LPC Chairman’s Blog
November 2019:My Reflections on Community Pharmacy
Christmas and the New Year have traditionally been times for reflection; thoughts of the past, what’s happening now and whatever the future holds. This year there will never be a better time to reflect on my 41+ years in pharmacy because I will be retiring at the end of December.
Today, pharmacy is a world away from what it used to be, but the ethos is still the same and patients are still at the heart of everything we do. There may be computers, a vast array of potent medicines, electronic prescriptions, and summary care record access, but we are still dispensing medicines to the local community as we have always done. Everyday interactions and conversations with patients are still a key part of the ‘day job’ and help to ensure that the profession is trusted and well thought of.
I no doubt view the way pharmacy used to be through ‘rose tinted spectacles’, but I do think that we had more time. Time to get things done without the frantic rushing and pressure that feels common place today.
There was certainly very little original pack dispensing and everything had to be either counted or made up from scratch using ancient skills that are no longer required. I remember making gallons of Kaolin and Morphine Mixture and then pouring it into 200ml bottles for sale over the counter – you should have seen the mess on the bench!
New therapies and new medicines have transformed people’s lives making it possible for people to live longer and to have a better quality of life for longer. The choice of medicine was very limited compared to what we have available today. In the past labels were handwritten and ‘lick and stick’ was the order of the day. Self-adhesive computer generated labels are one innovation I wouldn’t want to do without…
Year’s ago we didn’t say too much to the patient when we handed over their dispensed medicine. This was just in case we dared to say something that might have been contrary to what the doctor had told them. Fortunately, this unwritten rule has long gone and now all pharmacists proactively and routinely advise patients on how best to take their medicines. One thing that has not changed is the “It’s only tablets!” cry from patients who usually have a single-item prescription, but don’t notice the queue of patients already besieging the dispensary or the people waiting in line behind them.
There has been a lot of innovation and undoubtedly there will be more. Flu vaccination, malaria and travel advice services, and national services such as the new Community Pharmacist Consultation Service (CPCS) are just the current iterations. The new Community Contractual Framework (CPCF) means that once more community pharmacy is ‘at a crossroads’. This has been said many times before, but this time I think it’s actually true. The Government does not value the traditional dispensing process and they believe it could be done more easily (i.e. cheaply) if done at scale in remote locations (e.g. Hub and Spoke dispensing). The new contract is an attempt to change what we do in pharmacy and to give us a more expansive clinical role.
Nowadays the emphasis is more about delivering services which promote population health and wellbeing through improved health outcomes. Another key priority of course is integrating community pharmacy into an increasingly under pressure primary care arena. The LPC has supported the identification of lead Primary Care Network (PCN) pharmacists. It is important that all pharmacists and their staffs get actively involved in their local PCN to shape and develop local services.
What of the future? Well, the pathway for the next five years at least is known – the 5-year CPCF deal has seen to that. There will be annual reviews that will look at capacity, costs, pressures (workload) and delivery. How well pharmacy delivers its contractual obligations will be key to the future success of the sector. Currently, more than 80% of Derbyshire contractors have signed up to the new CPCS service, so we have made a great start. However, how well this service lands will be key to what is offered to us in the future. There may not be many CPCS consultations initially, but if the pilot studies are a success and GP referrals through CPCS become the norm then we will have proved that we can deliver clinical services.
I’ve had 41+ years of ‘life long learning’ and continuing professional development. The new generation of pharmacists will have to innovate and keep up to date just like I did. Who knows what pharmacy will look like in 40 years time? I didn’t have a crystal ball when I started and I couldn’t have imagined where we have got to today. The speed of change is accelerating all of the time with new technologies continuingly being developed, so whoever looks back in 40 years’ time will again be amazed by the developments and changes they have witnessed.
In the meantime, I would like to wish you all the very best wishes for the future!
November 2019: Pharmacy Quality Scheme – Foot and Eye Checks Audit
DIABETES FACTS; The NHS now spends around £10 billion a year – 10% of its entire budget on treating diabetes, there are currently four million people in England with the condition, someone is diagnosed every two minutes, and the numbers have doubled in the last 20 years.
Health checks for people living with diabetes are vital and we are all aware of the consequences of ignoring those early signs of problems. Diabetes UK encourages patients to have regular check-ups to prevent serious complications with feet, eyes, heart and kidneys but only 57% of Type 1 and 41% of Type 2 patients get even eight of the 15 basic health checks every year1 outlined below on an annual basis.
Full list of checks and support services:
- Blood glucose test (HbA1c test)
- Blood pressure check
- Cholesterol check (for blood fats)
- Eye screening
- Foot and leg check
- Kidney tests
- Advice on diet
- Emotional and psychological support
- Diabetes education course
- Care from diabetes specialists
- Free flu jab
- Good care if you’re in hospital
- Support with any sexual problems
- Help to stop smoking
- Specialist care if you’re planning to have a baby.
In a bid to address this issue a few changes have been made to the Pharmacy Quality Scheme (PQS), which replaced the Quality Payments Scheme (QPS). In particular, a Diabetic Foot and Eye Audit is now included in the “Prevention Composite Bundle”:
We must now: “Check all patients aged 12 years and over with diabetes who present with a prescription from 1st October 2019 to 31st Jan 2020 have had an annual foot and eye check (retinopathy). 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.”
Having foot and eye checks is clearly important and by participating in the audit you will raise the importance of the checks with your diabetic patients. Those who have not had their checks should be encouraged to get them and appropriate signposting will be an important element of the audit.
Foot complications are particularly common, because of either diabetic neuropathy (nerve damage or degeneration) or peripheral arterial disease (poor blood supply in the legs). In 2014-15 the cost of healthcare for diabetics related to foot ulceration and amputations was estimated at £1 billion in England, with two thirds of this spent on treating foot ulcers in primary, community and outpatient settings. In addition, there are 8,500 leg, toe or foot amputations every year (i.e. >160 per week). Yet it is thought around 1 in 4 Type 1 diabetics and 1 in 6 Type 2 diabetics miss their foot checks2.
Diabetic retinopathy is the leading cause of preventable sight loss in the UK. It is a major problem and around 1,600 people every year are certified as visually impaired or with seriously impaired vision. If blood glucose levels are not well controlled high levels damage the back of the eye and the longer the condition is left undiagnosed or untreated the greater the damage (possibly even causing blindness). Other factors involved are blood pressure and cholesterol levels, which should also be checked as part of the diabetic annual review process. It should be noted that diabetes increases the likelihood of glaucoma by 1.5x and cataracts by 2x – both of these can lead to blindness if not spotted.
The audit requires that you check every diabetic patient who presents a prescription from 1st October 2019 to 31st January 2020. Fortunately, each patient needs to be spoken to only once, but this will require you to have systems in place to facilitate this and record the interventions that have been made. I estimate that the average pharmacy will have about 350 diabetic patients (28 Type 1, 315 Type 2 and 7 other).
For more background information have a look at the VirtualOutcomes’ Diabetes Foot and Eye Audit – PQS webcourse. It only takes 10 minutes and gives a good insight into why it’s important that diabetic patients get checked annually. It also helps you understand what information you need to collect and provides some examples of forms that might be helpful when collating the required information.
Finally, to help you get ready for the audit, check out “PSNC Briefing 043/19: Pharmacy Quality Scheme – Foot and eye screening (retinopathy) checks for patients with diabetes”. It’s a comprehensive guide and includes helpful resources such as small flyers for prescription bags, GP practice briefing points, a template letter for GP practices, a data collection form and a suggested process map for conducting the audit.
N.B. The Foot and Eye Check Audit is one of five elements you will need to complete in order to claim the 25 points associated with the Prevention domain bundle (worth between £1,600 and £3,200).
1 Diabetes UK Tackling the crisis: Transforming diabetes care for a better future”
2 NHS Digital (2018) National Diabetes Audit, 2017-18 Short Report: Report 1: Care Processes and Treatment Targets
October 2019: NHS Community Pharmacist Consultation Service (CPCS)
The NHS Community Pharmacist Consultation Service (CPCS) will launch on 29th October 2019 as an Advanced Service and is a key element of the new Community Pharmacy Contractual Framework (CPCF). The service, which will replace the NUMSAS and DMIRS pilots, will connect patients who have a minor illness or need an urgent supply of a medicine with a community pharmacy
This is the first clinical service to be mobilised under the CPCF and will set the foundation for more services in the future. As you all know – good engagement and professional delivery by as many contractors as possible will be key to its success. N.B. The NUMSAS and DMIRs pilots will end on 28/10/19 and the new service will start the next day with referrals to pharmacies from NHS 111.
The intention is that CPCS frees up capacity in areas of the urgent care system including A&E and GP practices. This will help to integrate community pharmacy into these systems, support self-care and increase the awareness of community pharmacy as a convenient/accessible “first port of call’ for low acuity conditions and also for medicines access and advice.
In order to sign up for CPCS you have to register with the NHS BSA using the Manage Your Service (MYS) portal. Around 85% of Derbyshire contractors are already registered with the MYS, but those not yet signed up to the portal need to act quickly, because it can take 8 working days or so to process your registration.
It will take time to process your CPCS application; so the sooner this is done the better. You will need to complete a declaration confirming that you have read the service specification, will comply with its requirements and deal appropriately with referrals. Multiple pharmacy contractors that would like to register more than one pharmacy to provide the service can email the NHSBSA MYS team (email@example.com) to discuss how to bulk register pharmacies. In addition, there will be an opportunity to claim a transition payment supplement to help you set up for delivering the service – £900 if signed up by 1st December 2019 or £600 if signed up by 15th January 2020.
The service has a nationally agreed specification, which means a consistent approach with no local restrictions or ‘tweaking’. The NUMSAS and DMIRs pilots informed the development of the service, but changes have been made to make the new service easier to deliver. It should be noted that when you sign up to deliver CPCS you are agreeing to deliver both elements of the service (i.e. Urgent Medicine Supply and Minor Illness consultations) throughout your opening hours.
Once you have made your declaration the local Directory of Service (DoS) team will be informed and will activate you on the system. DoS is a web-based database of service providers and integrates with NHS care pathways. NHS 111 Call Handlers are not medically trained, but use an algorithm to identify the timescales for any support and will then make a referral to an appropriate practitioner. No medication details are taken and it’s important that DoS entries are up to date with opening hours including Bank Holidays.
If a CPCS intervention is required, the call handler will offer the two closest pharmacies to the patient. For Urgent Medicines the patient will be asked to call their chosen pharmacy within 30 minutes, whilst for Minor Illness the patient will be asked to attend the pharmacy. If the pharmacy isn’t contacted the pharmacist must make at least one attempt to contact the patient (within 30 minutes for an emergency supply or 12 hours for a minor illness consultation). Therefore, it is important that providers regularly check for referrals, which will come through PharmOutcomes in Derbyshire, but could also be through NHSMail if there are problems with PharmOutcomes (unlikely). N.B. Check both when opening the pharmacy and before closing.
When the patient comes in they should be seen in the consultation room, which must be equipped with IT by 1 April 2020. The IT solution to include PharmOutcomes access and SCR access, so everything is to hand, and forms are completed contemporaneously while the patient is on the premises. It is permissible to conduct telephone interviews, but this is not ideal as being able to see the patient gives a lot more information about how ill they actually are.
No mandatory training is required to deliver the service, because the necessary knowledge and skills are core competencies for pharmacists. However, pharmacists will want to ensure that they:
- Have an up to date understanding of the Human Medicines Regulations (HMR) in relation to the emergency supply of Prescription Only Medicines;
- Are able to communicate with and advise patients appropriately and effectively on low acuity conditions;
- Are able to assess the clinical needs of patients, including the identification of Red Flags (which are detailed in NICE Clinical Knowledge Summaries);
- Are able to act on the referrals received and make appropriate referrals to other NHS services and healthcare professionals;
- And are able to explain the service to patients and carers.
To support pharmacists to deliver this service competently and confidently, CPPE have developed a Gateway page and a Self-Assessment Framework for CPCS. Completing the Self-Assessment Framework identifies any knowledge gaps and pharmacists can address these by completing relevant e-learning and/or attending a face-to-face skills day.
The fee is £14 per completed consultation and all payment claims are made through the MYS portal. Products supplied as part of the Urgent Medicines strand of CPCS will be reimbursed (from the information on PharmOutcomes), but there is no product reimbursement for the Minor Illness strand of CPCS. EPS tokens that record patient declared exemptions need to be created and sent to the NHS BSA as part of the monthly batch of prescriptions but separated and marked “CPCS”. They are only used for patient exemption accuracy checking.
Initially, it is estimated that CPCS contractors will probably only have about four consultations a month. However, there are number of pilots being conducted and this could lead to a considerable expansion of the scheme as new referral opportunities come about. The pilots are looking at referrals from GPs, NHS 111 Online, Urgent Treatment Centres and possibly A&E. If the GP referrals’ pilot is a success then there could be 20 million or more consultations every year. If this happens then community pharmacy will be much better integrated into primary care pathways and the income will help defray that lost by the discontinuation of MURs.
September 2019: Changing Times
Change is afoot. The new Community Pharmacy Contractual Framework (CPCF) will begin on 1 October 2019 and will be the biggest shift in our ways of working since the current contract was introduced on 1 April 2005, 14 years ago.
The initial funding for the 2005 contract was £1.766bn, and you will be keen to discover what’s on offer this time. I can announce that we have a five-year settlement and the funding will be £2.592bn per year until the end of 2023/4.
Curiosity drew me to look up the inflation rate over the last 14 years. The Bank of England gives a figure of 47%, which means our then £1.766bn would be worth around £2.596bn in today’s money. You could argue that we haven’t made much progress. However, this would ignore a context of current financial pressures, ever increasing workloads and the fact that the Government was not so long ago looking to reduce the amount it spent on community pharmacy. Therefore, a five-year deal, even with static funding and a forecast inflation rate of 2% a year, should be viewed positively. It gives us stable and certain funding, in an environment of increasing economic and political uncertainty. In short, we have what’s been described as a ‘roadmap for delivery and change’. There will be closer integration with Primary Care Networks (PCNs) and contractors will have an increased role in protecting public health as well as having an expanded role in urgent care and medicines safety.
I have listed our new service delivery changes below.
NHS Community Pharmacist Consultation Service (CPCS) – this will be rolled out from October 2019, referrals will be made from NHS 111 and replaces the current NUMSAS and DMIRS pilots. Fortunately, in Derbyshire, we already have experience of the two pilots, so we are in a good place to transition to CPCS. The new service is supported by transitional payments and attracts a £14 fee per completed consultation. Follow-up calls to ‘no-show’ patients have been reduced to one and further developments will be piloted (e.g. referrals from GPs, NHS111 online, Urgent Treatment Centres and, possibly, A&E).
Clinical Services: Prevention – as part of delivering the essential services all pharmacies will need to have Level 1 Healthy Living Pharmacy (HLP) status by 1 April 2020. The vast majority of our pharmacies are already HLPs, so only a few will have to go through the accreditation process.
Additional Clinical Services will include:
- Hepatitis C testing, as a 2-year time limited advanced service, which will be introduced in 2019/20 for people using Needle & Syringe programmes;
- Data capture for national public health campaigns with exploration of the use of “digital marketing assets”;
- Pharmacy Integration Fund (PhIF) and the PCN Testbed programme will test services such as identification of undiagnosed CVD, point of care testing to tackle antimicrobial resistance, stop smoking referrals from secondary care, vaccination and immunisation, support for PCN service specifications and routine monitoring of patients on repeat medication.
Clinical Services: Medicines Optimisation – the development of a medicines reconciliation service for hospital discharge patients will ensure medication changes are picked up when the patient returns home. In addition, there will be consideration given to expanding the current New Medicines Service (NMS) to include further conditions and a new service to improve access to palliative care medicines will be piloted.
Clinical Services: Medicines Use Reviews (MURs) – being phased out and will be replaced by Structured Medication Reviews carried out by clinical pharmacists working within PCNs. Contractors will be able to provide up to 250 MURs this year (max. 200 by September and a further 50 by March 2020) and 100 next year.
Pharmacy Quality Scheme (PQS) – replaces the Quality Payments Scheme (QPS). There will be a few changes made to existing requirements with some of the quality criteria grouped into bundles for payment, slightly modified gateway criteria and to ease cash flow for contractors there will be Aspiration Payments (70% of the average number of points claimed across the two declaration periods in the 2018/19 QPS).
The above represents a shift away from a primarily prescription driven income stream and the Government will be pursuing legislative changes to allow all pharmacies to benefit from hub and spoke dispensing. PSNC is working with the DoH to identify a suitable model that will benefit the whole sector fairly. Other plans to enable change include exploring greater use of original pack dispensing to support automation, proposing legislative changes to allow better use of skill mix and enable clinical integration of pharmacists, and exploring the changes to funding and fee structures.
There’s still a lot of the finer detail to be agreed and there will be annual reviews of costs, capacity and progress within the Contractual Framework, so things will evolve and progress over the next five years. We may not know where we will end up, but at least we know the direction we are going.
Unfortunately, it remains the case that the Department of Health (DoH) still believes that there are too many pharmacies, especially where there are ‘clusters’ together. Some contractors may consider it commercially beneficial to consolidate and it’s important that the protection for those wishing to consolidate is strengthened.
Contractor Events and Support – PSNC will be holding a series of Sunday roadshow events for contractors and community pharmacists across England that will help you to understand the changes and how they will impact on your business.
If you don’t want to travel so far then please come to Derbyshire LPC’s AGM on Tuesday 17 September at Morley Hayes Hotel. Garry Myers, PSNC Representative, will give an overview of the recently agreed 5-year CPCF. This will include information to support contractors to deliver the first parts of the framework such as the NHS Community Pharmacist Consultation Service and the Pharmacy Quality Scheme. To come along and join us: book here.
Also, please join our Health Champions closed Facebook page. We are looking for members so please take a look at the page here https://www.facebook.com/groups/144590669467837/ and send a request to the group.
August 2019: What is effective communication?
The ability to communicate effectively is a key skill for any pharmacist. In fact, standard three of the GPhC’s Standards for Pharmacy Professionals states:
“Effective communication is essential to the delivery of person-centred care and to working in partnership with others. It helps people to be involved in decisions about their health, safety and wellbeing.”
But what does this mean in practice when speaking to a patient or carer? You know which key information would benefit the patient, but do you adapt what you say to meet the needs of the person you are communicating with? You may not get your message across as often as you might think, because the recipient may not have sufficient “Health Literacy” to fully understand what you are saying. For example a common instruction to: “Take two tablets in the morning with breakfast” could mean that NO tablets are taken when the patient misses breakfast!
A definition of “Health Literacy” by the World Health Organisation (WHO) defines it as: “The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.”
A recent survey commissioned by Stoke-on-Trent City Council Public Health (working in conjunction with Health Literacy Group UK from Keele University) on the levels of health literacy across Stoke-on-Trent concluded that 49% of the adult population had inadequate health literacy levels. I suspect that other areas wouldn’t fare much better, which means that roughly every other adult you speak to may not fully grasp the information you are giving.
Unfortunately, those adults with poorer health literacy are significantly:
- More likely to rate their general health as fair, bad or very bad;
- Less likely to be close to relatives or friends whom they speak to or see regularly;
- More likely to be aged 65 and over;
- Less likely to have access to the internet;
- Less likely to have qualifications;
- More likely to be retired or not working due to long-term illness or disability and less likely to be working as an employee;
If we can encourage and support our patients to be more health literate it will help improve their health outcomes and promote concordance with their medication.
Health Education England (HEE) has published a helpful “Health literacy ‘how to’ guide” which describes practical tools and techniques for health practitioners in a variety of settings. It offers advice on how to implement and enhance approaches and practice in a way which effectively supports people with low levels of health literacy. It’s quite detailed and provides a lot of CPD opportunities!
I would like to introduce you to one of these tools right now, one called ‘teach back.’ It’s a simple technique, which gets even easier with practice. It works by asking the patient to repeat or ‘teach back’ the information they have just received in their own words. If they can do this accurately you will know that they have understood you. If not, you should clarify or modify the information and repeat the technique until they’ve ‘got it’. Asking a question such as: “To check that I’ve explained everything properly, can you tell me how you are going to take your tablets?” is very different to: “Is what I have told you clear?”.
You should also be mindful of not overwhelming the patient with a stream of information. A technique called ‘chunk and check’, which can be used with ‘teach back’, involves breaking the information down into small ‘chunks’ and then checking that the patient has understood at each stage, before moving on, rather than waiting until the end. The conversation may take a little longer initially, but this is about setting the patient up for success and reducing the need for repeat conversations every time you see them.
So, remember – listen carefully to what your patient says, use simple ‘living room’ language, avoid medical jargon and explain things clearly in plain language.
Now, any questions?
July 2019: Primary Care Networks [PCNs] and You
Change, they say, is the one constant in life and when it comes to the NHS that certainly holds true.
Are you aware of the recent changes to the NHS landscape and, in particular, what’s happening in Derbyshire? You may well be aware that since April 2013 we had four Clinical Commissioning Groups (CCGs), but did you know the new/consolidated Derby and Derbyshire CCG (DDCCG) launched in April this year? This brought together 115 local GP practices, split between eight different places, to commission health services for Derbyshire’s population of more than 1,055,000 patients.
DDCCG is one of the partner organisations involved with our local Sustainability and Transformation Partnership (STP) – known locally as Joined Up Care Derbyshire (JUCD). The NHS Long Term Plan requires every STP to become an Integrated Care System (ICS) by April 2021; so more changes are on the way over the next couple of years.
The ICS, because it will cover the whole of Derbyshire, will truly have the capacity to support system-wide transformation of services. This includes workforce, capital and estates planning, specialised digital services and implementing changes to acute care services. This will be done under a single operating plan which encompasses both CCGs and NHS providers. The focus locally will be on new ways of working to:
- Help keep people healthy
- Give people the best quality care
- Run services well and make the most of available budgets
Under the ICS umbrella are a designated 8 ‘Places’, aimed at forming alliances which will help with integrating primary, community, local government and hospital services, with the development of new service models for anticipatory care.
