How safe is your A & E

This winter will be particularly difficult. Following a significant increase in the number of cases of influenza in Australia NHS managers and politicians are worried. We already know that our A & E departments are full and many are failing to hit their 4 hour targets. When you walk through the ‘major’ section is usually full with people waiting on beds and trolleys waiting for the hospital to find them a bed.

I worry about the staff. Despite a valiant effort there will still be a significant number of members of NHS staff who have not been vaccinated. Having said this, we cannot be absolutely sure that the immunisation we have will be as effective against predominant strains as we would have wished. The last thing a hospital wants is an outbreak in their staff.

I was reading an assessment of an A&E department in Paris. Over the last influenza season 21% of attendances had signs and symptoms compatible with influenza. When tested 36% of these actually did have influenza. Of course the rates were higher in older people and particularly those with at least one underlying medical condition. When you think about this approximately 8% of the attendances actually had influenza. That is about one in 12.

The scary bit is that they don’t know and they can’t put all 21% of their attendances into isolation. So while you are sitting in the crowded waiting room or worse still on a bed in the ‘majors’ one in 12 of those patients will have influenza.

There is a potential solution. The ambulance service and the hospital could use a rapid antigen influenza test. If you start with a product that is approved by the FDA (the US have very good standards) and it is CLIA waved (suitable for use by non-laboratory staff) then you can have a nose swab done and a result within 10-15 minutes.

The hospital would be able to isolate those patients with influenza very early in their route through the system. They could get fast tracked to appropriate treatment and kept isolated from the other patients. Hospital staff would be able to implement control of infection procedures to protect themselves and other patients.

In Paris they are changing. When you go into A&E with signs and symptoms compatible with influenza you will have to have a nose swab taken. It will help them use their precious isolation facilities better and accelerate their clinical decision making. It is actually going to save them money – lots of it.

If you want to be sure that fellow patients in the waiting room haven’t got influenza – I suggest you go to France.

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How prepared is your A&E

I was reading some of the work of Professor Enrique Casalino in Paris. Last year he noted that the number of patients attending his A&E had increased by 10%. On January 1st 2017 he noted that the average attendance had risen from 215 to 231 and the number of admissions from 25-35 a day to 30-40a day. He points out that this is an additional 5 to 10 admissions a day and this small increase puts the hospital into a precarious balance.

“The problem comes from the tension on the availability of hospital beds downstream of emergencies.”

I believe that is a problem faced all around the world and particularly in the UK. Pauline Philip, the National Director for Urgent and Emergency care believes that we need to free up more than 3,000 beds this winter and the government have responded by providing £350mto NHS trusts to help them cope with increased pressure over winter.

So Professor Casalino tried something…..

There were 1,099 patients admitted to his A&E service during 2016/7 winter with the signs and symptoms of influenza. They all had nose and throat swabs which were run at the time and then stored. The medical records of 500 of these were examined by experts (A&E and infectious diseases) and nurses and physicians from the A&E performed a rapid antigen test on the samples. They compared the results of the rapid test to the results produced by laboratory based PCR tests. They concluded that there was no difference in test performance as well as confirming the feasibility of point of care testing in A&E.

He hypothesised that the use of an efficient rapid diagnostic test may result in changes in the management of patients by ED physicians and facilitates a reduction in hospital costs in adult and geriatric patients by limiting examinations and treatments in the ED and reducing the number of hospitalisations.

He developed a decision-tree model for his total population of patients. The implementation of rapid tests was associated with a reduction in costs when the prescription of standard care in A&E is limited to patients that are influenza positive and especially with a fall in admissions of 20% in Influenza negative patients and a fall of 10% in influenza positive patients. He estimated that compared to their usual care, the implementation of rapid antigen tests may produce a saving for his hospital of 1.7million euros.

What would you expect the prof to do now? That’s right he is implementing it. He is using new diagnostics to increase the efficiency of his A&E service and to save money.

What would you expect the NHS to do…………..

 

Sorting out influenza

 

The NHS has been given a severe flu warning from Simon Stevens at the NHS Expo conference. It is not too unexpected. Systems that calculate the probability of bad seasons have been issuing gentle warnings for a while, doubts about effectiveness of the last vaccine and the reports from Australia of a rapidly mutating virus add an additional worry.

I don’t need to explain the impact of flu and what might happen if we have a particularly bad season. The whole point of Simon’s warning was to ensure that the NHS was prepared, but there is still no plan.

I would like to mention that influenza is not a reportable illness. Public Health England does collect some surveillance data on influenza (ILI) like illness from General Practice and NHS England ‘may’ respond by allowing the prescribing of antiviral medication during the period of apparent high reporting of ILI. It all seems a bit hit and miss to me so I would like to suggest a way forward.

