Pharmacy First: Acute Sore Throat

About this service

The NHS Pharmacy First service allows community pharmacists to assess, advise, and supply prescription-only medicines, including antibiotics where clinically appropriate, for seven clinical pathways 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. Under the Pharmacy First Patient Group Direction (PGD), antibiotic supply is only permitted for patients with a FeverPAIN score of 4 or 5 with severe symptoms who meet all PGD inclusion criteria. The vast majority of sore throats are viral and self-limiting.

All consultations must be recorded on PharmOutcomes (or the equivalent NHS-approved clinical platform) and claimed within the service. Following the consultation, the pharmacy must send notification to the patient's GP on the same day or the following working day, using the approved Pharmacy First IT system. Patients presenting outside the inclusion criteria must be referred or signposted according to clinical urgency -- to 999, A&E, urgent GP, same-day GP, or NHS 111 as appropriate.

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 (attend rapidly: symptom onset within 3 days scores a FeverPAIN point), 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. Also ask about rash (possible scarlet fever) and difficulty opening the mouth or severe unilateral swelling (possible quinsy).
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 (Pharmacy First PGD) Apply the Pharmacy First PGD -- not NICE NG84. A delayed (backup) antibiotic is not a permitted option under this service.
   • Score 0-1: do not offer an antibiotic. Provide self-care advice and safety-netting. Advise return to pharmacy after 1 week if no improvement.
   • Score 2-3: do not offer an antibiotic. Provide self-care advice and safety-netting. Advise return to pharmacy within 3 to 5 days if no improvement.
   • Score 4-5 with mild symptoms: do not offer an antibiotic. Provide self-care and safety-netting. Advise return within 3 to 5 days if no improvement.
   • Score 4-5 with severe symptoms: assess against all Pharmacy First PGD inclusion criteria. Supply antibiotic only if all criteria are met.
5. Counsel and safety net Advise on self-care (paracetamol or ibuprofen for pain and fever, fluids, rest, throat lozenges). Offer the TARGET RTI leaflet to all patients not receiving antibiotics. If supplying an antibiotic, explain: complete the full course even if feeling better, common side effects include nausea and diarrhoea, seek advice if no improvement after completing the course. Safety netting for all patients: return to community pharmacy or seek medical advice if symptoms worsen rapidly or significantly at any time, breathing becomes difficult, a widespread rash develops, there is difficulty opening the mouth fully, or unilateral neck swelling appears.
6. Record, notify, and submit the claim Complete the consultation record on PharmOutcomes before the patient leaves. Include all five FeverPAIN component scores and symptom severity for scores of 4 or 5. Following the consultation, the pharmacy must send notification to the patient's GP on the same day or the following working day, using the approved Pharmacy First IT system. 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 (Pharmacy First PGD)

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.

Pharmacy First Supply Decision by FeverPAIN Score

The Pharmacy First PGD is stricter than NICE NG84. Unlike primary care prescribing, a delayed (backup) antibiotic is not a permitted option under the Pharmacy First sore throat PGD. For score 4-5 with severe symptoms, all PGD criteria must be met before supply.

Antibiotic Choices (FeverPAIN 4-5 severe, PGD criteria met)

Phenoxymethylpenicillin is preferred over amoxicillin for streptococcal sore throat. Always confirm penicillin allergy status before supplying. Paediatric doses are specified in the Pharmacy First PGD and should be used in preference to weight-based BNF for Children dosing for this service.

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
  • Symptom severity assessment (mild or severe) for scores 4-5
  • Supply decision and rationale (self-care / immediate supply / referral)
  • Antibiotic supplied: name, strength, dose, quantity, batch number, and expiry date
  • Penicillin allergy status confirmed
  • Self-care advice and TARGET RTI leaflet offered
  • Safety-netting advice provided
  • Referral made (if applicable) and to which service
• Following the consultation, the pharmacy must send notification to the patient's GP on the same day or the following working day, using the approved Pharmacy First IT system.
• Submit the claim on PharmOutcomes within the service window. Failure to record before the patient leaves risks an incomplete or rejected claim.

Key takeaways

• Under the Pharmacy First PGD, a delayed (backup) antibiotic is not permitted. For FeverPAIN 0-3 and 4-5 with mild symptoms, the action is self-care and safety-netting only. Antibiotic supply is only appropriate for FeverPAIN 4-5 with severe symptoms when all PGD criteria are met.
• 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, trismus, or a muffled voice suggests quinsy: refer to hospital urgently and do not supply an antibiotic. A sore throat with a sandpaper rash suggests scarlet fever: refer to GP same day.

Download the checklist