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Dispensary Services Quality Scheme – Guidance
- Assessment by PCTs of performance against the criteria for payment
- Dispensing staff - minimum hours
- Dispensing staff duty of confidentiality
- Dispensing staff training and experience
- Governance of dispensary services
- Introduction
- Payment
- Review with patients of compliance and concordance with use of medicines
As part of the changes to the arrangements for dispensing doctors for April 2006, agreed as part of the General Medical Services (GMS) changes in 2006/07, a Dispensary Services Quality Scheme has been developed. The specification for this Scheme, which rewards practices for providing high quality services to their dispensing patients, is available on the BMA website and the NHS Employers website.
This guidance note, which supplements “Revisions to the GMS contract 2006/07: Delivering investment in general practice” has been developed by NHS Employers and the General Practitioners Committee (GPC) together with the Dispensing Doctors Association (DDA) to assist practices and primary care trusts (PCTs) to implement the Scheme. It follows the structure of the specification of requirements for receiving dispensary services quality payments and includes information about:
- payment
- dispensing staff training and/or experience
- minimum level of staff hours
- duty of confidentiality
- standard operating procedures, clinical audit and risk management
- patient information
- review with patients of compliance and concordance with use of medicines
- assessment of performance against the criteria for payment.
2. Payment
Key points:
- The contractor must provide the PCT with a written undertaking to carry out the services specified.
- The practice must carry out the services detailed in the specification.#
- The practice must nominate a GP who is accountable for the quality of dispensing services.
The specification for the Scheme includes information about the payment that should be made to a dispensing practice (contractor) when the PCT is satisfied that the contractor has complied with the Scheme requirements (as outlined in the rest of the specification).
The specification includes a number of conditions of payment:
- the practice must provide the PCT with a written undertaking to carry out the services specified. In the first year of the Scheme, practices must provide this written undertaking within eight weeks of the Directions coming into force (this date will be published when it becomes known)
- the practice must provide the PCT with the name of a GP who will have accountability for the dispensary services quality
- the practice must carry out the services detailed in the specification.
The main purpose of this written undertaking is for PCTs to understand which dispensing practices will be participating in the Scheme and how each practice intends to fulfil the requirements in the specification, so that appropriate monitoring arrangements can be put in place throughout the rest of the year.
For practices, this is an opportunity to prepare a plan of how the requirements of the Scheme will be demonstrated by the end of the financial year. It is recommended that practices identify how they intend to ensure that each section of the specification will be completed and, where appropriate, maintained.
The practice plan will assist in the necessary prospective agreement between the contractor and the PCT on the criteria to be used in selecting patients for review of compliance and concordance with use of medicines.
2.3 Accountable GP
As part of the written undertaking to carry out the services, the practice must provide the PCT with the name of a GP who is accountable for the quality of dispensing services.
The accountable GP may choose to delegate the delivery of dispensary services quality to a suitable person within the practice but the accountable GP will remain responsible for meeting the requirements of the Scheme at all times.
If the nominated accountable GP leaves the practice or is for any other reason unable to fulfil this duty then, within four weeks of this change, the contractor should provide the PCT with the name of another GP who is accountable for meeting the requirements of the Scheme.
3. Dispensing staff training and experience
Key points:
- The practice should consider the training and experience required by all staff who work in the dispensary; it will need to provide evidence that all staff working in the dispensary have the competencies and knowledge to perform the tasks and roles assigned to them.
- Staff should not work unsupervised in the dispensary unless they have the required experience and competencies.
The specification outlines the minimum training requirements and/or experience required for staff that work in the practice dispensary, including trainee dispensers. These requirements have been developed to be consistent with (but not replicate) the Royal Pharmaceutical Society of Great Britain’s (RPSGB) minimum competence requirement for pharmacy support staff. They apply to staff carrying out any of the following tasks:
- prescription receipt and collection
- the assembly of prescribed items (including the generation of labels)
- ordering, receiving and storing pharmaceutical stock
- the supply of pharmaceutical stock eg to nursing homes and private hospitals.
The requirements for qualifications and/or experience required are set out in the specification for both existing staff, who are employed by the practice on the date of the practice’s written undertaking to provide the service, and new staff who are employed by the practice after that date.
