Who to refer and red flags

The Pharmacy First PGDs give specific inclusion and exclusion criteria. The following is intended to give some pragmatic guidance on how these might be followed but is not intended to be all-inclusive or definitive.

Most of the people who attend a pharmacy with sore throat will be unwell and have pain but are not severely ill. A few patients may attend who have symptoms suggesting more severe illness or who are at risk of severe illness.

The most important requirement is to recognise severely ill patients and ensure they get urgent care. Many of the PGDs list rare or unusual causes of severe sore throat, such as Lemierre’s syndrome, Kawasaki disease or Yersinial pharyngitis. Pharmacists are not expected to diagnose these conditions, which usually require hospital investigation to establish the cause.

Also, some patients may seek assessment by the pharmacist but do not meet the criteria for the PGD under which the pharmacist is operating. These patients will need referral to the GP practice (or for urgent care, if required).

The NHS A-Z lists the following symptoms as red flags for sore throat with the necessary action being to call 999 or go straight to A&E.

Patient (including children):

• Having difficulty breathing or are unable to swallow
• Drooling – which may be a sign of not being able to swallow
• Making a high-pitched sound during breathing (called stridor)
• Having severe symptoms that are getting worse quickly.

The other diagnosis to consider is sepsis. See Table 2 on the next page for NHS A-Z advice on recognising the red flags for sepsis. The advice is to call 999 or go straight to A&E.

Patients who appear dehydrated may also need urgent referral. If quinsy or other throat/neck abscess is suspected, these should be referred to A&E urgently as well.