Vaccination – increase the campaign activity around vaccination. Stop petty arguments between community pharmacy and general practice by introducing an area wide reward based on joint achievement of vaccination. The more people that are vaccinated the better the community immunity.

Hospital triage – hospital A and E services have already started to purchase point of care tests for influenza A and B. The sensitivity and specificity of recently introduced tests are much improved at over 90% for influenza A. Patients coming through the door can receive a point of care test based on a nasal swab as they enter the system. More hospitals and out of hours services will join in.

General Practice triage – General Practice are waiting for CCGs to explain their preferred course of action. Patients coming into General Practice could be triaged using point of care tests and then managed through an appropriate pathway.

Community Pharmacy triage – Community Pharmacy are also waiting for CCGs to explain whether they will be included within flu triage. They are often the first stop for patients with ILI and it would seem sensible to start the triage process where most patients go. If excluded from the process Community Pharmacy could offer a private triage service to patients in association with anti-viral treatment via a PGD.  The Community Pharmacist would be well placed to advise patients who have flu on how to look after themselves and when to seek additional help.

Treatment – although there are doubts about the absolute effectiveness of treatment, it could be employed as an immediate option following a positive result. A campaign using the strap line ‘get tested – get treated’ might be useful.

Surveillance – Public Health England could create a system based on both laboratory and point of care test reports to obtain a more detailed picture of influenza within England.

It could all work and it might reduce the impact on NHS service and minimise the expected increase in winter deaths, but if you were to ask me what I thought – I would answer:

  • Warnings given to late
  • Not enough thought about how to get Community Pharmacy and General Practice really working together to increase vaccination uptake
  • Hospitals will introduce point of care triage – because they can
  • Commissioners won’t get their act together to introduce locally enhanced services around point of care testing for influenza across primary care (General Practice and Community Pharmacy)
  • A handful of community pharmacies will introduce a private service
  • Public Health England would have to pull out all of the stops to redefine flu as a reportable illness and get the mechanisms in place
  • It will be a bad flu season

Go on – prove me wrong…..

Community Pharmacy, Influenza and Winter Pressures.

Many Pharmacies are gearing themselves up for flu vaccination season. Training done, posters up, vaccines in the fridge and ready to start. I am sure that Community Pharmacists will do a grand job to ensure that we have a significant level of community immunity, but it is not as simple as that and perhaps we need some additional urgent action on top.

Simon Stevens told the Health and Care Innovation Expo in Manchester that he is worried. There are questions remaining about the effectiveness of the vaccines and we might be hit by the same H3 strain that affected New Zealand and Australia. He is worried that we may not cope and he is making sure that plans are in place for between 2,000 and 3,000 beds to be freed up. There will be huge challenge to General Practice who are already stretched and working at capacity.

This is the time for community pharmacy to come forward and say – this is what we can do.

A rapid antigen diagnostic test for influenza A and B is available from Sekisui through Una Health. It costs £6.50 per test and takes just a few minutes to read after a simple nasal swab. Community Pharmacy could offer these tests privately or be commissioned through the NHS. Following a positive test the pharmacist could offer antiviral treatment, again privately through a PGD. This all could be commissioned by the NHS following Simon Stevens warning to make sure you are winter ready..

If the NHS wanted to enhance this service then the Community Pharmacists could offer a semi-quantitative CRP test. CRP seems to correlate well with the severity of flu and is a known marker for chest infections.

This may reduce the number of people attending General Practice with general symptoms of flu. Patients with flu will be given enhanced information and a fast track access to their GP should their health deteriorate or they develop signs of a chest infection or dependent on their CRP levels. The rapid diagnosis and administration of antivirals may help to reduce the impact of the disease on the individual. Hopefully this will reduce the pressure on out of hours and secondary care also.

In parallel Community Pharmacies could be commissioned to run strep A testing. Managing patients with sore throat in the community pharmacy may also be helpful to reduce pressure on General Practice over winter.

Winter is coming – and this one may be worse than many before. It is time to act.

 

Is Community Pharmacy part of the NHS?

Is Community Pharmacy part of the NHS?

This is a really interesting question with no clear answer. It is a bit contentious and swings with the mood of people. However, it remains an important question that requires a proper answer.

Surprisingly, many pharmacists working in community pharmacy do believe that they are part of the NHS. The pharmacy that they work in has an NHS logo above the door, will have NHS materials on offer. They may have working relationships with hospitals, GP practices and community units and talk endlessly about integrated services and seamless care. They talk about people who enter their pharmacies as ‘their patients’ and take responsibility for aspects of their health, wellbeing and care.