Typically, a ‘Place’ will have a population of between 250-500k, but in Derbyshire this will average around 130k. The ‘Place Boards’ will be responsible for using the available resources to make sure there are equitable services for people living and working in the city and county. At this level the focus will be on:
- Supporting people to stay well for longer through a consistent set of work areas, which include frailty, falls, care homes and supporting people to die well
- Identifying what local people need in their area as regards their health and wellbeing
At an even more local level are the Primary Care Networks and here the focus is on strengthening primary care through supporting collaborative working across groups of general practices and other health and care providers, including community pharmacists. These networks will provide the structure and funding (per capita basis) for services to be developed locally, in response to the needs of the patients they serve. It is vitally important that community pharmacy teams are fully involved in the work of their PCN.
All GP practices had to be in a PCN by June 2019 and needed to sign up to a PCN Network Agreement. We are waiting for the final confirmation of the PCN geographies across Derby and Derbyshire (15 PCNs). These geographies will be confirmed in July and contractors will need to know which network area they are in. Therefore, the LPC will produce a contractor database to identify which PCN each pharmacy is aligned with.
It is important that community pharmacy teams are fully engaged with the work of the PCNs to optimise their provision of services to patients and, because the future development of local services will be influenced by PCNs. NHS England sees the initial priorities for community pharmacy engagement in PCNs to be:
- Supporting the provision of integrated urgent care services (e.g. NUMSAS and DMIRS)
- Work on prevention, such as provision of public health interventions and services, building on the work of HLPs
- Locally, other priorities may be agreed with PCN leaders, which may initially include optimising the provision of existing services, such as MUR, NMS and electronic repeat dispensing
We want to identify a ‘lead’ community pharmacist who works in each PCN to act as a main point of contact between the PCN and all the community pharmacies in that PCN geography. This will help support collaborative working, help integrate community pharmacy into the PCN, ensure robust 2-way communication and build relationships between the PCN Clinical Directors, PCN Pharmacists and Community Pharmacists.
These ‘lead’ community pharmacists will represent ALL community pharmacy contractors in the geography – not just their own pharmacy, and will be asked to feedback progress to the LPC, so we can collate and share good practices and ideas. In turn, the LPC will provide support for the ‘lead’ with communications support, advice and insights into best practice that is happening locally and nationally. If this is something you would like to be considered for please let the LPC know as soon as possible by sending an email with your contact details, including confirming which pharmacy you work in, to Jackie Buxton, LPC Chief Officer – firstname.lastname@example.org
Also, while I have your attention, I would like to point you towards our Health Champions closed Facebook page. We are looking for members so please take a look at the page here https://www.facebook.com/groups/144590669467837/ and send a request to the group.
May 2019: Public Health Campaigns and Community Pharmacy
Health Promotion Zones at their best can be impactful, engaging and effective in sharing Public Health messages and making a real difference to people’s health and wellbeing.
Promotion of healthy lifestyles (Public Health) is also an essential service (#4) as outlined in the Community Pharmacy Contractual Framework and NHS England requires pharmacies to participate in up to six Public Health campaigns a year. Some of the campaigns are developed stringently at national level, but others allow for flexible local tailoring to consider specific patient groups.
Our 2019/20 targeted campaigns are:
- Mid-February to mid-March – “Help Us Help You” Pharmacy campaign
- Mid-May to mid-June – Children’s Oral Health/Smile Month
- September – Antimicrobial resistance
- October – “Stoptober”/Smoking cessation
- November/December – “Help Us Help You” Winter campaign
- January 2020 – Alcohol
Looking at the six public health campaigns specifically it’s a challenge to know where to start. Helpfully, PSNC Briefing 011/17: “Healthy Living Pharmacy – Holding a health promotion event/campaign” provides the guidance you need to run an effective campaign. I recommend you use the “Annex 1: Checklist” to guide you through the process. This will help you show what you have done to engage and deliver an effective campaign, which delivered the campaign objectives and made a real difference to people’s lives.
Let’s take a look together at the “Children’s Oral Health/Smile Month” which runs from 13th May to 13th June this year:
Planning – Complete the “Annex 1: Checklist” and look for ideas that will work for you. You will find examples on the Oral Health Foundation’s website at http://www.nationalsmilemonth.org. In addition, do a little research and find out some interesting facts and figures – if they interest you, they may well impact on others (e.g. Sugar is a major cause of tooth decay. The average 5-year-old consumes their own weight in sugar each year and sugary drinks make up 29% of 11-18-year olds sugar intake).
Resources – Once you know the ‘angle’ you want to take you will need supporting promotional materials (e.g. posters, leaflets, visual aids, etc.), so allow at least a month to get these. There are lots of sources, but consider PHE’s Campaign Resource Centre, Charity websites and how about developing a simple questionnaire for customers to assess the impact of your campaign and to find out what works and what didn’t (for next time).
Training – This is easy for this campaign, because at least 80% of your healthcare staff should have already completed the CPPE Children’s Oral Health training for Quality Payments. If they need a refresher then have a look at the Children’s Dental Health training module on Virtual Outcomes. Don’t forget to brief staff on the campaign and how it will be run in your pharmacy.
Delivering – Setup the HPZ to make the display as attractive and attention grabbing as possible. You should have lots of leaflets and posters by now, so this stage should be easy. Remember, to remind staff that when they hand out a leaflet to briefly explain the contents and its importance to the customer. This could start a MECC discussion that will encourage the customer to make the behavioural changes necessary.
Evaluation and Reporting – What you have done to support the campaign should be evidenced, because it will help with any contract monitoring visits and building up your HLP portfolio. There should be a record of the number of people that have been spoken to during the campaign, photographs of your HPZ, and keep examples of the leaflets you used with a brief outline of what you did. N.B. When removing promotional materials don’t discard them, as they could be useful for future events or for customers who ask for help outside the campaign.
Last year NICE Guidance on “Community pharmacies: promoting health and wellbeing” [NG102] made recommendations on how pharmacy public health interventions could be more effective. I don’t think there were any surprises in what they came up with. We all know that training is important, as is local knowledge of local health priorities, so proactively seeking opportunities (e.g. Making Every Contact Count i.e. MECC), following behaviour change principles, raising awareness of health issues and offering advice/information in a way that will engage people will all make a difference.
To help us all share ideas and tips and to celebrate successes we have just set up a HLP’s closed Facebook page. We are just looking for members so please take a look at the page here https://www.facebook.com/groups/144590669467837/ and send a request to the group.
Reports and photographs of successful campaigns and ideas can also be sent to Derbyshire LPC (email: email@example.com), PSNC (email: Zainab.Al-Kharsan@psnc.org.uk); Public Health England (email: firstname.lastname@example.org); or at the PHE Campaign Resource website.
April 2019: Have you got mail?
The answer should, of course, be yes but where NHSmail is concerned this may not be the case for everybody. If you haven’t got a personal account and access to the pharmacy’s shared mailbox where you are working, you may well find life difficult.
The NHS England team send out all communications to shared NHS mail boxes so this is how you will receive drug alerts, information and service opportunities. As you will know, it’s also a secure mail service used for sharing patient identifiable and sensitive information.
All pharmacies should have a shared mailbox. There is a standardised naming format for the address of the shared mailbox:
This is separate to your personal mailbox and one which multiple members of staff can access. All staff have access to the mailbox and can send emails from this address.
The mailbox will have a nominated shared mailbox owner(s) who is/are responsible for controlling access to the account and undertaking any associated administrative procedures, such as providing access permissions and ensuring staff adhere to the Information Governance Toolkit Guidance.
The shared mailbox must be accessed on a regular basis to ensure all clinical referrals and urgent communications are received and processed in an appropriate and timely manner. At least two members of staff should be regularly accessing the shared mailbox. It is important to have a contingency plan for when these members of staff are both on holiday.
To encourage active usage of NHSmail one of the Quality Payment Gateway criteria states that on the day of the review:
“Pharmacy staff at the pharmacy must be able to send and receive NHSmail from their shared premises NHSmail account, which must have at least two live linked accounts.”
If the mailbox is not accessed, then vital information can be missed:
- NHS England sends out all communications to pharmacies via NHSmail. If you don’t have an account you will not receive vital updates and alerts. This can lead to operational difficulties and missed opportunities.
- Pharmacy services such as NUMSAS and DMIRS use PharmOutcomes for digital referrals to community pharmacy, but use NHSmail as the ‘back up’. Where NHSmail is used the mailbox should be regularly checked to pick up referrals in a timely manner.
How often should you check the NHS shared mailbox? I suspect you don’t check it as often as you do your own personal email account! However, the NUMSAS guidance is that checking should be done when a pharmacy opens and before the pharmacy closes each day. Also, I would recommend that you increase this frequency during OOHs periods, such as weekday evenings, weekends, and Bank Holidays. In this way you will minimise surprises when a patient comes in and expects you to know all about their referral.
Every pharmacy is allowed up to three individual NHSmail accounts linked to the pharmacy’s shared NHSmail mailbox. Additional accounts can be requested by contacting the NHS England Area Team, but this will be at their discretion and you will need to give a reason(s) for the request (e.g. extended hours working). For people that already have an NHSmail account there is no problem with adding them to the shared mailbox (the shared mailbox owner can do this). N.B. You do not have to be a pharmacist to have an individual NHSmail account – some pharmacies have allocated one of their individual accounts to a full time technician who can access it regularly and is usually at work when the pharmacist is on holiday or day off.
If you are leaving your Practice you will need to let the shared mailbox owner know, so that you don’t receive emails inappropriately. If you are leaving the profession, or not working any longer in community pharmacy, you will need to contact email@example.com who will mark your account as ‘leaver’ and it will be permanently deleted after 30 days.
Where can you find more information on NHSmail? Have a look at the PSNC website section on NHSmail for a comprehensive overview, answers to technical queries, some FAQs and an insight into some practical considerations you should take account of. Also, don’t forget to check out the Guide for Community Pharmacies using NHSmail.
March 2019: Discovering Virtual Outcomes
I’m delighted to announce that all community pharmacies in Derbyshire now have access to a FREE online training course designed to support NHS Public Health Campaigns, Healthy Living Pharmacy Champions and pharmacy teams in delivering public health messages. It’s called Virtual Outcomes and is full of practical help, tips and links to supporting resources.
The idea is that it will offer pharmacy staff an overview of key public health messages, insight into the problem and assist them in raising awareness in a bid to improve patient outcomes.
NHS England North Midlands has provided the funding for the training in order to help develop our Healthy Living Pharmacies and the courses are open to all Derbyshire contractors and their teams. The resource will hopefully assist Health Champions and help them when talking to patients about health issues or give ideas for health promotion zones.
There’s plenty of content already on the website and on the first of every month a new course will be available. There’s also a helpful training calendar with links to courses and event flyers, which can be used to plan training and events. Previous courses are listed and can be accessed at any time if there’s a particular local health issue that you would like to address; for example, smoking cessation, bowel cancer, etc…
The training can be accessed at work or at home via a PC, tablet or mobile device. All you and your team need to access the training is your OCS Code for your pharmacy. Go to the website, enter the code, confirm the address of your pharmacy, choose your training (e.g. Pharmacy Team Training) and select the course from the list. Once the course is selected you will be asked to register your details and submit them. You will then be able to start the course.
The courses take between 15 and 25 minutes to complete and there is no limit on the number of staff who can access the training from your pharmacy. At the end of the online tutorial there are some multiple-choice questions to answer. If the pass mark, or better, is achieved you will get an “Online Training Certificate” and this can be used to evidence staff training for HLP status or for GPhC inspections.
For each course there are resources available to support the learning and to provide opportunities for accessing promotional materials that could be used in health promotion zones (HPZs). Making full use of the training and the resources will help with ideas to create impactful HPZs to attract patient attention. The more team members who complete the training the better, as everybody will be able to respond to queries or proactively engage patients in conversations around the chosen health topic.
So, how easy is it to undertake the training? Well, in the interest of research I did the “Smoking” course as its “No Smoking Day” on 13 March. The video was interesting and had a lot of facts about smoking prevalence, the morbidity associated with smoking, the benefits of giving up smoking and how to support patients in making informed choices about what products would help them quit. I found the latter particularly helpful, as there were some really practical hints and tips that could easily be given to patients about how to use these products.
I found the ‘pace’ of the video a little too fast, but it was easy to pause and rewind if you thought you might have missed something important or didn’t quite ‘get it.’ Anyway, I did the multiple-choice questions and I’m now the proud owner of a newly printed “Online Training Certificate”. Fortunately, it doesn’t show the actual pass mark, but you can always do the questions again if you don’t pass or wish to achieve that elusive 100%…
The web links with the “Smoking” course were for national charities or for websites where you could get additional information about the subject (e.g. NHS Choices, Smoking in Pregnancy, etc.). The charities listed were comprehensive and offered access to leaflets and posters which supported the required ‘angle’ to take to promote your specific focus. For example, you might want to focus on smoking and cancer (Cancer Research UK) or smoking and cardiovascular disease (British Heart Foundation).
HLPs are a great way of getting involved with your local community. By highlighting public health issues you will have the opportunity to engage in conversations with patients and make a difference to their long-term health and wellbeing. By doing the training it’s virtually certain you will improve outcomes!
February 2019: Falsified Medicines Directive (FMD) – Are you Ready?
It’s now more than six years since the FMD (Directive 2011/62/EC) came into force in a bid to combat the risk of counterfeit medicines reaching patients across Europe.
The aim continues to be the prevention of the entry of falsified medicinal products into the legal supply chain. The directive applies to almost all prescription-only medicines (POMs), including generics, but it doesn’t apply to specials and a few other products which are unlikely to be dispensed in the community. However, there is an exception to this and over the counter (OTC) omeprazole now has to be decommissioned even though the ruling is only supposed to apply to POMs.
On or after 9 February all new prescription-only medicine packs issued into the UK market must bear FMD safety features and have pack data loaded into the UK’s National Medicines Verification System (a.k.a. the UK hub). Unfortunately, for the first couple of years following FMD implementation there will be quite a few products in the supply chain which are not FMD-compliant. This ‘old’ stock can be supplied as it was on the market before the start of FMD, but eventually everything will be used up and only FMD-compliant stock will be available in the supply chain.
FMD-compliant packs must have two safety features. The most obvious one is the anti-tampering device (ATD); you will have noticed that these have been in place for sometime now, as you will have been breaking through them when splitting packs. Secondly, every pack will have a unique identifier (UI) in the form of a 2D matrix (barcode), containing the batch number, expiry date, product identifier, and a unique serial number for the pack. The UI will be scanned, and the information checked against the database held at the UK hub.
As part of the dispensing process from 9 February ALL community pharmacists will be required when dispensing FMD-compliant stock, to check that ATDs are intact prior to dispensing and change the status of packs from “active” to “inactive-supplied” by scanning the unique 2D barcodes. Sounds simple enough, but there are a lot of practicalities to consider and, of course, you will need to follow associated Standard Operating Procedures (SOP) to ensure compliance.
What happens when the barcode is scanned? Quite a lot actually, as the UI is checked against the UK hub database to verify the pack’s serial number and to see if it’s been marked as previously dispensed, recalled or expired. If the medicine is supplied to a patient the status of the product will be flagged as “inactive-decommissioned.“ This decommissioning process prevents packs with the same UI from being authenticated – duplication of UIs could indicate falsification.
When should the packs be scanned? This will vary from pharmacy to pharmacy, so you will need to follow the appropriate SOP for the organisation you are working for. Things to consider are how the process fits in with the normal workflow and how the FMD software system has been setup. Decommissioning would normally occur at the time the medication is handed over to the patient, because otherwise the medication may have to be recommissioned if it’s not picked up within ten days.
The ten-day window allows the medication status at the UK hub to be changed back to active, if a mistake has been made and/or the patient hasn’t picked up their medication. After this time a product cannot be recommissioned and the legislation requires that any medicines not picked up must be disposed of. This could be a costly mistake, as the medication cannot then be supplied to another patient (i.e. you can’t dispense something that shows up as “inactive-decommissioned” on the UK hub database).
If an original pack is dispensed then the process is straightforward. However, when you have to split a pack to dispense the required quantity then it’s a little more complicated. The pack should be decommissioned when the first part of it is supplied to a patient, not forgetting the ten-day rule of course. Subsequently, when you dispense from the split pack there is no need to scan it again because the status has already been changed. It should be noted that, because the pack isn’t being scanned, the system would not alert you to recalls or expired medicines. Therefore, these will have to be checked manually at the time of dispensing.
What happens if the system alerts you to something that’s on the UK hub database, but has already been marked as “inactive-supplied”? Back to those SOPs again and you will need to contact the Medicines and Healthcare Regulatory Agency (MHRA) and the supplier of the product. Also, it will be worth checking other packs of the same product in case there’s more of this possible counterfeit stock.
Want to find out more about FMD? PSNC has a useful factsheet about what you need to do to prepare for FMD – see PSNC Briefing 058/18. Also, it’s worth checking out the FMD Source website, which provides UK pharmacies with authoritative and reliable information on implementing FMD. Finally, there’s SecurMed, the UK Medicine Verification Organisation, which enables FMD to be implemented
January 2019: A New Year Developmental Opportunity
Happy New year! With fresh beginnings in mind I’d like to announce an opportunity I’m urging all Derbyshire pharmacists to consider getting involved with.
In a unique collaboration with De Montfort University, and via the Pharmacy Integration Fund, we are co-ordinating a programme to deliver a postgraduate module focusing on skills, which support Quality Improvement in healthcare practice. The module is in line with the Public Health agenda and the development of Healthy Living Pharmacies (HLPs). The specialised training is fully funded and will help you develop the skills necessary to evaluate and improve, where necessary, your business and how you approach your practice.
All pharmacists working two or more days per week in a community pharmacy can access this free accredited training. Contractors, employees, relief and locum pharmacists are all welcome and it doesn’t matter if you have recently qualified or whether or not you are in the ‘later’ stages of your career!
Pharmacy is changing: with moves towards more clinical practice and in particular helping patients improve their general health and wellbeing. The concept of HLPs is part of this and provides lots of opportunities to provide more patient-centred care. However, there is more we can do.
The Quality Improvement Module on offer allows you to work independently on your own project in your own pharmacy:
- You will be able to apply what you have learnt in your day-to-day practice to improve existing services using appropriate quality tools;
- Develop an understanding of theoretical and professional aspects of clinical pharmacy practice, management and services;
- Design and management of patient-centred pharmaceutical services taking account of local and NHS priorities;
- Further develop your critical reflection skills.
We all want to do a good job and we want to make a difference. However, there can often be a number of different options when we decide to make some changes to the way we do things. Do we always choose the best option first time? Probably not, and often the changes are part of an evolution rather than a revolution.
This training will help you gain insights and develop the skills necessary to make more informed choices. We’ve chosen to support the quality improvement module, but in other areas the modules could include clinical topics, medicines optimisation, and therapeutics. This is a single module, equivalent to 15 credits, which may be transferrable to another Higher Education institution and could form part of the training needed to gain a Post Graduate Certificate (60 credits needed).
So, what’s involved? Well, attendance is required at three face-to-face sessions (early February, early March and late June) and there is distance learning, which takes place over 6 months. The distance learning is online and supported by a tutor. In total the module will take around 150 hours. This may sound a lot, but the face-to-face training time counts towards the total and the practical work that you have to do in your pharmacy will as well. We all have to complete a ‘peer review’ as part of our revalidation with the GPhC this year, so the fact that you will be working alongside your peers, during the three face-to-face sessions, may help you with this as well.
The practical aspects of the module will involve looking at how your pharmacy supports the delivery of public health messages and what impact you are having. A baseline assessment of your current practice will provide a ‘before’ picture of how you are doing. Later, towards the end of the module, you will look at the ‘after’ picture to evaluate the differences, improvements and changes you have made.
It is intended that the work you, and others undertaking the module, do forms part of a research study to evaluate this innovative programme. In addition, it will help to build an evidence base that can be used to persuade commissioners to seek community pharmacy involvement when they want to deliver key health and wellbeing issues or develop services that support the public health agenda.
To find out more, please email LPC Chief Officer Jackie Buxton, at firstname.lastname@example.org. We will be seeking ‘Expressions of Interest’ and begin to register pharmacists throughout January, so don’t delay making your application. I hope you will want to take the module. It will help you develop skills and insights that will help you transform aspects of your business that you wish to improve. The foundation you build now will help you deliver quality improvements throughout your career.
December: Quality Payments Update
In September a new Quality Payments Scheme was announced with several revisions to the existing criteria. The revised scheme will run for the remainder of the 2018/19 financial year.
The review point will be Friday 15th February and claims can be made any time between 4th February and 1st March. The NHS BSA will carry out claims’ validation within a week of receipt. Early submission is advised as contractors who appear not to have met the criteria in relation to their declaration will be informed and will have the option to provide further evidence to support their claim.
So what’s new? PSNC Briefing 051/18: A summary of the second Quality Payments Scheme 2018/19 gives the detail of this and provides a useful guide to the changes. There are now five Gateway Criteria rather than the previous four and passing the Gateway Criteria does not in itself earn any quality payment, but does allow access to the scheme:
- The contractor must be offering at the pharmacy Medicines Use Review (MUR) or New Medicine Service (NMS); or must be registered for NHS Urgent Medicine Supply Advanced Service Pilot;
- The NHS.UK entry, including bank holiday opening hours, for the pharmacy must be up to date;
- The results of the last completed Community Pharmacy Patient Questionnaire is publicly available on the pharmacy’s NHS.UK page or for distance selling pharmacies it is displayed on their website;
- Pharmacy staff at the pharmacy must be able to send and receive NHSmail from their shared premises NHSmail account, which must have at least two live linked accounts; and
- The contractor must have consulted the NHS Digital Warranted Environment Specification (WES) and/or their System Supplier(s) and have assured themselves, and can demonstrate, that all their operating system and browser versions currently in use in their pharmacy to link to NHS Digital systems, such as the Electronic Prescription Service and Summary Care Record, comply with the WES; and are therefore supported by NHS Digital for connectivity to NHS Spine systems.
The Quality Criteria have been revised, including the number of points available for each criterion, and only the Digital/Urgent Care domain (NHS 111 DOS entry is up to date) and the Workforce domain (80% of staff in patient facing roles are “Dementia Friends”) remain unchanged. Therefore, additional work will be required to ensure that claims can be legitimately made for the points available within the domains (i.e. Patient Safety, Public Health, and Clinical Effectiveness).
Of particular note is that some additional staff training will need to be completed by the review point:
- Children’s Oral Health– 80% of customer facing staff need to have successfully completed this training. This includes counter staff, dispensing staff and pharmacists and CPPE registration is required (includes counter staff and dispensers). The training requires watching a 20-minute video, doing a little reading/preparation and then taking the online e-assessment.
