Pharmacy Leadership in London -NUMSAS

 

The NHS Urgent Medicine Supply Advanced Service (NUMSAS) is rolling out across London from March 2017. London is in the final phase of this program which is due to run until March 2018.

The service aims to support pharmacies accept referrals from NHS111 and requests from customers for an emergency supply of their medicines.

It is a fantastic opportunity. The NHS Alliance has advocated the greater referral from NHS 111 to Community Pharmacy, the underwriting of costs of the medicines and a fee for the service. It is not new; several innovative CCGs had already implemented this sort of service. As you can imagine it is the last sort of thing a doctor wants to be sorting out in out of hours or in A&E. And it is part of the contract.

Congratulations to all London Community Pharmacies that have taken this service on – well done – I appreciate that it took a little time and trouble, but it will all be worth it. And to those who have not – just get a wiggle on!

It sends out a message to our patients saying that we can do more than you think and it builds a link to NHS 111 which some areas are expanding by using money from the Pharmacy Integration Fund.

It is the way forward – for patients to be directed to the pharmacy as their first point of call.

It isn’t a pilot – it is a test. You have the choice to either pass the test or fail it. Passing may mean that it becomes a permanent feature of the NHS contract. Passing may also mean that this forms the foundation of further work and further services. Failing is simply unthinkable.

So this is the time to test the mettle of leaders in London. It is not a request – ‘would you like to’ – it is an instruction ‘just do it’. Anything much less than 100% is not good enough. It is a point of pride for London to respond and answer the call for action.

 

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NHS England – where is the vision and understanding?

Some times I wonder much the people at NHS England understand about the pressures in the NHS and how sensible they are with their solutions. It often doesn’t seem very sensible to me and it includes just putting increasing pressure on the few. It is more about good news and less about reality.

So we watch the announcements that GPs are going to be located in A&E and urgent care hubs. That’s nice. I didn’t appreciate that there were so many GPs around kicking their heels. Most of the GPs I talk to are rushed off their feet, working long hours and inundated with paperwork.

I noticed the new guidance around influenza immunisation. It is great that we are expanding the immunisation of children right up to the age of 8. It is very important that we enhance community immunity and make real efforts to hit the Public Health England targets.

So, bearing in mind the importance of community immunity – what do you think they have suggested? That’s right – increase GP workload – that should make them happy. And then employ some more school nurses to administer vaccine in schools and let GPs pick up all the ones that miss their scheduled time slots. I didn’t know that there was a glut of school nurses? I assume that every CCG in England will have to employ a couple more. That is, perhaps another 500 nurses, but where will they come from? Yep that’s right from the overworked GP practices or the permanently under pressure hospital system.

Now sitting out there are loads of community pharmacists. With the national program there are thousands who have been trained and will go through training again this year. They were forcibly excluded from immunising children this year by NHS England denying them access to the nationally purchased stock. And now left out again.

I don’t believe it!

There are plenty of community pharmacists out there. Not necessarily a ‘glut’, but there are enough so you could commission a community pharmacy to look after every school in the country.

Now here’s the maths. There are 16,000 state funded primary schools, perhaps 2,000 independent and a 1,000 special schools and there are 11,000 community pharmacies. So that’s simple – two each. Visits to immunise by class and allowing parents to bring their children to the pharmacy if they missed it the first time.

It is pretty simple. If the average primary schools size is 280 pupils then perhaps there are 300 immunisations to do which will hardly be difficult for a pharmacy to achieve.

All it takes is a little understanding, utilise spare capacity and reduce demand on the most pressured services.

But what will happen? I suspect that it will be more pressure on general practice, by giving them more to do and then taking their nurses away.

Does GP attitude need to change?

It is a difficult question and one that has perhaps already been answered. Despite a significant real term increase in funding for General Practice – they are still in trouble. It is just not enough and unless demand can be managed or possibly reduced then General Practice in its present form cannot be sustained. I should add that I am a great supporter of practice pharmacists – in fact every practice should have at least one. Skill mix is important, but is it the only solution – how much can we do within the existing funding cap is demand rises by 5% a year?

