Practice Experts Prescribing for minor ailments—a prime opportunity to advance our profession

Minor ailments—also known as common ailments, self-limiting conditions, ambulatory conditions, and low acuity conditions—are generally defined as health conditions that can be reliably selfdiagnosed (by a patient) and managed with self-care strategies and/or minimal treatment, including prescription therapies.1 Pharmacists have a longstanding history of providing direct care to patients presenting with minor ailments. This involves patient assessment by the pharmacist and recommendation of nonprescription and prescription therapies, self-care strategies and referral to other healthcare professionals when required.

Canadian estimates show that 10%–30% of physician visits are for minor ailments. This is problematic due to the escalating costs of care, as well as more limited access to these primary care providers. Pharmacists are wellpositioned and trained to address minor ailments. They can increase patient access to timely and quality care for these common conditions in the community, potentially reducing physician and emergency room visits/wait times, and ultimately reducing the burden on the healthcare system.2,3

Pharmacists in the United Kingdom have had the authority to prescribe drugs for minor ailment management for more than two decades. In Canada, all 10 provinces have adopted, or are currently pursuing, various degrees of prescriptive authority by pharmacists for specific conditions that fall under the minor ailment umbrella. However, there is no overarching national initiative for these minor ailment programs. The degree of prescriptive authority and scope of practice varies by province. Certain provinces permit prescribing for select minor ailments, while other provinces allow prescribing for any minor ailment, using any drug.4

Alberta, the first province to allow autonomous prescribing by pharmacists in 2007, did not limit scope to specific ailments or drugs.5 In contrast, pharmacists in Saskatchewan may prescribe Schedule 1 substances, but must follow a detailed protocol for each ailment. They are also restricted to a set formulary of medications specified per condition, as outlined in their provincial regulations.5 Pharmacists in Ontario are now authorized to prescribe for 13 minor ailments (this began January 1, 2023).6 Most recently, British Columbia announced plans to allow pharmacists to initiate therapy for minor ailments, with details expected to be formalized in 2023.7

Until recently, Alberta, Saskatchewan and Quebec were the only provinces where pharmacists were compensated by their provincial governments for prescribing treatments for select minor ailments. In 2022, Prince Edward Island, Nova Scotia and New Brunswick added funding for select ailments. Ontario community pharmacies are being reimbursed at a rate of $19 per in-person assessment and $15 per virtual assessment for all 13 ailments. This fee will be tied to the assessment itself, regardless of whether it results in a provision of a prescription, and will be capped at a maximum number of claims per ailment annually.8 Funding details have not yet been announced for British Columbia.

Why this is an important opportunity for the pharmacy profession?

Pharmacist prescribing for minor ailment (PPMA) programs are a significant milestone in the evolution of the pharmacy profession.9 Partaking in PPMA services will encourage pharmacists to practise to their optimal scope, take on a greater role within the healthcare system, and improve patient satisfaction.9 PPMA programs will also provide the pharmacy profession with important opportunities to promote efficiencies within the healthcare system by reducing the need for referrals to other healthcare professionals and improving access to timely care, which could lead to overall reductions in healthcare costs across Canada.10 The benefits of pharmacist prescribing on health outcomes are well documented. For example, the RxOUTMAP study found that uncomplicated cystitis management by pharmacists in New Brunswick is effective and safe, and results in high patient satisfaction.11

Research in different parts of the world suggests that pharmacists generally have a positive attitude towards PPMA.12 PPMA may encourage pharmacists to seek continuing education and training, which promotes life-long learning and continuous improvement in clinical competencies. Expansion of scope to include PPMA services may also encourage schools of pharmacy to undergo curriculum revision, so that new pharmacy graduates have the confidence to partake in PPMA prior to licensure.13

Which minor ailments are included?

The minor ailments included in PPMA programs vary across the Canadian provinces (see Canadian Pharmacists Association’s summary available at https://www.pharmacists.ca/cpha-ca/ function/utilities/pdf-server.cfm?thefile=/ Common_Ailments_English_PDF. pdf ).14 In general, PPMA programs include dermatological, gastrointestinal, reproductive, genitourinary, respiratory, mouth, musculoskeletal, eye, psychiatric, central nervous system, nutrition, lifestyle, travel immunizations, preventive and other conditions.14

How can pharmacists integrate minor ailment assessment and prescribing into their practice?

Successful integration of PPMA into a pharmacy practice depends on various factors such as pharmacist training, comfort level with assessment and prescribing for minor ailments, staffing, workload, remuneration, employer and/or managerial support, adequate workplace resources and access to clinical information.15 In addition to understanding the facilitators and barriers to implementing PPMA programs in your practice setting, the following three practical tips may be helpful for successful PPMA integration:15

1. Identify educational needs: Take your provincial college board-approved mandatory orientation module. This will assist with understanding, interpreting and applying PPMA implementation details and protocols in your practice, and help reinforce important practice expectations to support quality patient care.13 It is important for pharmacists to self-assess their need for additional continuing education over time to ensure they have the current knowledge, skills and judgement necessary, so that their care is in accordance with existing clinical practice guidelines.13

2. Optimize workflow: Employ a team approach in the promotion and delivery of the service by conducting a pharmacy team training and orientation session and delegating various tasks (so everyone has a specific and clear role in the process). Hire/ enable pharmacy technicians in your pharmacy to practise to their full scope, to free up time for pharmacists to engage in more clinical tasks. It may be advisable to schedule appointments for patients wishing to access prescribing services when overlap in staffing is available. Manage patient expectations and build in buffers throughout the workday (e.g., extend your prescription wait times if possible) to allow for opportunities to conduct minor ailment assessments if they present.