- Risk Management– 80% of pharmacists need to have completed this training and passed the online e-assessment. The pack was sent out in February and may have already been done. It is available online for download if the original pack has been lost or mislaid.
I’ve done the CPPE training and although fairly straightforward it does take some time. For the Children’s Oral Health allow at least an hour and for the Risk Management pack anything between two and four hours. Additional time will be needed to support non-GPhC registered pharmacy team members with the CPPE registration process. It should be noted that CPPE have some useful resources that support the claiming of Quality Payments as well as information on the registration process and training packages.
The e-assessments involve timed multiple-choice questions. This could be a challenge, and a new experience, for non-GPhC registered pharmacy team members. The e-assessments have an 80% pass mark and involve 10 multiple-choice questions with 45 minutes allowed – anybody that doesn’t hit the pass mark is blocked out of the system for 20 hours. Also, the ‘ticking clock’ counting down the time in the corner of the screen really isn’t helpful and just adds to the pressure…
It’s two years since the Quality Payments Scheme was introduced in December 2016 and £75 million was paid to community pharmacy contractors who met the specified quality criteria – so, I know this is a busy time of year, but it is worth the time and effort.
November: Pharmacy Integration Fund
NHS England set up the Pharmacy Integration Fund (PhIF) in October 2016 in a bid to open up workstreams and opportunities for pharmacists. The aim of the fund was to drive greater use of pharmacists and pharmacy technicians in new, integrated care models and integrate and support the development of clinical pharmacy practice in a wider range of primary care settings. In essence the idea was to create a more effective NHS primary care patient pathway.
The programmes outlined below also provide great opportunities for pharmacists to develop their professional skills and knowledge. In some instances, it’s possible to gain academic qualifications. Also, there will be no shortage of CPD cycles to undertake, which will help with GPhC revalidation. Probably, more importantly, you will be helping to build the evidence base for better integration of community pharmacy with the wider NHS.
Workforce Education and Development – All pharmacists working two or more days per week in a community pharmacy can access free accredited training (post-registration training and development). The modules include clinical topics, medicines optimisation, quality improvement and therapeutics. Community pharmacists can complete a single module (typically equivalent to 15 or 20 credits) or up to 60 credits during a year and gain a Post Graduate Certificate. The LPC is working with De Montfort University (DMU) to coordinate this programme for community pharmacists in Derbyshire and the focus will be on quality improvement around the public health agenda, fitting in with the development of Healthy Living Pharmacies (HLPs).
Leadership Development – Community pharmacists and technicians can apply for the Mary Seacole Leadership programme, which is an NHS-led flagship programme designed to develop leadership and management skills. CPPE is working in collaboration with the NHS Leadership Academy to offer the programme and participant feedback has been very positive. Successful completion will support the drive for quality services in community pharmacy and really make a difference to patient’s health and wellbeing.
Medicines Optimisation in Care Homes (MOCH) – the MOCH programme was launched in March 2018 and focuses on care home residents, across all types of care home settings and aims to deploy dedicated clinical pharmacy teams. Funding was successfully applied for and implementation is currently underway. In Derbyshire the project is being organised at Sustainability Transformation Partnership level, known locally as Joined Up Care Derbyshire.
Integrated Urgent Care (IUC) – previous pilot work has shown pharmacists can add value to the clinical skill mix working within the IUC hub, completing calls and providing self-care advice across a range of calls that involve the use of medicines. Pharmacists recruited to these positions tend to work two shifts a week – training and support is provided to help integrate with the multi-disciplinary team at the hub.
National Urgent Medicine Supply Advanced Service (NUMSAS) – was commissioned as an Advanced Service, initially from 1st December 2016 to 31st March 2018, but recently extended until the end of March 2019. There is now a requirement to check and use the patient’s Summary Care Record, unless there is a good reason not to. Latest information is that more requests for emergency supply of medicines are handled by NUMSAS rather than Out of Hours (OOH) Services.
Digital Minor Illness Referral Scheme (DMIRS) – based on a pilot study in the North East where NHS 111 call handlers could refer patients requiring advice and/or treatment for low acuity conditions to community pharmacists. The pilot has now been extended to include the area covered by Derbyshire Health United (DHU). Sign up to the service is through the NHS Business Services Authority website. In the North East 75% of pharmacies signed up, so we need at least 160 pharmacies in Derbyshire to do the same.
Digital Developments – the fund has been used to support work, which has been led by NHS Digital (e.g. messaging and transfer of care data between settings, supporting the uptake of NHSmail by community pharmacists and supporting the roll out of the EPS tracker by NHS 111 and IUC hubs).
Pharmacist in General Practice – The roll out of pharmacists in general practice, funded by NHS England, started prior to the establishment of the PhIF, but it has been used to fund education and development for the pharmacists and an evaluation of the programme
October: Digital Minor Illness Referral Scheme
Introducing the Digital Minor Illness Referral Service (DMIRS)
With current financial pressures leading to decommissioning of services, it’s not every day that a new service is introduced. So it’s great news that we have the opportunity to sign up to deliver the new Digital Minor Illness Referral Service (DMIRS). The service was successfully piloted in the North East where it was known as the Community Pharmacy Referral Service (CPRS).
So, what’s it all about? The North East pilot was part of the Pharmacy Integration Fund which was set up in October 2016 to ‘drive the greater use of community pharmacy in new, integrated local care models.’ This particular element involves a new pathway whereby patients who have contacted urgent care services can be supported with managing self-limiting minor illness closer to home.
Here, in the East Midlands we are part of the second wave of the pilot. This area is one of three chosen to progress the service and develop it further to see if the model can be successfully replicated. Locally it is open to any pharmacy in the area covered by the NHS 111 service run by Derbyshire Health United. This is a very large footprint and includes 20 CCGs, 5 LPC areas, 900 pharmacies and a population of 5 million people.
So, what might we expect to happen? If we take a look at the figures from the first pilot it’s encouraging. Since December 2017 there have been more than 10,000 referrals and 450 out of 600 pharmacies signed up to deliver the service. There have been no serious incidents and patient satisfaction has been high.
The outcomes were:
- 38% given advice on managing their illness;
- 28% given advice and also purchased an OTC medicine;
- 17% advised to make an appointment to see their GP;
- 14% referred back to the Out of Hours (OOH) provider for further investigation
- 3% treated under a local Minor Ailments Service (MAS)
How it Works
Access to the service is through the NHS 111 service. When a patient calls the call handler will ask them a series of questions to triage them to the most appropriate support. Depending on these answers the system will suggest a referral to a community pharmacy for a low acuity condition. The call handler will tell the patient: “I’m going to arrange for you to attend your nearest community pharmacy, where you will receive expert advice, closer to home and without the wait you would experience at your GP (or OOH).”
The Directory of Services will show the call handler a list of pharmacies which provide DMIRS, starting with the closest, and the patient can choose which pharmacy they wish to attend. Once the pharmacy has been selected a PharmOutcomes referral will be made to the pharmacy. The patient will be advised to attend, in person, within so many hours (depending on the severity of the symptoms) and that this is a new NHS service where a pharmacist will see them in a private consultation room to assess and advise on their condition.
The PharmOutcomes referral will provide all of the information that the patient gave the call handler (i.e. the answers to some 27 questions!). The service is integrated with the NHS pathway clinical triage system (validated to ensure appropriate decisions are made). PharmOutcomes will send an email to the management email address alerting the pharmacy to the fact that a referral has been made.
On the first occasion a pharmacist accesses the service they will need to enrol with their GPhC number and confirm that they know how to deliver the service. Subsequently, this step will not be necessary and they will be able to go straight to the referral. The pharmacist will consult with the patient in the consultation room and have access to the PharmOutcomes service for information and data capture. Appropriate advice is given about the illness and this may or may not involve the sale of an OTC product. During the consultation the patient is advised what action to take if their condition worsens.
It is a requirement that the pharmacist checks NICE Clinical Knowledge Summaries (CKS), Fortunately, links to NICE CKS are embedded in PharmOutcomes, so everything is to hand to ensure that appropriate advice is given and any risk factors are identified. If any ‘red flags’ are picked up, or the pharmacist has concerns about the patient’s condition, then they need to use the escalation pathway, as the patient requires higher acuity care. Options are as follows:
- Pharmacist calls NHS 111 and press *7 (out of hours) to discuss the patient’s condition;
- Pharmacist supports patient with getting an appointment with their own GP (in hours);
- Call 999 if more urgent.
Sign up to the service is through the NHS Business Services Authority website. Once this has been done the NHS England contracting team will send out a launch pack to confirm registration. Further work will then be done with Directory of Service (DoS) Leads, DHU testing with the pharmacy, followed by DoS ‘go live’ and then the pharmacy will receive an email informing them that DMIRS is active.
Why should you sign up? Importantly, you will be helping to build the evidence base for integrating community pharmacy into urgent care pathways and getting patients used to seeing a pharmacist about everyday minor illness. This is also a great opportunity to support patients, receive a £14 fee for each consultation and it will only take around 10 minutes for an average consultation. In the North East 75% of pharmacies signed up, so we need at least 160 pharmacies in Derbyshire to do the same. Just use the NHS BSA hyperlink and you will be on your way.
September: Medicines order Line (MOL)
Over recent decades medical practice has changed dramatically. A Cambridge University study recently found that around half of over 65-year-olds in England are taking at least five different daily medications.
The study examined changes in medication usage in the older generation over a 20-year period and revealed that 20 years ago only 12 per cent were taking as many. It was also noted that the proportion taking no pills at all had dropped from around 20 per cent in the late 1990s to just seven per cent today.
This huge increase in multi-medicating means more and more prescriptions must be dispensed. As well as processing the requests, it’s increasingly important for us to check medicines requested are both needed and current. Excessive or incorrect ordering and stockpiling can be a significant cause of wastage and with GP budgets under financial pressure this is increasingly relevant. It’s a fact that unused prescription medicines cost the NHS in Derbyshire over £6 million every year.
We are all familiar with the three options below for patients who request repeat medication:
- Handing in repeat slips to GP practice – which does mean being able to get to the practice easily and may require another journey to pick up the repeat prescription (unless arrangements are in place for the prescription to be sent to a nominated pharmacy).
- Handing in repeat slips at a community pharmacy – pharmacy staff can help manage the process, but some surgeries insist that the pharmacy is signed up to the “Derbyshire Repeat Prescription Code of Practice”, so this support may not be available if there is no local agreement in place.
- Online ordering or email request – but patients need to be comfortable with IT and be computer literate. The prescription is sent electronically to a nominated pharmacy or collected from the GP practice.
The Medicines Order Line or MOL however is relatively new, not available from every surgery and not everybody will be familiar with the way it operates. Therefore, I recommend that pharmacy staff familiarise themselves with the MOL operation, so that they can support those patients whose surgery has chosen to use MOL.
With the MOL telephone requests are made to a call centre handler who follows a ‘Script’ to identify exactly what medication is required. The requests are then sent to the patient’s surgery for signoff. The prescription is then sent electronically to a nominated pharmacy or collected from the GP practice.
The service is provided on behalf of the GP practice and Derbyshire CCGs, between 9.30am and 2.30pm Monday to Friday. Dedicated, experienced and trained call handlers, with access to patients’ medical records, will answer the call. The aim is to ensure that patients order only what they need (includes the correct quantity of medication), in a timely manner, to reduce the amount of medication waste.
The rationale behind the MOL is to empower patients to self-care, high on the local CCG agenda, and manage their conditions, collaborate with GPs and CPs to improve the repeat ordering process. In addition, the call handlers can answer queries from community pharmacies about the status of prescriptions, although this is not a primary objective and pharmacy staffs are expected to have taken suitable measures to locate prescriptions before they call. To support healthcare professionals the lines will remain open after 2.30pm until 4.00pm, but this will not be promoted to the general public.
Currently, in Southern Derbyshire 15 practices are enrolled for MOL and 4 practices are in the process of enrolling. Signup to MOL must be managed and consists of two phases, which allows time for all parties to adjust to the new system.
Phase One – Practice joins and encourages patients to ring the order line to order their repeat medication, this is the preferential route. MOL operatives have direct access to the GP clinical system and can process the patients’ requests in real time, advise on medication review dates, overdue recall dates, etc. Orders will only be processed 7 days before a medication is due and no earlier unless there are mitigating circumstances. All PRN medicines are queried to ensure orders are placed for only what is needed. The MOL will also offer synchronisation of quantities and ensure the repeat template is accurate.
Phase Two (a) Pharmacies who have NOT signed the Code of Practice – six weeks written notice will be issued to all nominated pharmacies assigned to the GP practice and to inform them that the GP practice will no longer accept repeat prescription requests on behalf of their patients (supporting leaflets for patients are available). The nomination will remain the same unless patients request a change. If delivery arrangements are in place patients are advised to contact the pharmacies directly to confirm them.
If patients still require the support of a ‘managed repeat service’ the pharmacy should complete the exemption form and return to the GP practice. The GP practice will then enter a read code “MOL EXEMPT” onto the patient’s clinical record. The reasons for exemption may include, capacity, 7-day prescriptions. The pharmacy will then need to ring the MOL to order on behalf of these patients. If the exemption is not on the patient’s record the MOL will NOT accept orders from the pharmacies for patients. If a patient has a compliance aid orders will be accepted14 days before they are due, to allow time for dispensing the packs.
Phase Two (b) Pharmacies who HAVE Signed the Code of Practice – GP practices who enter into Phase 2 will contact all of these pharmacies with the notice date and request that they ring the MOL to order on behalf of all their patients for whom they have a ‘managed repeat system’ in place. The GP practice will no longer accept faxed/written or verbal requests for repeat medication for patients. Pharmacy staff will be asked the same questions as the patients when they call the MOL to order on the patient’s behalf.
With any system change there is always a period of adjustment until things settle down. Pharmacy staff can help in several ways:
- Ask patients to call the MOL directly for their next order (if the practice is registered for MOL)
- Ensure that patients are given the right-hand side of their prescriptions (some patients are reporting they don’t always get this, which causes ordering difficulties)
- Promote the use of electronic repeat dispensing (eRD) – project underway to look at practices and to increase uptake
- Emergency supply requests can be dealt with by the MOL (there could be future synchronisation issues if patients were to be ‘advanced’ any medication)
- Deliveries are not an NHS service, so ensure patients understand how any delivery service operates from the pharmacy
August: Helping to Keep us all Safe
As a pharmacist of many years, one of the main sources of job satisfaction has been to help the people I serve. Wherever I’ve worked, the ethos has always been to do what we can for those who come to the counter. This may have been First Aid for minor injuries, advice on self-care or medicine taking or just a friendly chat and some calming words if somebody was anxious or distressed.
Earlier this year I learned that the Derbyshire Safe Place Scheme was being re-launched and widened. It’s now available to all adults and not just those with learning disabilities over 16, and more than 180 shops and businesses across Derbyshire have already signed up.
Derbyshire County Council (DCC) runs the Safe Places scheme in partnership with MacIntyre, Derbyshire Police, Trading Standards and the Derbyshire Learning Disability Partnership Board. It’s a very effective way of providing vulnerable individuals with support when needed. It’s straightforward and uncomplicated and involves putting the Safe Places sticker in public buildings such as libraries, GP Surgeries, Pharmacies and shops in towns and communities across Derbyshire.
The sticker shows ‘Keep Safe’ card holders that help can be at hand. This means that anybody who is vulnerable and feels anxious, threatened, lost or unwell when out and about can find help wherever they see the “Safe Place” sticker.
Keep Safe cards hold information an individual wants people to know about them and an emergency contact name and telephone number should they be in crisis. If they show their Keep Safe card at a Safe Place this will prompt staff to find them somewhere safe to wait, use the information on the card to call family, friends or support staff or to call the police or ambulance if it is an emergency.
More than 900 people in the county carry a Keep Safe card and carrying it not only provides comfort to an individual, but also to carers/parents.
DCC is working closely with the Alzheimer’s Society and Making Space to help people living with Dementia by ‘spreading the word’ at various events and meetings across the county to encourage people to apply for a Keep Safe Card. Pharmacies can help by raising awareness of the scheme and actively promoting it as part of the Dementia-friendly pharmacy initiative. There are currently over 7,000 people diagnosed with dementia in Derbyshire and this figure is set to rise by 30% by 2030.
More Safe Places are needed to ensure accessibility and comprehensive coverage throughout the county. This will help people to be safe and encourage independence, helping to reduce isolation.
I would like to see a sticker in every community pharmacy window. The application process is straightforward and the LPC is working with DCC to streamline the process as much as possible. In the meantime pharmacies that would like to become a safe place can visit derbyshire.gov.uk/becomeasafeplace and here you will find an online application form.
If you would like to learn more about Safe Places or see where all the Safe Places are in the county please visit www.derbyshire.gov.uk/safeplaces. DCC is in discussion with Derby City Council about including the city in the county scheme, which will further improve access.
Community pharmacies, as the name suggests, serve their local community and pharmacies have always been ‘safe havens.’ Please join me in promoting this through the Safe Place scheme.
Going on holiday? Yes, boarding pass? Yes, passport? In pocket? Is the oven off? I’m sure I checked, did you?
Oh, and have you packed enough tablets for a fortnight in the sun?
As pharmacists, we’ve no doubt all had to help patients with emergency medication supplies. Whilst this is relatively straightforward to deal with in the UK, it’s not so easy when abroad. Also, even if you have enough medication to go on holiday with there could still be problems, with rules varying from country to country.
‘Googling’ the question: “Can I take my medicine abroad?” yields 85 million hits, so there’s plenty of information out there, but what are the best and most reliable sources of information? As usual, NHS Choices gets my vote! They answer the question in a stepwise manner and have useful links which provide the detail and the real answers to the question.
I’ve already mentioned that preparation is the key. Planning should start two months or so before departure. This allows plenty of time for arranging additional medicine to cover the trip and to find out whether or not special arrangements are needed.
Advise patients to:
- Always carry medicines and medical equipment (e.g. needles, syringes, etc.) in their original, correctly labelled packages;
- Keep enough medicine for the trip in hand luggage (hold baggage doesn’t always arrive in the same country as the traveller);
- Make sure they have a copy of their prescription with them;
- Have a spare supply of medication, along with another copy of the prescription, in hold luggage (in case hand luggage is lost).
Most people know there are restrictions on the amount of liquids which can be taken in hand luggage. It should be noted that essential medicines of more than 100ml can be taken, but supporting documentation from a medical professional is required. Airport staff might still want to screen liquids at the security point though.
Having a copy of the prescription shows entitlement to have the medication. In addition, it could be worth asking the GP, or surgery, for a letter detailing the prescribed medication and the name of the health condition(s). Having this will help to avoid problems at customs and be useful if medical help is needed whilst away. It should be noted that GP practices might charge for such a letter, because this is not an NHS service.
Controlled medicines can be particularly problematic as there are additional legal controls which apply. A personal licence to take controlled drugs abroad may be needed. Specific requirements also apply to the information that must be available and how the controlled medicines should be carried. Examples of controlled medication include:
- Anti-anxiety medicines (e.g. benzodiazepines)
- Opioid analgesics
- Some medicines that contain hormones, such as anabolic steroids
For travel of less than three months there is no need for a personal import or export licence. However, a detailed letter from the prescribing doctor which confirms patient name, date of birth, travel itinerary, names of prescribed controlled drugs, dosages and total amounts of each to be carried is definitely advised.
A personal licence, issued by the Home Office, may even be required (e.g. for travel abroad for more than three months). This can take at least ten working days but it will allow you to take prescribed controlled medicines for personal use out of the UK and bring them back when you return.
If there’s any doubt whatsoever about which medications are allowed, it’s extremely important to check regulations for other countries by contacting their UK embassy. Different countries have different regulations, so careful planning and a little research is needed to avoid problems and a spoiled holiday
June 2018: ‘Staying Healthy and Connected’. Carers week 11-17 June
Derbyshire has 118,000 unpaid carers, often with significant health needs of their own. That’s why we’re supporting Carers Week this month and raising awareness of the vital role they play in our society.
Carers face many barriers to keeping themselves fit and well and it’s a fact that 51% of them let a health problem go untreated. According to Carers UK, many carers are unaware of how or where to get help for themselves – this is where pharmacists may be able to help. Many of our pharmacies are Healthy Living Pharmacies and promoting Carers Week in Health Promotion Zones (HPZs) could be a great opportunity to highlight the support that carers can, and do, receive from community pharmacy.
This year’s theme is ‘Staying Healthy and Connected’ and the LPC has worked with Adult Care, Derbyshire County Council, and arranged for the following to be sent to every Derbyshire pharmacy:
- Pharmacy Poster for Carers Week for display in HPZs or other location
- “Walk a mile in my shoes” Poster to highlight the Carers in Derbyshire empathy project
- Healthy and Connected booklets for Carers to provide an overview of Derbyshire County Council’s services on offer to unpaid carers
For some people, caring comes on suddenly; a loved one is taken ill or has an accident; a child is born with a disability. For others, caring creeps up unnoticed; parents begin to struggle and find it more and more difficult to remain independent; a partner’s health gradually gets worse.
Also a lot of carers don’t think of themselves as being a carer. They just see what they do as a part of their relationship with the other person, and they regard themselves as a husband, wife, son, daughter, sibling, or just as a friend. Whatever the relationship it’s important that the carer looks after their personal health and wellbeing. This was highlighted in last year’s “State of Caring Report 2017”.
The report found that caring could have a significant effect on health, with the pressures of providing care taking a toll on both carers’ physical and mental wellbeing:
- Three in five carers have a long-term health condition (compared with half of non-carers);
- 7 in 10 said they find it difficult to get a good night’s sleep, because of their caring;
- 8 in 10 said they feel more stressed, because of their caring role;
- Over half said they have reduced the amount of exercise they take, because of caring;
- Nearly half reported that they have found it difficult to maintain a balanced diet or have suffered depression, because of their caring role.
For more information and ideas take a look at the Carers Week website: https://www.carersweek.org and for the “Walk a mile in my shoes – Carers Empathy Project”: http://www.carersinderbyshire.org.uk/walk-a-mile-carers-project.
The “Walk a mile in my shoes carers empathy project” where some local carers have had their stories recorded is particularly interesting. The stories are all very different and the carers talk about the good, the funny, the difficult, rewarding and most frustrating aspects of caring. Importantly, some have given advice for other carers or shared their hopes for the future. Why not have a listen? It could make a difference and help you realise that every carer has a unique story and that there are lots of ways you can help to make a difference.
