Quality Criteria

Contractors passing the gateway criteria will receive a payment if they meet one or more of the quality criteria bundles/standalone criteria listed in the tables below. Some of the quality criteria are bound together in composite bundles; contractors will need to achieve all activities within a bundle to receive payment for the bundle. Each bundle/standalone criteria is designated a number of points (the number of points has not yet been finalised, PSNC will alert contractors when this information is available).

Risk management and safety composite bundle

1. 80% of all pharmacy professionals to have completed the CPPE Risk Management training and assessment.
2. 80% of all pharmacy professionals to complete CPPE sepsis online training and assessment. Apply learning to respond in a safe and appropriate way when it is suspected that someone has sepsis. Disseminate alert symptoms to staff, to ensure referral to pharmacist.

The pharmacy has available, at premises level, an update of the previous risk review that the pharmacy team at the premises had drawn up for a risk in that pharmacy. This update must include a recorded reflection on the identified risk and the risk minimisation actions that the pharmacy team has been taking and any subsequent changes identified as a result of the reflection. The risk review should include the risk of missing sepsis identification as a new risk as part of the review, record demonstrable risk minimisation actions that have been undertaken to mitigate the risk.

Note: Pharmacies that did not claim for the risk management quality criterion previously and wish to claim at the next review point must have two identified risks, including the risk of missing sepsis as above, as part of completion and claiming for this whole composite bundle.

4. 80% of all pharmacy professionals to complete CPPE Reducing look-alike, sound a-like errors (LASA) e-learning and assessment.
5. A new written safety report (and subsequent actions completed in line with current criterion) at premises level available for inspection at review point, covering analysis of incidents and incident patterns (taken from an ongoing log), incorporating learnings from CPPE LASA e-learning. This should include a review of and subsequent actions where mitigation taken has failed to prevent a LASA incident from occurring, evidence of sharing learning locally and nationally, and actions taken in response to national patient safety alerts. Demonstrable evidence of actions identified in the patient safety report have been implemented.

Medicines safety audits complementing QOF QI  bundle


Lithium audit aligned with requirements of the NPSA alert on Lithium.

All patients prescribed lithium:

  1. To be asked if they have had their lithium levels checked in the last 3 months and other relevant blood tests at appropriate intervals, e.g. for kidney (renal) and thyroid function every 6 months, whether this was/wasn’t the case recorded on the PMR, or appropriate form/patient record, and referred as appropriate.
  2. Asked whether they understand signs of lithium toxicity, e.g. upset stomach and go through these with the patient if they do not know what they are:
    • Record if they did/didn’t know signs of lithium toxicity.
  3. Asked whether they know what to do if they miss one or more doses:
    • Record if they did/didn’t know the appropriate action when they missed dose(s) and whether this advice was provided.
  4. Asked if they understand how to prevent toxicity, e.g. adequate fluid intake especially if exercising heavily:
    • Record whether they did/didn’t know how to prevent toxicity and whether this advice was provided.
  5. Provided with general healthy living advice.
  6. Monitored for interactions (OTC and prescription medicines) with lithium:
    • Record whether patient was taking or had taken medicines OTC which interact with lithium with/without the advice of a pharmacist or doctor.R
    • Record whether patient was given advice not to take OTC medicines, including herbal remedies or supplements, without speaking to a doctor or a pharmacist.

If the pharmacy has no patients prescribed lithium, complete a safety audit of patients prescribed phenobarbital, methotrexate or amiodarone as alternatives, in line with the QOF QI.

7.  Valproate safety audit: An audit of the provision of advice on pregnancy prevention for girls and women of childbearing potential taking valproate:

  • Ensure that all girls and women of childbearing potential who have presented a prescription for valproate, during a specified 3-month period, have been advised on the risks of taking valproate in line with all the requirements as detailed in MHRA Drug Safety Update 2018, including the potential impact on an unborn child, have been provided with a Patient Guide and have seen their GP or specialist to discuss their treatment and the need for contraception. This intervention should be recorded on the PMR, or appropriate form/patient record.
  • Report the number of patients dispensed a prescription for valproate who are old enough to become pregnant and been provided advice and information in line with the MHRA Drug Safety Update 2018
8.  NSAID audit:

  • Contractors should implement, into their day-to-day practice, the findings and recommendations from the previous clinical audit on NSAIDs prescribed for those 65 years and above without gastroprotection, undertaken as part of the Quality Payments Scheme for the February 2019 review point. The findings and recommendations from the audit will be published in a report by NHS Specialist Pharmacy Service (when this will be published is still to be confirmed. The pharmacy must then repeat the audit of NSAIDs and gastro-protection for all patients 65 years and over, including notifying the patient’s GP where professional concerns are identified, sharing their anonymised data with NHS England, and incorporating any learning from the re-audit into future practice.

Note: Pharmacies that did not claim for the NSAID audit quality criterion previously and wish to claim at the next review point as part of completion and claiming for this whole composite bundle must complete the audit for the first time and complete the other elements as described above.

Submission of information to NHS England should be reported on the MYS application as part of all above audits.

Prevention composite bundle

9. The pharmacy is a Healthy Living Pharmacy level 1 (self-assessment).
10.  All patient-facing staff are Dementia Friends.
11. The pharmacy has completed a specified dementia-friendly environment checklist and created an action plan which includes making some demonstrable recorded changes to the environment in line with the checklist, as appropriate.
12. Check all patients with diabetes who present from 1 October 2019 to 31 Jan 2020 have had annual foot and eye checks (retinopathy) – please note, eye checks are only for patients with diabetes aged 12 or over. Make a record on the PMR or appropriate form/patient record and signpost/refer as appropriate. The total number of patients who have had this intervention, the number that have not had one or either check in the last 12 months and where they have been appropriately signposted/referred should be recorded and reported as part of this criterion.
13. The sales by the pharmacy of Sugar Sweetened Beverages (SSB) account for no more than 10% by volume in litres of all beverages sold. The pharmacy must have either achieved this by the review point or declare that they will be meeting this by 31 March 2020.

Primary Care Networks bundle

14.  Demonstrate that pharmacies in a PCN area have agreed a collaborative approach to engaging with their PCN, including agreement on a single channel of communication, e.g. by appointing a lead representative for all community pharmacies in the PCN footprint to engage in discussions with the PCN.

Asthma bundle

15. The pharmacy can show evidence that asthma patients, for whom more than 6 short-acting bronchodilator inhalers were dispensed without any corticosteroid inhaler within a 6 month period, have since the last review point been referred to an appropriate health care professional for an asthma review; and can evidence that they have ensured that all children aged 5-15 prescribed an inhaled corticosteroid for asthma have a spacer device where appropriate in line with NICE TA38 and have a personalised asthma action plan. Refer to an appropriate healthcare professional where this is not the case.

Digital enablers bundle

16. NHS 111 DoS profile – Update the pharmacy’s NHS 111 DoS profile via DoS updater, including opening hours for Bank Holidays, and promptly update as information changes, to ensure information is accurate for the public.
17. Demonstrable access to SCR.