Pharmacy First: Acute Sore Throat

About this service

The NHS Pharmacy First service allows community pharmacists to assess, advise, and supply prescription-only antibiotics for seven common conditions without a general practitioner (GP) appointment. The acute sore throat pathway (pharyngitis and tonsillitis) applies to patients aged 5 and over with a sore throat lasting up to 7 days.

Pharmacists use the FeverPAIN clinical scoring tool to estimate the likelihood of a bacterial (group A streptococcal) infection and decide whether to supply antibiotics immediately, consider a backup (delayed) supply, or recommend self-care only. The vast majority of sore throats are viral and will resolve without antibiotics.

All consultations must be recorded on PharmOutcomes (or the equivalent NHS-approved clinical platform) and claimed within the service. Supply is governed by the current Pharmacy First Patient Group Direction (PGD). Patients presenting outside the inclusion criteria must be signposted to their GP or NHS 111.

Who to offer the service to

Include

• Aged 5 years and over
• Sore throat present for 7 days or fewer
• Able to swallow fluids and medicines
• NHS eligibility requirements apply
• No red flag features present (see below)

Exclude

• Under 5 years old: outside the Pharmacy First pathway -- refer appropriately (to GP, NHS 111, or urgent care depending on symptom severity)
• Pregnant or breastfeeding: do not automatically exclude. Follow the current sore throat PGD -- erythromycin is available for pregnant individuals aged 16 and over who require treatment and cannot receive penicillin. Apply the PGD criteria and local pathway.
• Severely immunocompromised (for example, on chemotherapy, high-dose oral steroids, or biological agents): refer to GP same day
• Symptoms not improving after 3 days of antibiotics already prescribed: refer to GP
• Recurrent or frequently recurring sore throats requiring further assessment: refer to GP
• Sore throat present for more than 7 days: refer to GP
• Suspected quinsy (peritonsillar abscess): refer urgently to hospital -- see red flags
• Suspected epiglottitis: call 999 immediately -- see red flags

How to deliver the service

1. Confirm eligibility Check age (5 or over), symptom duration (7 days or fewer), ability to swallow, and absence of red flags. For pregnant or breastfeeding individuals, apply the relevant sore throat PGD criteria rather than automatically excluding them.
2. Take a focused history Ask about: onset and duration, fever in the past 24 hours, visible pus on tonsils, severity of throat pain, cold or cough symptoms (these reduce the FeverPAIN score), current medications (especially immunosuppressants), penicillin allergy, and whether the patient is pregnant or breastfeeding.
3. Apply the FeverPAIN score Score each of the five criteria individually and sum to a total. Record each component separately in the clinical record -- recording only the total is insufficient for audit purposes.
4. Make the supply decision Use the FeverPAIN score alongside the full clinical picture. The score guides but does not replace clinical judgement or red flag assessment.
   • Score 0-1: self-care advice only. Explain that antibiotics are unlikely to help.
   • Score 2-3: consider no antibiotic or a delayed (backup) antibiotic according to the Pharmacy First pathway. If a delayed supply is offered, advise the patient to wait 3 days before using it.
   • Score 4-5: assess against the Pharmacy First PGD criteria and supply antibiotics where appropriate.
5. Counsel and safety net Advise on self-care (paracetamol or ibuprofen for pain and fever, fluids, rest, throat lozenges). If supplying an antibiotic, explain: complete the full course even if feeling better, can be taken with or without food, common side effects include nausea and diarrhoea. Safety netting: seek urgent advice if breathing becomes difficult, symptoms worsen rapidly, a rash develops, or there is difficulty opening the mouth fully.
6. Record and submit the claim Complete the consultation record on PharmOutcomes before the patient leaves. Include all five FeverPAIN component scores. Submit the claim within the service. Failure to record before the patient leaves risks an incomplete or rejected claim.

FeverPAIN score: results and next steps

FeverPAIN Scoring Tool

Score one point for each criterion present. Maximum score: 5. Record each component separately in the clinical record.

Cough and coryza reduce the score. Their absence increases the probability of bacterial infection. FeverPAIN supports clinical assessment but does not replace consideration of red flags, exclusion criteria, or the wider clinical picture.

Supply Decision by FeverPAIN Score

Antibiotic Choices

Phenoxymethylpenicillin is preferred over amoxicillin for streptococcal sore throat. Always confirm penicillin allergy status before supplying. Use BNF for Children for all paediatric weight-based doses.

Recording and submission

• Record on PharmOutcomes (or NHS-approved equivalent) before the patient leaves the consultation area.
• Mandatory fields:
  • Patient name, date of birth, and NHS number
  • Presenting complaint and duration of symptoms
  • FeverPAIN score: all five component scores and the total
  • Supply decision and rationale (self-care / delayed supply / immediate supply)
  • Antibiotic supplied: name, strength, dose, quantity, batch number, and expiry date
  • Penicillin allergy status confirmed
  • Self-care advice and safety netting provided
  • Referral made (if applicable) and to which service
• For each consultation, record the individual FeverPAIN component scores, the total, the management decision (self-care / delayed supply / immediate supply), the antibiotic supplied if applicable, and the safety-netting advice given. These are the fields auditors most commonly check.
• Submit the claim on PharmOutcomes within the service window. Failure to record before the patient leaves risks an incomplete or rejected claim.

Key takeaways

• Score FeverPAIN on every consultation and apply it alongside the full clinical picture: 0-1 means self-care only, 2-3 means consider delayed supply or no antibiotic, and 4-5 means assess against PGD criteria and supply where appropriate.
• Always confirm penicillin allergy status before supplying: phenoxymethylpenicillin is first line; the correct clarithromycin adult dose is 500mg twice daily for 5 days.
• A unilateral swollen tonsil with uvular deviation or a muffled voice suggests quinsy: refer to hospital urgently and do not supply an antibiotic.

Download the checklist