A distinction is drawn between those working under supervision and those working independently in the dispensary.
Guidance is given below on training and qualifications that meet the requirements set out in the Scheme.
3.2 Training and qualification standards for non-medical staff whose role is not wholly dispensing
This section applies to staff for which dispensing forms only a part of their duties in the practice, eg receptionists and nurses.
As explained in paragraph 2.1.2 of the specification, the negotiating parties have taken a pragmatic approach to the training requirements and accept that, providing staff are competent to perform those tasks that fall within their roles and responsibilities, it is not necessary for all of them to undertake a formal dispensing qualification. In such cases, the accountable GP (or suitable delegate) is responsible for making a decision as to whether or not a member of staff can satisfactorily be certified competent in the duties they undertake.
In some cases the work of such staff members will be covered by Standard Operating Procedures.
If the principal role of an individual member of staff is working in the dispensary, the training and qualification requirements usually apply.
3.3 Training and qualification standards equivalent to the pharmacy services S/NVQ level 2 for staff whose role in the practice is wholly or principally dispensing
Most staff working in the dispensary will be required to be competent to a minimum standard equivalent to the pharmacy services Scottish /National Vocational Qualification (S/NVQ) level 2, or undertake training towards this standard. Staff undertaking the required training will usually be expected to complete the course within the course-provider’s usual timetable.
The use of a unit route is acceptable. This means that the member of staff can meet this standard by completing each of the units of the S/NVQ (or equivalent) relevant to their role. In such cases the member of staff would usually not receive a full S/NVQ level 2 certificate from the course provider.
The unit route avoids the need for assessment by a supervising pharmacist. Practices may choose to fund pharmacist sessions for the purposes of such assessments but this is not a requirement of the specification.
Examples of appropriate courses designed specifically for staff not working under the supervision of a registered pharmacist are included in this guidance.
Course units required to obtain the qualification when working in doctors’ dispensaries are usually set out by providers of these courses. Accreditation of these S/NVQs is a matter for course providers and NVQ accreditation centres, not for PCTs.
A dispensary staff member’s achievement of a pharmacy services S/NVQ level 2 or 3, or their registration as a Pharmacy Technician, would qualify as suitable to meet this criterion for the scheme.
Where, in line with the specification, the practice can demonstrate that it is not possible or appropriate for these staff to undertake a formal qualification, then it is recommended that the accountable GP (or suitable delegate) undertake a formal competence assessment. This competence assessment is further described below.
It is expected that staff starting work as a dispenser after the introduction of the Scheme will normally undertake the formal qualification.
Lack of specific funding for the required course/package will not be an acceptable reason for staff not undertaking training equivalent to the pharmacy services S/NVQ level 2 training.
3.4 Competencies for all dispensing staff
Staff should not work independently (unsupervised) in the practice dispensary unless they have the required experience and competencies.
In order to determine whether a member of dispensing staff is competent to a minimum standard equivalent to the pharmacy services S/NVQ level 2 in the area that they are working in (as required by the specification of requirements at paragraphs 2.1.4.1, 2.1.4.2 and 2.1.5), it is recommended that the accountable GP (or suitable delegate) refer to Appendix A of this guidance. This appendix, which draws on guidance from the RPSGB, provides a list of competencies against each work area. This will enable the accountable GP to make a decision as to whether or not a member of dispensing staff can satisfactorily be declared competent in the duties they undertake.
Holding a qualification as a dispenser at a standard equivalent to S/NVQ level 2 or higher does not exempt the member of staff from an assessment of their competence. This competence assessment forms part of the governance framework of the dispensary.
Practices will wish to reassess competence as part of structured personal and professional development assessments or appraisals.
It is recommended that each staff member working in the dispensary demonstrate competence in the following areas:
- customer service
- health and safety
- teams and teamwork.
- the supply of prescribed items (including prescription receipt and collection)
- the assembly of prescribed items
- ordering, receiving and storing pharmacy stock
- the supply of pharmaceutical stock.
The following courses are examples of currently available courses that are acceptable alternatives to the pharmacy services S/NVQ level 2 for the purpose of this Scheme.
