1. Introduction

1.1.The United Kingdom Medicines information (UKMi) service in England has a national service level agreement (SLA) with NHS Direct (NHSD) to answer referrals of complex medicines calls. This guidance is intended to support UKMi pharmacists in handling NHS medicines call referrals from NHSD and to do this in a consistent way across MI centres.

1.2.The handling of a NHSD referral has several stages. For some stages, the procedure is the same as for all other types of enquiry received by UKMi and so the reader is referred to the relevant UKMi policy, guidance and/or standard operating procedure (SOP). Other stages are unique to NHSD referrals and this guidance covers these. See Table 1.

Table 1: Stages of Handling NHSD Medicines Call Referrals and UKMi Policy, Guidance and Standard Operating Procedure

Relevant UKMi policy, guidance and/or SOP
Decision to refer to UKMi / NHSD medicines algorithm.
NHSD-UKMi Guidance for Referral of Complex Medicines Calls to UKMi.
Receipt of the NHSD referral / This guidance.
NHSD-UKMi Guidance for Referral of Complex Medicines Calls to UKMi.
Initial contact with the caller / This guidance.
Analysis of the question / Local Enquiring Answering Guidelines
Search strategy & coverage / UKMi standard search patterns
Local Enquiring Answering Guidelines
Delivery of the answer / This guidance.
Documentation of the referral using MI Databank / This guidance.
UKMi SOP-04 Documenting Enquiries
Serious Adverse Incidents / UKMi SOP-03 Adverse Incident Reporting
NHSD Serious Adverse Incident Procedure
  1. Roles and Responsibilities of NHSD Staff
  2. Health Advisors (HAs) are non-clinical frontline members of staff that receive calls from members of the public. They log the call onto the NHS Direct Clinical Assessment System (CAS) and prioritise it by questioning the caller and using a tool called CSPT (Call Streaming and Prioritisation Tool).

As part of their role, HAs may also use protocols on CAS and hard copy resources to answer calls about

Access to medicines e.g. out of hours pharmacies, repeat prescriptions and supply (but not advice on suitability) of emergency hormonal contraception.

Interim care instructions on analgesia for dental pain.

Ingested substances of low toxicity.

2.2.Health Information Advisors (HIAs) answer calls that are non-symptomatic (the subject does not have any new or worsening symptoms) where information is required about health or medicines. They use the specific Medicines Algorithm to answer non-symptomatic calls about medicines.

2.3.Nurse Advisors (NAs) may answer symptomatic or non-symptomatic calls. For symptomatic calls, algorithms are used to assess the symptoms and decide the most appropriate course of action. If the call also has a medicines element to it, the NA can use the Medicines Algorithm to answer this aspect of the question.

2.4.Dental Nurse Advisors (DNs) are qualified dental nurses who answer dental calls only. These may be symptom or non-symptom based. DNs answer all dental calls according to local procedures.

  1. NHSD Decision to Refer the Medicines Call to UKMi

3.1.For full guidance refer to the NHSD-UKMi Guidance for Referral of Complex Medicines Calls to the United Kingdom Medicines Information Service (UKMi).

3.2.There are two separate national queues for NA and HIA calls (DN calls are part of the NA national queue). Both HIA and NA calls can be referred to UKMI via the national speed dial number.

3.3.HIAs are instructed to refer medicines calls to UKMi if:

The caller is taking 3 or more prescribed medicines.

The caller is pregnant and/or breastfeeding and there is no NHSD Q&A that directly answers the question.

The caller is asking a question about medicines that is unclear or difficult to understand.

Information that answers the question cannot be found, or that found is contradictory, unclear or confusing.

The call is outside the competency of the HIA.

In addition, they are advised to consider referral to UKMi if the subject has a complicated medical history or the subject is taking any:

High-Risk Medicine (e.g. Aminophylline, Carbamazepine, Ciclosporin, Digoxin, Lithium, Methotrexate, Phenytoin, Theophylline, Warfarin)

Unlicensed medicine or their medicine is being used in an unlicensed way.

Black triangle medicine.

At times of high call volume, HIAs may refer unassessed medicines calls to UKMi via the speed dial number. In these cases, the HIA will not have gathered all the background information and so UKMi will need to clarify with the caller after taking the referral (see section 6).

3.4.NAs are instructed to use their professional judgment when deciding whether to refer a medicines call to UKMi. There are no criteria stipulated for when a medicines call must be referred. However, the Medicines Algorithm prompts the NA when to consider this option.

3.5.In some cases the NA or HIA may simply be calling UKMi for clarification or consultation regarding an enquiry, and the call may not be transferred. It is important to document these calls for statistical purposes.

