Clinical governance deadlines: PSNC answers your questions

PSNC’s director of operations and support, Gordon Hockey, answers your questions about the upcoming clinical governance deadlines, explaining what your pharmacy needs to do and why

The key points

  • The Community Pharmacy Contractual Framework incorporates an NHS community pharmacy’s terms of service, which includes a series of clinical governance requirements
  • The deadline for completing the IG Toolkit, publishing results of your annual CPPQ and conducting two clinical audits is 31 March 2018
  • Contractors also need to send a copy of the pharmacy’s annual report to their local NHS England team as soon as possible after 31 March.


Q. Winter is always a busy period and I’m struggling to find the time to complete the clinical governance requirements. What would you advise I do?

PSNC’s advice is to start working towards completing these clinical governance requirements as soon as possible and not to leave it to the last minute. These requirements are important and are not as onerous as they might at first appear.

Community pharmacy contractors should refer to our quick reference guide that identifies the key actions to be completed by 31 March 2018 (available from PSNC). There is also additional information on the PSNC website that gives more detail on how to comply with these and other clinical governance requirements.

Once contractors have completed this year’s requirements, I would encourage them to begin planning early for 2018/19; many can be undertaken earlier in the year (April to March), which helps to manage the workload.

Q. There are many new requirements on top of original contract clinical governance requirements, such as the patient safety report that forms part of the Quality Payments Scheme. I think many of us would like a checklist of exactly what needs doing annually. Is that a possibility?

The information is on our website, but I think a calendar or checklist of requirements is a good idea; this would need to include both deadlines and ongoing requirements. We will look at this.

We have been assisting NHS England with its national ‘post payment verification’ pilot, which is undertaken by the NHS Business Services Authority (NHSBSA). As part of this work, a contractor calendar has been suggested and we might usefully combine the two.

Q. It’s really hard to stay on top of what is mandatory and what is good practice – can you help clarify this?

The Essential Services within the Community Pharmacy Contractual Framework – including the clinical governance requirements – are mandatory and the advice we issue seeks to make this clear. Many of these requirements overlap with, or relate to, standards or good practice guidance issued by the General Pharmaceutical Council and the Royal Pharmaceutical Society, respectively, and these organisations issue their own guidance.

Q. Do you have any template audits that I can use for the clinical audit requirement?

My colleagues in the PSNC Services Team recommend the Community Pharmacy Oral Anticoagulant Safety Audit, created by the NHS Specialist Pharmacy Service. This audit is available to all contractors via the online PharmOutcomes platform, making the process easier. More information and paperwork for other audits can be found here.

Q. Once clinical governance tasks are completed, what do I need to do?

Of the upcoming clinical governance deadlines, each requirement is different:

  • Information Governance (IG): The IG toolkit should be completed and submitted online.
  • Community Pharmacy Patient Questionnaire (CPPQ): The results of the CPPQ must be published in one of the following ways:

– in the pharmacy as a leaflet or poster;

– on the pharmacy’s website; or

– on the pharmacy’s NHS Choices profile.

PSNC has produced a template report for publication, available here.

  • Complaints report: A copy of the annual complaints report should be sent to the local NHS England team (even if the pharmacy hasn’t had any complaints). To assist pharmacies, PSNC has prepared a template summary of complaints, which can be used as an index of complaints as they are received and closed – you can find this here. It is recommended that the pharmacy also keeps its own copy of the report, which can be stored electronically or as hard copy.

Q. What are consequence of not doing the clinical governance tasks?

The clinical governance requirements are part of an NHS community pharmacy’s ‘terms of service’ and therefore must be completed to meet the pharmacy’s contractual obligations. They are important for the provision of pharmaceutical services to patients. If a contractor fails to complete these actions, NHS England may seek an explanation and the result could be informal dispute resolution and/or a breach notice.

Q. This year’s IG Toolkit has no changes, but I’ve heard that it will be replaced with a new regimen, which it’s rumoured will require more hard evidence of compliance undertaken. Is that true?

Revision of the IG Toolkit is work in progress and the final format for 2018/19 is still to be determined; we will provide more information on the changes as soon as they have been finalised. The introduction of the General Data Protection Regulation on 25 May this year will mean certain revisions are necessary.


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