sulted about the management of common ail- ments, which are frequently self-limiting prob- lems. They also share clients, in that many people may consult pharmacists and doctors about the same symptoms. There is general acceptance that effective primary care is best achieved through interprofessional teamwork. If pharmacists are serious in their commitment to teamwork, it is logical that the formulation of their practice and education guidelines should not be in isolation of the views of other professionals. It is at present unclear if the clients that pharmacists refer to GPs are those that the GPs themselves feel they should see, and/or if there are other symptom groups that GPs think should be referred.

The aim of this study was to obtain the views of GPs about which symptoms they felt pharmacists should refer: first, investigating their views in

Centre for Pharmacy Practice, School of Pharmacy, University of London, Brunswick Square, London, England WClN 1AX Felicity Smith, PhD, FRPharmS, Lecturer in pharmacy practice

Int J Pharm Pract 1996;4:30-5

30 THE IXTEH\rATIO\AI . J o t RYAL OF P H A R M A C Y PRA( :TICE, MARCH 1996

relation to particular symptoms; seconclly , estah- lishing the level of agreement between them; and, finally, comparing the results wi th the existing referral practices of pharmacists.

Method

The survey was conducted as a postal question- naire. A questionnaire was clevelopecl which listed as 62 symptom groups tlie symptoms that liacl heen presented to the pharmacists i n tlie earlier

A sample of (it‘s ( 1 18) was rancloinly selected from lists obtained from four Greater I,onclon family health services authorities (FHSAs). This represented one in eight of the GPs registered in these FHSAs. The F H S A s covered Iwtli inner city and outer London areas. Tlie earlier study, among pharmacists, liacl also heen concluctecl in inner and outer city areas of (ireater Imitlon.

The development of tlic questionnaire posed some problems. Every case presented to a phar- macist will I)e unique, and there may he eircum- stances under wliicli any symptom slioulcl be referred. Keferral decisions may also Iw influ- enced by tion-verbal ol)servation, previous knowledge of the client and/or otlicr factors. These issues could not he explored i n detail with individual respondents in a questionnaire i n the way they could be by a qualitative study. Howev- er, pharmacists must make their decision about whether or not to refer on the basis of limited information gathered from the client. Inviting contributions from GPs regarding wliicli clients they believe should be referred requires that some generalisations are made. The present method enabled the range of views and differences of opinion between GPs to be investigated, as well as extracting the similarities, regarding wliicli clients they wished to see.

The questionnaire was developed and piloted with a group of GPs who advised on the grouping of the symptoms, the construction of the question- naire and the formulation of the instructions.

Participants were asked to indicate on the form against each of the symptoms listed what referral advice they felt would be appropriate: either “direct referral” (advice to see a doctor immedi- ately or as soon as possible), “referral not re- quired” (if they felt that advice to see a doctor should not be necessary), or “referral in some cases.” If indicating the final category, they were asked to specify criteria to be taken into account, eg, time since onset, severity of symptoms, accom- panying symptoms, failure of over-the-counter (OTC) medicines, requirement for prescription only medication, client’s age or recurrence. The responses for each symptom were coded and the data analysed using the Statistical Package for the Social Sciences (SPSS).”

study.”

Results

Fifty-seven completed questionnaires were re- turned following the initial mailing and one re- minder (response rate 48 per cent). On investiga-

I

20-40%[ <20%

40-60%

>60%

I t I I I

<20%

20-40%

40-60%

>60%

0 5 10 15 20 25 number of respondents recommending: I

Figure I : Recommendations on proportion of symptom groups requir ing direct referral

I I N W

<20% vi n e E 20-40% s n

2 40-60%

0)

E

8l la P

L

>60%

/ / / / 0 5 10 15 20 25

number of respondents recommending: ’

1 I I I %

Figure 2: Recommendations on proportion of symptom groups requir ing “referral in some cases”

7 <20%

vi n

e

9 Ul E 2 0 4 %

P

4040% B a,

>60% P number of respondents recommending:

Figure 3: Recommendations on proportion of symptom groups foi which a referral should not be necessary

tion, no significant differences (0.05 level) were found in the sex or practice size between the responders and non-responders.