  1. National UKMi Rota for NHS Direct call referrals

4.1.10 Regional UKMI centres (RMICs) take part in the national UKMi rota for NHS Direct medicines call referrals (see appendix B).

4.2.The RMIC should not use the phone designated for receipt of NHS Direct call referrals for any other types of call during their scheduled sessions. All outgoing calls (including those to callers referred from NHS Direct) should be made from another ‘phone.

4.3.Once a RMIC has taken the agreed quota of calls they should contact the NHS Direct Workflow Coordinator on 0845 602 0706 or email (flag as high priority) and ask for the relevant RMIC number to be “zeroed out”.

4.4.If the NHS Direct Workflow Coordinator cannot be contacted by phone or email then contact the UKMi NHSD Workflow Coordinator (Northwick Park UKMi NHSD Pharmacist or deputy).

4.5.Unforeseen circumstances (e.g. sickness or local emergency) may mean that a RMIC is unable to fulfil the scheduled commitment. In these circumstances the UKMi lead for that site should negotiate with the other 3 RMICs on their rota day to cover the calls. The UKMi Lead should inform both the Workflow Coordinators (NHSD and UKMI) of the arrangement.

  1. Receipt of NHSD Medicines Calls Referrals

5.1A Medicines Information (MI) pharmacist or appropriately trained and supervised Pre-registration Pharmacist, Pharmacy Technician or other Medicines Information Service member of staff should receive NHSD referrals.

5.2Referrals are received by telephone from NHS Direct HIAs, NAs or DNs:

Monday to Friday 9am-8pm excluding Bank Holidays.

Saturday and Sunday 9am-3pm, excluding Bank Holidays.

If the referral is received at the end of the working day then professional judgement should be exercised in deciding whether to answer the question that day or the next working day.

5.3UKMi should collect and record the following information from NHS Direct:

Full name and role (HIA, NA or DNA) of the staff member referring the call.

NHSD site and contact details.

NHSD CAS number for the call.

Full name, DOB, gender and contact details of the subject.

If a third party call, full name, DOB and contact details of the caller as well as their relationship to the subject.

The caller’s question.

All relevant clinical details ascertained by NHS Direct (e.g. PMH, allergies, medicines, breastfeeding/pregnancy).

Suitable time to call the patient back.

5.4UKMi should give NHS Direct the following information

Full name of the member of staff who takes in the referral.

UKMi centre.

UKMi enquiry number for the referral. This should be prefixed with the appropriate letters to indicate which UKMI centre e.g. NW 50365 for North West MI Service.

UKMI centre / Enquiry Number Pre-fix
East Anglia / EA
Leeds / L
London (NorthwickPark) / NWP
London & SE / LSE
Newcastle / N
North West / NW
South West / SW
Trent / T
Wessex / W
West Midlands / WM
  1. Initial Contact with the Caller

Sometimes an answer can be prepared immediately, in which case go to section 7. If preparation will take longer than 1 hour or if essential background information is required before starting the research then proceed as follows:

6.1.Phone the caller within 1 hour of receipt of the referral from NHS Direct to confirm the question and gather any further necessary background information, unless the caller has requested a different time for this.

6.2.If the caller’s phone does not accept calls from anonymous sources (i.e. where the number is “withheld”) contact NHS Direct and ask them to call the caller back in order to provide another number that they can be contacted on.

6.3.Attempt to make initial contact with the caller on 3 separate occasions. A morning or afternoon on the same day counts as 2 occasions. Document your attempts to make contact.

6.4.If necessary leave an answer phone or voicemail message as follows:

“Hello this is a message for [Caller’s Name]. My name is [First Name]. I am a pharmacist calling in response to your enquiry to NHS Direct. Please could you call me back on [RMIC number] weekdays before 5pm. Thank you”

6.5.If you are unsuccessful after 3 attempts, close the referral and document that you were unable to contact the caller.

6.6.On speaking to the caller, first confirm that you are speaking to the appropriate person and then introduceyourself to the caller using the following script:

“My name is [First Name]. I am a pharmacist calling in response to your enquiry to NHS Direct.”

This response ensures consistency within the UKMi network, and prevents the caller identifying the individual medicines information centre or pharmacist.

6.7.Confirm the caller’s question and the essential background information already given by NHS Direct. Request any further necessary background information to answer the question.

6.8.Agree a mutually convenient time to phone the caller back with an answer. If necessary, explain that you prefer not to leave a message on an answer phone or by voicemail in case it is overheard by a third party and also because you may need to discuss the answer with them.

