AMR – failing to join up the dots

 

If anyone is attending the Chief Pharmacists conference and listening to Dame Sally Davies would you ask her a question for me. “Why is there not an antiseptic guardian program?”

Antiseptics are very important. Most surgical infections are caused by bacteria that are lurking on or within the skin. The solution that you apply to the skin is very important to reduce the chance of a surgical site infection. These infections can be deep and very dangerous or superficial and very annoying, sometimes appearing days after discharge from hospital. They all require the use of an antibiotic. I agree wholly with Dame Sally that unless we tackle antimicrobial resistance then routine operations will become more dangerous, however it is equally important that we tighten up the use of antiseptics to reduce surgical site infections to reduce the use of antibiotics. Even Lord Carter mentioned the need to reduce surgical site infections – it is an unnecessary waste of money and cause of suffering to patients.

The problem in the UK started over 10 years ago when we allowed, perhaps even supported, a workplace disinfectant (biocide) to be introduced and bypass both the medicines and biocide legislation. We played on the inadequacy or perhaps just the unwillingness of the Health and Safety Executive to get involved in the NHS and the blind side of the CQC to implement the existing biocidal products regulations. The MHRA battled to ensure appropriate labelling, but we know that few surgeons read the label. This failure was ignored by NHS England and even the RPS who, to this day, have consistently failed to clarify biocides and their legal position to members. It is perhaps sad to reflect that the use of workplace disinfectants (biocides) on patients in the NHS is now considered custom and practice.

We face a future is simple a rush to the bottom. Who can sell the cheapest antiseptics to the NHS. And when you don’t want to use workplace disinfectants – can you find the cheapest alternative. There are no new antiseptics coming into the UK market – what is the point of researching new products and getting a licence – being sterile, single use and evidence based – when austerity and apathy means that nobody will use them.

Let us reflect on what is actually happening. You can split the hospitals into four groups:

  • Using workplace disinfectants (biocides) in patient care
  • Using lower strength chlorhexidine off label where you might expect an excess of late onset superficial infections
  • Using aqueous povidone iodine (may be masquerading as povidone iodine alcoholic tincture) where you might expect an excess of both deep and superficial infections
  • Using a sterile, single use, evidence based, licensed medicine

If you want to overlay this with clinicians who like to use two layers of one over the other, those that use 70% alcohol you have a total hotch-potch.

So we find ourselves in a position where we do not have high quality research. Surveillance rarely goes outside the hospital to pick up late infections that would present to the GP and there are usually no feedback mechanisms. Many hospitals select the cheapest product that they can source. Some are happy to put the use of workplace disinfectants on their risk register and avoid telling patients what they are using. And the MHRA and CQC who acknowledged that gap in the implementation of the existing legislation within their memorandum of understanding have done nothing.

If you ask others you may find that NHS England believe it is a regulation issue and the CQC believe it is a hospital management issue. The RPS don’t believe it is a priority for them. So come on Sally – get a grip – and launch an antiseptic guardian program. At least get us some decent research.

Note: when I refer to biocides as workplace disinfectants it is because the legislation supporting the biocides fits under the Department of Works and Pensions and not the Department of Health and Social Care. The implementation responsibility sits with the Health and Safety Executive, but is delegated to the CQC in hospital premises.

Public Health England’s team recently published their research on antiseptics. They found that when subjecting certain bacteria to very low concentrations of a common antiseptic, the bacteria coped and became resistant to colistin and many other antibiotics. This is important research telling us that improper use of low strength antiseptics may influence bacterial resistance.

 

 

 

 

 

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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.

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…………..

 

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.

 

Is the NHS chasing pavements?

The NHS seems to be always chasing pavements rather than getting to the point and sorting things out. It has never been about structure and competition – it has always been about relationships and working together. It cannot be all about illness, but must focus on wellness and health creation. It is not about access it is about demand.

Demand has two elements:

Can we share demand – bringing other players in to share the load?

Can we reduce demand – adopting health creating practice and giving people control, connection and confidence?