Proportion of symptom groups to be referred Figures 1, 2 and 3 show the variation between . - -

w R C H 1996, THE INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 31

respondents in the proportion of symptom groups they thought should be directly referred, referred in some cases, or for which a referral should not be necessary.

Most respondents recommended direct referral for only a small proportion of symptom groups, 60 per cent believing it should be necessary for less than 20 per cent of the 62 symptom groups listed. Three respondents felt that direct referral was an appropriate action for more than half of the symptom groups, and no respondents consid- ered it necessary for more than 60 per cent (Figure 1). On average, respondents stated that approximately one-fifth (21 per cent) of the 62 symptom groups listed should be directly re- ferred.

The mean number of symptom groups for which respondents would not expect a referral to be necessary was 26 (42 per cent). One respon- dent felt this course of action appropriate for more than three quarters of symptom^ groups.

Thus, the majority of respondents believed that many symptom groups are suitable for manage- ment by pharmacists. For symptoms that respon- dents believed should sometimes be referred, they usually (in 96 per cent of cases) suggested criteria on which this decision should be based.

4nalysis of recommendations for symptom groups Table 1 shows, for each of the symptoms listed, the percentage of respondents who recom- mended direct referral, referral of some cases or that a referral was not necessary. The comments made by the GPs who recommended referral for some cases of particular symptom groups are discussed below.

For upper respiratory symptoms, the doctors generally felt that a direct referral was not routinely necessary except for clients who were wheezy or breathless. Persistent cough was rec- immended for referral if it continued for more than one week (some respondents stated two or :hree weeks) andlor was accompanied by the production of coloured sputum, especially if dood was present, andlor if the client was ssthmatic or wheezy; also recommended for refer- ral were elderly people, night-time symptoms and :hest pain. The most common criterion for refer- -a1 of sore throat was duration of more than one Meek, but severity, systemic illness, malaise, iifficulty in swallowing and pus on the tonsils Mere also mentioned.

Respondents believed many gastrointestinal iymptom groups suitable for management by lharmacists. However, they recommended refer- .a1 for indigestion or reflux persisting for more han two weeks (the stated times varied from one o eight weeks) in which OTC remedies had failed; ilso mentioned were such symptoms accompanied )y weight loss or in an elderly person.

It was felt that constipation should be referred f OTC laxatives had proved ineffective and the ime since onset was more than two weeks (speci- ied times ranged from one to four weeks). Some eespondents wanted new presentations of symp- oms in older people to be referred. A wide range

Table 1: GPs’ referral recommendations for symptom groups Symptom Percentage of respondents (n=57) recommending

direct referral in referral not referral some cases necessary

Upper respiratory: Common cold Sore throat Cough Hayfever W heezelbreat h lessness

Gastroi ntestina I : I ndigest ionlref lux Constipation Diarrhoea/vomiting Haemorrhoids Intestinal worms

Mouth ulcers Sore gums Cold sores Chapped lips Discoloration of tongue/

thrush Bad breath Toothache

Irritation/weeping Stye Stickiness RedneWaccidental injury

Ear: Earache Ear wax

Young children: Infant teething Infant feedingwind Nappy rash Fluoride supplements Hyperactivity Childhood infectious disease Travel sickness

Corns/bun ions Ha rd/crac ked skin Verruca Ingrowing toenai I Athlete’s foot Foot odour Chilblains

Joint pain Back pain Chest pain Headache

Acneheenage spotdskin infestation .