  1. Delivery of the Answer

7.1.Attempt to make contact with the caller to answer the question on 3 separate occasions. A morning or afternoon on the same day counts as 2 occasions. If you are unsuccessful after 3 attempts, then close the referral. Document your attempts to make contact.

7.2.If necessary a message can be left on an answer phone or voicemail system as per section 6.4.

7.3.On speaking to the caller, confirm that you are speaking to the appropriate person before introducing yourself or delivering the answer.

7.4.Some referrals may be difficult to answer because of legal or ethical considerations. NHS Direct staff are trained to deal with these types of calls and have internal policies to guide their practice. If a call of this nature is referred then follow the appropriate UKMi guidance (See Table 2).

7.5.It will not usually be necessary to provide written information or to put an answer in writing. The decision whether to do so or not is guided by professional judgement, and the content and presentation should be guided by local practice. (An example template for a letter is given in Appendix C).

Table 2: UKMi Guidance for Handling Enquiries with Legal or Ethical Considerations

UKMi guidance
Ethical dilemmas (general guidance) /
Enquiries from the Police /
Enquiries and legal proceedings /
Working with the media /
Third party enquiries /
Physician-patient relationship /

7.6.It is important not to contact a healthcare professional concerning a named caller’s medical history without the patient’s permission. Callers regard NHS Direct as an anonymous service. If you consider that, for example, it is important for a caller’s well being that information is passed to his/her GP, the following options are suggested depending upon urgency, local practice, and the caller’s willingness to involve others:

Ask the caller if you can phone the GP.

Ask the caller if you can write to the GP and explain that you will copy the letter to both caller and GP. For urgent situations, the GP letter can be faxed. If writing to a GP don’t forget to include the caller’s date of birth and address to enable accurate identification.

If you need to refer the caller to A&E, you may in some circumstances wish to contact the A&E yourself and provide further information in an appropriate form.

Send two copies of a letter to a caller and ask that they take/send one to the GP.

Give your contact details to the caller and ask that they pass these on to the GP.

7.7.In the unlikely event that the caller refuses to give permission for you to contact a healthcare professional when you feel that is important:

Clearly explain to the caller why you think it is necessary.

Do not contact the healthcare professional without permission.

Document that you offered to contact the healthcare professional and the caller refused.

  1. Documentation using MI Databank
  2. Refer to UKMi SOP-04 Documenting Enquiries
  3. Dealing with Serious Adverse Incidents

There are two likely Serious Adverse Incident scenarios.

9.1.The UKMi Centre answering the NHS Direct patient referral is responsible for an adverse incident (error or near miss).

Refer to and follow the UKMi SOP-03 Adverse Incident Reporting.

Report the incident to the NHS Direct Pharmaceutical Advisor.

9.2.The UKMi Centre identifies an adverse incident (error or near miss) occurring within NHS Direct).

Consult with the UKMI lead for the NHS Direct site concerned and identify the names for relevant local and regional NHS Direct contacts (see below).

Report the incident to the following people within NHS Direct:

The National Pharmaceutical Advisor.

The staff member who usually deals with UKMI matters at the site concerned.

The appropriate Regional Director of Nursing for the site concerned.

The appropriate Regional Clinical Governance Lead or the site concerned.

Appendix A: Flow of NHSD Medicines Call Referral


Key

MIDB = Enquiry database used by UKMi

CAS = Enquiry database used by NHS Direct

Appendix B: National UKMi Rota for NHS Direct medicines call referrals

WEEK 1

1st on / 2nd on / 3rd on / 4th on
Monday / Trent / Wessex / South West / West Midlands
Tuesday / South West / West Midlands / North West / Newcastle
Wednesday / North West / Newcastle / L&SE / East Anglia
Thursday / L&SE / East Anglia / Leeds / Lon (NWP)
Friday / Leeds / Lon (NWP) / Trent / Wessex

WEEK 2

1st on / 2nd on / 3rd on / 4th on
Monday / Wessex / Trent / South West / West Midlands
Tuesday / West Midlands / South West / North West / Newcastle
Wednesday / Newcastle / North West / L&SE / East Anglia
Thursday / East Anglia / L&SE / Leeds / Lon (NWP)
Friday / Lon (NWP) / Leeds / Trent / Wessex

Appendix C: Example Contents for Letter Template

Contents should include the following statement (or similar)

If you have any questions relating to the content of this letter, please call us on [insert telephone number].

If you require health advice or information on any other matter, please contact NHS Direct on 0845 4647, who will be available to take your call 24 hours a day.

The letter should also contain the NHSD logo, the UKMI logo, logo of the regional MI unit and hospital address.

Written By: UKMI NHSD Working GroupDate: June 07 Review: June 08

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