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Chapter 6
Getting organised for promoting and
supporting self care as a pharmacy team
This chapter describes how you can get organised in a community pharmacy to design a strategy and implementation plan in relation to supporting self care. The outcome should be a culture whereby supporting self care is integral to all your developments and services making the most of local initiatives and the pharmacy contract. Pharmacists and the staff will promote and support self care as part of their everyday work in effective ways.
The community pharmacy is a natural hub for promoting and supporting self care. Integration of community pharmacy into primary care is closer to becoming a reality as a result of the new contractual frameworks for pharmacy and general practice. Pharmacy teams cannot promote self care in isolation from other health care professionals and their teams, and it is more important than ever that patients and the public receive consistent messages about self care. Look back at Chapters 3 and 4 to realise how the community pharmacist can be included in the PCT’s and general medical practice’s efforts at supporting self care. Community pharmacy teams can follow the algorithm in Figure 4.1 in a similar way to that of general medical practice teams, to build a self care culture and focus on worthwhile self care support interventions.
Requirements and opportunities: the community pharmacy contract
The community pharmacy contract promotes the involvement of community pharmacy teams in self care.1
The contractual framework has three types of service:
- essential: provided by all pharmacies, with national specification and funding
- advanced: provided by accredited pharmacies, with national specification and
funding
- enhanced (with national template and locally commissioned).
There are three interconnected essential services that directly concern self care and will be provided by all pharmacies (see Table 6.1).
Supporting self care
The ‘Supporting self care’ essential service covers both self-limiting problems and long term conditions.
| Essential service | Description | Focus | What’s new? |
| Support for self care | Provision of advice and support by pharmacy staff to enable people to derive maximum benefit from caring for themselves and their families | Support for self management of selflimiting and long term conditions | Recording of pharmacist’s contribution to care |
| Signposting | Provision of information to people who require further support, advice or treatment which cannot be provided by the pharmacy. Where appropriate, this may take the form of a referral | Other health and social care providers, and support organisations | Opportunities for referral to health and social resources more formal than before |
| Promotion of healthy lifestyles (public health) | Provision of opportunistic advice on lifestyle and public health issues to patients receiving prescriptions and proactive participation in national/local campaigns to promote public health messages | General pharmacy visitors and ‘hard to reach’ groups. People presenting prescriptions for diabetes, those at risk of CHD, particularly those with hypertension, those who smoke and those who are overweight | Brief interventions in long term conditions; targeted using prescriptions; participation in health campaigns now compulsory |
Self-limiting problems
Commonly referred to by health professionals as ‘minor ailments’, self-limiting problems will resolve with or without treatment. The essential service ‘Support for self care’ incorporates the traditional community pharmacy work of responding to requests for advice about symptoms, recommending OTC treatments and advice on home remedies, and referring to another health professional where needed. The new element is the requirement for record keeping for certain transactions: ‘For patients knownto the pharmacy staff, records of advice given, products purchased or referrals made will [our emphasis] be made on a patient’s pharmacy record when the pharmacist deems it to be of clinical significance’.1
This requirement for record keeping is the first time that there has been an explicit acknowledgement of the role of pharmacy advice and treatment for self-limiting conditions within the NHS. It is also the first time that community pharmacy’s contribution to clinical care has been documented. Its long term value will be in the implementation and whether pharmacists and other members of the primary care team use the documentation in follow-up. These records will become increasingly important as more treatments for intermittent and long term conditions switch from prescription only to OTC status. Auditing records for what advice has been given, and how, will enable pharmacists to review their standards of care and safety and make plans for improvement.
People seek advice in pharmacies about a wide range of health problems. Pharmacy staff have always performed a triaging role in advising when self management is appropriate and when further expert advice is needed. Community pharmacies are one source of advice and treatment about minor illness in primary care. Patients might see their GP, a nurse in a general practice-based nurse-led ‘minor illness clinic’ orNHS Walk-in-Centre (WIC) or seek advice from the NHS Direct range of services. The number of different settings and health professionals involved increases the risk of people receiving differing advice. The PART model (prevention, await resolution, relief of symptoms, toleration of symptoms) is used in Table 6.2 to explore the factors influencing these differences.2
influencing these differences.2 In some areas, ways of increasing consistency between health professionals are being found, such as shared information leaflets for patients (see example in Box 6.1).
