Clinical Governance

Clinical Governance

Schedule 4 of the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 set out the ‘Terms of Service of NHS pharmacists in four parts.  Part 2 are the Essential services, Part 3 are the Hours of opening provisions, and Part 4 set out the other terms of service, which includes Clinical Governance.  Adherence with the clinical governance requirements is thus a part of the terms of service.

The clinical governance requirements of the community pharmacy contractual framework (CPCF) cover a range of quality related issues detailed below, help and support for which can be found on the PSNC website: click here

  • Guidance for pharmacy contractors
  • Audit
  • Chaperone policy
  • Clinical governance lead
  • Complaints procedures
  • Confidentiality
  • CPPQ (patient satisfaction survey)
  • Patient safety incident reporting
  • Practice leaflets
  • Raising concerns (Whistle-blowing)

Clinical Governance  – Actions required by 31 March 2019

Replacement for IG toolkit

The Data Security and Protection (DSP) Toolkit for 2018/19 is now available for completion; this replaces the Information Governance (IG) toolkit that contractors have completed in previous years. The deadline for submitting this year’s IG return is 31st March 2019.

A key feature negotiated by PSNC is that where a contractor declares that they have completed our GDPR Workbook for Community Pharmacy, the number of questions they will be asked to respond to in the Toolkit will be significantly reduced. Further information about the new toolkit is available at:

Topic Requirements By when?
Data Security and Protection (formerly IG) Toolkit

To complete and submit an annual Data Security and Protection Toolkit.*

*Note that PSNC has published new guidance to support submission of the new Toolkit.

31 March each year
Community Pharmacy Patient Questionnaire (CPPQ) To conduct an annual CPPQ and publish the results. 31 March each year
Clinical audit

To conduct two audits each year: one on a topic of your choice* and one nationally determined by NHS England.

*Please note, the non-steroidal anti-inflammatory drug (NSAID) audit for the Quality Payments Scheme cannot be used as the pharmacy own audit.

Pharmacy own audit deadline: 31 March each year

National audit deadline: Midnight on 30 December 2018

A fourth clinical governance requirement, whilst not due by 31 March, should be completed shortly afterwards and as such it is best to begin work towards achieving this alongside the requirements listed above.

Complaints report To prepare an annual report each year and send a copy to the local NHS England team. As soon as practicable after 31 March each year

To help support contractors in meeting the above requirements, PSNC’s Regulations and Support Team has also produced a quick reference guide identifying the actions to be completed by 31 March 2019, as well as details of ongoing clinical governance requirements.

PSNC Briefing 004/19: Upcoming clinical governance deadlines – actions to be completed by 31 March 2019

The LPC have put together the following Checklist, which pharmacies can print out and check off as appropriate:

Pharmacy Annual Requirements Checklist – pdf




PSNC Support

PSNC has developed a series of guidance documents to assist community pharmacy contractors as they work towards their information governance (IG) declaration for 2018/19. Previously known as the IG Toolkit, this year contractors must complete the new ‘Data Security and Protection Toolkit’ no later than 31st March 2019.

Please read the full PSNC article for more information, Guidance Documents and Next Steps by clicking the link below:

Embed IG update Jan 2019:

Dentist Optoms and Pharmacy Communications – Issue 18