Clinical Governance

Due to the COVID-19 pandemic, some of the arrangements below have been put on hold. Please click here for more information.

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
  • Business continuity & emergency planning
  • Chaperone policy
  • Clinical governance lead
  • Complaints procedures
  • Confidentiality
  • CPPQ (patient satisfaction survey)
  • Patient safety incident reporting
  • Practice leaflets
  • Patient safety incident reporting
  • Raising concerns (Whistle-blowing)

Clinical Governance  – Actions required

COVID-19 Update: Some of the Clinical Governance deadlines have been amended:

PSNC Briefing 045/2020: Regulatory and contractual dispensations agreed to assist contractors with the ongoing COVID-19 pandemic

Topic Requirements By when?
Data Security and Protection Toolkit

To use the Data Security and Protection Toolkit to complete and submit an annual information governance (IG) return.

See PSNC Toolkit webpage for more information and guidance.

No action will be taken against contractors who have not completed the Data Security and Protection toolkit for 2019/20, provided they are working to complete the toolkit for 2020/21. Contractors have an extended deadline for completion of the 2020/21 toolkit, with submissions required by 30th June 2021. View new PSNC guidance
Community Pharmacy Patient Questionnaire (CPPQ)

To conduct an annual CPPQ and publish the results.

See PSNC CPPQ webpage for more information and guidance.

For 2020/21, it has been agreed that contractors are not required to undertake the CPPQ.
Clinical audit

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

*Please note, any audits undertaken as part of the Pharmacy Quality Scheme cannot be used as the pharmacy’s own audit.

See PSNC clinical audit webpage for more information and guidance.

For 2020/21, it has been agreed that contractors are not required to complete an NHSE&I determined national clinical audit, also contractors are not required to undertake a contractor chosen clinical audit





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. COIVD-19 update: NHSE&I has announced a system wide “pause” of the NHS complaints process


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

Pharmacy Annual Requirements Checklist – pdf




Visit PSNC Clinical Governance page: Click Here