Carers are valuable members of society, they do a lot for family and friends who are older, ill or have a disability, so why not do something for them to help them stay healthy and connected?
May 2018: New (Novel) Psychoactive Substances – what can you do?
New (Novel) Psychoactive Substances – What can you do?
Everybody has heard of “legal highs.” The newspapers are full of stories about them and the current No. 1 storyline is how “Black Mamba” is turning people into zombies. With this in mind the LPC ran a couple of development events about New (Novel) Psychoactive Substances (NPS) to give pharmacists better insight into the problems associated with these drugs.
A National survey showed that a third of adults have taken a drug during their lifetime, with one in 11 adults (16-59yrs) having taken an illicit drug in the last year. Between 2003 and 2014 there was a 77% increase in hospital admissions with a primary diagnosis of “poisoning by illicit drugs.” More recently, East Midlands Ambulance Service reported 188 callouts in the first two weeks of August 2016, mainly in the Derby and Notts. area.
Community Pharmacy is well placed to offer support, identification and signposting about illicit drug use in general. However, I don’t think I have ever had a conversation with a patient about their use of NPS’s. The development event showed I wasn’t alone in this. There’s a gap in our knowledge and we do need a basic understanding of these substances.
So, here’s a starter for ten:
Synthetic Cannabinoid Receptor Agonists (SCRAs) (e.g. Spice, Black Mamba, etc.) for relaxation, euphoria, dis-inhibition, energised and altered consciousness. These are smoked or inhaled, and are rarely used in bongs/snorted or ingested. Detrimental effects: (a) Acute – include convulsions, paralysis, psychosis, extreme bizarre behaviour, tachycardia; (b) Chronic – psychosis and aggression.
Depressants (e.g. Ketamine, known as Special K or Kit Kat, benzodiazepines, etc.) for ‘buzzing”, euphoria, relaxation, increased sociability and increased libido. These are mixed with drinks to minimise the salty taste and occasionally snorted, but rarely injected. Detrimental effects: (a) Acute – include drowsiness, cardiac problems, GI effects, hypothermia, respiratory depression and coma/death (usually in combination with alcohol or benzodiazepines); (b) Chronic – severe dependence.
Dissociative (e.g. Ketamine,) for dissociation, intense detachment, perceptual disorders, auditory and visual hallucinations. These are snorted and rarely taken orally or injected. Detrimental effects: (a) Acute – include nausea, slurred speech, dizziness, collapse, agitation, tachycardia and visual hallucinations; (b) Chronic – psychosis, depression, anxiety, cognitive impairment and dependence.
Stimulants (e.g. Mephedrone, Khat, Bath Salts, etc.) for euphoria, elevated mood, reduced hostility, increased sensuality, improved sexual functioning, prolonged sexual performance. These are snorted, mixed with drink due to taste and injected. Detrimental effects: (a) Acute – psychosis, jaw clenching, teeth grinding, tremor, tachycardia, headache and convulsions); (b) Chronic – psychosis, depression, anxiety, cognitive impairment and dependence.
Hallucinogens (e.g. LSD, Magic Mushrooms, etc.) for euphoria, mild stimulation, altered sense of time and space, enhanced music appreciation, visual distortions, and intensified sexual feelings. These are taken orally, sublingually, buccal and rarely snorted, Detrimental effects: (a) Acute – dysphoria, panic, paranoia, tremor, tachycardia, hyperthermia, and depersonalisation; (b) Chronic – flashbacks, persisting perceptual disorders and rarely dependency.
Makes you wonder why anybody would want to take any of the above. To make matters worse people don’t really know what they are buying – what it says on the tin is invariably not exactly what’s in the tin! There’s no way of knowing the strength or what the substance has been adulterated with, or how you could react to what you have taken on each occasion.
Harm reduction advice may mitigate some of the worst problems for people. A lot of this is common sense:
- Seek urgent medical treatment if you’ve taken too much and don’t use other drugs in the hope of counteracting the effects;
- Two or more substances taken at the same time increase the risk of overdose and complications (especially sedatives such as alcohol and ketamine);
- Always have somebody with you and do not use these substances when you are alone;
- If going to sleep, sleep on your side in case you are sick during the night;
- If you are with somebody who has fallen asleep, or is unconscious, place them in the recovery position;
- Drink plenty of water and keep hydrated.
For more information specifically on NPS have a look at http://www.thedrugswheel.com. The Drugs Wheel, which was originally designed as a training tool, seeks to classify the drugs to allow for tailored advice and harm reduction to be given by category. This means that you don’t need in-depth knowledge of all of the drugs currently around (i.e. you can provide generic advice).
If you want some more detail about NPS visit project NEPTUNE at http://neptune-clinical-guidance.co.uk/e-learning/ for free online e-learning developed in partnership with the Royal College of Psychiatrists.
If you need to signpost somebody for help then try http://www.talktofrank.com. This website offers friendly and confidential drugs advice and an insight into users’ experiences.
On 26 May 2016 the Psychoactive Substances Act became law, making the “legal highs” become illicit to supply or possess with intent to supply. Unfortunately, the new law didn’t prove effective and there was an amendment to the Misuse of Drugs Act 1971. This made synthetic cannabinoid receptor antagonists (SCRAs) a Class B Drug under Part 2 of Schedule 2 of the Misuse of Drugs Act 1971. See link: Circular 010/2016. The penalty for possession of a Class B drug is up to five years in prison, an unlimited fine or both – https://www.gov.uk/penalties-drug-possession-dealing
Unfortunately, these drugs are taken by a percentage of the general public but if we at least have a sound understanding of their affects then we can try to support harm reduction.
Pharmacy First Update
Spring has now sprung and I’m not sure where the time goes. As busy pharmacists the months, and indeed years, seem to roll on at an ever-increasing speed.
It was way back in early December 2016 that Southern Derbyshire CCG (SDCCG) and Erewash CCG (ECCG) launched their Pharmacy First Minor Ailments Scheme. Since then around 12 thousand people have benefitted, and with one in five GP consultations taken up by minor ailments, 18-20% of GP workload, this must have helped relieve at least some pressure on our local GPs’ time.
A recent two-month SDCCG scheme report, covering the period between 1st November and 31st December 2017, showed 2,234 ‘provisions’ or ‘personal interactions’ with community pharmacy contractors. This was 1,757 in SDCGG and 149 in in ECCG – a 6.7% increase in activity from the previous two-month period. Interestingly, the majority of people accessing the scheme were under the age of 13 (65%) and the remaining activity was spread fairly evenly across other age groups.
In fact, out of the 2,234 patients who accessed the scheme during November and December only six were referred on to another healthcare provider; to their GP, with a 50% split of urgent (within 24 hours) and non-urgent. Referrals were all made in line with the Pharmacy First Protocols.
It was also found that the two main reasons for accessing the service were temperature/fever (44%) and head lice (13%).
132 Community Pharmacies in Southern Derbyshire and Erewash are signed up to participate in the scheme, and, of these, 113 provided service to eligible patients in the two-month report period. If these pharmacies hadn’t delivered the service 95% of the consultations would have transferred to GP appointments!
The report concluded that: “the Pharmacy First Scheme continued to have a good uptake with some community pharmacies seeing a high number of patients. G.P practices and participating community pharmacies continue to promote the scheme to patients and ensure eligible patients are signed up to the scheme.”
The scheme was reviewed in March this year to determine its viability by the four CCGs’ (Southern Derbyshire, Erewash, Hardwick & North Derbyshire), because of the introduction and implications of their new Self-care policy. The schemes users, providers and other stakeholders were included in the review and the outcome will be revealed in due course.
We are also now conducting a small-scale extended care pilot study, supported by NHS England North Midlands (NHSE-NM), which will look at Ear, Nose & Throat (ENT) and Eye conditions. The pilot study will involve up to eight pharmacies in Derbyshire and 15 in Nottinghamshire. All of the participating pharmacists have attended a CPPE course with a focus on ENT and Eye, so that they have the necessary skills to support patients with these conditions.
PGDs are a key element of the service and they will facilitate the supply of antibiotics after an appropriate assessment. Participating pharmacies have been supplied with the necessary medical equipment, at NHS-NM expense, to use during the consultations (e.g. 3m Littman otoscopes, Braun Thermoscan thermometers, and consumables).
The overall aim of the service is to ensure that patients can access self-care advice for the treatment of ENT and Eye, and, where appropriate, can be supplied with antibiotics or other appropriate treatments, at NHS expense, to treat their condition. As part of the service patients will be examined and a full assessment made of their condition. This will ensure compliance with PGDs and help the pharmacist make appropriate decisions on the most suitable treatment to address the patient’s symptoms.
The money for the pilot is non-recurrent funding and the success of the pilot will determine whether the extended care service is commissioned in the future. On completion of the pilot the service will be evaluated to consider its usefulness with a view to applying for further funding to extend it to both a wider number of pharmacies and, potentially, to cover a greater range of conditions. Watch this space!
March 2018: Swallowing Issues and Dysphagia
I find it hard to resist a good leaflet. At Continuing Professional Development (CPD) events there’s often a wide choice and it would be rude not to take at least one. At the time I’m full of good intentions to read them, but all too often the leaflets are placed on a ‘read later’ pile, which over several months/years becomes precariously tall.
The other day I tackled ‘the mountain’ and came across several leaflets on swallowing difficulties from Rosemont Pharmaceuticals Ltd. ®. I started reading and was soon reminded of how common it is for people to have problems taking their medication. In my own practice I’ve noticed increased prescribing of orodispersible tablets and, when dispensing for care homes, a lot of crushing of tablets is required.
We’ve probably all struggled at some time or another to take tablets or capsules. A 2007 article published in “Pharmacy In Practice” suggested around 60% of people over the age of 60 sometimes struggle to swallow solid medications. As part of the survey, people were asked if they have ever needed to open a capsule or crush a tablet in order to swallow the medication and 70% of respondents said they had. A similar proportion admitted to not taking their medication, as it proved too hard to swallow.
If a patient reports difficulty taking their medication, there are usually alternative dosage forms that can help to alleviate the problem. However, perhaps less than a third of patients are asked by their prescriber if they have difficulties taking tablets or capsules before they are given a prescription. This is when non-compliance could be an issue, not because patients don’t want to take their medication, but because they can’t physically take it.
Dysphagia is a common problem and there are several causes:
- Neurological causes (damage to the nervous system can interfere with the nerves responsible for starting and controlling swallowing) – stroke, Parkinson’s disease, multiple sclerosis, dementia, motor neurone disease, etc.
- Congenital and developmental conditions – learning disabilities, cerebral palsy, cleft lip and palate
- Obstruction – some conditions cause an obstruction in the throat or a narrowing of the oesophagus, which can make swallowing difficult – mouth cancer, GORD, infections (e.g. TB and thrush can lead to oesophageal inflammation), etc.
- Muscular conditions (rare) – scleroderma and achalasia (I had to look these up too!)
- Ageing – as you get older, the muscles used for swallowing can become weaker and this may explain why dysphagia is relatively common in elderly people
- COPD – makes it difficult to breathe in and out easily and this can impact on the ability to swallow properly
Pharmacists have a key role in supporting patients to take their medicines and recommending alternatives if they become aware a patient can’t take their medication easily. For more information http://swallowingdifficulties.com has some excellent resources for patients and healthcare professionals. I particularly like the facility whereby you can type in the name of a drug and get an instant report of the forms in which it is available. Also, particularly useful for healthcare professionals, there is additional information on coatings and an indication of whether it would be safe or appropriate to crush.
As professionals it is vital to remember that crushing a tablet or opening a capsule means you are changing the form of the medicine, meaning that the use of the drug in this way is unlicensed.
Licensed medicines have been tested for effectiveness and safety and there will be an associated data sheet giving all the licensed indications, routes of administration, etc. There are legal consequences of crushing tablets. When something is prescribed off-license the liability rests with the prescriber and crushing or dispersing a tablet would render it unlicensed, unless this is recommended in the data sheet (probably unlikely in most cases). Other healthcare professionals without prescribing rights are not legally permitted to recommend medicines for off-label unlicensed use – doing this would contravene the Medicines Act.
It’s very important to consider medicines optimisation in patients with dysphagia. Keele University has done a great deal of work in this area and supports the following website https://www.dysphagia-medicine.com/index.html.
Finally, it’s not just adults who have problems taking their medicines, so go to the Medicines for Children website to find out more about helping children swallow tablets. If we start helping children, then we may not have as many adults who say they can’t take tablets in the future!
February 2018: Availability of Medicines
Last month I wrote about “The Real Cost of Supplying Generics” and how pharmacy contractors are struggling to cope with stock shortages, funding cuts, cash flow and the constant battle to ensure that patients get the medicines they need.
The national press is also taking an interest in the problem and The Times published an article on 7 December with the headline, “Patients hit by shortages of drugs as prices soar.” They reported that at least 100 drugs have been affected by supply problems, forcing health officials to approve temporary price rises of up to 4,000% to boost stocks.
PSNC has also produced a briefing document, “Unprecedented drug shortages: Briefing for CCGs, GPs and other NHS prescribers” which has been shared with our CCGs and the LMC.
The situation is only likely to get worse and it can be difficult to know how to respond to patients’ questions. With this in mind Community Pharmacy Cheshire and Wirral have shared the document below with LPCs. I’ve made a few minor amendments and I hope you will find this helpful in your practice.
Medicines Supply Issues
There are currently difficulties sourcing medicines which is leading to problems. All pharmacies are faced with the same situation and are asked the same questions, so I thought it might be helpful to cover the top six key questions.
- Why is my medicine out of stock?
The recent weakness of the pound within global currency markets plus the closure of some drug production facilities by the Medicines and Healthcare products Regulatory Agency (MHRA) has meant supply of some medicines have been dramatically reduced. Consequently, there are acute shortages of around 100 different generic drugs. This has meant vast cost increases, which must be paid initially by Community Pharmacies, then via drug cost reimbursement mechanisms, and ultimately by the NHS.
- I can’t get my medicine from my usual pharmacy but another pharmacy has it – why is that?
There are two main reasons for this. Firstly, different pharmacies use different suppliers and it will depend on whether their wholesalers have stock or not. Secondly, some manufacturers restrict the amount of a specific medicine that a pharmacy can order. This is known as a quota. Once a pharmacy has used their quota for the month it can be really hard to get any more until the start of the next month.
- What is the difference between brands and generics?
A brand is the name the manufacturer or pharmaceutical company gives to the medicine (for example Nurofen™) and only that manufacturer can make, sell and market that brand. If your doctor prescribes by brand name the law says we have to supply that brand.
A generic name specifies the ingredient of the medicine (for example ibuprofen). Often generic medicines are made by a number of manufacturers. If your doctor prescribes using a generic name we can supply any manufacturer’s generic product that we have in stock or can obtain.
- Why are my new tablets a different size, shape and colour?
Because some medicines are in short supply your usual tablets may not be available. In this case, to make sure you don’t go without medication your pharmacist may supply you with the same medicine, but from a different manufacturer so your tablets may change their appearance (e.g. colour, taste, shape, etc.). The main variation is likely to be with the packaging, as this will reflect the manufacturer’s ‘house’ style.
The medicine has the same active ingredient, so it should work just as well for you, but if you have any queries or concerns don’t hesitate to talk to your pharmacist.
- What is my pharmacy doing to help?
Most pharmacies have several wholesaler accounts, but the sheer scale of
the medicines shortages means that lots of wholesalers don’t have stock available. Pharmacies are trying really hard to find stock for their patients. This includes seeing if stock may be available for you in other local pharmacies. This is a national problem and pharmacy representatives are working with the Government to help resolve these problems.
- What can I do to help?
- Order your medication in plenty of time (but not normally more than seven days before it is due).
- Only order what you require. If you have unused medicines in your cupboard use these first (remember to check the expiry date).
- Your pharmacist is trying really hard to source these items so please bear with them if they are having difficulty getting medicines for you.
None of the above will come as a surprise to you I’m sure, but it may help you counter some of the frustration that patients have when they can’t get their regular medication easily. Unfortunately, it will probably do little to help address your own frustration with not being able to get stock. It is hoped that health officials find a long-term solution to the issue rather than ‘quick fix’ concessionary pricing. This helps, but doesn’t tackle the fundamental issue of shortages affecting the UK market.
Chairman, Derbyshire LPC,
Thank you to Community Pharmacy Cheshire and Wirral for allowing us to use this document in Derbyshire
January 2018: The Real Cost of Supplying Generics
A generic medicine is the equivalent of a branded drug. They have the same dosage, intended use, effects and side effects. The route of administration is the same as are the risks, safety, strength and pharmacological properties. Some variation is allowed for colour, taste, shape, and excipients, but these are only minor differences and the major variance is packaging, reflecting the manufacturer’s style.
So what? Well, financial pressures associated with these generic drugs are draining community pharmacies of underlying cash reserves. In conjunction with funding cuts, this is leaving many community pharmacies close to breaking point in terms of cash flow. We are facing a very real danger of Community Pharmacy closures which would be a catastrophe not just for the Pharmacies, but for the patients they serve.
Historically, the average cost of generic drugs in the UK have been the lowest in the world by a significant margin, saving billions of pounds. The only other country with prices approaching ours is New Zealand where they have a heavily restricted prescription market supported by central procurement. The most expensive market is in the USA.
So, what’s made a difference in the UK? The short answer is: “effective procurement.” The Government closely monitors procurement activities and, by agreement with community pharmacy, collects substantial sums in generic drug rebates. Since 2005 these rebates have totalled £11-14bn (depending on who’s figures are used). This is in the context of the entire annual NHS primary care drugs bill of around £9bn.
However, sterling weakness on global currency markets, and closure of some drug production facilities by the Medicines and Healthcare products Regulatory Agency (MHRA) has meant availability of some generic drugs have been dramatically reduced. Consequently, there are acute shortages of around 100 different generic drugs. This has fuelled some eye wateringly large cost increases, which must be paid initially by Community Pharmacies, then via drug cost reimbursement mechanisms, and ultimately by the NHS.
Unfortunately, it’s probably only going to get worse as the issue is complex, multifaceted, and has clearly been exacerbated by the impact on Community Pharmacies’ funding cuts imposed by the Department of Health. These cuts imposed by The Department of Health on 1st December 2016 reduced overall funding to Community Pharmacies by around 12% in actual real terms.
So, why should cash flow and depleted cash reserves matter? Well, pharmacies must physically buy drugs (otherwise known as procurement), from their own cash resources to supply dispensed medicines to patients on the NHS. It then takes Community Pharmacies up to 90 days to receive full and accurate payment from the NHS under the drug cost reimbursement mechanisms for the drugs supplied. This should be contrasted with the payment terms demanded by the drug wholesalers that supply Community Pharmacies, which require full payment for all supplies made to Community Pharmacies within 60 days.
Community Pharmacy teams’ absolute priority is always to ensure continuity of supply to their NHS patients, irrespective of the actual price paid to the wholesaler for individual drugs. However, it must be recognised that, because of the funding cuts imposed by the NHS, the overall combined cost to Community Pharmacies of providing the NHS dispensing service, and the cost of the drugs supplied isn’t being fully met by NHS reimbursements for the service and cost of the drugs dispensed to patients. This means that after the costs of delivering the NHS dispensing service (e.g. staff and premises costs) are taken into consideration many drugs are now being supplied at a significant actual real cash loss by Community Pharmacies.
There is limited supply of some generics and the choice of what is purchased will be influenced by availability of stock, the price at which this stock can be purchased, and the demand for the product. This has resulted in Community Pharmacy teams spending many hours of extra time every day attempting to source drugs for their patients, to maintain continuity of supply, but in the face of a drastic reduction in funding which has in turn stretched staff resources to breaking point.
This situation is clearly unsustainable given the cash resources depletion driven by the funding cuts and has left many pharmacies struggling to obtain some products for all patients. At the same time, they must attempt to protect their overall viability and in doing so the integrity of services they provide to their local communities.
Therefore, it is simply not always possible to supply a patient with their ‘regular’ brand of generic, because there may be none to be had anywhere or, it could be prohibitively expensive when compared with what the price the NHS will pay for it.
But, it’s not all about money. Theoretically, patients shouldn’t notice any difference when they are given a different generic. Some patients don’t mind having different generics dispensed to them on an almost monthly basis. However, for others it can be a real problem if they aren’t happy with the situation. They may have taken the same generic medicine for years. Changes in the market have adversely affected continuity of supply and constant changes of generic manufacturer could affect confidence in the medication leading to poor compliance and ultimately rising treatment costs and even increased morbidity.
Are we seeing the end of ‘cheap’ generics? It’s going to be increasingly difficult to repeat the historical savings of the last ten years or so. What is certain however is the ability of Community Pharmacies to continue to effectively drive prices down for taxpayers is going to be extremely difficult. In this context the Government funding cuts to Community Pharmacies look perverse and misguided. They may come to realise this as the NHS drug bill climbs and they realise, probably too late, that they have effectively killed the goose that has laid them billions of pounds worth of golden eggs…
Chairman, Derbyshire LPC,
[I should like to thank Garry Myers, LPC Committee Member and Community Pharmacy Contractor, for his insights and contribution to this blog.]
December: Is Christmas good for you? Well, there’s always the New Year!
Working in a busy pharmacy at Christmas certainly has its challenges. The increased activity may be good for business, but can be exhausting and I’m always ready to rest on Christmas Day.
My absolute favourite is the last-minute rush to buy a bottle of perfume minutes before closing time on Christmas Eve. Generally, by men who have suddenly realised they might be in serious trouble if they don’t have a present to give their loved one and often accompanied by: “You couldn’t wrap it for me, could you?”
There’s the huge increase in items that all need to be dispensed in ‘double quick’ time! This is on top of the rise in footfall at the counter as people stock up on those ‘just in case’ remedies to get them through the festivities. I know we’re only closed for a couple of days at most, but it seems these items are mysteriously required almost a month in advance of when they would normally be due!
We all have our own unique Christmas traditions, often started when we were children or when we had children of our own. I’ve been considering what the ‘average’ Christmas entails in terms of consumption and realised that our new Health Champions will have their work cut out come the New Year as they encourage people to make changes to their lifestyle. There’ll be a ‘window of opportunity’ with New Year’s Resolutions, so perhaps we should be planning for this now and getting materials in to support activities in our “Health Promotion Zones” (HPZ). The top three interventions to consider are weight loss, alcohol consumption and smoking cessation.