Eczema/dermatitis/dry skin Allergy/urticaria Insect bites Cuts/a brasions/wounds Bu rns/sca Ids Warts/moles Sun burn/sunscreen Body odour/sweating

Hair infestation Dandruff

How to lose weight Feeling run down Anxietyherves Insomnia Benzodiazepine dependence Vitamin supplements Cystitis Pregnancy test Night cramDs

Oral:

Eye:

Feet:

Pain:

Skin:

Hair:

Diet and general wellbeing:

0 3 3 7

89

5 2

16 21 14

7 5 6 2

18

7 5

40 24 46 82

57 19

4 13 8

11 59 76 4

2 2 9

2 9

23 18 79 14

13 32 22 2 9

35 36

2 4

7 2

13 27 45 41 91

7 46

7 16

33

19 73 81 36

7

77 77 73 63 21

58 44 35

5 39

24 51

42 22 30 15

41 44

9 32 34 13 28 22 13

42 19 21 63 26

5 28

64 68 14 70

51 57 60 29 64 56 55 18 16

16 29

32 48 37 34

7 3

51 19 32

81 24 16 57 4

18 21 11 16 65

35 51 59 93 43

69 44

18 54 24 3

2 37

87 55 58 76 13 2

83

56 79 70

5 70 93 63

13 14 7

16

36 11 18 69 27

9 9

80 80

77 69

55 25 18 25 2

90 3

74 52

Gizng up smoking 12 25 63

of comments was made concerning referral in cases of diarrhoea, covering duration (24 hours to one week for adults), age (direct referral for very young and elderly), failure of OTCs and accompa- nying symptoms of fever and dehydration. Most respondents believed that referral was not neces- sary for intestinal worms.

For oral symptoms, few respondents recom- mended direct referral. The vast majority of comments were that if a referral was to be made it should be to a dentist.

Most respondents felt they should see cases of eye injury. For other eye symptoms, they believed it was appropriate to try OTC remedies first and refer only if these failed.

The majority of respondents thought pharma- cists should refer people with earache, although some qualified this to include only cases of persistence for more than 24 to 48 hours (one respondent stated one week), children or when accompanied by fever or discharge. For ear wax, the general view was to advise the use of oil or drops and then see a doctor if necessary. Objec- tions to the use of cotton buds were also ex- pressed.

Most doctors felt that cases of childhood infec- tious disease and hyperactivity should be directly referred. Other symptoms should be managed by the pharmacist or referred to the health visitor.

Similarly, most respondents felt that foot symp- toms, except cases of ingrowing toenails, could be dealt with by pharmacists. Referral to a chiropo- dist was sometimes mentioned. Comments includ- ed referral of corns or bunions if infected, of cases where surgery might be required and of people with diabetes. For chilblains, a main concern was that pharmacists should consider concurrent medication, eg, beta-blockers, and other causes of vasculitis.

With the exception of chest pain, for which the vast majority of respondents would wish pharma- cists to refer, the comments regarding pain symp- toms were mixed. Generally, it was felt that severe cases persisting despite OTC analgesics should be referred. For back pain, the recommended period before referral varied from one to six weeks. Joint pain involving multiple joints, swelling, or system- ic symptoms was also suggested as an indication for referral. In decisions of whether or not to refer clients with a headache, the respondents considered accompanying symptoms, in particu- lar, nausea, vomiting, visual disturbance, neck stiffness, increasing pain and children also suffer- ing with a fever, to be important, as well as persistence (one day to two weeks) and failure to respond to OTCs.

Most respondents were in agreement that some skin problems did not warrant a referral. It was felt that eczema/dry skin should be referred if severe or extensive and OTC products had not relieved it. Many respondents felt that cuts and wounds, before referral, should be assessed by the pharmacist for severity, need for surgical closure and infection, and that tetanus status should be checked. Although many respondents requested that all moles should be referred,

Table 2: Pharmacist’s referral practices for symptom groups (from earlier studyg) Symptom group Total Percentage

number of of cases cases referred presented

Upper respiratory 212 8 Gastroi ntesti na I 80 20 Oral (excluding teeth) 2 4 17 Toothache 11 4 5

31 3 5 56

Eye Ear 9 Infant teething 14 14

Foot problems 20 15 Pain (excluding headache) 38 24 Skin symptoms 104 15 Hair 12 0 Diethitamins 2 6 4 Anxiety/wel I being 32 13

feedinghappy rash

others thought that this was only necessary if thl symptoms were suspicious (eg, change in colour shape, size, itchiness) or if the pharmacist was ii any doubt. Referral was generally not Considered necessary for warts. The majority of respondent stated that acne and urticaria need be referred only in severe cases where OTC products hac failed.