Course provider |
Course title |
Buttercups Training Ltd |
NVQ2 dispensing assistants course for dispensers in dispensing doctors’ practices |
Buttercups Training Ltd |
City and Guilds NVQ level 2 in pharmacy services |
Buttercups Training Ltd |
City and Guilds NVQ level 3 in pharmacy services |
The People’s College, Nottingham |
Edexcel BTEC professional development certificate in dispensing practice |
The People’s College, Nottingham |
BTEC intermediate certificate in dispensing practice |
Boots the Chemists |
Pharmacy assistants training course |
Lloydspharmacy |
Dispensing assistant training course/dispensers training programme |
National Pharmaceutical Association |
NPA dispensary assistants’ course |
Birmingham Children’s Hospital NHS Trust |
Competency based programme for dispensing assistant technical officers |
South West Medicines Information and Training |
South west pharmacy accredited training scheme |
University Hospitals of Leicester NHS Trust |
ATO dispensary training scheme |
Omission of a course from this list does mean that it is not suitable for the scheme. It is recommended that the accountable GP and PCT consider any other courses’ underpinning knowledge and competencies when assessing equivalence for the purposes of the scheme.
3.6 Experience required to work independently in the practice dispensary
The specification sets out the requirement of 1,000 hours of work experience in a GP dispensary or community pharmacy. This equates to approximately 27 full-time working weeks (37.5 hours a week), and 50 weeks at 20 hours a week. It is recommended that annual leave and sickness should not count towards the requirement of 1,000 hours for the purposes of the scheme.
4 Dispensing staff – minimum hours
Key points:
- The practices should agree the minimum level of staffing with their PCT - this may not be the same as the hours of availability of the dispensing service to patients.
“The contractor must, in consultation with the PCT, agree a level of staffing that reflects the dispensary’s configuration and hours of opening.”
It should be noted that the minimum level of staff hours may not be the same as the hours of availability of the dispensing service to patients. It is recommended that the level of staff hours relate to those hours that staff are engaged in dispensing activities, and not to other activities they may undertake in the practice.
The assessment of minimum staffing hours must take account of the requirement in the specification that contractors must ensure that their staffing levels and underpinning systems and processes can “reasonably be expected to safeguard patient safety”. PCTs will wish to judge contractor’s levels of staff involved with dispensing against this criterion.
PCTs may find it useful to determine the minimum levels of staff hours by considering reference to the number of dispensed items that are dispensed on average each month, excluding personally administered items.
The following table can be used as a guide for practices and PCTs in determining the level of staffing:
Number of items dispensed per month |
Dispensing staff hours each week |
1 to 499 |
10 |
500 to 999 |
20 |
1,000 to 1,999 |
30 |
2,000 to 3,499 |
40 |
3,500 to 4,999 |
56 |
5,000 to 6,499 |
75 |
6,500 to 7,999 |
94 |
8,000 to 9,499 |
112 |
9,500 to 10,999 |
131 |
11,000 |
150 |
Contractors could be expected to employ a staff member for an extra 19 hours for each additional 1,500 items dispensed per month above 11,000 items.
5 Dispensing staff – duty of confidentiality
Key points:
- All employee contracts for dispensing staff should include a duty of patient confidentiality as a specific requirement.
Practices should ensure that all employee contracts for dispensing staff include a duty of patient confidentiality as a specific requirement with disciplinary procedures set out for non compliance.
Practices will wish to ensure that dispensary staff (as with all staff) are aware that information about a patient is confidential and should not be disclosed to anyone. However, it is recommended that some different issues relating specifically to dispensaries be included in staff training and assessment, and in practice policies and procedures.
Before advice is given on taking a medicine, it is recommended that dispensary staff find out whether the person collecting the medicines is the patient. It is usually appropriate to provide information on how to take the medicines and advise patients what to do in the case of any particular problems. However, the accountable GP will wish to ensure that staff are aware of the type of queries that should be referred back to a doctor or other registered health professional in the practice (e.g. nurse or pharmacist).
It is recommended that care is taken when answering casual questions (such as “what’s it for?”) from an individual collecting medicines on behalf of someone else.