Weight Loss – Christmas only comes once a year, so why shouldn’t you have turkey with all the trimmings, Christmas pudding, mince pies, cream, cheese, trifle, pork pie, chocolates, nuts, a glass of something (or two…)? Well perhaps we ought to think about the calories at least for a moment before ‘the big day’. A typical Christmas dinner will probably be around 1,000 calories and, during the day, you could get through almost 6,000 calories.
Impressive! It’s a good job we don’t eat like this everyday. To maintain body weight a woman needs 2,000 calories and a man 2,500 calories per day. However, most adults would probably like a little less weight to carry around, so to lose one pound of weight per week we need to reduce these figures by 500 calories a day (e.g. don’t have Christmas pudding with custard and brandy butter = 587 calories).
For the HPZ there’s no shortage of ideas on how to lose weight and signposting people to these resources could make a huge difference to them. How about: the NHS Choices Weight Loss 12-week programme, which combines advice on healthier eating and physical activity. There’s a week-by-week information pack that can be downloaded and a stick-it-on the-fridge planner to keep track of progress.
Alcohol Consumption – this peaks at Christmas and I found an interesting 2006 article from the Independent Newspaper. They stated that: “More alcohol than ever before will be consumed this festive season, prompting warnings from medical experts of a “health crisis”, particularly among young women.
“Over the 12 days of Christmas, the average Briton will get through 18 pints of beer, three bottles of wine, one bottle of spirits and four glasses of fortified wine – the equivalent of 137 units of alcohol in less than two weeks. This puts drinkers at real risk of liver disease and other alcohol-related conditions.”
For the HPZ – a reminder of the current alcohol drinking guidelines, which were updated in 2016, for the first time in over 20 years. The new guidance has the same message for men and women: to keep health risks to a minimum you are safest not to regularly drink more than 14 units per week. Also, drinking should be spread evenly over 3 or 4 days and not done in a day or two’s binge.
Smoking Cessation – this is the single most important intervention to make as half of all long-term smokers will die early from smoking-related diseases such as heart disease, lung cancer and chronic bronchitis. For example, men who quit smoking by the age of 30 add 10 years to their life and stopping at 60 adds 3 years. It’s never too late to make a change that will vastly improve your health and wellbeing and this is without even considering the huge financial savings that accrue from not smoking.
For the HPZ – why not consider a display of Nicotine Replacement Therapy (NRT) products and signpost to the NHS Smoke free website?
Studies have shown that you’re four times more likely to quit with help. Additional support is available from local stop smoking services and you should have contact information available for those people who require additional support.
Derby City has its Livewell Stop Smoking Support Service and county-wide there is the new Live Life Better Derbyshire Stop Smoking Service. Unfortunately, neither service makes use of the community pharmacy network and accessing the support may not be straightforward or all that convenient. Livewell has been around for some time, but Live Life Better Derbyshire only took over smoking cessation services on 1st December.
However, your Health Promotion Zone is an opportunity for you to engage with your customers and make a difference to their wellbeing and health outcomes. Why not make a commitment to “Addressing Local Health Needs” as your New Year’s Resolution? It’s simple, worthwhile and will definitely keep you busy all year around.
I would like to take this opportunity to wish you all a very Happy New Year!
Vitamin D Deficiency and Health
National statistics show that increased prescribing of vitamin D, namely Colecalciferol, is a growing trend.
In England there were almost 20 million Colecalciferol prescriptions in 2015 at a cost of around £90 million pounds, putting it in the #1 position of the BNF 9.6 Vitamins Top 10. The next nearest competitor was Thiamine, prescribed 2.5 million times.
With a four-fold increase in the number of prescriptions for Cholecalciferol between 2005 and 2015, you could be forgiven for thinking there is an epidemic of deficiency.
So why do we all need vitamin D and why aren’t most people getting enough of it?
Vitamin D promotes calcium absorption in the gut and helps regulate the amount of calcium and phosphate in the body. This ensures normal mineralisation of the bones and prevents hypocalcaemia tetany. It is also needed for bone growth and bone remodelling by osteoblasts and osteoclasts.
A lack of vitamin D can lead to bone deformities such as rickets in children and osteomalacia in adults. Also, together with calcium, vitamin D helps protect older adults from osteoporosis.
Vitamin D is a fat-soluble vitamin which is naturally present in only a few foods making it hard to get hold of. There are however a number of options, but typical portion size could be an issue and needs to be taken into account. There may be some people, who would enjoy eating 10 rump steaks, or six whole boiled eggs or 8 bowels of cereal, but there can’t be that many and it certainly doesn’t look to have the makings of a healthy diet.
See below for an indication of vitamin D content of foods in relation to a typical portion:
- Oily fish – salmon (steamed 9.9µg), mackerel (grilled 13.6µg) and tuna (baked 4.7µg)
- Red meat – liver (lamb, fried 0.9µg) and beef (rump steak, fried 1µg)
- Eggs – whole boiled (1.7µg) and yolks (2.3µg)
- Fortified foods – bran flakes/corn flakes/rice cereal (1.3µg) and fat spreads (0.75µg)
It looks like eating more oily fish could be the best option as this comes closest to providing an adequate amount of vitamin D without having to consume an excess amount of food.
Vitamin D is also known as the “sunshine vitamin”, because it is produced endogenously when ultraviolet rays (UVB) from sunlight strike the skin and trigger vitamin D synthesis. The substance itself whether from food, supplements or sun exposure is actually biologically inert and must undergo two hydroxylations in the body for activation.
Unfortunately, vitamin D synthesis in the skin only really works for part of the year and then there’s a risk of sunburn and skin cancer if you really ‘go for it’! From late March until the end of September most people can make enough vitamin D from being out in the sun as follows:
- Go outside every day for at least a short period – sitting indoors by a sunny window doesn’t work as the UVB rays can’t get through the glass
- Expose forearms, hands or lower legs uncovered and without sunscreen
- Length of exposure required will vary with skin colour and how much skin is exposed
What happens in winter? In the UK, there just isn’t enough UVB radiation to promote vitamin D synthesis in the skin. Therefore, from October to early March there is no chance of making your own vitamin D, which means that you will need to ensure adequate dietary intake (see above) or take vitamin D supplements. The latter are readily available and the Department of Health recommends that some groups of the population definitely make sure that they get enough. As detailed on the NHS Choices website, these groups are:
- All babies from birth to one year of age (including breastfed babies and formula fed babies who have less than 500ml a day of infant formula)
- All children aged one to four years old
- People who are not often exposed to the sun – for example, people who are frail or housebound, or are in an institution such as a care home, or if they usually wear clothes that cover up most of their skin when outdoors
In 2007 the Scientific Advisory Committee on Nutrition (SACN) considered the evidence on vitamin D and health and concluded there was insufficient data to reconsider the Dietary Reference Values (DRVs) for vitamin D. However, in 2016 SACN produced a 304-page report: “Vitamin D and Health”, which changed their previous advice and they recommended that everyone in the general UK population, aged 4yrs and above, should have 10µg/day (400IU/day).
For those not included in the specified groups above the recommendation is that, everyone over the age of five years (including pregnant and breastfeeding women) is advised to consider taking a daily supplement containing 10µg of vitamin D. But, you can have too much vitamin D and for most people 10µg will be enough as a daily supplement. The advice is not to have more than 100µg a day for an adult, children 1-10 years it’s no more than 50µg per day, and babies under 12 months the maximum is 25µg.
The current recommendations are based on bone health. Vitamin D may also have a role in other health outcomes, which include reducing the risk of Type 1 and 2 diabetes, cancers, cardiovascular disease, infectious diseases and autoimmune diseases. There’s a lot more research to be done, but the evidence for improved bone health alone is enough to convince me that vitamin D supplementation is vital during the winter months for most people.
Hospital Discharge: Next steps?
Patient discharge from hospital should be a positive, stress free experience – the opportunity for a patient to return to normality with proper professional support.
With more than 13 million hospital admissions in England every year, a slick NHS wide best-practice process should really be in place. However, the sheer scale of the NHS, the number of admissions and indeed readmissions makes this real a challenge. In 2012-13 there were 1 million readmissions within 30 days of discharge at a cost of £2.4 billion!
In the same year between October 2012 and September 2013 there were around 10,000 reports to the National Reporting and Learning System (NRLS) of patient safety incidents related to discharge. Around a third were cited as being due to poor communication. It is sadly the case that information, even when provided, is not always acted on in a timely manner which can result in avoidable deaths, failure of continuity of care and avoidable readmission to secondary care.
So something needs to change. Developing an integrated approach to patient care and proper support following hospital discharge has been shown to reduce frequency of hospital readmission and generate significant savings for the local health economy1:
As pharmacists, it is no surprise that “Patients receiving a follow up review at their community pharmacy were three times less likely to be readmitted to hospital after discharge.”
Therefore, involving community pharmacy makes economic sense and pharmacy should be an integral part of patient discharge pathways.
We know that if a patient has been in hospital only around 1 in 10 will come out on the same medicines they went in on so pharmacists need to assure themselves that the correct medication has been prescribed when they receive the first post-discharge prescription.
Currently, most queries will result in a call to the surgery, but, with the patient’s informed consent, the Summary Care Record (SCR) could be accessed. N.B. GPs have ownership of the SCR and any updates to medication will need to be done by them and updates are processed overnight, so there could be a delay.
With unintended discrepancies in patient’s medicines after discharge from hospital affecting up to 87% of patients there is great potential for adverse health consequences and many of these could be preventable.
GPs are usually sent a discharge summary, including a current medication list, within 24 hours of discharge. A patient’s pharmacist doesn’t routinely get this information at the moment. This causes problems, as medication changes may not be acted upon (e.g. dose changes, continuity of newly prescribed medicines, discontinuation of previous medication, etc.).
How much better would it be if the pharmacy received the discharge information directly and at the same time as the GP?
GOOD NEWS: This is now possible with PharmOutcomes and Chesterfield Royal Hospital (CRH). With support from NHS England North Midlands they have implemented a fully integrated solution, which should help to make a real difference. It will reduce hospital workload and all discharge information can be transferred automatically to the community pharmacy when the discharge letter is published. The community pharmacy will be notified of all referrals requiring action at the top of their PharmOutcomes service screen. In addition, a non-patient identifiable e-mail is sent to the pharmacy to notify them.
Referral criteria will be agreed between NHS England and CRH, so not every newly discharged patient will be notified to the pharmacy. This will mean that those ‘at risk’ patients most in need of support will be prioritised. Consequently, there will be opportunities for New Medicine Service (NMS) interventions and post-discharge MURs. It should also help with workload as post-discharge information will be received in a much timelier manner.
The LPC fully supports the smarter referrals facility and encourages all pharmacists to make the most of the opportunities that are on offer. In particular, post-discharge MURs can provide invaluable support and should be conducted if at all possible. This would ensure that the patient was fully aware of any changes, side effects and interactions, and knew why they were taking any new medication (or not taking their old medication). What better way to discharge your responsibilities…
In December 2014 the Royal Pharmaceutical Society published a referral toolkit: “Hospital referral to community pharmacy: An innovator’s toolkit to support the NHS in England”. This document laid out the case for change:
- 30-50% of patients don’t take their medicines as intended
- Non-elective admissions are estimated to cost £1,739
- Between 30% and 70% of patients have either an error or an unintentional change to their medicines when their care is transferred
- 1.3 unintended discrepancies for every medicines reconciliation completed by a non-pharmacist member of staff
- Two-thirds of discharge summary letters are inaccurate or incomplete prior to pharmacy screening
Well that change has come and I hope you will join me in welcoming it!
Chairman, Derbyshire LPC,
What causes 44,000 deaths a year, costs the NHS around £2.93 billion a year, affects more people than heart attacks and kills more people than bowel, breast and prostate cancer combined? Awareness about the answer to this question is so low that in May this year the World Health Organisation (WHO) made it a global health priority.
It’s sometimes called the “silent killer” and is colloquially known as “blood poisoning”. The correct medical term is sepsis and it’s a life-threatening complication as a result of an infection when the body’s immune system goes into ‘override’. It can affect various internal organs and it should only be called septicaemia when bacteria have invaded the blood stream.
It occurs when the immune response of the body is so extreme that it damages the body. It can occur because of problems spreading from other parts of the body, such as chest infections, urinary infections, ulcers, or cuts and bites on the skin.
There are three increasingly dangerous stages of sepsis:
- Sepsis – infection is present and there are symptoms such as high or low temperature, fast heart rate, sometimes with rapid breathing
- Severe Sepsis – when the infection starts to interfere with the normal function of some of the body’s organs
- Septic Shock – symptoms of severe sepsis, but, with blood pressure falling to dangerous levels, organs fail as they don’t receive enough oxygenated blood
Who’s most at risk? Unsurprisingly, it’s people with a poorly functioning immune system, such as those with cancer, organ transplant, or AIDS, or because of medical treatment (e.g. chemotherapy, or steroids). However, it is important to remember that healthy people can develop sepsis, so it pays to be vigilant. Other groups at risk are young babies (immature immune system), pregnant women and the elderly (especially those with other conditions such as diabetes).
An appropriate broad-spectrum antibiotic will be given, but bacterial resistance can cause the treatment to fail. It should also be noted that other microbes could cause sepsis including fungi, viruses and parasites. Symptoms will be similar and what may have started as a localised problem becomes widespread affecting all of the body’s organs and tissues. Sepsis should be treated as a medical emergency and treatment is usually given in hospital and often in an intensive care unit.
So why don’t more people know about the condition? Sepsis isn’t talked about very often, although this is beginning to change as various awareness campaigns gain media attention. We hear of people dying from infections, but the cause of death is usually stated as being due to a specific primary condition such as pneumonia (infection of the lungs). This means sepsis is seldom listed as the cause of death and so many people think it’s not a problem.
Public Health England launched a campaign in December last year. The target audience in this instance was parents/carers of children from 0-4 and the key message was that sepsis is a rare, but serious complication of an infection. Catching sepsis early can improve chances of treatment, so if a child has any of these symptoms the parents/carers shouldn’t be afraid to go to A&E immediately or call 999:
- Are breathing very fast
- Have a ‘fit’ or convulsion
- Look mottled, bluish, or pale
- Have a rash that does not fade when you press it
- Are very lethargic or difficult to wake
- Feel abnormally cold to touch
Sepsis was made a global health priority in May 2017 when the World Health Assembly and the World Health Organization adopted a resolution to improve, prevent, diagnose, and manage sepsis. This marks a quantum leap in the global fight against sepsis. It’s World Sepsis Day on Wednesday 13th September and one of the key ambitions for the day is to raise public and professional understanding and awareness of sepsis.
In the words of Dr Ron Daniels, chief executive of the UK Sepsis Trust:
“We could save 12,500 lives a year and improve the quality of life for another 100,000 survivors just by recognising sepsis earlier and delivering good basic care.”
Prompt medical treatment saves lives and the first hours are most important. Be vigilant: look out for this silent killer!
August 2017: Public Health Campaign Resources and Advice
I am proud to announce that Derbyshire LPC has trained 178 Health Champions and 125 Health Leaders with funds from Health Education East Midlands and NHS England North Midlands.
The training however is just the beginning. Our Healthy Living Pharmacies (HLP) may be asked to provide their Portfolio of Evidence by various inspectors at any time (e.g. RSPH Evaluators, GPhC inspectors, NHS England, etc.), so it’s important that this information is kept up to date and accurate.
I’ve been asked several times for advice on what would be an appropriate health promotion topic and where to look for supporting resources. I would love to provide a definitive answer, but HLP is all about the pharmacy identifying LOCAL public health needs and engaging with their local population by addressing these needs in an appropriate manner.
I can say that the Public Health England Campaign Resource Centre is excellent and has everything you need to deliver their award winning campaigns at a local level. Just register for an account to gain access to lots of free professionally produced material (e.g. posters, leaflets, etc.). You can see what campaigns they are promoting and one of these could be relevant to you at a local level (e.g. Be Clear on Cancer).
A general overview of public health needs can be found in the JSNA/PNA, Director of Public Health’s Annual Report or after discussion with commissioners or public health professionals. More accessibly, online Health Profiles provide a snapshot overview of health for each local authority in England (can be drilled down to district level). This highlights issues that can affect health locally and is effectively “your starter for ten”.
If you are looking for ideas then check out the PSNC website. There’s plenty of guidance on everything pertaining to HLP, so why not start with their HLP Overview. Want specific ideas and suggestions on health promotion events and campaigns then take a look at the HLP Promotion Ideas section.
I also advocate regular visits to our Derbyshire LPC Website to see what’s happening locally and for information that could be relevant to your locality. Our meeting reports provide information and specific guidance on opportunities for contractors. In addition, the monthly Chairman’s Blog looks at topical matters and we use Twitter (follow us @DerbyshireLPC) to highlight news stories that could be of interest.
What about topical news stories in the media? There’s always something going on and health news regularly hits the headlines, especially if you are a Daily Mail reader! So keep abreast of what’s happening:
National newspapers will give an insight into current health issues (e.g. obesity, diabetes, smoking, etc.) and these may be relevant to what’s happening in your area
Local newspapers will highlight current local issues – also, the LPC provides copy to local newspapers (monthly) on a health related topic and this is now being taken up regularly (e.g. carers week)
National Days/Weeks – look out for these and build on the publicity that surrounds them to create local interest and engagement (e.g. No Smoking Day on 8th March, Carers Week w/c 12th June, etc.).
Additional resources can be sourced from the so-called ‘Third Sector’ (i.e. the voluntary or community sector organisations that are not-for-profit and non-governmental) a.k.a. charities:
Charity websites can be an excellent source of information and usually free materials or educational material you could use to brief/train staff (e.g. National Osteoporosis Society, Diabetes UK, Asthma UK, etc.) – if you can identify a local health need there will almost certainly be a charity for it!
Local Charities – link with local charities for health promotion – they can provide local insights and may be willing to support the local health promotion events (i.e. a Win: Win situation)
I can also advise that whatever you decide to do make sure you have planned your campaign carefully, so you have the resources you need to create impact and interest.
When building your portfolio you will need to show evidence of your pharmacy’s health promotional activities. There needs to be a Health Promotion Zone that is clearly marked and accessible, looks professional and is appropriately equipped with up-to-date professional health and wellbeing information which meets identified local needs.
Finally, don’t forget to make use of your new Health Champion. They will be looking for opportunities to make a difference, so work with them and coach them to take ownership of health promotion. They are probably your most valuable resource! Finally, don’t forget to brief your staff and provide any training that might help them better understand the ‘ins and outs’ of your campaign. They need to be on board, so they can talk confidently to customers and get their engagement to make lifestyle or other changes. This is where that HLP leadership training should ‘kick-in’.
Before I conclude this month’s blog it is important to remind you of a few housekeeping matters:
- The first declaration period for the Quality Payments Scheme closed on 12th PSNC reported that over 11,000 pharmacies have completed a declaration for this period and should expect their first payment under the scheme at the end of June.
- The second review point is Friday 24thNovember and this is effectively the deadline for becoming a registered Healthy Living Pharmacy (HLP) Level 1.
- Contractors who have not previously been accredited, as an HLP must have an entry in the Royal Society for Public Health (RSPH) online register as a profession-led self-assessed HLP Level 1, as detailed inthe NHS England Pharmacy Quality Payments Quality Criteria Guidance.
- Completion of the assessment of compliance on the RSPH websitedoes not meet the HLP quality criterion; RSPH will need to confirm registration (RSPH will endeavour to contact contractors by mail or email within 10 working days) before a contractor can claim the HLP quality criterion.
That’s all for now folks!
July 2017 : The Importance of Medicines Administration Record [MAR] Sheets
You will be aware that the MAR Sheet service started in 2005 and has remained largely unchanged since. The specification is basic and was originally called “Pharmacy Labels for Attachment to Medicines Administration Sheets for use by Social Services Provided by Community Pharmacy Services.” The service was commissioned by the PCT and contractors could choose whether they wanted to participate. When PCTs became defunct the responsibility transferred to CCGs.
You will also be aware that the need for MAR sheets in order to help avoid medicine-related hospital admissions has never been greater. During the decade this service has been in existence staff turnover of care agencies appears to have increased and the average length of time for visiting service users per visit has come under pressure. Without this important support in place there could be an increase in demand for residential care sooner rather than later as it becomes increasingly difficult to support patients in their homes.
It is currently the case that the Local Authority delivers Adult Care Services and in May 2016 they issued Medication Management Standards which replaced the old Overarching Medication Policy. The guidance sets out the minimum standards for the provision of assistance to customers directly supported by Derby City Council People Services Directorate, (Adults and Health), or Derbyshire County Council Adult Care and agents acting on their behalf. It is expected, by both local authorities, that any provider acting on their behalf will ensure the principles within the document are incorporated into their policy and practice.
In July 2016, Derbyshire County Council Adult Care produced a detailed policy on Home Care Medication and Health Related Activities. The policy aims to promote the independence of clients to manage their own medication wherever possible. It is accepted, however, that in some cases, clients will require support with some parts, or all, of their medication.
The guidance is designed to support employees, managers, and carers involved in the provision of Home Care services.
- The client must agree to any support provided and there will be an initial assessment to determine what these needs are and how they will be addressed.
- Home Care staff will not make judgements on medication (e.g. take as required unless adequate dosage and directions are on the Medication Administration Record (MAR) sheet).
- The prescriber must write clear instructions on the prescription including the reason for the medicine as well as the dose range and the maximum dose.
- Assistance with medication can only be provided where there is a support plan, medication and associated risk assessments and recording documentation accessible in the client’s home.
- Home Care staff must only administer medication from the original container, which the pharmacist has dispensed into, and not from any container filled by any other person.
- All support with medication must be recorded at the time it is provided, by the person who provides it, so having a MAR sheet is an essential part of the support being provided.
- If a client refuses to take medication from either the original container or compliance aid (e.g. blister pack), the Home Carer must record this with the appropriate code on the visit record sheet, the MAR sheet.
- Where blister packs are provided there should be a description of each tablet in the blister pack. If the client then refuses any tablet from the pack, the Home Carer will be able to identify the tablet being refused. Under these circumstances, a record that describes the colour, size, shape of the tablet will need to be included on the visit record sheet and MAR sheet.