Issues of diet and general wellbeing produced i

range of responses. For some of these symptoms eg, requests for vitamins or pregnancy tests, mos GPs did not think referrals necessary. Somi respondents clearly found it difficult to makl generalisations regarding these symptoms, possi bly because many are primarily psychological ii nature. Criteria of duration and severity wen often mentioned. Referral was also suggested ii cases where the pharmacist believed that thl doctor’s support would be helpful, eg, some case of wanting to lose weight, giving up smoking o feeling run down. Hence it would be difficult tc make generalisations or develop guidelines fo pharmacists for these symptoms.

Respondents’ recommendations compared witl pharmacists’ practices The comparison betweei the GPs’ recommendations and the practices o pharmacists was made using the results of thl earlier study, which involved 716 consultation between pharmacists and clients.” The proportioi of cases that the pharmacists referred for eacl symptom group is shown in Table 2. For soml symptom groups the results were based on a smal number of cases.

In general, the symptoms for which the phar macists had reported high referral rates coincidec with those for which the majority of the GPs ii this study recommended referral, and the symp toms for which pharmacists had reported lo\ referral rates were those for which most GPs fel that referral should not be routinely necessary.

For instance, the pharmacists’ referral rate fo upper respiratory symptoms was low and, witl the exception of wheeze/breathlessness, whicl was a rare presentation to pharmacists compared with other respiratory symptoms, most GPs fel

MARCH 1996, THE INTERZIATlOhAL JOLRNAL OF PHARMACY PRACTICE 33

that referral should not be necessary except in certain cases. Similarly, for problems with hair and diethitamins, the pharmacists’ referral rates were low and most of the GPs felt that a referral should not be necessary in all or most cases. The pharmacists’ referral rate for ear symptoms was high, and only two per cent of the GPs said that referral was not required for people with earache.

For certain symptoms, the GPs recommended that clients should be referred to health profes- sionals other than themselves, in particular den- tists, health visitors and chiropodists. These practices were also seen in the pharmacists’ referral patterns.

Discussion

Respondents were sampled from four FHSAs in the London area; different demographic locations within the metropolis were represented. Although there are many similarities in general medical practice throughout the United Kingdom, it cannot be assumed that the results are generalisa- ble to GPs in other areas. No significant differ- ences in sex and practice sue between the re- sponders and non-responders were found; however, the responders may include proportion- ally more practitioners who have strong views regarding the pharmacist’s role in advising on common ailments or who have an interest in promoting a co-ordinated interprofessional ap- proach to the management of symptoms.

This study provides information on the views and expectations of GPs on when pharmacists should refer clients who present with common ailments. For many symptom groups the majority of respondents believed referral, and hence their involvement, to be unnecessary, indicating that they felt it appropriate for pharmacists to deal with these. This suggests that the majority of GPs see pharmacists as having a role in dealing with minor ailments that is distinct from their own. That the failure of OTC remedies was a common reason for GPs to recommend referral of particu- lar symptoms indicates that they felt that for these symptoms a pharmacist could be the first port of call.

For many symptoms where the respondents considered a direct referral of all cases unneces- sary, they specified criteria on which to base a decision to refer. From the responses, it seems that implicit assumptions were made that phar- macists possess the clinical and inter-personal skills needed to gather information from the client and to make a judgment regarding, for example, “evidence of infection,” “evidence of inflamma- tion,” “unusual history,” “need for surgical closure of wounds” and “severity of back pain,” as well as manage many minor symptoms without recourse to referral.