But they are not allowed to join the NHS Pension Scheme. Pharmacists in hospitals and General Practice are – because they are part of the NHS. This may be established from way back in history when community pharmacies were seen as a business and had a significant private retail element to their business. This is no longer the case and many Community Pharmacies are 90% NHS income.

What about premises. Many community pharmacy premises are used mainly for the delivery of the NHS contract. When a community pharmacy wants to upgrade their premises, either through a refit or extension they have to fund this out of their own pockets. So the community pharmacy that delivers the pharmacy contract and bears the NHS logo is 100% supported by the owner of that business. There may be pharmacies that need a refit and development of clinical space – the NHS offers no help to them. The NHS has limited responsibility for the quality and state of the community pharmacy estate.

On the other hand George Osborne committed £1b to the GP infrastructure plan. GPs are allowed to claim notional rent, cost rent or leasehold cost reimbursements. GPs are financially supported to expand their premises. Many GP principles own their premises. The NHS pays them notional rent, based on a calculation of what they would have to pay to lease their own property from themselves. If the NHS supports capital investment, then the rent would be reassessed and payments increase to reflect the value of the improvement. Should the GPs hand back their contracts, then they may be the owner of valuable premises that have received significant funding from taxpayers through the NHS.

At the moment it is easy to suggest that NHS England does not consider Pharmacies or Community Pharmacists to be part of the NHS. Permission to use a logo is a step in the right direction, but it is hardly a great commitment. NHS England doesn’t really look after their community pharmacists or their pharmacy estates.

The Rt Honourable Steve Brine said at the RPS conference that he was committed to improve the integration of community pharmacy into primary care and public health pathways. He knows that pharmacy professionals are committed to the NHS. Perhaps it is about time to change the basis of that arrangement:

  • Please support community pharmacists to be seen as a core part of the NHS and open up the ability for them to join the NHS pension scheme.
  • Please support the development of community pharmacy premises, ensuring that we have an estate that is fit for the future demands of the NHS.

Will the NHS put their money where their mouth is?

The MMP Blog

The NHS Innovation Accelerator Program was launched in 2015. We learnt then that it was all about finding innovation and making sure that it is implemented quickly in the NHS. The key phrase in the launch was:

“The innovations will help to prevent diseases, speed up diagnosis, improve safety and efficiency of services and increase patient participation in decision making, self-management and research. This will lead to better health outcomes and a more sustainable NHS.”

In 2016 the Strep A sore throat test and treat service was announced within the program as a community pharmacy based service where patients with a sore throat could be diverted from General Practice and could be tested to see whether they had a Strep Ainfection and would benefit from antibiotics. When a GP sees a patient with a sore throat they use their clinical judgement as to whether it is bacterial or viral and…

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Strep A and the Community Pharmacy Revolution

The impact of sore throats on the economy and the NHS over winter and spring is huge. One in ten will contract a sore throat every year – that means 6million cases every year. A proportion of these will be caused by a bacteria – commonly strep A. This is a contagious infection and easily spread. You may be contagious 2 – 3 days before the symptoms begin and then for a further 14 days- well after the symptoms have cleared. It is also responsible for more serious infections such as scarlet fever in children and invasive disease.

If you were in the US the advice would be simple – pop down to your pharmacy or medical facility and get tested. In fact this advice is fairly common across Europe. The test would be a rapid antigen detection test (RADT) that takes just a few minutes. Sensitivity is 96% and specificity is 98% vs culture. If positive you get an antibiotic and if negative, just symptomatic advice. Following the initiation of an antibiotic and the fall in fever you can go back to work or school in 24 hours.

Their strategy is:

RADT Instruction % who have strep A Comment
Positive Prescribe antibiotic 96% 4% are needlessly given an antibiotic
Negative No prescription 2% 2% remain contagious for 14 days

 

If you have a sore throat – go and get tested. If you are a healthcare worker, carer of the elderly or work in schools it is even more important that you go and get tested.

In the UK we have a rather quaint love of the ‘educated guess’. We send all these patients to the GP who use the Public Health and NICE supported FEVERPAIN score. The strategy is as follows:

FEVERPAIN score Instruction % who have strep A Comment
4 – 5 Prescribe antibiotic 62-65% 35-38% are needlessly given an antibiotic
2 – 3 Delayed prescription 34-40% Patients with infection returned to community untreated for 72 hours
0 – 1 No Prescription 13-18% 13-18% remain contagious for 14 days

 

We are diverted by concentrating on symptoms rather than infection. If you have an infection and receive an antibiotic then your symptoms may improve quicker, but perhaps only by half a day. Some would suggest that this half a day is not worth the investment without considering the value of reducing transmission. Others reflect on antibiotic resistance, but still to this day there has not been a single strep A isolate found that is penicillin resistant.