NICE Guidelines were published 30th March 2017; “Managing medicines for adults receiving social care in the community.” This guideline covers medicines support for adults (aged 18 and over) who are receiving social care in the community. It aims to ensure that people who receive social care are supported to take and look after their medicines effectively and safely at home. It gives advice on assessing if people need help with managing their medicines, who should provide medicines support and how health and social care staff should work together.
- Section 1.5 of the Guideline covers record keeping. Social care providers are required by law (The Health and Social Care Act 2008 [Regulated Activities] Regulations 2014) to securely maintain accurate and up to-date records about medicines for each person receiving medicines support. Care workers should use a MAR to record any medicines support that they give to a person. This should ideally be a printed record provided by the supplying pharmacist, dispensing doctor or social care provider (if they have the resources to produce them).
- Section 1.9 of the Guideline covers ordering and supplying medicines. Supplying pharmacists and dispensing doctors should supply medicines in their original packaging. A compliance aid should only be considered when an assessment has been carried out by a health professional (e.g. a pharmacist), in line with the Equality Act 2010, and a specific need has been identified to support medicines adherence. Also, supplying pharmacists and dispensing doctors should consider supplying printed MAR sheets for a person receiving medicines support from a social care provider.
Provision of MAR Sheets through community pharmacy should remain a Locally Commissioned Service, whether commissioned by CCGs, Local Authorities, or a combination of these commissioners in partnership. Every pharmacy in Derbyshire should be invited to contract as a provider. As this service is currently commissioned, any proposal to decommission it should be referred to the Improvement and Scrutiny Committee (Health) at Derbyshire County Council, and/or the Protecting Vulnerable Adults Board at Derby City Council for their consideration of the impact that this would have on a very vulnerable group of people.
June 2017: Join me in supporting Carers Week – June 12 to 18
Carers Week is an annual campaign which aims to highlight the challenges faced by carers, recognise the contribution they make to families and communities throughout the UK and generally raise awareness of their plight. The week is supported by a partnership of seven charities and the focus this year is on building communities which support carers to look after their loved ones well, while recognising them as individuals with needs of their own.
I wrote last month about the key role Community Pharmacy has in supporting carers. Carers Week is now an opportunity to show your support and I encourage you to get behind the campaign. If you want to know more about building support take a look at this research report, which was published last year. Key concerning facts from the report include:
- Three in four carers don’t feel their role is understood and valued by their community
- 51% have let a health problem go untreated
- 50% said their mental health has worsened
- 31% only get help when it is an emergency
- 72% have given up work or reduced their hours
- 57% are more stressed about being able to care well
- Older carers – 61% have let a health problem go untreated and 59% say their health is becoming a significant worry
There’s a three in five chance that we will become carers at some time in our lives. Therefore, let’s start to build a community resource which offers the support we may one day need to access ourselves. For some of us that time could even be now and with 118,000 unpaid carers in Derbyshire there are plenty of opportunities to make a difference to people’s lives.
Many of you will be actively working towards achieving Healthy Living Pharmacy (HLP) Level 1 accreditation. This is not just a ‘tick box’ exercise, as the underpinning quality criteria need to be evidenced. This can be in the form of an HLP evidence portfolio, so participation in a campaign such as Carers Week could be a part of this. It would fit in well with the ‘Public Health Needs’ and ‘Community Engagement’ criteria, but also give you an opportunity to setup a ‘Health Promotion Zone’ as part of the ‘Health Promoting Environment’ criterion.
I have been asked what support the LPC is offering with developing ideas for health promotion events, so I would like to take this opportunity to commend Carers Week to you. There are now around 170 Health Champions working in our pharmacies. This important training initiative means that we have a valuable resource that we can use to make a difference to people’s lives. Your new Health Champion can get behind this campaign and provide information/support to carers during Carers Week (12th to 18th June).
Want some resources? Following a recent meeting with Adult Care officers, Derbyshire County Council has offered to supply carer information packs for pharmacies to hand out to family/unpaid carers during the awareness week. The packs will include a Guide to Carers services leaflet, a Carers Benefits factsheet and Derbyshire Carers Association leaflet. Pharmacies can also be supplied with printed, laminated copies of a poster to promote the information packs. See below for how to obtain the packs.
You now have your ‘starter for ten’. It would be great to hear about your successes with this campaign, so I would be very interested to learn how you got on (email: email@example.com). Alternatively, for those of you on twitter, why not send a tweet to @DerbyshireLPC or @carersweek #carers.
Derbyshire has an estimated 118,000 unpaid carers who provide care and vital support for family members or friends. That’s more than one in ten of the population whose loved ones simply couldn’t manage without their help. It’s an important role that will fall to three in five of us at some time during our lives.
Working in a community pharmacy means we often get to know the people who come in and learn who looks after who by seeing the prescription they bring in or collect. In day-to-day interactions we get a feel for how they are coping and are able to offer advice and support where needed. These are our opportunities to try to spot if the carer is being affected by the stresses and strains of their responsibilities which may be beginning to wear them down and affect their health.
A key part of what community pharmacy does for these carers or the person they care for is signposting – not called an ‘essential service’ for nothing. Whilst we can help answer queries on medication, or provide healthy living advice, other agencies have a vital role to play. In particular, Local Authorities who provide key public services and support for carers:
- Derby City Council – http://www.derby.gov.uk/health-and-social-care/carers/
- Derbyshire County Council – http://www.carersinderbyshire.org.uk
Unfortunately, the demand for services, particularly from the elderly, is only going to increase, because of demographic changes. In a recent report, Future of an Ageing Population, it was stated that as well as an increase in the amount of ill health, population ageing would mean a greater prevalence of age-related conditions. In fact, the ‘oldest old’, who have a substantial risk of requiring long-term care, are the fastest growing age group in the UK.
Increasingly, there is a move to transfer care into the community in an attempt to reduce people’s reliance on hospitals, nursing homes and other high-cost services. This not only shifts costs, but further shifts responsibility onto families and communities. None of this will work unless there are enough unpaid carers willing and able to respond to the demands.
There are many ways in which unpaid carers can help:
- Personal needs – help with cooking, washing, etc.
- Practical – shopping, changing light bulbs, mowing the lawn, etc.
- Finances – ensuring bills are paid, appropriate benefits claimed (if applicable)
- Emotional – a listening ear, somebody to sit and chat with
- Supervisory – help with taking medicines and monitoring changes in health
- Personal Assistant (PA) – manage GP and hospital appointments,
The amount of support required will vary according to individual needs and circumstances, but will, in all likelihood, increase over time. This generally means an increasing burden for the carer and can lead to difficulties if their own health suffers.
The one thing that is certain is that it’s not an easy job. Caring can be stressful and have a negative impact on the carer and, when asked, around 85% of carers say that their responsibilities have affected their mental and physical health. When a carer can no longer cope it can lead to an emergency situation. Therefore, it’s vital that the carer looks after their personal health and wellbeing.
As community pharmacists we can help to support this in these ever changing and challenging times. If we can care for the carer then we really can be a vital part of the community in which we work and live.
April 2017: We are the champions!
I’m sure you’ll agree that improving the health and wellbeing of our local population, in helping to reduce health inequalities, is a good way to go about a day’s work.
The thinking behind the Healthy Living Pharmacy (HLP) is just that, but for these to exist we need our Health Champions. A key element of becoming an HLP is that at least one member of the pharmacy staff (one Full Time Equivalent) has completed the training and assessment of the Royal Society for Public Health (RSPH) Level 2 Award in Understanding Health Improvement.
After completing the training, and enduring my first invigilated exam in nearly forty years, I can testify from first-hand experience that it’s not an ‘easy ride.’ The training encompasses a wide range of health matters, encourages candidates to develop communication skills and develop strategies that will help them make a difference to people’s health and wellbeing.
Following the training you will be equipped to:
- Know how inequalities in health may develop and what the current policies are for addressing these;
- Understand how effective communication can support health messages;
- Know how to promote improvements in health and wellbeing to individuals;
- Understand the impact of change on improving an individual’s health and wellbeing.
So, what is the role of a Health Champion? A champion can be defined as: “a person who vigorously supports a person or cause”. This fits in well with the concept of being a Health Champion:
- Brief interventions are done with people to encourage them to make small, but simple, changes to their lifestyle or behaviour from which they will accrue health or wellbeing benefits.
- What better cause is there than promoting good health? The World Health Organisation (WHO) has a holistic definition of health: “A state of complete, mental and social wellbeing, not merely the absence of disease or infirmity”. Who wouldn’t want that for themselves or their family and friends?
A vital part of the role is to develop an understanding of local needs and priorities. Some of this information can be gained from looking at Health Profiles and it’s a great place to start looking for insights. Local priorities are defined and the health summary shows how the health of the local people compares to the rest of England. It can be viewed at district level, but local knowledge counts and knowing your customers is essential.
The pharmacy is likely to have only limited resources and a strategy will be needed involving the whole team. In an HLP it’s all about team effort and developing a culture of working together to make a difference, so getting everybody ‘on board’ shouldn’t be difficult.
The Health Champion can help research ideas and options for ways of tackling a particular area of health. It could be something as simple as contacting a local charity, ordering health information leaflets and promotional materials. The important thing is that the key messages are clear, understood by every member of staff and seeks to address a local health need.
All Health Champions need to have to have a passion and desire to make a difference. HLPs provide a platform for them to make that difference, but our teamwork will make the biggest difference of all to the health of the people of Derbyshire.
March 2017: Making Each and Every Contact Count
Everyday around 130,000 people come through the doors of one of our many pharmacies across Derbyshire.
That means around 130,000 different conversations, interactions and prescriptions. But for those who have completed Making Every Contact Count (MECC) training that also means something else. They will be on the lookout for opportunities to support people to make beneficial changes to their physical and mental health and general wellbeing.
MECC offers a brief, or very brief, conversation on health or wellbeing factors that can help an individual. One of the key skills is knowing how to start that conversation and when it’s appropriate to do so. Not every interaction is suitable and it’s all about timing and choosing the right moment. It’s about facilitating behavioural change and supporting people to make informed choices about their health and lifestyle. It would be great if the advice was accepted straightaway but we all know that the individual has to be ready to make a change, has to want to make a change, and be prepared to give up their ‘vices’ to ensure that change.
The risk factors to look out for are well known and will come as no surprise: smoking, hypertension, alcohol intake, being overweight or being physically inactive.
However, what if your own lifestyle isn’t ‘great’? This can make it difficult to start that conversation, but if you aren’t perfect then at least you can empathise with the person you are talking to. Change isn’t easy and a poor lifestyle is usually very easy to maintain! Being aware of ‘what good looks like’ is the first step and there are plenty of sources of information that will support you in this.
As a start why not take a look at the ONE YOU Public Health England website. There’s a 10-minute quiz you can do that’s designed to point you in the right direction. It’s not a medical assessment, but the insight into your own lifestyle could be life changing. It looks at smoking, drinking, eating, moving, sleep and stress. Hopefully, you won’t have problems in all of these areas and you will be encouraged to do something differently, which is the very essence of MECC.
Last month I wrote about Healthy Living Pharmacies (HLPs) and how they have an ethos focused on promoting healthier lifestyles. An integral part of becoming a Health Champion, or undertaking the associated HLP leadership training, is completing basic MECC training. In fact this needs to be completed before the training, where the initial learning will be reinforced.
Many organisations, such as NHS England and local councils, are committed to embedding MECC into the millions of day-to-day interactions that take place. Potentially, by working together at scale, there is massive support for population behavioural change, and the aim is for individuals and communities to significantly reduce their risk of disease. Many long-term diseases are closely linked to known behavioural risk factors where even small lifestyle changes can make a big difference to life expectancy and morbidity.
So, let’s join together and make every contact count for ourselves and the thousands of patients who might just leave through the same doors with a desire for change.
February 2017: The Paradigm of Healthy Living Pharmacies
Each working day we dispense medicines to help patients get better, feel better and live longer. We offer advice on how to live with health problems, avoid health problems and stay healthy for longer. We do all this, but could we do more or do things even better?
The answer is yes. The Healthy Living Pharmacy (HLP) concept was initially developed in Portsmouth in 2009. Since then the idea has gone from strength-to-strength to become an ongoing national programme. Currently, there are 2,000+ pharmacies accredited, or on route to being accredited, as HLPs; they employ over 3,500 pharmacy staff qualified as health champions. This represents a serious investment in public health services.
If every pharmacy was a Healthy Living Pharmacy there would be many more business opportunities. HLPs are well liked by customers with 99% approval ratings in evaluations. Commissioners are attracted by HLPs, because they have proven commitment to service delivery and engagement with the public health agenda (HLP Level 1 status could become a contractual gateway criterion). Also, HLPs sit very well with the concept of “place” as set out in Sustainability and Transformation Plans.
So, what would a member of the public notice when they visited an HLP? The pharmacy would have a different ethos – being an HLP isn’t just about the “badge” it involves a change of culture as well. The Health Champion, and other staff, may proactively approach them about health and wellbeing issues and will know about local services for referral or signposting. There will be a health promotion zone and there should be a health promotion campaign running which is linked into local priorities and health needs.
What does becoming a HLP involve?
- A pharmacy must have at least one qualified Health Champion with the Royal Society of Public Health (RSPH) Level 2 Award in Understanding Health Improvement. This qualification provides Health Champions with an understanding of the principles of promoting health and wellbeing of the local population.
- The pharmacy must meet a set of quality criteria, including consistent delivery of commissioned services. This is self-assessed using the Public Health England HLP Level 1 Quality Criteria guidance and be appropriately evidenced. The quality criteria are set around workforce development, premises and engagement. Achieving HLP Level 1 is now a quality payment criterion for the new Quality Payments Scheme.
- Leadership training, a key component and vital element, supports the development of the pharmacy team and changes the culture from reactive to proactive provision of health services.
The HLP concept provides a framework for commissioning public health services through three levels of increasing complexity and required expertise. A good example of this would be a smoking service:
- Core – health promotion, self care, signposting, OTC supply of NRT
- Level 1 Promotion – pro-active health promotion, brief advice, assess willingness to quit, signpost to services
- Level 2 Prevention – NHS stop smoking service, cancer awareness, Health Check
- Level 3 Protection – COPD and cancer risk assessment with referral; prescriber for stop smoking service
Still not convinced, and think HLP accreditation is too difficult? Well help is at hand. Health Education East Midlands (HEEM) has provided funds to pay for Health Champion Training and Leadership Training (mapped to HLP criteria). This training will be organised by the LPC and will be delivered by accredited training providers across Derbyshire. The opportunity is open to every pharmacy in the county and 100% take-up would clearly show the commitment of community pharmacy to deliver on the public health front.
Changes to the pharmacy contract, workload pressures, and funding concerns all come together to make “a perfect storm.” In the face of this storm it’s time to up skill our frontline staff, commit resources to developing our workforce and show that we are ready for any opportunities that come our way. In short, it’s time for a paradigm shift…
January 2017 Minor Ailments: Major Opportunity
I am delighted to announce that following a successful pilot study of a minor ailments scheme in the Swadlincote area, Southern Derbyshire CCG has now commissioned the service from community pharmacy contractors. I’m sure you will agree that this is a major opportunity to show what we can do to help patients access the treatment they need in a timely and safe manner.
The “Pharmacy First” scheme was launched on 1 December and will be reviewed in March 2019. It has already had a vote of confidence with EVERY community pharmacy in Southern Derbyshire signing up to deliver the service. Erewash CCG practices will also participate, but it will not be available in North Derbyshire CCG or Hardwick CCG areas.
Southern Derbyshire CCG’s vision and five-year plan includes promoting self-care to free up GP time for the management of more complex long-term conditions and to reduce the reliance on secondary care or out of hour’s services.
One in five GP consultations are for minor ailments and the treatment of minor ailments was found to account for 18-20% of GP workload with 90% of these consultations solely for minor ailments. In the SDCCG area, this equates to around half a million consultations per year, and, potentially, these consultations could be done in a community pharmacy.
For those of you with long memories, you will recall that there was a scheme called “Pharmacy First” over 10 years ago in the Derby area which was decommissioned at the end of March 2011. The original scheme was paper-based, very labour intensive, and somewhat cumbersome to deliver. Other areas in Derbyshire operated similar schemes and they all had their own formularies, which didn’t make it easy when working as a relief pharmacist! However, the new scheme is underpinned by PharmOutcomes, which will ensure ease of operation.
Each ailment has an associated protocol and the consultation will involve:
- Service user assessment (must be present in the pharmacy) – there are inclusion and exclusion criteria for each condition
- Provision of advice and written information as set out in the protocol
- Completion of the Pharmacy First Consultation Proforma on PharmOutcomes
- And, only if appropriate, supply of appropriate medication from the formulary
Where patients present with symptoms that need urgent referral the pharmacist should record the reason on PharmOutcomes. The system will then generate a pre-populated letter, including the reason for referral and supporting information, which the patient can take with them. The pharmacist will counsel the patient on whether or not the referral is urgent or non-urgent, so the patient can decide what they need to do to access the treatment they need.
Pharmacists need to complete a Declaration of Confidence (DoC) for Minor Ailments Services before being able to offer the service. These DoCs will be checked by the PharmOutcomes system when the pharmacist logs-on for the first time. There will be a four-month grace period for completion of a relevant CCPE pack (e.g. “Common Clinical Conditions and Minor Ailments”, which is based on the training required to deliver the Scottish MAS).
Southern Derbyshire CCG has gone to great lengths to ensure that the scheme is a success. They have provided comprehensive supporting documentation and put on training for pharmacy team members.
With 100% sign-up it’s now down to community pharmacy to deliver the scheme as professionally and as effectively as possible. Successful delivery could mean that more ailments are added to the scheme and the CCG may also consider commissioning additional services from us. This is a major opportunity for pharmacists in Derbyshire to show how they can support self-care.
The Department of Health announced on 20th October that the Government was going ahead with the funding cuts to community pharmacy. It had been hoped that they would see reason and choose not to impose revised contractual arrangements. Unfortunately, despite serious opposition to the plans, including a petition with over two million signatures, the changes will start on 1st December.
Unsurprisingly, the word “cuts” did not feature in the announcement. The line was that the plans would modernise community pharmacies and this modernisation would ensure a better quality service, whilst relieving pressure on other parts of the NHS.
However, it is difficult to see how reducing the amount paid to community pharmacy by £113 million (-12% on average) between December 16 and March 17, followed by a further reduction of around 7.5% for the 2017/18 financial year, could help transform anything positively.
The new package will phase out establishment payments which currently run at an average of £25,000 per pharmacy and will place greater emphasis on rewarding pharmacies for the quality of services they provide. The new measures include the first ever reward system for pharmacies and £75 million has been allocated to fund this Quality Payment Scheme. It should be noted that this is not ‘new’ money and will be part of the 2017/18 overall funding of £2,592 billion.
To qualify for payments under the scheme, pharmacies will have to meet four gateway criteria:
- Provision of at least one advanced service; and
- NHS Choices entry up-to-date; and
- ability of staff to send and receive NHS mail; and
- on-going utilisation of the Electronic Prescription Service (EPS).
On a positive note NHS England North Midlands is already looking at how they can support Derbyshire contractors to achieve gateway criteria and they hope to publish a toolkit shortly. There will no doubt be additional guidance from PSNC and the vast majority of contractors should be able to achieve the criteria.
However, NHS Mail is likely to pose a challenge, through unprecedented demand for setting up email addresses and problems with data governance. The latter is of particular concern to larger companies, because they are required to keep an auditable archive of emails sent by their employees. There is also the ‘small’ issue of no corporate footer/disclaimer, which is a standard legal practice elsewhere.
So, what’s on offer? There are six domains; patient safety, patient experience, public health, digital, clinical effectiveness and workforce, with associated criteria and either one or two review points during the year (end of April 17 and end of November 17). Achieveing the criteria earns a maximum of 100 points and the expectation is that each point will be worth around £64 each. This could increase to a maximum of £128 per point if there wasn’t universal achievement of 100 points.
In Derbyshire, if every pharmacy earned £6,400 from the Quality Payment Scheme, the income would be around £1.4 million. Additional benefits would accrue, because achieving anything approaching 100% would demonstrate to commissioners that community pharmacy had quality at its core. The cuts are likely to be damaging, but demonstrating quality engagement could lead to new service opportunities becoming available.
I encourage all contractors to get through the gateway, achieve maximum points, and engage with the Quality Payment Scheme. It will show commitment to quality, which could open doors to additional opportunities and you will see that quality counts for more than points!
November; Medicines and more…Just Ask Your Pharmacist!
This year’s National Pharmacy Association “As Your Pharmacist” campaign takes place from 7th-14th November. It will once again seek to encourage the public to make greater use of community pharmacy; not just to collect prescriptions, but to access wide-ranging support for medicines taking and healthy living advice. These campaigns have been taking place for some twenty years – surely by now everybody has got the message?
Unfortunately, there is still little public awareness of the range of services on offer. In fact one survey* found that only 23% of pharmacy users considered pharmacies the best place to seek general health advice. This perception needs to change, if pharmacy is to play more than a peripheral role in helping the NHS with ever increasing demands for healthcare.
Our raison d’étre has to be the key to unlocking the potential of community pharmacy. In 2015 around 1.1 billion prescription items were dispensed, so we know people are visiting pharmacies. In fact the number of items dispensed has increased by over 50% in the last ten years. More people are receiving more help than ever before and more visits to pick up medication means more opportunities to advise and support patients.
So what can we offer? A key element has to be personalised medicines advice and this can be done formally through a Medicine Use Review, or informally when handing out a prescription, or in responding to a patient’s question. Helping patients understand their medicines, and what they can do to manage their condition, will help to improve their outcomes and reduce the burden on other healthcare providers. No appointment necessary, easily accessible, and friendly/welcoming staff mean promoting our other services should be easy.
Supporting self-care for the treatment of common ailments is another area where pharmacy could excel. Allied to this is urgent care where the patient has a medical or health-related condition, which they believe they need help with that day. The pharmacist can advise on suitable treatment options to help the patient make an informed choice of what to do next. If the patient reports more serious symptoms that are a cause for concern, then they can be referred to a different healthcare provider, armed with the reassurance that they are not wasting anybody’s time (e.g. GP, OOH or A&E).
The flu vaccination service is now in its second year and is providing not only a great service, but also helping to promote community pharmacy as more than just a place to get your prescriptions dispensed. It’s likely that pharmacists will be much more involved in the management of long-term conditions in the future, which, given that these conditions are largely managed by medicines, has to make sense. These clinical services will be increasingly important in the future and will help to instil public confidence in what’s on offer.