GPs will tell you that there is too much bureaucracy, the payment systems are fractured and there are too many boxes to tick and too many meaningless pathways. But they will truthfully say that demand is the killer. More patients, with more expectation, more complex conditions and getting older; delivering care to the quality that they desire and making a decent return on a lifelong investment in their practice is becoming impossible.

Many practices have reorganised, included more nurses and practice pharmacists in the attempt of becoming more efficient and absorbing/distributing the workload. It is working, but nurses are difficult to find and the pharmacist programs needs to be accelerated. I hear that my local CCG wanted 26 and got none from the last round. Too little or too slow or both.

But there is a glimmer of hope. The GP federation is sitting down with the Local Pharmaceutical Committee and laying some cards on the table:

GP – we have too many people entering our service. Many have minor or self-limiting conditions; need some monitoring or a follow up test. The sheer volume and growth occupies increasing amounts of our time. It is great to talk to our practice population, but we need a form of out-of-practice triage.

Pharmacist – we have too few people entering our service. Over the years we have focussed on the dispensing element and then adding value to the safe and effective use of medicines. 90% of our income might be focussed on this element and the NHS has now cut this significantly and told us that we have to change. We need more people that have minor or self-limiting conditions; we can do some monitoring and provide other services. We want to look after more people and service their health needs and help them to create health.

Did the penny drop – the lightbulb come on – eureka – an epiphany?  Actually there was a little ‘chin-scratching’, followed by a GP pulling up a note about the Strep A sore throat test and treat service via the innovation network; did you see the research in Eccles on minor ailment services; did you know we could do this test, make that diagnosis, offer these medicines.

Of course the CCG came up in the conversation –“ they want us to stop prescribing these medicines – its difficult – could you help?”.

So the game has started, the relationships are forming, ‘one primary care’ is becoming a reality. I really hope that the Pharmacists are invited to join the federation. I also hope that the CCG will get behind it and NHS England will show some interest – it will be unforgivable if they don’t.

Stage one started – the community pharmacists are going to share the demand and reduce the pressures in General Practice. Stage two – we need community pharmacy to move from healthy living pharmacies to health creating pharmacies. That will come next.

I have no idea where this will go. I do know that the NHS desperately needs community pharmacy to take a bigger role. And my fingers are crossed that people will be interested, very excited and very committed to delivering an answer rather than chasing pavements.

Will the NHS put their money where their mouth is?

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 whether they need an antibiotic or not. The community pharmacies within this program would be able to make a diagnosis based on the presence of Strep A in the throat and take appropriate action. It is critical to use antibiotics only in patients with a proven infection. The program was hoped to affect 1.2million GP appointments over a period where winter pressures are extreme.

We know a little about the OSOM test used in the published feasibility study that says it is easy to use, has very high sensitivity and selectivity and it is possible to run a service including this test. Strep A related diseases such as scarlet fever and invasive strep A are at an all-time high. The service is just as much about reducing symptoms in individual patients as it is in reducing transmission of infection.

We also know that much of the NHS is under great pressure and we are starting to worry about unmanageable winter pressures. NHS England has launched its GP forward View and have committed to putting resources behind reducing pressures on General Practice. And the DH will spend a lot of money supporting a ‘Pharmacy First’ campaign.

The innovation network has been talking to CCGs, GPs and community pharmacies and have plans to introduce the service more widely (nationally) aiming for a launch on September 1st 2017.

So this is where we are at. Community pharmacy wants to do it – GPs want community pharmacy to do it as it might remove 1.2million appointments over winter. And patients will benefit from choice and convenience. But will it happen? It might all be down to money.

If the innovation accelerator program actually means anything to Mr Stevens, Sir Bruce or Mr Hunt they should remind CCGs that adopting innovation is not an ‘option’, but a responsibility.

Mums the word

Childbirth is tricky. Mums may have been doing it for ages and many people call it natural, but the truth is that it opens up the mum and the baby to some risks. In many ways Mums need to be prepared and there are many groups out there that are set up to help. We also keep talking about choice and Mums have to listen very carefully to the advice that they are given and then try to make the best choice for themselves

Some community pharmacies are setting themselves up to help and provide advice and a range of services that would help a mum to be ready for the birth and when looking after their precious baby.

Why community pharmacy? Well that is simple – they are the most accessible source of healthcare advice and represent choice and convenience.