Why should we be worried? The dramatic increase in Scarlet Fever notifications seen in the 2013-2014 season has continued at this level, meaning we have the highest levels for 50 years. Can we be complacent because the incidence of severe complications still seems low? The incidence of invasive disease is also increasing and data from the 2015-2016 season suggested that levels were 45% above the average for the previous years. There is no room for complacency as mortality remains at 15% and as high as 55% for some infections.

 

This season I am hoping for four things:

We create a consistent narrative  “have a sore throat – get tested”

Community Pharmacy takes a lead and start offering strep A tests to people with a sore throat.

The Strep A sore throat test and treat service, that was supported by Simon Stevens within the NHS Innovation Accelerator and throughout the innovation network actually gets commissioned somewhere.

We have a different conversation and stop supporting an ‘educated guess’ process where a better objective test is available and widely used. Let’s concentrate on reducing transmission and reducing the use of needless antibiotics.

Winter is coming! Guest blog by Connect2Pharma

As we enter into another winter – you know – that season that follows summer and autumn that the NHS has a habit of forgetting about – are you making plans?

GP practices will be crammed full, OOH will not be able to cope and more A&E services will be redirecting ambulances around the country. People will be getting coughs and colds and sore throats.

The Strep A Sore Throat Test and Treat Service using the OSOM® Strep A test was included in the NHS Innovation Accelerator program after the publication of the feasibility study. Last year 300 independent pharmacies delivered the service privately. You should be proud, because we passed your feedback and views into the team working to develop the proposal further. A proposal has come through the innovation network and a couple of weeks ago we heard that a significant amount of money was going through Academic Health Science networks to fund innovation proposals.

Will it happen – will there be an NHS commissioned service? Personally I think the answer will be yes – there will be a few pilots commissioned with very strict criteria and several hurdles to get over.

Let’s think about this. We have two scoring systems – CENTOR and FEVERPAIN – they help to differentiate people with a viral sore throat from those that have a bacterial sore throat. They aren’t fantastic. With a FEVERPAIN score of 4 or 5 the recommendations are to give antibiotics, but the score is only 60-65% predictive. And with a score of 2 or 3 where delayed antibiotics are recommended it is only 34-40% predictive. The only conclusion is that a lot of people who don’t need antibiotics get them and some that would benefit don’t.

We all understand that antibiotics only reduce the symptoms by a short period of time, but they do reduce the period of infectivity from 14 days down to less than 24hr. You might consider this important for a condition that spreads. A family with one case has about a 45% change of a second member getting the condition. And we should remember that scarlet fever and invasive Strep A are caused by the same bacteria and can have very different outcomes.

The test is remarkably simple and will identify Strep A antigens. It takes just a few minutes to do and has both high sensitivity (96%) and selectivity (98%). It is inexpensive and comes in packs of 20 or 50.

Pharmacies working with us say that it is a simple and straightforward service. That many patients just want to know – and find the service quick and convenient. They often purchase symptomatic treatment alongside the test – whether it is bacterial or viral. We all know that this service supports the PharmacyFirst campaign and helps to reduce some of the pressure in General Practice.

The up-front investment costs are low and supporting materials are available on our website www.connect2pharma.co.uk there are also links to a manufacturer on line training course, the UK distributor and a company that supports a PGD. It is all there.

If you are in a larger group then talk to us or the distributor about arranging a training program for you.

Ordering details

To order your OSOM® Strep A Tests today contact UNA Health via telephone on 01782 575180 or email at info@unahealth.co.uk. Remember to quote the Connect2Pharma account number – 7513, for discounted prices.
 
The following discounted prices are available to Connect2Pharma members.
 
OSOM® Strep A Tests are available at a special price of £90 for 50 tests, this equates to £1.80/test (normal list price of £105 for 50). RRP £9.50/test.
 
Alternatively we also now have a smaller pack size of OSOM® Strep A Tests which are available at a special price of £45 for 20 tests, this equates to £2.25/test.

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A shortage of healthcare professionals

Every day there is a commitment to creating more healthcare professionals. We need thousands of GPs, thousands of nurses and now thousands of mental health workers. There is a pool – and when you pull from one it creates a shortage in another. It takes years to train and nurture healthcare professionals and then we reduce their income and make them work harder – unjustly it is just the way it is. While we fiddle, valuable professionals look towards their retirement, move to agencies and find better paid jobs elsewhere. The spirit only lasts so long before camaraderie and the value of doing a valued job wears thin.