| Advice area | Content | Influencing factors |
| Prevention | Advice on action/s to take to prevent recurrence | Access to current evidence |
| Await resolution | Evidence of natural history and timescale of condition Evidence of effectiveness of treatment or other advice |
Patient experience and Access to current evidence Level of consensus between professionals |
| Relief of symptoms | Evidence of effectiveness of treatment or other advice | Patient experience and preferences Access to current evidence Level of consensus between professional |
| Toleration of symptoms | Natural course of symptom/ condition Expected time to improvement or resolution |
Level of consensus between professionals |
| Triggers for referral | Specific symptoms and/or duration of problem | Professional decisions about what requires an ‘urgent’ appointment |
Box 6.1: Shared patient leaflets on minor ailments for pharmacies and
practices |
Community pharmacy minor ailment scheme
In many areas, pharmacy advice and treatment for self-limiting problems has been incorporated into locally-commissioned NHS services, as community pharmacy minor ailment schemes (MAS). This increases patients’ access to services and improves the management of workload in general practice by transferring some work to other professionals. The MAS service can be commissioned by PCTs as an enhanced service in the pharmacy contract. Patients who are exempt from NHS prescription charges receive any treatment needed from a locally agreed formulary, free of charge. Examples of ailments included in existing schemes are given in Box 6.2.
Box 6.2: Conditions included in NHS minor ailments schemes
Source: Pharmaceutical Services Negotiating Committee Enhanced service template: minor ailment schemes |
Conditions included in a scheme are agreed between local GPs, community pharmacists and the PCT. Eligibility for patients to participate is also decided locally. Schemes can be open only to patients who are referred during a request for a GP appointment, or through self-referral. The pharmacy contractor receives a locally negotiated consultation fee plus, where a medicine is supplied, the cost of the medicine.
Some schemes include ailments where the only effective treatment is aPOMand use a patient group direction (PGD) to enable the pharmacist to supply it. The legal definition of a PGD is ‘a written instruction for the sale, supply and/or administration of named medicines in an identified clinical situation. It applies to groups of patients who may not be individually identified before presenting for treatment’.4 PGDs are appropriate to manage a specific treatment episode where the supply and administration of a medicine is necessary, as in first contact services and urgent or emergency care. The commonest examples are topical antibacterials to treat conjunctivitis (although chloramphenicol eye drops have since been switched from prescription to OTC availability) and oral antibacterials to treat uncomplicated urinary tract infection (at the time of writing the outcome of a consultation for the switch of trimethoprim to OTC availability was awaited) and for impetigo. In some areas the MAS is used specifically to divert people who are known to need a treatment that is a POM (see example in Box 6.3).
Box 6.3: Taunton Deane MAS In the first year there were 560 consultations, with Saturday showing the highest demand. Just over half of the medicines supplied on PGD were for conjunctivitis, 20% for urinary tract infection and 9% for impetigo. Sixteen of the 18 local pharmacies were involved in consultations (ranging from fewer than ten to over 80 per pharmacy). The PCT has continued discussions with the OOH providers and A&E about commonly presenting conditions that could be managed in pharmacies. |
A particular advantage of pharmacy MAS is that they can provide NHS cover when local GP surgeries are closed at weekends and patients might otherwise go to A&E.
Providing ready access to emergency hormonal contraception (EHC) is now an important role of community pharmacies; this has reduced attendances at A&E.6 A systematic review concluded that access to EHC had improved and that women rated the pharmacy supply positively.7 Although EHC is available for purchase OTC the cost precludes its use for many women. Some PCTs have established a scheme to improve access to emergency contraception, where the supply is made from community pharmacies without charge to the patient using a PGD.
Community pharmacists also contribute to OOH services, particularly by providing telephone advice for patients who have been triaged (see Box 6.4).
Box 6.4: Out of hours advice from a multidisciplinary team in primary care FCMS has some 50 000 patient contacts per year. In addition to OOH medical services, the centre includes emergency social services, night nursing, emergency dentistry, mental health crisis team and palliative care equipment. The centre also provides OOH medical support for the local NHS WIC. An audit of patient consultations showed that 45% were for minor ailments, the commonest of these being: cough (32%), temperature (19%), sore throat (19%), earache (12%), diarrhoea (8%) and head lice (5%). Analysis of the prescriptions written for minor ailments at FCMS prior to the introduction of the multidisciplinary service in 2003 showed that 46% were for non-prescription medicines. Work has identified which patients can be streamed to the pharmacist or nurse rather than the GP. In addition to providing telephone advice, pharmacists can supply medicines for minor ailments to patients who visit the centre. |
Pharmacists’ role in supporting self care in long term conditions
Community pharmacists can ‘do more to help patients, keep them out of hospital and educate them and their carers about medication’.8 The Department of Health public health strategy for the ‘health promoting pharmacy’ aims to ‘improve the health of people with long term conditions by helping them with their medicines, promoting healthy lifestyles, supporting self care, signposting to other services and working closely with community matrons and case managers’.9
The contribution that community pharmacists could make is summarised in Figure 6.1.
The pyramid represents people with long term conditions, where 70–80% can take care of their condition with a small amount of support from professionals. Pharmacist input at Level 1 includes health promotion and opportunistic counselling, practical help with medicines use, and advising on the appropriate use of OTC medicines. These activities are covered by the essential services of support for self care and public health.