The pharmacy often starts the process by offering for sale the pregnancy test, but there are a number of other things that they can offer during the pregnancy and after delivery.

  • Influenza vaccination. Obviously the NHS would want 75% of pregnant women to receive immunisation, but we are a long way of that. So the Pharmacy team may have an important role to try to increase the immunisation in this particular group. There are other important immunisations mentioned here https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/510981/9738_PHE_Pregnancy_DL_16pp_leaflet_13_web.pdf
  • Assessment and treatment of anaemia. Anaemia is relatively common during pregnancy. A simple and inexpensive test will provide a Haemoglobin level and haematocrit within a minute. Women with low haemoglobin measurements may be offered a suitable over the counter products and retested at a later date. You may wish to consider point of care tests for HIV and Hepatitis B.
  • Group B Strep Awareness and test. Group B Strep is carried by 1 quarter of all women through their pregnancy. The bacteria can be transferred at birth to the baby. A few babies will develop a Group Strep B infection that might include a chest infection right through to meningitis and sepsis. It is the most common cause of sepsis in the newborn. Despite a number of petitions the UK does not recommend universal screening, but both NICE and the RCOG recommend routine intravenous antibiotic prophylaxis to carriers. Community pharmacy in association with the Group B Strep Support charity are well placed to both raise awareness and offer for sale a test recommended by Public Health England and not routinely available in the NHS.
  • Supportive care on minor conditions. Things like reflux, back pain and stretchmarks may not be minor conditions, but a community pharmacist would be well placed to offer advice on suitable remedies, taking into account salt content and general applicability.
  • Support post-delivery. Mum and baby can have a wide range of common complaints from sore nipples and tiredness to nappy rash, childhood dermatitis and wind. The pharmacy team will be able to offer advice and a range of helpful solutions to most common problems. Some pharmacies offer advanced feeding advice for those mums which struggle to breast feed or use standard formulas.

It is very important that Mums always get good advice and support and the community pharmacy may be just the right place

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…

View original post 209 more words

Community Pharmacy: Living the dream and facing reality

A community pharmacy is an independent contractor of the NHS. I would like to explore that a little more. To me it simply means that you have set up a business and risked your cash and livelihood on the success of that business. It is an important thing – a lot of cash and a lot of risk, but how independent are you and do you think like a business?

Dependency. Perhaps we should really call you and independent dependent community pharmacy, as in reality, most are heavily dependent on the NHS contract. So for many it is the hand that feeds you; the organisation that drives your income and therefore the return on the investment that you have made. Usually when a majority employer says jump – we ask ‘how high’ – we deliver ‘added value’ to that employer to ensure that they ‘keep sweet’. It is not about rolling over, but maintaining an adult relationship. So when that employer issues a ‘white paper’ – the equivalent to saying jump – it is frankly unbelievable to say no. There would usually be some negotiation, some compromise, some hope.

So now that employer is playing hardball and we wonder why? So let’s get the QP done and the NUMSAS and open up sensible lines of communication. Turn this into a learning experience and move on. Perhaps an opening gambit of ‘where do you want community pharmacy to be in two or three years’, ‘how can we work together on this’ even, ‘how about this as an idea’. Letting you all into a little secret – the Pharmacy integration fund – it is supporting those that want to engage – just watch it and wonder whether you could have had that nationally.

Independency. So we have a whole range of minor contracts with individual members of the public. They come in and get a product or a service and put some money in the till. That’s interesting! A business would be asking – ‘do I have enough minor contracts and are these with the right people’, ‘do I fulfil their needs, offer them excellent service, get them talking about me’. Believe me, the safety and security of any business is dependent on the breath of contracts they hold – it is unwise to put all of your eggs in one basket.

I get a little tired about some of the reasons:

  • My customers do not want to pay for things – then you have the wrong customers – find some new ones.
  • My customers do not avail themselves of the services that I offer – do they know about it and are you offering these services to the people that want them
  • I don’t have sufficient footfall – then use a little marketing or go to where the people are.

This is changeable – that is my point – every business thrives when it seeks out new opportunities and new contracts. You are an independent business so think about it and do it.