So, what can be done today? Take every opportunity to engage with patients, support them with all aspects of their medicines taking and help them with any problems they present with. Be proactive, make a difference to patients’ lives and actively encourage all of your customers to ask for your help. #askyourpharmacist
October: Stand up to the risk of falls
It’s a sad fact that by the time you have finished reading this, someone in Derbyshire will probably have had a fall.
There are more than 50,000 falls across our county every year. Not all lead to serious injury, but on average there are ten fractures every day – including three broken hips. Older people are especially vulnerable. So how can you reduce the risk?
NHS Choices provides an overview of falls. There’s information about what causes a fall – such as balance problems, muscle weakness, poor vision or low blood pressure – plus an easy-to-use tool to assess your own risk.
We have an excellent Strictly No Falling prevention service locally, providing appropriate exercise to improve strength, balance and coordination. National recommendations state that we should all be active daily and try to do at least 2.5 hours of moderate activity each week, to strengthen our muscles and bones.
Community pharmacists in Derbyshire are proud to be playing a part, having campaigned successfully to raise awareness of osteoporosis, which increases the risk of broken bones. It’s World Osteoporosis Day on 20th October, so why not support the National Osteoporosis Society with their #laceupforbones fundraising?
The charity’s website offers excellent support to osteoporosis sufferers, for whom bone-strengthening medication is essential. Talk to your pharmacist too, because certain medicines and combinations significantly increase the risk of falls. Unnecessary prescribing, drug interactions and side-effects can all do more harm than good.
Extensive work on this has been done in the US, where the so-called Beers List is designed to help improve the safety of prescribing in older adults.
Pharmacists can also offer relevant guidance on lifestyle and hazards in the home. In a Falls Prevention Service by community pharmacy in Doncaster:
- 95% of patients reviewed were taking one or more ‘high-risk’ medicines, 32% were experiencing fall-inducing side effects, 22% had fallen in the past year
- 10% were referred to a specialist falls clinic
- Over 50% who had suffered a previous fragility fracture had not been prescribed medicines which help prevent bone loss
Commissioners – THINK PHARMACY as part of an effective solution to the ever-increasing costs associated with falls. It will improve patient outcomes too.
Patients – ask your pharmacist for advice on falls and falls prevention – because with a pharmacist, you always know where you stand!
September: Flu Fighting – Round 2
Last year, for the first time, NHS England commissioned a community pharmacy flu vaccination service. How did it go? Well, from a standing start, and with last-minute paperwork causing delays and problems for contractors, more than 7,000 (61%) of community pharmacies got involved nationally – 146 (67%) in Derbyshire. Almost 600,000 vaccinations were carried out across the country, with an average of 83 per participating pharmacy.
This year there will be another opportunity to benefit from this accessible and convenient service from pharmacies. In fact, it will be available for an extra month (until the end of March 2017). This time, there will be a separate pharmacy-specific Patient Group Direction (PGD), rather than last year’s general one for a range of healthcare professions. The PGD provides the legal basis for being able to administer the vaccine and ensures patient safety.
The Flu Plan for Winter 2016-17 provides detailed information on a range of measures to reduce the impact of flu. For those who become ill the NHS will provide direct care, but the wider health and social care system quite rightly has a strong focus on prevention. There’s a need to increase vaccine uptake among clinical risk groups, pregnant women and healthcare workers.
Clinical risk groups (under-65’s) cover patients whose pre-existing medical issues mean that flu presents a particular threat to them. Everybody in these groups should be actively offered flu vaccination, with at least 55% accepting. Last year vaccine uptake was only around 45%. This is worrying because such people are much more likely to become very unwell from flu and flu-related illness, as well as their existing condition getting worse.
Are you over 65? You can have a free flu jab and in this group, the ambition is for 75% to be vaccinated (WHO target). Last year we were close to this target, which is a great achievement given that numbers are growing due to an ageing population.
Pregnant women are particularly vulnerable to severe complications of flu. During the period 2009-12, one in eleven maternal deaths were due to influenza infection*. Therefore, all pregnant women are recommended to receive the flu vaccine, irrespective of their stage of pregnancy. There is also evidence that vaccination during pregnancy provides passive immunity against flu to infants in the first few months of life.
Healthcare workers – the target here is to vaccinate at least 75% of healthcare workers who have direct patient contact. This is something for occupational health services, as frontline health and social care workers have a duty of care to protect their patients and service users from infection. It is an important contribution to infection prevention and control.
Vaccinations are vital to protect people for whom seasonal flu is a real danger. More than 8,000 deaths a year are attributable to it. The ‘new’ pharmacy service makes it possible to expand the reach of vaccination to a wider population and should be welcomed. It is another example of how essential community pharmacy is to the health of our population.
August: Bites and Stings? The Buzzword is Pharmacy!
Summer is here – ‘party time’ for insects with lots of opportunities to make themselves a nuisance and our lives a misery. Although getting bitten or stung is quite common, you usually suffer only minor irritation. But some stings can be painful, cause serious allergic reactions or severe infections that need medical treatment (sometimes urgently).
Community pharmacists can be the first port of call for those needing help – but we need to be alert to the unusual. Not every bite or sting will have a small-localised reaction that responds to basic treatment (wash area, cold compress and don’t scratch) or simple topical treatments such as sprays or creams containing local anaesthetics, antihistamines or a mild steroid.
Antihistamine tablets can help reduce itchiness and swelling, but some people get severe local swelling and in this case a short course of oral corticosteroids may be required for three to five days. Antibiotics may be needed if wounds are infected and there’s a lot of swelling and blistering or if there’s pus.
NHS Choices has excellent guidance and this highlights the symptoms where urgent medical help is needed (i.e. anaphylactic reactions):
• Wheezing or difficulty breathing
• Nausea, vomiting or diarrhoea
• A fast heart rate
• Dizziness or feeling faint
• Difficulty swallowing (dysphagia)
• Confusion, anxiety or agitation
So, what are the potential complications with a bite or sting?
• Secondary Bacterial Infections are quite common (e.g. impetigo and cellulitis).
• Lyme disease – caused by ticks (which are arachnids rather than insects). There are 2,000 to 3,000 cases in England and Wales each year (15-20% of cases occur whilst abroad). If untreated there can be long-term problems with the nervous system (e.g. meningitis and encephalitis although the latter is rare).
• Malaria – everybody knows about this one, but not everybody takes their anti-malaria medication when in risky areas. Each year there are around 1,500 cases of malaria in travellers returning to the UK. It should be noted that half of all cases are caused by the Plasmodium falciparum parasite and this is potentially fatal.
• Zika virus (mainly spread by mosquitos) causes a very mild infection and isn’t generally harmful. But, it is much more serious in pregnant women, as there’s evidence it can cause birth defects (i.e. abnormally small heads or microcephaly).
The obvious answer is to take care to reduce your risk of getting bitten or stung. If you are, carefully remove any sting as soon as you can and use the correct technique – get it wrong and you could make matters worse (e.g. bee stings and pinching out the sting with your fingers or tweezers). Not sure what to do? Make a beeline for your pharmacist and ask for help. That’s why we’re here.
July: Hay Fever – not to be sneezed at
The hay fever season has arrived. Bringing with it discomfort, irritation and often misery for the 16 million people or so affected by the condition. But, those unaffected are often less than sympathetic – because at first glance the symptoms are ‘trivial’:
- Sneezing or coughing
- A runny or blocked nose
- Itchy, red or watery eyes
- An itchy throat, mouth, nose and ears
Doesn’t sound too bad! What’s all the fuss? Yet a third of adults who get hay fever say their symptoms have a considerable impact on their work, home and social life.
I started with hay fever over 50 years ago when I was around six. In those less enlightened times the condition wasn’t as well recognised, or as common, as it is now. My mother took me to the doctor, eventually, and only after several severe sneezing fits and coughing bouts whilst haymaking. He prescribed Piriton®, which was the medication of choice at the time (not that there was much choice).
Unfortunately, this made me very drowsy, so I often avoided taking it and just put up with the consequences. As I got older, my symptoms lessened and now it only affects me for a few days each year. Even better, the new generation of once-daily hay fever tablets don’t make me drowsy, which is great – this has definitely improved my compliance.
If you don’t want to wait 50 years for a ‘cure’, what should you do? Ask your pharmacist of course, because hay fever symptoms can be addressed in a wide variety of different ways and they’ll be able to talk through the options. There may not be a cure, but you can feel a whole lot better and have better quality of life.
Still not convinced hay fever symptoms need to be treated? Consider the following from Allergy UK:
- A recent small study, by the University of Maastricht, suggests that getting behind the wheel with hay fever symptoms has the equivalent risk of driving with a blood alcohol level of 0.05% (very roughly a pint of beer).
- Where hay fever symptoms are not controlled, the risk of developing asthma is tripled (according to Allergy UK’s 2014 report “One Airway One Disease”).
Asthma is a potential killer. Many patients with asthma may notice their symptoms get worse at this time of year due to hay fever. Therefore it’s worthwhile checking patients’ inhaler techniques, especially if it’s been a while since they were shown how to use them correctly. It’s very easy to get into ‘bad habits’ and pharmacists are ideally placed to provide refresher demonstrations. A few simple changes to inhaler technique can make a big difference to health during this time. Yet another reason to “Ask your pharmacist” – it could save your life.
June: Sustainability and Transformation Plans – will they be transformational?
The latest ‘must have’ is a Sustainability and Transformation Plan (STP). These plans have to be submitted for approval to NHS England by the end of June, with a brief to show how an area would improve health and wellbeing, transform the quality of care and be sustainable financially. This is the ‘triple aim’ of the NHS Five Year Forward View.
The NHS in England has been divided up into 44 ‘footprint’ areas – bringing together local health and care leaders, organisations and communities to develop local blueprints (i.e. the STP) for service transformation over the next five years. Derbyshire is one of these footprint areas, currently covered by four CCGs. The new planning approach is designed to help ensure that services are planned by ‘place’, rather than solely around individual institutions.
So, how does community pharmacy in Derbyshire fit in? The short answer is: “We don’t know”. LPCs, other organisations and the public were supposed to be able to contribute solutions by being involved in development of the local STP. However, the LPC hasn’t been given an opportunity to set out the case for using community pharmacy resources to make a difference. I fear we’ll be faced with the aftermath of a desktop exercise.
Transformation can be for the better, but also for the worse. The entire NHS is under pressure – not just to deliver the required £22 billion savings by 2020, but also to meet the ever-growing patient demand for healthcare services. These problems seem to be in the news almost daily.
We can’t continue with the present system. It isn’t sustainable (for much longer) in its current form and it needs to be transformed from what has become something of an ‘ugly duckling’ into a ‘swan’. This is what the STP is supposed to help deliver.
What does the community pharmacy network in Derbyshire bring to the table?
- 217 community pharmacies – there’s certain to be at least one pharmacy in every ‘place’ identified
- Located at the heart of the communities, they are not only a valuable health asset, but also an important social asset
- Our pharmacies are uniquely placed to deliver public health services – 130,000 visits every day, easy access, a wide variety of locations, and informal environments
- They are often used by people who may not access conventional NHS services, which helps to reduce health inequalities
- Patients and the public trust their pharmacy teams and build relationships with them through frequent contact
What better place to begin the transformational process than by leveraging the asset that is community pharmacy? Research by Durham University has shown that most people in England can get to a pharmacy easily (i.e. within 20 minutes). This access is even easier in deprived areas with the greatest need for healthcare services.
The researchers believe that delivering more services in community pharmacies could not only take pressure off other parts of the NHS (at a potentially lower cost to the taxpayer), but also help to improve public health and tackle the unacceptable health inequalities that still exist.
For a lot of healthcare there is something of an ‘inverse care law’, whereby access to services is better in places with the least need. However, the opposite is true for community pharmacy – for this sector there exists a ‘positive pharmacy care law’.
Pharmacy Voice has articulated very well what needs to happen: “Think of your pharmacy as a dispenser of health…” The core aim of their Dispensing Health initiative is for everyone to begin to think of the community pharmacy as a dispenser of health, as well as medicines; as a gateway for the maintenance of good health and the self-management of long-term conditions; as a health hub on the high street.
Therefore, if you want to make a difference, have a big impact and reduce pressure on GPs and others – as well as making better use of scarce resources – ask your pharmacist for help! The existing community pharmacy network is strong and easily accessible, but could be used much more effectively if given the opportunity to play more of an integrated role in primary care. Investing here will give an STP the biggest chance of success.
May: Summary Care Record Access – The Start of a Journey
A “Brave New World”, where pharmacists can access patients’ records has finally arrived. The phased rollout of Summary Care Record (SCR) access reaches Derbyshire this month. To start with, pharmacists may feel daunted by the number of tasks they need to complete before they can access their first record. However, working through the PSNC SCR implementation checklist will help.
Although pharmacists will not be able to add to patient records at least they’ll now be able to view them. Many patients will be surprised that pharmacists couldn’t do this anyway. Patient Medication Records have been an enormous help in supporting patient care, but they are limited mainly to details of previously prescribed medication. SCRs, on the other hand, provide professionals treating patients with faster access to key clinical information.
As ever in the NHS, there had to be an initial pilot study. Fortunately, the rollout was accelerated when the benefits became obvious. Key findings from the Health and Social Care Information Centre (HSCIC) ‘Proof of Concept’ report published in May last year were:
- Effectiveness – reduced need (in 92% of encounters) to signpost patients to other healthcare services such as A&E, Out-of-Hours GP, NHS 111, and GPs
- Efficiency – reduced need to contact GP practices for more clinical information (especially useful when practices were closed, e.g. at weekends)
- Safety – around 1 in 5 encounters avoided the risk of a prescribing error (the majority of these cases had the potential for moderate or major harm)
- Patient Experience – reduced waiting time for resolving queries (pharmacists were able to meet the needs of the patients in 96% of reported cases)
So what happens when you’ve completed the training, had your smartcard access rights upgraded with specific SCR roles assigned to it, and there’s a Standard Operating Procedure (SOP) in place? Simply, check your access using the test NHS numbers provided in the HSCIC sample SOP (in the checklist). Now you’re ready to go, but you need informed consent and express permission to view a record for a patient directly under your care. Access to the system is monitored and there will be a privacy officer appointed to audit and review access.
Complying with information governance requirements, having the patient’s permission and recording your access on their Medication Record will ensure that viewing the SCR is trouble free. Your patient will benefit from improved support and decision making on your part. The additional information available will reinforce safe and effective care, treating common conditions and responding to emergency requests for medicines.
Access to SCRs is a valuable first step towards better integration of community pharmacy into primary care. However, the ultimate goal should be for pharmacists to have read and write access to health records. This will enable other healthcare professionals to be aware of the important interventions made by pharmacists on a daily basis. When we can do this, we will truly have entered a “Brave New World”.
April: Bowel Cancer Awareness Month – Better Safe than Sorry
The NHS Bowel Cancer Screening Programme has been running since 2006, and it saves lives. The FOB test used has been shown to reduce the risk of dying from bowel cancer by 16%. Early detection is the key to survival, but in some areas only a third of people actually complete the test they’ve been sent. Why should this be?
This is a home test offered to all 60-74 year olds in England. It checks for the presence of blood in a stool sample, or rather three samples. Therein lies the problem – people find it embarrassing or unpleasant to even talk about the test they have just received, never mind actually completing it. However, embarrassment is a small price to pay for peace of mind. A letter is sent within two weeks and most people (98 out of 100) will receive a normal result. What a relief!
But what if the result is ‘unclear’ or ‘abnormal’? ‘Unclear’ doesn’t mean you have cancer and a retest will be requested up to twice more, with the majority ultimately getting a ‘normal’ result. ‘Abnormal’ is what everybody fears, but even this doesn’t mean you have cancer. You’ll be offered a colonoscopy as a follow-up, which is dreaded even more than the test. As with most medical procedures, there can be complications and you will be given all the information you need to make an informed choice about whether or not to go ahead.
A colonoscopy is the most effective way to diagnose bowel cancer. For most people it is quite straightforward:
• About 5 in 10 will have a normal result (no cancer or polyps)
• About 4 in 10 will be found to have a polyp (a non-cancerous growth, but which can become cancerous in future if left)
• About 1 in 10 people will be found to have cancer
What can community pharmacists do to raise awareness of bowel cancer? Supporting Bowel Cancer Awareness Month during April is a great start – as is knowing about the screening programme when talking to patients. The FOB test is seen as complicated and this puts people off doing it, without them really thinking about the benefits of early diagnosis (early detection = 90% cure).
Encouraging participation in the screening programme should therefore be a key action. If only a third of eligible people currently do the test, there is an opportunity to make a difference to the two-thirds who have ignored, refused or ‘don’t fancy’ doing it. Pharmacists can also help to reduce the risk of bowel cancer by encouraging a healthy lifestyle:
• Fibre – an important part of a healthy diet, which keeps everything moving through the digestive system
• Fruit and Vegetables – ‘5 A Day’ recommendation
• Protein – chicken, fish and pulses but avoid processed meats
• Hydration – taking in fluids throughout the day
• Keeping active and maintaining a healthy body weight
Understanding the symptoms of bowel cancer is essential and knowing when to signpost is a key skill for pharmacists. Not everybody is lucky enough to have a test…
March: Think Kidneys – Keep in Good Shape
February: Community Pharmacy – Helping Communities Stick Together
January: A New Year’s Resolution for Smoking Cessation
December: Antibiotics are for Life! #AntibioticGuardian
November: Ask Your Pharmacist About Medicines and More
October: Osteoporosis – Do you have a skeleton key?
September: Flu-Fighting – a Growing Role for Pharmacy
August: Think Pharmacy! First, Fast and Hassle Free!
July: Staff Training – An Investment Not A Cost
June: A Better Outcome for Pharmacy – and Commissioners
May: Swotting up on the Electronic Prescription Service
April: Collaboration is the Key to Successful Services
Think Kidneys – Keep in Good Shape
How many people actually understand what their kidneys do and how vital they are? Pharmacists can play an important role in raising awareness and educating patients in how to keep their kidneys in good shape. Reducing the risk of chronic kidney disease (CKD) is a focus for World Kidney Day on Thursday 10th March.
Kidneys rid our body of dangerous toxins by processing them and producing urine. This is why CKD is so serious. It can lead to the need for dialysis or a kidney transplant, and is ultimately life-threatening.
The disease involves a gradual loss of kidney function over time, with increasing complications and ill health. However, its progress can be slowed by changes in lifestyle and the right diet – so people can directly influence their health prospects if they know how.
General advice for keeping kidneys healthy includes: avoiding a high salt diet (don’t add salt at the table); stick to a healthy balanced diet; maintain a healthy weight; keep active and exercise regularly; don’t smoke; and avoid regular or long-term pain medication (unless prescribed).
It’s also important to stay hydrated. A good rule of thumb is to drink eight good-sized glasses of fluid a day – that’s almost 2 litres (all fluids count toward the daily total).
Problems can arise rapidly through Acute Kidney Injury (AKI), often in someone who is already at risk (pre-existing kidney disease; aged 65+; congestive heart failure; diabetes; liver disease). All healthcare professionals need to be alert and aware of the triggers for AKI, including:
- Sepsis or infections
- Hypovolaemia (dehydration, bleeding)
- Certain medicines (which can either damage the kidneys or impair renal function in some circumstances)
AKI may have no early symptoms, so it can be difficult to spot. A possible sign is a low volume of urine being produced, although this is not always the case. However, someone with AKI can suddenly experience nausea and vomiting, confusion, low or high blood pressure, abdominal pain, slight backache or oedema. There are up to 100,000 deaths annually, a third of which could be avoided! One in five people admitted to hospital as an emergency has AKI.
Community pharmacists are in a strong position to help those most at risk. We can develop understanding of the dangers and educate patients about what to do if they become acutely unwell. Pharmacists can also advise on the “Sick Day Rules”, which could involve a temporary cessation of medicines where the risk of AKI is deemed to be high – to stop things going ‘pear-shaped’…
Community Pharmacy – Helping Communities Stick Together
In December, the Department of Health (DH) dropped a bombshell for pharmacists in Derbyshire and elsewhere. It announced a £170 million funding cut for community pharmacy and radical changes to the way the sector operates.
The Government doesn’t seem to have any precise idea what the full impact will be. But I believe the fallout could be catastrophic for a service, which is a key part of the social capital of this country – the ‘glue’ that helps to hold communities together.
Every day, 130,000 people visit Derbyshire’s 217 pharmacies, making them the county’s most accessible health locations. The Government believes the sector could be more efficient, without comprising service quality or public access. Dr Keith Ridge, Chief Pharmaceutical Officer, has even said there may be 3,000 too many pharmacies (equates to a loss of more than 50 pharmacies in Derbyshire alone). We cannot allow that to happen.
The last ten years have seen a 48% rise in the volume of prescriptions dispensed, while the number of pharmacies has only risen by 18%. So the huge extra workload is being met very efficiently and pharmacies already operate a lean business model.
In announcing the cuts, the DH talked of developing large-scale automated dispensing, to provide opportunities for efficiencies. This would include more ‘hub and spoke’ arrangements, and even a worrying ‘click and collect’ option with, at first sight, limited opportunities for patient counselling. These proposed changes to the existing network can only be a long-term ambition because the technology and infrastructure aren’t in place.
In any case, community pharmacies are not impersonal remote dispensing factories. In many communities the facilities that have traditionally provided elements of social capital (post offices, banks, pubs, etc.) are being lost. Increasingly, the pharmacy is the last establishment left to fulfil this role. Even the DH admits that access to a pharmacy is even more important in areas of deprivation (i.e. pharmacies are located where they are needed).
Here are just a few of the ways that community pharmacy contributes to social capital:
- Advocacy, advice (not just health-related), and signposting to other services
- Access for medicines – including additional support with compliance aids
- Home deliveries – free of charge
- Helping to reduce GP workload and improve access to healthcare services – handling patient medication queries, dealing with minor ailments, etc.
- Hospital discharge – making sure medication is ‘right’ after a hospital stay
- Local Authority services – delivering public health services and supporting vulnerable people (e.g. MAR sheets)
- Local staff talking to local people – shared values and beliefs
- A ‘shoulder to cry on’
- Friendly and usually familiar faces behind the counter to just chat with!