Practices will wish to store medicines awaiting collection in a way that they can not be observed by members of the public collecting their own medicines.
The accountable GP will wish to ensure that staff are instructed on how to proceed if medicines are being collected by people they do not know. It is recommended that staff request identification in all such cases or follow a standard operating procedure approved by the accountable GP.
6. Governance of dispensary services
Key points:
- Standard operating procedures (SOPs) should reflect what is actually being done in the dispensary.
- The practice will want to ensure that it is providing the required information for its patients.
Effective governance arrangements encourage and provide a structure for dispensary staff and GPs to risk assess the dispensary processes.
6.1 Standard Operating Procedures (SOPs), clinical audit and risk management
The accountable GP (or their delegate) should ensure SOPs are in place and reflect what is actually being done in the contractor’s dispensary (and, where appropriate, additional dispensaries). SOPs provide a useful basis for effective training and assessment of competence.
It is recommended that the DDA’s Guide to Developing SOPs is used as a benchmark for good practice.
PCTs will not wish to request or endorse any SOPs but may check that they are present and that they are routinely followed by dispensing staff
Practices will wish to ensure that clinical audit programmes include the dispensing systems, and assess the nature and quality of information given to patients by the staff dispensing in the practice, to help patients get the best from their prescribed medicines. It is recommended that the learning from these audits is shared with all practice staff, not only within the dispensary.
It is recommended that clinical audit programmes also use the information that the dispensary may provide to contribute to audits of other parts of the practice’s services eg patient information, records, critical incidents.
Serious untoward incidents in dispensing should be reported as set out in the specification, and used as a learning opportunity for all dispensing staff and others in the practice.
Practices will wish to ensure that the practice policy and procedures for managing risks in providing dispensing services is supported by the accountable GP. This will help dispensary staff with continuing professional development and ensure that dispensary staff refer appropriately within the practice, if they identify areas of concern arising from dispensing.
Where possible it is recommended that records of dispensing and interventions by dispensary staff are integrated with other records in the practice, and that these contribute into the overall practice records-management systems.
SOPs available may be expected to address the following aspects of dispensary services to ensure:
- the provision of high quality medication
- that medicines are dispensed accurately and with adequate safeguards. It is recommended that this includes label production, selecting and preparing the medication, appropriate containers, checking of assembled medicines and checking of Controlled Drugs
- safe issuing of medication including confidentiality
- provision of suitable information to the patient, or where appropriate, carer
- that medicines are dispensed in a hygienic manner
- suitable equipment is available.
- Health and Safety at Work Act
- COSHH Regulations
- Controlled Drugs: Misuse of Drugs Act and supplementary guidance eg following the Shipman Enquiry
- Medicines Act and regulations
- cash handling and collecting and accounting for NHS monies eg prescription charges and exemption claims
- prescription form handling before and after dispensing
- gifts and hospitality (see also “Excessive or Inappropriate Prescribing: guidance for health professionals on prescribing NHS medicines” and ABPI/MHRA guidance on “Inducements to prescribe”).
6.2 Information
The specification details the information that the practice will be expected to provide for their patients.
7 . Review with patients of compliance and concordance with use of medicines
Dispensing review of use of medicines (DRUM) - key points
- This review should be undertaken face to face with the patient to find out their compliance and agreement with their prescribed medicines, and to help identify any problems that they may be having.
- The DRUM is different to the Medicines Use Reviews (MUR) in community pharmacy, a clinical medication review (level 3) and the Quality and Outcomes Framework (QOF) indicators for medication review.
- The practice may find it helpful to use the suggested DRUM record template in this guidance.
Within the Dispensary Services Quality Scheme the review of patients’ use of medicines (DRUM) should be undertaken face- to-face with the patient, to find out their compliance with, and agreement (concordance) with, the medicines they have been prescribed and to help identify any problems that they may be having. Patients should be given the opportunity to raise questions about their medicines. The primary purpose of these reviews is to help patients understand their therapy and to identify any problems that they are experiencing and, where appropriate, suggest possible solutions. The review should seek to optimise the impact of treatment for an individual patient and any changes resulting from the review should be agreed with the patient.
