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.


Medicines for Life

Usually we think of medicines for diseases. It puts the focus on the disease and the disease at the centre of the consultation. We might use data to talk about the effectiveness of a medicine in changing a surrogate marker for disease activity and we start to assess the effectiveness of a medicine on its ability to change a surrogate marker per unit cost to achieve this. The drive towards cost-effectiveness simply pays lip-service to a patient

When we talk to patients, we set targets related to surrogate markers for example – ‘we are going to try and bring the HbA1c down a little’.  And we even ask patients to return when they feel the disease has got worse, for example – ‘pop back when the pain gets worse’. All of this contributes to a discussion being disease centric.

Patient centricity means that the patient is at the centre of any consultation and treatment. We talk about it endlessly and every graphic has the patient clearly at the centre. When we use the phrase ‘patient experience’ it is often linked to compliance seeking reasons why people may not comply with medicines. We look at endless ways of improving compliance and reducing waste without making a simple discovery. Poor compliance may be an active decision – I never wanted this anyway – or a passive decision – I was never convinced that this medicine would truly help me. We may cover up these issues within a medical model and the need to provide population treatment in a cost-effective way.

Helping people to create health is the most important element of what we do. The focus should be on the patient, how they live their life, how they are managing and what they are not managing. And then consider what could be done to make that better.

Medicines may fit in three ways:

  • A medicine that cures a condition and allows a patient to life the life that they once had. There may be no drop in function after cure
  • A medicine that prevents a disaster from happening to someone who is actually living a normal life by their current standards
  • A medicine that treats a symptom that may allow the patient to achieve a function that they had lost

We may want to ask what is normal. People wake up, get washed and dressed and go out. They may work or just meet people to fulfil a social need, settle down, go to bed and sleep. When you apply these thoughts to people you may get a very wide variety of responses back, but the most important question is ‘what matters to you?’. The goal of health creation is to give people control over their own life, meaning and purposeful social contact and activity and the confidence to make a positive impact on their own life and the lives of others.

Not all things that matter to people can be solved by a medicine. There are many things, such as social isolation and a feeling of worthlessness that don’t have a medicine for and we need a clear health creation solution as described in the recent NHS Alliance manifesto, but if that is the answer then I have a range of medicines that may play a part.

A near term target might be to get out to a coffee shop, pub, a neighbour’s house, a workshop or other social gathering. When asking, ‘so what is stopping you’, I may have a whole range of medicines that can reduce symptoms and enable small improvements in function that might enable to patient to reach this goal.

A mid term target might be to return to employment. We have to acknowledge that many conditions are sufficiently severe to prevent return to the same job, but with some help we may be able to help people return to an alternative vocation.

A long term target may be to still be alive and see your grandchildren. So with support we may have medicines that help people to live a longer life.

It is a big change. I am focussing on the individual and what matters to them. I am engaging the community to provide support in health creation. I am tailoring medicines to support living. I am evaluating the benefit of medicines on a different level. And I am booking the follow up at a defined and agreed interval to talk about progress and the benefits of treatments – not their failure.

Medicines are for life

Outcomes in diabetes

Wow – this was posted over two years ago!

The MMP Blog

It’s funny when you start a discussion on outcomes in a condition such as diabetes. The usual tripe comes out – HbA1c and then some idiot talks about cost-effectiveness and then those silly QIPP indicators and QoF points. I can even get angry when someone adds medicines safety and adherence. My heart sinks and I really know that the NHS has problems.

So – let’s start from a different place. The person with diabetes wants to feel confident that they can manage their condition over a long period of time. They want to feel that they are in control and they are on top of things. They want to feel well. I even highlighted the key words to make it simple.

Hmmm – the room has now gone totally silent.

I now have to stop the ones that are trying to tell me that they do this, by reading…

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