Clinical Governance

Clinical Governance

Due to the COVID-19 pandemic, some of these requirements below have been put on hold.

Clinical governance deadlines and certain other requirements in the CPCF have been postponed or pushed back to later in the year due the focus on patient care and public protection around the COVID-19 outbreak. NHSE&I has stated:

Other contractual requirements We understand that coming up to the end of the financial year contractors may be busy completing contractual requirements. We will not take contractual action against contractors who have not, by 31 March 2020, yet competed requirements associated with their community pharmacy patient questionnaire, updating their practice leaflet, completing their pharmacy clinical audit or competing the Data NHS England and NHS Improvement Security and Protection Toolkit self-assessment (information governance requirements still apply).The following from NHS Digital is helpful:

Any health campaign activity should now be focused entirely on providing official messaging to the public regarding COVID-19. We will not require data returns at the current time, eg regarding NMS and MURs or complaints, and will delay, where possible, provider assurance activity and routine contract monitoring visits.

Our regional teams will be asked to review the current need for Local Enhanced Services that are not considered to support the national COVID-19 response, local audit and local assurance activities and local data collections.

These decisions will be kept under review. Other areas are also being considered and we will include updates in future letters.

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.

Guidance for pharmacy contractors

The PSNC/NHS Employers guidance summarises the CPCF clinical governance requirements:

PSNC and NHS Employers guidance for pharmacy contractors on clinical governance (all references to PCTs in this document should now be interpreted at relating to the local NHS England team)

The clinical governance approved particulars define specific requirements which are set out in the Terms of Service. These approved particulars will be updated to reflect the changes agreed to the community pharmacy contractual framework in September 2014.

Clinical Governance Service Specification (note – this service specification was published in 2004 and has not been subsequently updated. The PSNC/NHS Employers guidance provides an up to date source of information on the CPCF’s clinical governance requirements)

Changes agreed to the community pharmacy contractual framework in September 2014 included amendment of the clinical audit and patient safety incident reporting requirements. Further information on the amended requirements can be found in PSNC Briefing 015/14: Changes to Contractual Requirements 2014/15.

Related resources


Business continuity & emergency planning

CPPQ (patient satisfaction survey)

Complaints procedures

Practice leaflet requirements

Patient safety incident reporting

Raising concerns (Whistle-blowing)

Chaperone policy

PSNC briefing on Chaperone Policies – this guidance document summarises the Chaperone Guidance issued by the National Clinical Governance Support Team. It is not mandatory to have in place a chaperone policy, but pharmacy contractors may wish to consider the adoption of a policy in order to protect patients and staff.

Clinical governance lead

Outline job description for a clinical governance lead (Microsoft Word) – each pharmacy is required to have a clinical governance lead, to act as the main contact on clinical governance matters between the pharmacy and the local NHS England team.


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