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.

Clinical governance deadlines fast approaching

PSNC has produced a quick reference guide identifying the actions to be completed by 31 March 2017, as well as details of ongoing clinical governance requirements: PSNC Briefing 012/17: Upcoming clinical governance deadlines – actions to be completed by 31 March 2017.

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


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.

Complaints procedures


CPPQ (patient satisfaction survey)

Patient safety incident reporting

Practice leaflets

Raising concerns (whistle blowing)

  • PSNC guidance on raising concerns
  • Public Concern at Work raising concerns guidance – for those pharmacy contractors who have not yet implemented a policy, there is a policy template available on page 15 of this guidance which has been developed for the NHS.
  • The Royal Pharmaceutical Society has prepared clinical governance guidance.  Whistleblowing is included in its document ‘Reducing workplace pressure through professional empowerment’.  The Society has also produced, for its members, guidance on raising concerns and speaking up safely in pharmacy.
  • The GPhC has created a guidance leaflet which sets out the responsibilities of pharmacy professionals to take action if they believe patients and the public are at risk.
  • Whistleblowing: Public interest disclosure – “prescribed persons”. Please note that with effect from 01 February 2016, the list of prescribed persons is updated with the notable addition, as prescribed persons including Health Education England and the National Health Service Commissioning Board i.e. NHS England.  
  • A “prescribed person” is an organisation or individual that a worker may approach outside their workplace to report suspected or known wrongdoing. It provides the right for a worker to take a case to an employment tribunal if they have been victimised at work or they have lost their job because they have ‘blown the whistle”. Prescribed persons are identified in law, an up-to-date list can be found here and the Department for Business Innovation & Skills has published Guidance.
  • On 01 April 2016, NHS England published Freedom to speak up: raising concerns policy for the NHS – a national integrated whistleblowing policy that is hoped will standardise the way NHS organisations support staff who raise concerns.
  • Whistleblowing / raising concerns about risk, malpractice or wrongdoing which is believed to be compromising patient care, working conditions or calling into question the induction or training for staff is nothing new. Anyone who works (or has worked) in the NHS, or for an independent organisation that provides NHS services can raise concerns. This includes agency workers, temporary workers, students, volunteers and governors. It is expected that this policy (produced by NHS Improvement and NHS England) will be adopted by all NHS organisations in England as a minimum standard to help to normalise the raising of concerns for the benefit of all patients. 
  • Pharmacy contractors are not NHS organisations, but provide NHS services. Under the terms of service, pharmacy contractors must ensure that there are arrangements (which must include a written policy) for ensuring that all staff and locums who, arising out of their employment with them are able to make what is a protected disclosure i.e. whistle blow / raise concerns. Pharmacy contractors should already have in place a whistleblowing policy but it is appropriate to review to reflect the updated NHS England guidance.

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