These reviews will help patients with many of the practical issues that they face with using medicines, for example:
- knowing how to take their medicines (with water and/or food)
- identifying medicines they do not want or do not take any more (so that a decision can be made on whether to remove from their medication list)
- discussing how they open containers, including the need for compliance aids where appropriate
- using devices such as inhalers
- talking about side-effects
- identifying what to do if they think they may have two medicines for the same purpose.
It is recommended that the dispensing review of medicines also:
- takes place in a private consultation room or opportunistically at the dispensary (provided issues of confidentiality and patient preference can be satisfied)
- is performed in a systematic manner and significant outcomes documented in the patient’s notes
- where appropriate, provides patients with documentation in preparation for the review and/or as feedback on the matters covered in the review and actions discussed as a result of the review.
7.2 Other medication/medicines reviews
There is a degree of overlap and potential confusion about the different types of medication/medicines’ reviews. These include Medication Reviews as specified in the Quality and Outcomes Framework (QOF), Medicines Use Review (MUR) as an advanced service in the national community pharmacy contractual framework and dispensing review of use of medicines (DRUM) for the Dispensary Services Quality Scheme.
It is perhaps reasonable and appropriate that there is some duplication across all of these reviews, for example it is recommended that awareness about compliance and about the development of side effects are considered on an ongoing basis.
The DRUM is different to the other reviews in the following ways:
- it is not the same as the MUR in community pharmacy and does not cover all aspects of that advanced service for community pharmacists
- it is not the same as a clinical medication review (level 3) conducted using access to the patient’s notes, records of prescriptions and non-drug care and results from laboratory tests etc
- it is not the same as the QOF indicators for “medication review” in the 2006/07 revision of QOF (Medicines 11 and Medicines 12). The Level 2 medication review required for QOF M11 and M12 is a “treatment review”, looking principally at the suitability of the medication for the indication identified from the patient’s notes, and may be undertaken without the patient – for instance, to remove unwanted items from the repeat medicines list and consider dose adjustments.
Person undertaking review: |
Yes/no/ |
Comments |
Action taken |
Dispensing review of use of medicines done? |
|||
Patient understands medicines’ purposes and is in agreement with this (concordance)? |
|||
Patient is taking medicines as prescribed (compliance)? |
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Side effects reported? |
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Special needs affecting |
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Inefficient use/wastage/unwanted medicines on prescription list or supplied? |
This template may be adapted for clinical computer software or for paper-based records.
It is recommended that the practice plan includes agreement with the PCT on the READ code that will be used by all dispensing practices in the PCT to record the dispensing review of use of medicines (DRUM), to help practices and PCTs monitor and track progress. This code should be different to the local READ code used for QOF medication review recording.
7.4 Patient selection for Dispensing Review of Use of Medicines
The practice will wish to ensure that the types of patients that will be targeted for the dispensing review of their use of medicines are agreed with the PCT, at the time the practice plan for the Scheme is submitted.
8. Assessment by PCTs of performance against the criteria for payment
Key points:
- It is recommended that the PCT decides in consultation with the practice what written evidence may be required.
To help practices and PCTs deal with this, it is recommended that PCTs decide, in consultation with practices, what written evidence may be required. This could include:
- statement of number of items dispensed per month (excluding personally administered items)
- statement of number and qualifications of all staff who work in the dispensary and the number of staff hours per month spent on dispensing-related activities
- copies of written information provided for patients about the dispensary services available
- copies of all current and revised SOPs relating to dispensing; it is suggested that revised SOPs should be kept for at least two years
- copy of the practice’s procedures for audit, adverse incident reporting and investigation, risk management, patient confidentiality and data protection
- evidence that the practice is participating in agreed local PCT reporting and learning schemes for incidents relating to dispensing
- a protocol or template for reviewing with patients their compliance and concordance with prescribed medicines
- copy of standard contract for dispensing staff including duty of confidentiality
- evidence that all dispensing staff employed by the practice comply with the requirements in the training section of the specification
- services provided to dispensing patients in accordance with the Scheme recorded in patient records, including reviews of compliance and concordance with prescribed medicines
- reports of adverse incident investigations
- training courses undertaken by dispensing staff and qualifications obtained
- annual staff appraisals and personal development plans.