Commissioners sometimes miss the importance that community pharmacy have in the treatment of a wide variety of complains, but never more than in GI. Sometimes the community pharmacist does not realise how important they actually are and organise themselves to be a potential solution for CCG commissioning issues. And I know that belly ache is not as sexy as diabetes and COPD, but it is a secret spender that everyone ignores.
So let’s just think this through….
Community pharmacy see and treat the majority of patients with upper (dyspepsia and GORD) and lower (IBS, constipation, abdominal discomfort and diarrhoea) complaints. That is a simple fact – more than 70% of patients who have these conditions never see a GP and rely on the limited range of medicines that the pharmacist can sell with often a package of lifestyle advice.
The proportion that get through to general practice are also managed expertly by the GP and a percentage of these get referred for specialist advice or diagnostic uncertainty.
When you look at this problem from the other end you see that more than half of the GI consultant new patient referrals are for these conditions. Specialists love to ‘visualise’ so endoscopy rates are huge and I become frightened by the associated costs here. The mortality rate for upper endoscopy is about 1 in 12,000 and lower 1 in 5,000 and morbidity quoted as 1 in 230 and 1 in 440 – although in the US they quote 1 in 2,000 endoscopies result in death and 1 in 200 a complication leading to long term morbidity – interesting. Add to this that approximately half of all non-cancer colonoscopies have no NHS follow up (approximately 1,000 a year for an average CCG) and you start to wonder what is happening. I will leave the complex discussions on value of early diagnosis now our 5 year survival rate for oesophageal cancer has crept over 12% to other more clever people.
If anyone knows where I live than my local CCG has one of the highest rates of flexible sigmoidoscopy and colonoscopy in the country matched with one of the lowest rates of referral for suspected cancer referrals – all documented on the right care site. So hang on a minute – if they are not using much of the endoscopy capacity for cancer then what they doing? Oh and they only spend an addition £1m on elective GI admissions compared to 10 similar CCGs. And what’s that – over 5,000 upper GI endoscopies a year? We do like our scopes!
We do need to think about this differently from the top. The rates of activity for endoscopy is listed under NHS England Domain 1: preventing people from dying prematurely. This suggests that a high rate is good and those with low rates are poor. Concluding that the more endoscopies that we do, the more lives we will save is frankly ridiculous (see above).
If the NHS is going to cope then the flow must be reversed and patients managed at the lowest and least costly point within the NHS. I might also suggest that this is perhaps the best place for them to be managed – rather than climb the escalator within the medical model of care. So if I use the example above they may have approximately £2m to play with. So roll up, roll up – who wants to take on better GI care?
‘cough’ – while I wait for a super intermediate care service to be established which will suck all of the expertise out of primary care and create yet another level of complexity – can I make another suggestion?
Just start by noting that the NICE clinical guideline for IBS, if nothing more, clarifies that IBS is a ‘primary care’ disorder. And the NICE clinical guideline on dyspepsia includes a pathway for the community pharmacist. So NICE firmly believes that a community pharmacist is capable of identifying alarm or red flag symptoms.
The least expensive and more effective care is ‘self-care’. So why don’t GPs and community Pharmacists just get together and sort it out. I am sure that there are patient support organisations out there that can supply super self-management plans. The community pharmacist can implement them and the health trainers (usually only found in Healthy Living Pharmacies) can help with some of the lifestyle advice. You may need to commission some additional dietetic support – but some enlightened CCGs like Greenwich already have dieticians within their medicines optimisation team.
You will also have to look at treatment pathways and access to medicines. This is a little more difficult as you will have to put some PGDs in place and build repeat prescribing links between community pharmacists and general practice. The ability of a community pharmacist to supply a PPI and reasonable quantities of an effective alginate is important in upper GI complains. Let’s create the ability to supply medicines that improve the bowel habits and tackle the abdominal pain and bloating in IBS. We, as pharmacists, must recognise that many of the medicines that are currently supplied over the counter and even some that are issued on prescription for IBS have ‘limited’ evidence of effectiveness. No actually I should say – some have ‘good’ evidence(level 1) that they don’t work.
I would go so far as to create community pharmacy based ‘gut clubs’ where people with common bowel complaints, particularly IBS, can get together and discuss ways in which they can make their lives better. This is so important when even the most effective and evidenced based medicine may only reduce the abdominal pain by 50-70% and the patient must ‘learn’ to manage the remainder.
The more people that can adequately manage their condition by themselves with the occasional support of a community pharmacist, the fewer will be referred to general practice. The fewer referred to general practice, the fewer that will be referred to specialists for ‘visualisation’.
So the challenge is out there for community pharmacy, general practitioners and CCGs to sort this out and deliver better patient care for significantly less money.