We could always look overseas – try to attract healthcare professionals from other countries to come and work here. This was very successful – it keeps us going for now, but we need to do more.

We could put all of our hopes in technology, supplying services through the internet and connecting services to create efficiency and share expertise. It will help, but it is hardly the replacement for one-to-one contact and a personal experience. I reflect that it was the joy of one-to-one interactions that first brought me into the NHS and for many patients it is the one thing that they value most.

We must understand and use our resources better. The program to put pharmacists into General Practice is not new. I worked with GPs 20 years ago and I hope that they found my help valuable. It took 20 years for the NHS to catch on and launch their program to pump prime pharmacist placement. Fantastic, I say, knowing that my local GP federation are now looking for at least 14 pharmacists. But what we will discover soon is that we have a lot of pharmacists, but not ones with the necessary skills. It does make you wonder what workforce planning is all about.  But we will succeed, training and supervision will now happen and after a rocky start this program will fly and we will see an increasing number of patients benefiting from seeing a pharmacist in General Practice.

We also have 10,000 pharmacies in England. As dispensing medicines becomes automated and delivered to your door or popped in a convenient collection locker – what is the plan? Is ‘close them’ the right answer?

As I watch high streets decline, the post office is gone, the banks are going the Pharmacy is the anchor store that remains. Do councils appreciate that when they go the high street dies? Do they want to build healthy communities without a Pharmacy as a central point?

It is about time that we took a second look and a hard think about what we want of a local healthcare provider – often open long hours and still offering one-to-one and face-to-face contact. What might we want / need:

  • Full minor illness management with integration in existing out of hours services
  • Active delivery of public health services and the creation of health and wellness services
  • Point of care diagnostics
  • Long term condition management
  • Managing medicines for housebound and frail elderly

Then we need to plan for this – engage owners and look at the training and developmental needs of front line pharmacists. Support the redesign and development of pharmacies. And start developing a wider training program that works.

We need a stronger structure that better links NHS England via the LPNs to the LPCs and individual contractors.

It isn’t really difficult- it just needs some vision and the will to do it. While there is no magical GP or practice nurse tree – we could create something special by developing our pharmacy led healthcare on the high street.

 

Community Pharmacy grieving process – what to do next

Watching community pharmacy going through a grieving process is interesting, but it has to end sometime.

Disbelief happened in December when the letter from NHS England was first received. Although we knew that relationships between the PSNC and NHS England were broken, we did not believe that they would send such a letter. It is all too easy to ignore that this letter was written, the change in core contract was always going to happen.

Some people became angry. How could NHS England think this? How can NHS England not see the value in community pharmacy. There was an understandable expression of anger including a court case that must have cost more than £1m, a PWC report that must have cost £300k. Not to mention A love my pharmacy campaign raising over 2 million signature that must of cost a small fortune.

I am not sure that the bargaining stage has really started. I haven’t seen the olive branch offered and an alternative plan put forward. Pharmacy Voice did produce a Community Pharmacy Forward View, but the response was to remove funding and halt this approach. No one has looked back at the various white papers and associated documents and said ‘sorry’ you wanted us to change, but we said no.

Some pharmacies have gone straight to depression – they are feeling sorry and regret mixed with a lot of fear and uncertainty. There are many waiting for the value of their investment to tumble, their profits to fall and perhaps their business to become unsustainable. They realise that they have to do something – but it is too difficult while they are delivering all those free services and trying to earn another penny on a packet of pills.

However, some are coming through it, moving into a stage of emotional detachment and objectivity. They have an understanding that cutting overheads to the bone will not give the continued stability to the profitability of a business. They need revenue and they have to create it now. They need to think differently about high value customers and how they can create a range of services and products to better fulfill their healthcare needs. They may have to look for new groups of customers and reach out to people in all walks of life through marketing.

Connect2Pharma offer exactly that, by developing new innovative services from the ground up. Their services are wrapped up into parcels of care, which includes everything that you need to implement and develop a new service – marketing materials, training and links to distributers and manufacturers. This parcel of care concept was a runner up in the C and D awards.

But please don’t think that this is all you have to do. You do have to market the service, find new customers and link services and sales to maximise the opportunity.

Don’t take my word for it though visit their site and explore their services. They include: Strep A sore throat test and treat service, Coeliac disease testing, PSA screening, Strep B testing, Heart Check, Sexual health testing, Detection of early diabetic foot disease testing and many more to come each month

www.connect2pharma.co.uk 

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