- A human alternative to internet services – vital for patients not comfortable with computers and modern technology
Social capital is difficult to quantify, but thousands of people will feel it if it’s lost. The Government’s proposals are a real threat to the network of community pharmacies. If the network is damaged then no amount of glue will put it back together again…
A New Year’s Resolution for Smoking Cessation
Smoking is linked to 100,000 deaths in the UK every year. The Smokefree NHS website clearly explains why stopping smoking is so important on several levels:
- Health: every single cigarette causes real harm.
- Family: second-hand smoke is dangerous for anyone exposed to it, especially children. Smoking during pregnancy can increase the risk of miscarriage, stillbirth or sudden infant death.
- Financially: on average people who quit save around £250 per month (a whopping £3,000 a year!).
You’re four times more likely to quit the habit with NHS help, but just how easy is it to access this support in Derbyshire? We have different approaches from the two local authorities responsible for running smoking cessation programmes.
Derby City Council has Livewell, which offers a free 12-month healthy lifestyle service including smoking cessation. Access is by application and some programmes are full, but there are local drop-in clinics according to their website. When Livewell took over three years ago, community pharmacy was excluded from the service.
Derbyshire County Council funds smoking cessation as part of a wider contract for Integrated Wellbeing Services. Derbyshire Community Health Services NHS Foundation Trust (DCHS) became the lead provider in 2014, offering stop smoking services via Live Life Better Derbyshire. Pharmacies and GPs can sub-contract with DCHS to become community-based providers if they find the terms acceptable. However, at the time of writing, no providers appear to be listed.
It feels like ‘traditional’ formal smoking cessation programmes are becoming more difficult to access, with would-be quitters pursing alternative strategies. In fact, Derbyshire county official ‘quit attempts’ have fallen by two thirds, from 9,400 in 2010-11 to 3,155 in 2014-15.
So what else is on offer? Ask your pharmacist for help, as smoking cessation advice and nicotine replacement medication are available from every community pharmacy. This support is easy to access and no appointment is necessary.
It’s estimated there are around 2.6 million users of e-cigarettes in the country and about 4 in 10 are using them as a D.I.Y. option for quitting. Public Health England (PHE) stated last August that vaping is safer than smoking and could lead to the demise of the traditional cigarette – the first official recognition that it is less damaging to health. PHE concluded that on “the best estimate so far”, e-cigarettes are about 95% less harmful and could one day be dispensed as a licensed alternative to traditional anti-smoking products.
E-cigarettes have rapidly become the most widely used quitting aid in England, even though they are currently neither medicinally regulated nor available via an NHS prescription. They vary considerably in quality and specification, so care is needed. However, the Medicines and Healthcare Products Regulatory Agency intends to regulate e-cigarettes as medicines from 2016. With one product already signed-off, this could mean a revolution for smoking cessation services. But, will GP waiting rooms be full of patients wanting prescriptions for such products? I suppose we’ll just have to suck it and see…
Antibiotics are for Life! #AntibioticGuardian
Antibiotic literally means life-killing (based on the word’s ancient Greek roots) which is a slightly strange, bearing in mind their role in fighting infection. Whatever the definition, there’s no doubt antibiotics have saved millions of lives – but how effective will they be in the future?
One of my earliest childhood memories is of being given Achromycin™ Syrup. It was thick, smelt terrible and tasted even worse, so it had to be doing me good! Today’s equivalents are far more pleasant with more palatable flavours. Looking back, I reckon that I have probably averaged one course of antibiotics every year.
Whilst I always considered myself to enjoy reasonable health, this record of antibiotic taking doesn’t sit well with me now. Unfortunately, it’s probably typical of most people’s experience, so is it any wonder that the ‘wonder drugs’ of yesteryear aren’t as effective as they once were?
We now know that within a couple of years from the launch of a new antibiotic, resistance starts to develop. Matters are made worse by the inappropriate use of antibiotics, which affects the resistance pattern for microbes for the whole community. Significant quantities are used in farming and although legislation is in place to restrict this, it is still wide-spread and routine. This leads to more antibiotic resistance and has a potential impact on their effectiveness in humans.
In their antibiotic awareness campaign the Royal Pharmaceutical Society (RPS) stated:
“With this ongoing increase in antibiotic resistance, pharmacists can play a vital role in providing you with the best advice about medicines. Pharmacists are the first port of call for help and advice about how to treat common conditions such as coughs and colds, but also recognise more serious symptoms and know when you need to seek further treatment.”
Community pharmacists are well placed to provide help and support on how over the counter medicines can help to treat the symptoms of illness. Studies have shown that patients are less likely to ask their GP for antibiotics if they’re advised what to expect in the course of an illness and given self-care advice with realistic recovery times. Therefore, I would encourage the use of the new Treating Your Infection Leaflet for Community Pharmacy leaflet (developed by Public Health England, the Royal College of GPs, etc.).
In addition, counselling patients on how to use appropriately prescribed antibiotics properly will help ensure effective treatment – take as prescribed, never share or give away antibiotics and complete the course will all help spread the word. Public Health England established the Antibiotic Guardian initiative and is asking people to pledge their commitment to take steps to reduce antibiotic resistance (i.e. to safeguard these life-saving drugs for future generations). It should be noted that pharmacists are the largest single group to make the pledge (RPS, November 2015).
We all have a part to play in ensuring that antibiotics remain effective in the long-term. We must ensure that antibiotics are for life and not just for (this) Christmas.
Ask Your Pharmacist About Medicines and More
It’s Ask Your Pharmacist Week on November 9-15. The National Pharmacy Association (NPA) is again backing this important campaign and pharmacists across the UK are being encouraged to raise public awareness of the range of services available through community pharmacy.
Why do we need a campaign like this every year? Surely the message must have got through about the help that’s on offer? Unfortunately, the answer is: “No, it hasn’t”. In Derbyshire 130,000 people on average visit a pharmacy every single day. That’s 130,000 opportunities to ‘Ask Your Pharmacist a Question’ about medicines, healthy lifestyles, long term conditions, common ailments etc. – and anything else you want an answer to.
No appointment necessary, an informal environment, convenient opening hours and an expert on medicines who’s truly accessible. And best of all, it’s free! Research has shown that consultations with a pharmacist about minor ailments have favourable health-related outcomes, so you can trust the advice you’re given.
But what about a serious illness? There are 15 million people in England with long term conditions, virtually all of which are largely controlled by medication. Pharmacists are medicine experts and are only too keen to share their expertise. This can be done through a Medicine Use Review where the patient sits down with the pharmacist and goes through their medication. Or it can be a quick chat about something of concern; whether it’s major or minor doesn’t matter.
Perhaps you’ve been prescribed a new medicine? Surely you will have questions about it: with food or after food, in the morning or at night, side effects, how does it work? Again, no problem – there’s a free NHS New Medicine Service to support some long-term conditions. Even if your new medicine is not ‘on the list’, your pharmacist will still be happy to talk to you about it. Research has shown that within 10 days, two-thirds of patients report problems with side effects, difficulties taking the medicine or a need for further information.
We all know the NHS is under pressure. The media paint a bleak picture and it won’t be long before ‘winter pressures’ and A&E stories are making more headlines. If you need help, why not make your life easier and ‘Ask Your Pharmacist’ for advice?
A lot of people just want reassurance that their problem isn’t serious enough to bother the doctor. In fact, around 40% of GP appointments are for things that don’t require a GP consultation, so Think Pharmacy instead. You could save time and perhaps get treated more quickly with an over the counter product. If the pharmacist thinks you would benefit from seeing a GP, that option is then open to you. In fact, signposting is an essential role of community pharmacy, so you can be confident of getting good advice about an appropriate course of action.
Save yourself an unnecessary trip to the GP, or even A&E, by seeking help from your local pharmacist instead. Pharmacists don’t just dispense medicines; they dispense great advice too, so Ask Your Pharmacist and Make More Use of them. You’ve only got to ask…
Osteoporosis – Do you have a skeleton key?
Osteoporosis (literally ‘porous bones’) results in low bone mass, increasing the possibility of fracture. Adult skeletons are made up of 206 bones and are at their strongest around the age of 30. This means that bones get naturally weaker as we age and osteoporosis significantly increases the risks involved. Broken bones aren’t inevitable, but they are much more likely.
So what’s the KEY to strong bones? The short answer: a healthy balanced diet (containing calcium and vitamin D) with plenty of exercise throughout life. What could cause problems: smoking (smoking slows down bone building and can result in early menopause) and excessive alcohol consumption (increases risk of osteoporosis, falls and fractures).
- 46,000 people in Derbyshire and three million nationally are thought to have osteoporosis.
- Half of all women and one in five of men over the age of 50 will break a bone as a result of poor bone health.
- Every year there are 300,000 fractures as a result of fragile bones.
- Many hip fractures lead to permanent disability or even premature death
A KEY local initiative for World Osteoporosis Day on 20th October will be a pioneering partnership between pharmacists in Derbyshire and the National Osteoporosis Society – the first of its kind anywhere in the country. Community Pharmacy Derbyshire is paying special information packs from the charity to be sent to more than 200 pharmacies across the county. The aim is to promote the role that community pharmacists can have in supporting the many local people who live with osteoporosis.
There are several KEY areas where pharmacists can help:
- Help people identify their risk of having a fracture
- Advise on making changes to diet and lifestyle to protect bone density
- Support osteoporosis patients with their medicines taking, so that they gain the maximum benefit and reduce their probability of having a fracture
Patients: What’s the KEY to success? Got a question about bone health? Ask your pharmacist and take your medication as prescribed. Believe it or not, 30% – 50% of people with long term conditions do not take their medication correctly. Pharmacists can advise on when and how to take it, discuss any possible side effects, and answer general questions on osteoporosis to help improve understanding and outcomes.
Commissioners: we need to UNLOCK the potential of community pharmacy in Derbyshire. There are around 10 fractures, including 3 broken hips, in Derbyshire every day. Why isn’t there a pharmacy Falls Prevention Service to identify people at high risk of falling (there were more than 50,000 falls in Derbyshire in 2012), so that they can be advised/helped to reduce their chances of falling? Potentially, this could be the KEY to reducing the costs of fractures.
Flu-Fighting – a Growing Role for Pharmacy
NHS England has commissioned a national community pharmacy flu vaccination Advanced Service. Therefore, this winter all adult patients who are eligible for NHS flu vaccinations will be able to have them free of charge at local community pharmacies.
The service will only be ‘new’ in the sense that it is being commissioned nationally for the first time. Pharmacies have been offering vaccinations for several years under local agreements. In the 2014-15 flu season:
- 21 out of 25 NHS England Area Teams commissioned a flu vaccination service from community pharmacies
- Pharmacists vaccinated 232,388 patients (at NHS expense) – not including patients vaccinated under private schemes
- 98% of people vaccinated in pharmacies would recommend the service to a friend
The NHS aims to protect 75% of ‘at risk’ patients against flu every year (such as pregnant women, older people and those with respiratory disease or other serious conditions). However, last year just 44% of people in some groups had the vaccine.
This is where community pharmacy can have a big role to play. We already have the expertise and trained workforce out there through local services and private schemes. True, more pharmacists will need to be trained to ‘gear up’ for increased numbers. This shouldn’t be a barrier, as many contractors will have training programmes in place.
There are three main benefits of a community pharmacy service:
- Accessibility – pharmacies are in the heart of communities where people live, work and shop (93% of users found pharmacy flu vaccination more accessible than other services).
- Convenience – many pharmacies are open for longer hours than GP practices, including at weekends, and appointments may not always be necessary.
- Hard-to-reach groups – 1.6 million people visit a pharmacy every day, and these contacts help pharmacies to access traditionally hard-to-reach groups (e.g. West Yorkshire 2014/15: 28% of patients vaccinated had chronic respiratory disease and 14% were diabetics; overall, 47% were administered to ‘at risk’ groups).
It has been suggested that pharmacies will ‘cherry pick’ patients, leaving GPs to tackle the harder-to-reach groups, but there is no evidence for this. In fact, pharmacies have more regular contact with many vulnerable people and their carers than other healthcare professionals do. In 2014/15 16% of vaccinations were administered to those who had not previously received an NHS vaccination and 15% would potentially have gone unvaccinated if not for pharmacy.
Vaccinations are vital to protect people for whom seasonal flu is a real danger. More than 8,000 deaths a year are attributable to it. The ‘new’ pharmacy service makes it possible to expand the reach of vaccination to a wider population and should be welcomed. It is another example of how essential community pharmacy is to the health of our population.
Think Pharmacy! First, Fast and Hassle Free!
One in five GP consultations and roughly one in 12 Accident & Emergency (A&E) visits are used to prescribe and treat minor ailments – annually costing the NHS £136m for A&E alone.
We all know that if these patients called into their local pharmacy and had a chat with the friendly face behind the counter they would save already struggling NHS large amounts of time and money. But I’m not just interested in cash savings, I care about patient experience.
A patient suffering a minor ailment is likely to want the condition treating and treating fast. If the first port of call is the doctor they face numerous hurdles:
- Contacting the surgery for an appointment and feeling guilty about bothering them
- A potentially lengthy stay in the waiting room
- The consultation itself may be stressful because time with the GP is limited. If they have rehearsed what to say, will they say it right?
- Assuming they are handed a prescription (by no means a foregone conclusion), they then have to find a pharmacy
What was a ‘minor’ problem has fast become a frustrating journey which has taken a good deal of time to resolve. If the ailment has occurred ‘out of hours’ in the late evening, at night, or over the weekend, the situation will only be worse.
So, what if there was a better way? What if there was an easier option? Well …there are a total of 217 pharmacies in Derbyshire and 99% of people can get to a pharmacy within 20 minutes. My advice is why not Think Pharmacy?
- No appointment necessary
- An informal environment
- Convenient opening hours make accessing a pharmacy relatively easy, even at weekends
- Consultations with a pharmacist for minor ailments have been shown to provide favourable health-related outcomes
Your pharmacist can provide advice and support on the management of a whole host of minor ailments. If they consider your symptoms to be more than ‘minor’ and worthy of further investigation you will be signposted to the appropriate service.
Derbyshire LPC is keen to see a Minor Ailments Advice Service (MAAS) introduced in the county because it would mean that ‘minor ailments’ were dealt with cost-effectively at an easily accessible location. In advance of this service the LPC urges commissioners and patients to Think Pharmacy! First, Fast and Hassle Free!
Staff Training – An Investment Not A Cost
Health Education East Midlands (HEEM) is seeking input into how the pharmacy workforce is developed to ensure future practice demands can be met. Improving capability and engagement will be key to success and to enabling the profession to fulfil its potential.
Pharmacists are well served by the Centre for Pharmacy Postgraduate Education (CPPE) and have easy access to high quality training in various formats to suit their preferred learning style. This ensures they can acquire and develop the skills necessary to provide a wide range of services. Derbyshire LPC also runs regular development events to help pharmacists confidently to deliver both local services and the national advanced services (i.e. Medicine Use Reviews and New Medicine Service).
However, pharmacists can’t do everything themselves. They need support staff to allow them time to deliver all aspects of their professional duties. Pharmacy technicians support the dispensing process from end-to-end and help relieve workload pressures. They too will have undergone specific development for their role and on-going training will be needed to ensure they keep up-to-date with changes to dispensing processes (e.g. EPSr2, etc.).
The ‘unsung heroes’ of the pharmacy workforce are the counter staff. Their contribution to relieving pressure by dealing with over-the-counter medication requests, triage of people’s symptoms, and just selling ‘stuff’ is often overlooked. Having skilled counter staff to support the pharmacist and engage proactively with the public is vital to the smooth running of any business. These staff need to have good knowledge about products and services – including being able to direct people to local health and wellbeing services. This supports the pharmacy contract requirement for promoting healthy lifestyles (Public Health), signposting to other healthcare providers and supporting self-care. It also supports the nationwide Making Every Contact Count (MECC) initiative.
Further up-skilling of counter staff can be achieved through them having the Royal Society for Public Health Understanding Health Improvement Level 2 award. Putting them through this course allows them to pro-actively support and promote behaviour change, improving health and wellbeing. A contractor survey (as part of an evaluation of Healthy Living Pharmacies) confirmed the importance of non-pharmacist staff in delivering public health services – and there was also clear evidence that pharmacy staff were engaged and enthused by opportunities to make a difference. The potential for this to contribute to better service outcomes is clear.
Better outcomes are good for business and will encourage repeat visits from satisfied customers. Pharmacy is a service industry and the public want/expect good service. Failure to provide this will soon have an impact on ‘the bottom line’. Therefore, making staff feel valued and investing in staff training isn’t counter productive. It makes your counter productive!
A Better Outcome for Pharmacy – and Commissioners
PharmOutcomes1 is a secure web-based system which helps community pharmacists to be more effective by streamlining the management of services commissioned from them. Sounds simple – and it is!
Here we have something that supports the work of pharmacy by capturing data and building up an evidence base. The advantages for service commissioners are many:
- A wide range of templates easily tailored to meet local needs
- Patient data captured and stored securely (meeting NHS Information Governance requirements)
- Complete control of who can provide services – accreditation is a simple process
- The ability to embed supporting documents in client records, giving extra information
- Completed records immediately saved on the system, so activity is seen in real time
- Comprehensive data for effective performance management and service insight
- Scrutiny down to individual provider level through expanded audits
- Automated claims for payment, with total activity recorded and extracted at an agreed time
- Effective communications through direct messaging to providers (with read receipts and action confirmations)
Locally the LPC, on behalf of Derby City Council, has used the PharmOutcomes platform to support Substance Misuse and Oral Emergency Contraception services since April 2014. The commissioner (Derby City Public Health) has found that all the above points have been delivered. The data received has been used to monitor performance and make appropriate changes to their services to improve outcomes.
Further endorsement of the system comes from the NHS Area Team for Derbyshire and Nottinghamshire. They have been so impressed by what PharmOutcomes can do that they purchased their own licence. They have used it to support:
- Influenza Vaccinations – pilot study
- Domiciliary MURs – pilot study
- Hospital Discharge – North Derbyshire
STOP PRESS: In collaboration with the LPC, Derbyshire County Council will use PharmOutcomes to support their Substance Misuse Services from this summer – bringing the benefits of PharmOutcomes to yet another commissioner.
So a plea from pharmacists to our commissioners2: please don’t automatically choose an existing supplier to provide IT support for pharmacy services. Talk to the LPC about PharmOutcomes and get a better deal for yourself and a better outcome from pharmacy.
Swotting up on the Electronic Prescription Service
It’s hard to believe that a whole decade has passed since the Electronic Prescription Service (EPS) was launched – under which the paper prescription remained as the legal entity, but with a parallel electronic transmission.
The second release (r2) of EPS began in 2009. Today, it’s still not complete. In Derbyshire fewer than half (48%) of GP practices have implemented EPS r2. So what does a bit of “SWOT” analysis tell us about the whole system?
EPS prescriptions are transmitted to the patient’s chosen pharmacy and arrive in good time to be dispensed, leading to improved workload management. Patient safety is enhanced through reduced transcription errors. Time is saved by pharmacies not having to physically collect prescriptions and surgeries have benefited from a reduced workload. Patients collect prescriptions from their nominated/regular pharmacy, which helps with building relationships.
Where’s the prescription? Has it been downloaded? Have the labels been printed? Have the items been dispensed? Are you looking for a ‘white’ prescription or did the surgery issue a ‘green’ one? Has the system crashed and you need a token? The prescription ‘treasure hunt’ is the highlight of many people’s day!
Deployment takes eight weeks. The 20 nearest pharmacies receive an email notification (from Arden and Greater East Midlands Commissioning Support Unit). Then, six weeks later, the six nearest pharmacies are invited to a business change meeting. Planning is a must and meeting with local GPs to agree changes to processes is vital. Both parties are in this together, so don’t waste the opportunity to ensure a smooth implementation.
Lack of training, locally agreed processes not followed, system failure and the need to run two systems (‘green’ prescriptions are still out there) all contribute to stress and increased workload. There’s also an issue with patient expectations, because to a patient, electronic = instant – so “why haven’t you got the prescription”…?
However, EPS r2 isn’t going away. In fact, full take-up in Derbyshire is not that far off, with new practices deploying at the rate of one a week.
Now is a good time to review your systems and procedures, so that you have a robust operation. Where necessary, provide additional training. Not everybody will ‘get it’ first time and using the system will almost certainly throw up issues you hadn’t even considered during all that careful planning.
Alternatively, employ staff with ESP – at least they’ll be able to find that missing prescription!
Collaboration is the Key to Successful Services
The 2013 NHS reforms transformed contractual arrangements for additional services from community pharmacists.
Enhanced Services used to be developed by PCTs with the Local Pharmaceutical Committee, leading to a Service Level Agreement. Now, only NHS England (NHSE) can commission them. Our Local Area Team has done a great job in obtaining funding for some innovative services. The Chair of the Local Professional Network has played a particularly influential role in this. Of particular note are the Emergency Supply Service and the Medicine Use Reviews pilot.
Locally Commissioned Services are commissioned by other bodies such as Clinical Commissioning Groups and Local Authorities. CCGs have to use the NHS Standard Contract, which can be 100+ pages!
Local Authorities have more leeway in how they do things. There are two main models for LA contracting:
- Framework agreements – directly commissioned services (e.g. Emergency Hormonal Contraception in Derby City).
- Lead Contractor – one organisation runs the entire service for the LA and sub-contracts to pharmacists as necessary (e.g. Derbyshire Community Health Services NHS Trust and lifestyle services – smoking cessation, Nicotine Replacement Therapy supply, obesity services, etc).
There is no requirement for these new commissioners to engage with the LPC and this has led to problems. In fact, the LPC can help with the development of contracts that will be well received by all parties. Because of our unique insight into community pharmacy, we know what will work and what won’t. We can offer advice on service fees, service set-up/operation, data collection, training requirements, administration, etc. In short, everything a commissioner needs to gain contractor engagement and commitment to the service.
As a practising community pharmacist, I want to deliver a wide range of services that meet the needs of the local population and improve outcomes. However, workload pressures can make this a challenge. Whenever I talk to commissioners about services, I’m always conscious of how easy or difficult they will be to operate in practice.
Collaboration is the key to achieving a situation where:
- Commissioners gain engagement and service delivery
- Contractors get a return on their investment
- Pharmacists can easily deliver services without increased workload pressures
The LPC is here to get a ‘Win Win’ situation for everybody, especially for our patients. So the message to service commissioners is – please involve us. We’re here to help!