In the middle of the pyramid at Level 2 are the people whose long term condition needs more support from health professionals. Their asthma or diabetes might be more difficult to control for example.
At the top of the pyramid at Level 3 are the people who need the most intense level of support from the health service. These patients may have co-morbidities and conditions such as heart failure, chronic obstructive pulmonary disease and diabetes with complications. These patients have exacerbations of their condition that lead to multiple admissions to hospital.
Working at Levels 2 and 3 in the pyramid in Figure 6.1 relates to advanced and enhanced community pharmacy services. The example in Box 6.5 shows the service model that has been used in diabetes.
Box 6.5: Integrated support for people with diabetes Hillingdon PCT, working with a private sector company, Pharmacy Alliance, designed a community pharmacy based programme for people with type 1 and type 2 diabetes, who were receiving antidiabetic medication. The community pharmacists provide a medicines support service to these patients, and facilitate optimal disease management and monitoring, in collaboration with GPs and other health care professionals. Pharmacists invite patients to take part and gain their consent to participate in the programme. The patient’s random blood glucose, haemoglobin A1c (HbA1c), total cholesterol, blood pressure, body mass index (BMI) and waist measurement are taken and recorded. The patient then completes two questionnaires that assess their information needs and explore their beliefs about medicines. The pharmacist provides advice in response to the patient’s answers.Where the pharmacist identifies a need that cannot be met by the pharmacy, the patient is referred to their GP. The patient returns for a review at two-monthly intervals. Patients receiving the service have shown improvements in all clinical measures and in their understanding of their condition and medication. |
Asthma is another area where community pharmacy can potentially make a large contribution. Research conducted by Asthma UK found that ‘people with asthma would appreciate more support and advice from their local pharmacist: for example, parents have told us that they see pharmacists as a valuable source of information about their child’s asthma’.10 Two examples of community pharmacy-based support for asthma are described in Box 6.6.
Box 6.6: Asthma consultations in community pharmacies Boots, in collaboration with Asthma UK, have introduced an asthma service, initially in 50 of its stores across England. All pharmacy staff including health care assistants and dispensers have been trained to identify whether people’s symptoms are well controlled, by asking three questions recommended by the Royal College of Physicians that focus on nocturnal and daytime symptoms, and whether these disturb sleep or curb daily activities. People are offered a tenminute appointment with a specially trained pharmacist, and receive advice on managing their treatment and symptoms more effectively. Consultations cover inhaler technique, medicines management and lifestyle advice such as coping with coughs, colds or hay fever. Improving treatment compliance among patients with asthma was the aim of a pilot by the Moss Pharmacy company. The service was offered initially by eight of the company’s pharmacies and involved pharmacists developing an asthma action plan for a patient, reviewing and educating the patient’s inhaler technique, and monitoring the patient for six months. The pharmacist tackled compliance problems, or difficulties with inhaler technique, and any issues that could not be resolved were referred to GPs. Patients found to have uncontrolled symptoms, drug interactions or needing dose adjustment were also referred to the GP. Actions taken by the pharmacist were recorded in the patient’s care plan. |
One mechanism for community pharmacists to provide input to long term conditions is the advanced service of medicines use review (MUR).1 The consultation for MUR can be used to ask trigger questions which may identify the need for further support, as in the asthma example above.
Pharmacies can contribute to long term condition management by providing accessible monitoring tests. The example relayed in Box 6.7 shows how this can work. A major challenge is the integration of pharmacy test results with GP records so that work is not duplicated, and information can be accessed by others who need it.
Box 6.7: Greater Manchester High Street testing pilot Twenty-two pharmacies in Stockport, Oldham, Salford and Ashton, Leigh and Wigan PCTs, in a pilot public/private sector collaboration regularly monitor patients with diabetes and/or coronary heart disease. The pilot is sponsored by the Department of Health and supported by Pharmacy Alliance. Participating pharmacies include independents, regional multiples and national multiples. The pharmacists complete a specific training programme and the premises’ facilities are upgraded with NHS support. Patients can choose whether to continue using existing services or the new services. Those that choose the pharmacy option are invited by their pharmacist for an initial consultation. A patient history is taken and tests are performed by the pharmacist prior to a consultation with the patient. Measures regularly taken include:
The consultation covers the impact that medication, lifestyle, diet and activity can have on the patient’s condition, and uses the test results to illustrate what changes can be made. Patients are seen at least twice a year. Exceptionally, the pharmacist may need to refer the patient back to their GP for urgent review. The pilot aims to promote greater collaboration between community pharmacists, GPs and other local healthcare providers. Data gathered in the consultation are relayed online to be inserted into the patient record and the GP’s QOF record.6 Equipment selection, staff training, quality control, external quality assurance and performance management all form part of a governance system. |