For a number of the symptom groups, the GPs in this study indicated that referral should be made to health professionals other than them- selves, in particular, to dentists, health visitors and chiropodists. In fact, analysis of the pharma- cists’ referral practices in the earlier study

showed that clients are sometimes referred to other health professionals.’ Despite the common- ly voiced perception of the pharmacist as a relatively isolated health care professional, it is necessary and expected by GPs that pharmacists are familiar with the functions of other members of the primary health care team.

Other studies have revealed mixed feelings among medical practitioners on the role of phar- macists in dealing with common ailments. These have generally been concerned with the pharma- cist’s advisory role as a whole rather than with responses to particular symptoms. A study among physicians and pharmacists in New South Wales found that physicians had supportive attitudes towards pharmacists giving advice on non-pre- scription medicine use, while they were less supportive of them advising on the use of pre- scription medication.” Seventy six per cent of responding GPs in a study in an area of South London agreed that “it should be part of the pharmacist’s role to advise patients on minor symptoms,” though a significant minority (nearly one-quarter) seemed not to subscribe to this view.12

In a postal survey about possible extensions to community pharmacists’ roles, 66 per cent of responding GPs in three areas of England agreed and 18 per cent disagreed with an “increased role in managing minor i l lne~s.”’~ In a 1983 study asking GPs to consider the suitability of particu- lar symptoms for being dealt with by pharmacists, respondents rated colds and influenza, cough, mouth ulcers and muscular aches and pains as “very desirable” for pharmacists to treat but piles and cystitis as least s~i tab1e.I~ Since then, pharmacy undergraduate and postgraduate edu- cation has been addressing the needs of pharma- cists in managing symptoms presented in the pharmacy, and this role of the pharmacist has received considerable attention in the\ pharmacy and public media.

The majority of respondents in the present study felt that a direct referral was not appropri- ate for more than half the symptom groups (Figure 1). They varied more in the proportion of symptom groups that they felt should not warrant a referral (Figure 3) and in the criteria suggested.

The variation in their views will to some extent reflect their awareness of the availability of OTC products and their perceptions and experiences of pharmacists’ advice.

Although for many symptoms general guide- lines can be drawn based on these respondents’ recommendations, some variation between the recommendations was also apparent. Local dis- cussion between pharmacists and GPs, including sharing of views, wishes and expertise, will be necessary if co-ordinated practice is to be achieved. This would help promote teamwork in which each health professional is aware of the work of the other and both are satisfied that the clients they share receive a safe and high quality service. Co-ordination of advice should also im- prove adherence, reduce the incidence of conflict-

34 THE INTERNATIONAL J o L ‘ m A L OF PHARMACY PRACTICE, MARCH 1996

ing advice, which is frustrating to I)oth yrofes- sionals and clients, and promote client confidence in community pharmacy and other primary care services.

ACKNOWLEDGMENTS: Thanks are clue to the medical practitioners who assisted in the pilot work and took the time to complete the questionnaire.

References

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8. Pharmacists: how reliable are they? Which? Way to Health, December, 1991:191-4. 9. Smith FJ. Referral of clients by community pharmacists in primary care consultations. Int J Pharm Pract 1993;2:86-9. 10. SPSS: Statistical package for the social sciences. Chicago: McGraw Hill, 1983. 11. Ortiz M, Walker WL, Thomas R. Physicians: Friend or foe? J Soc Admin Pharm 1989;6:59-68. 12. Woodward J. GPs and community pharmacists - a study of attitudes. Pharm J 1992;249:99-101. 13. Spencer JA, Edwards C. Pharmacy beyond the dispensary: general practitioners’ views. Br Med J 1992;304: 1670-2. 14. Morley A, Jepson MH, Edwards C, Stillman P. What do doctors think of pharmacists treating minor ailments? Pharm J 1983;231:387-8.

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