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A GP's view on the DMIRS: Will patients actually pay for OTC items?

"I look forward to the DMIRS hopefully making its way down to my area"

Pharmacies should receive referrals from GP surgeries, but patients may be reluctant to pay for over-the-counter (OTC) items, says GP Toni Hazell

“I’d like an appointment. I’ve had a sore throat since yesterday.”

My GP practice uses full telephone triage – if you want to see a GP, you have to speak to one first. Part of the reason why many GPs are triaging appointments is that, despite public information campaigns, the message that some conditions are best taken to a pharmacist just doesn’t seem to be getting through. I am constantly amazed by the number of young, otherwise healthy people who ring me after a few days of experiencing low back pain, a dry cough or a sore throat, having tried no OTC medicine.

It has been postulated that the demise of the multi-generational nuclear family has increased the need for patients to seek healthcare advice, when in the past they might have just asked Grandma or Mum. Whatever the reason, it isn’t sustainable to routinely use scarce GP time for minor illnesses. However, not all patients will be able to make a judgement as to whether their illness is minor. This is an area where pharmacists can have a key role.

A pilot project which ran from 2017 to 2019 involved NHS 111 directing patients with ‘low acuity conditions’ to a pharmacy consultation. These include things like sore eyes, mouth ulcers, vomiting, emergency contraception and ear wax. Following the success of this project, NHS England is piloting a new version of this Digital Minor Illness Referral Service (DMIRS), under which GPs will refer patients with these low acuity conditions to pharmacies.

The pilot will initially cover seven areas in England, but could be rolled out nationwide. The commissioner estimates that 6% of GP consultations (20.4 million a year) could be transferred to community pharmacists, which if correct, would help to take some of the strain off primary care.

In principle, this seems a sensible scheme. Patients will be directed to the correct healthcare professional, and if they have a good outcome then maybe in the future they will go straight to the pharmacy. There is the safety net of a pharmacist assessment; no triage system is 100% sensitive and specific.

Any patients whose condition turns out to be somewhat ‘higher acuity’ than first suspected can be directed back to their GP or A&E, if their symptoms have progressed or weren’t accurately described. If the pharmacist recommends medication, it can be bought over the counter or given via a minor ailments scheme.

This is my only reservation – many patients are reluctant to buy OTC products if they don’t pay for their prescriptions. A realisation that triage to a pharmacist may hit you in the pocket could lead to patients being reluctant to take part in the scheme. However, many GPs, myself included, already take a firm line on prescribing things like paracetamol. The latest NHS England guidance aimed at reducing prescribing of medicines that are available over the counter should further reduce such prescriptions from general practice, and therefore level the playing field in this regard.

The DMIRS is a welcome addition to the plethora of ways in which we can help direct patients to the most appropriate healthcare professional, and I look forward to it hopefully making its way down to my area.

Toni Hazell is a GP based in a practice in London


Leon The Apothecary, Student

Toni, would it be fair to say you feel pressured by patients to supply OTC items on a prescription, rather than referral? Would you agree if both GP Surgery and Pharmacy gave a very clear identicial message we could start tackling this cultural norm?

Toni Hazell, GP

Yes, often and the concern is that NHSE won't necessarily back me up in the event of a complaint. I once had a 4-page complaint with lots of bold/underlining (the modern equivalent of green ink) because I had dared to suggest that parents of small children should always have liquid paracetamol in the house................


Rajeshvari Patel, Community pharmacist

Please let us have the results of this pilot. After having had some referrals, I would be very interested in finding out how useful this service  is and also how many consultations have not  been reimbursed as patient did not turn up inspite of being chased by the pharmacist. Please put the responsibility on to the patient to contact the  pharmacy if they want advice and treatment. Valuable day time minutes are spent in calling  and chasing the patient who then doesn’t turn up. 

ABC DEF, Primary care pharmacist

TL, DR. A simple big fat "no" is the best and only answer to the question. End of. People in this country are simply getting next level spoon-fed and spoilt to an extent that they think everything grows on trees and comes with no cost. 


Leon The Apothecary, Student

I agree with you here. Although I fear saying no is more difficult than it seems. The fear of having complaints put against you for "denying medicine" can be pretty scary for a professional.

Kevin Western, Community pharmacist

I think the scheme is a reasonable attempt to replace the various minor ailments schemes there were scattered around and will at last be a national approach. How well it works will depend on how well we use the opportunity, and how rigorously GPs stick to its principles. 

If the only option is a purchase then they will either do so or wait until the symptoms subside. We will have the benefit of a fee either way as I read it, better than simply giving free otc advice then them going to the GP for a script which may then go anywhere and is not going to generate a lot of income.

Where it falls down is what happens when patients revert to coming to us directly? we then lose the consultation fee. 

if its worth the NHS money to take these people out of GP surgeries, surely its still worth money when they come to us from the start and we shorten the loop, or should we start referring everybody to the GPs :-)

Richard MacLeavy, Non Pharmacist Branch Manager

I agree, its the buying over the counter that will stop the success of scheme. In my view it re-raises the debate over free prescriptions. If they got rid of all the exemptions and reduced the price of prescriptions to £1 an item then patients would be more willing to partake in DMIRS. The difference between paying for something or getting it free is greater that paying slighty more. It would also stop all those on free prescriptions over ordering and the associated waste, simplify the administration which itself would save alot of money and if you allowed pharmacies to keep the £1 it would make reimbursement simpler and solve the under funding of pharmacies.

Alexandra Robbins, Community pharmacist

I’ve often thought the same myself. The majority of people place no value on items they receive for free.

Richard Binns, Primary care pharmacist

I think the plastic bag charge is a good example, not a huge fee but suddenly makes people think twice about wastage 

Leon The Apothecary, Student

90%-95% I believe was the reduction in single use plastic carrier bags. Highly successful just on those figures alone!

SP Ph, Community pharmacist

"""This is my only reservation – many patients are reluctant to buy OTC products if they don’t pay for their prescriptions. """

Not just you but I'm sure all of the community Pharmacists will say this is the main reason why people would not be willing to participate in this scheme.

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