3. Leverage technology: Adopt scheduling, assessment and/or documentation tools—especially if adapted to the regulations of your province. This can make the entire process more efficient and effective. For example, the Ontario Pharmacists Association has partnered with MAPflow, a cloud-based, clinical decision-making and implementation support tool designed specifically for the Ontario pharmacy practice environment.16 It features a series of conditional logic questions to guide assessment and facilitate development of customized, evidence-based care plans for patients by providing first- and second-line in-scope therapeutic options. Documentation is automatically generated and ensures compliance with Ontario’s regulatory framework. Other platforms featuring dynamic and static questionnaires are also available nationally. (Disclosure: the author is the CEO and co-founder of MAPflow.)

How can you minimize friction and turf wars with other prescribers?

Successful integration of a formal minor ailment assessment and prescribing service into a given practice setting will require the development of interprofessional collaboration strategies with the relevant healthcare providers involved. Pharmacists are strongly encouraged to take a cautious approach to PPMA services by communicating with other clinicians regarding the PPMA program specifics, detailing the conditions included in the regulations (if applicable), reassuring the prescriber(s) of the timely notification of care plan they can expect to ensure continuity of care, and emphasizing that the patient’s best interest is always upheld and at the core of what we do.5 Educational sessions by pharmacists for physicians, nurse practitioners and other prescribers regarding PPMA specifics may be important, to ensure prescribers have adequate knowledge regarding pharmacist scope and training for PPMA service delivery. Interprofessional collaboration, shared decision making and ongoing discussions with patients and prescribers regarding PPMA treatment plans for a given patient may also help avoid friction and turf wars and solidify mutual trust.

Summary

The expanded role of pharmacists over the years has been beneficial in several services related to immunization, smoking cessation and diabetes. PPMA programs offer an opportunity for pharmacists to provide yet another valuable service to patients. Let’s take this collective opportunity to be proactive in the rebranding of our profession’s public image as care providers, and solidify our role as accessible and knowledgeable medication therapy experts.

Dr. Nardine Nakhla is a practising community pharmacist and a faculty member at the University of Waterloo School of Pharmacy. The author thanks Ali Syed, HBSc, PharmD, MSc, PhD candidate at the University of Waterloo School of Pharmacy for his coauthorship of this article.

References

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2. Ambizas EM, Bastianelli KM, Ferreri SP, et al; Nonprescriptions Medicine Academy Steering Committee. Evolution of self-care education. Am J Pharm Educ 2014;78(2):28.

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4. Taylor JG, Mansell K. Patient feedback on pharmacist prescribing for minor ailments in a Canadian province. Innovations in Pharmacy 2017 Feb 15;8(1). https://pubs.lib.umn.edu/index. php/innovations/article/view/497/491 (accessed November 30, 2022).

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6. Ontario Regulation 460/22. Government of Ontario. Updated May 3, 2022. https://www.ontario.ca/laws/ regulation/r22460 (accessed December 14, 2022).

7. Government of British Columbia. Expanded pharmacy services. Updated May 3, 2022. https:// www2.gov.bc.ca/gov/content/health/accessinghealth-care/pharmacy-services (accessed December 14, 2022).

8. Brady T. Update on Ontario’s minor ailment funding, December 16, 2022. https://www.canadianhealthcarenetwork. ca/update-ontarios-minor-ailmentfunding?oly_enc_id=5346G4950923I6Y&utm_ source=omeda&utm_medium=email&utm_ campaign=NL_CHN_Pharmacist_REG (accessed December 20, 2022).

9. Ontario Pharmacists Association. A decade in the making: minor ailments prescribing in Ontario. Updated June 7, 2022. https://opatoday.com/adecade-in-the-making-minor-ailments-prescribing-inontario/ (accessed November 30, 2022).

10. Famiyeh IM, McCarthy L. Pharmacist prescribing: a scoping review about the views and experiences of patients and the public. Res Soc Admin Pharm 2017;13(1):1-6.

11. Beahm NP, Smyth DJ, Tsuyuki RT. Outcomes of urinary tract infection management by pharmacists (RxOUTMAP): a study of pharmacist prescribing and care in patients with uncomplicated urinary tract infections in the community. Can Pharm J 2018;151:305-14. doi: 10.1177/1715163518781175.

12. McIntosh T, Munro K, McLay J, et al. A cross sectional survey of the views of newly registered pharmacists in Great Britain on their potential prescribing role: a cautious approach. Br J Clin Pharmacol 2012;73(4):656-60.

13. Nakhla N, Shiamptanis A. Pharmacist prescribing for minor ailments service development: the experience in Ontario. Pharmacy (Basel) 2021;9(2):96. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC8167622/pdf/pharmacy-09-00096.pdf (accessed November 30, 2022).

14. Canadian Pharmacists Association. Common ailment prescribing in Canada. Updated 2022. https:// www.pharmacists.ca/cpha-ca/function/utilities/pdfserver.cfm?thefile=/Common_Ailments_English_PDF. pdf (accessed November 30, 2022).

15. Jebara T, Cunningham S, MacLure K, et al. Stakeholders’ views and experiences of pharmacist prescribing: a systematic review. Br J Clin Pharmacol 2018;84(9):1883-905.

16. Ontario Pharmacists Association. Ontario Pharmacists Association launches new digital health tool to support minor ailments program. https://www. newswire.ca/news-releases/ontario-pharmacistsassociation-launches-new-digital-health-tool-tosupport-minor-ailments-program-838049492.html (accessed December 20, 2022).