GPs can’t be everything to everybody. You can’t deal with ill-health and wellness and the current social disaster of poverty and lack of elderly care all by yourselves – something has to give. You can’t be in your practice, in A&E, running urgent care, in the care home, leading commissioning and now running gardening clubs – it is just not possible. However, here is something valuable about continuity of care, the ‘family doctor’ and knowing and trusting that there is a GP there when we all need one. It is a balancing act and General Practice cannot be the sponge for every worry, but it is far too valuable to risk losing.

So here are a few suggestions:

  • Managing demand is about triage and offering alternatives. Get behind the NHS Alliance document ‘supporting the development of community pharmacy practice’. Start to see community pharmacy as just an extension of the practice – looking after patients with more common acute complaints (minor ailments) and as a discharge route for patients to take over their own care. Think about how you can help community pharmacists look after more of your patients, more of the time. Can you offer skype access to support their growing experience and fast track appointments?
  • Reducing demand is about developing the ability of individuals and local communities to create their own health and wellbeing. It was mentioned briefly in the Next Steps to the 5 year forward view. We all know that creating health is so very different from treating illness and GPs need to be supporters of the creation of primary care based health and wellness hubs that can engage the power of communities. It changes the question from ‘what is the matter with you’ to ‘what matters to you’. Activities like these can make a significant reduction in attendances in General Practice and Urgent and Emergancy Care. See some of the work that the NHS Alliance is doing on this.
  • Bringing in local providers. Please don’t try to solve all problems – just rent a room. There are others that can give people advice on welfare, benefits and housing and deliver social prescribing – build that relationship. It would be even better if they were located out of the practice, perhaps in community pharmacy or community owned facilities. Have you thought about engaging housing associations – they want the same outcomes as you – fit and health residents that can manage their long term conditions without going to hospital.
  • Breaking the boundaries between ill-health and wellness. While GPs offer medical services to people who are well then there is no boundary in peoples’ minds. It is easier to think that if I am ill I go to see a doctor – but if I am well then I go and see someone else. This may lead to alternative provision of some services, but I understand, for example, that community pharmacists in New Zealand can offer contraceptive services. It is not about skill mix in general practice – this one is about defining what a GP practice does and then creating partnerships.

I, for one, want General Practice to survive. To be there when I need you and to see faces that I recognise and know me. I want to be in control of my own health, knowing that there are people who can help me to reach my goals and the GP is the conductor in the background, but there when I need him/her. I would prefer to get my results locally – perhaps in the community pharmacy so I can own my condition. However it is time to face the facts – you are not going to get what you need – and you need to think differently.

Screening for prostate cancer – evidence vs wisdom

The UK currently operates a policy not to offer routine PSA screening to men. It is an interesting decision, particularly if you are a man of a certain age and starting to think about your future.

You may be worried to know that across London an average of 385 men with prostate cancer are diagnosed via emergency presentation every year and in NW and SW London combined 491 men presented late with stage 3 or 4 disease. This isn’t particularly clever for a disease that takes a long time to progress and reflecting that at stage 4 the 5 year survival is probably less than 30%.

I can appreciate that PSA is not always raised in prostate cancer and that there are other reasons why PSA might be raised – so there are false positives and false negatives. It can also not differentiate from a slow growing tumour and the much more dangerous aggressive form. Once a man has an elevated PSA the next stage of the examination may be a repeat test and then a digital rectal examination to actually feel the gland. From that point the investigations usually become much more invasive and there is a significant impact on a man who has these investigations. This has driven the risk-benefit analysis in some studies to a point where screening is not recommended.

Recently I was impressed of a report about multi-parametric MRI which appears to be a much more effective tool, preventing men from having a needless biopsy and all the associated side effects. I also understand that there is a program in place to make this test much more available which can only be a good thing. Perhaps this is one factor in reconsidering the evidence or applying different wisdom?

The largest study in Europe first published in 2009. At this point 182,000 men had been screened every 4 years and compared to a control. The cumulative incidence of prostate cancer was 8.2% in the screening arm versus 4.8% in the control group. Screened patients were more likely than control patients to have organ-confined (clinical T1-2) disease, non-metastatic disease, and lower Gleason Score (≤ 7) at diagnosis. This translated into a decreased risk of prostate cancer mortality among the screened patients, with a risk ratio of 0.85. In more practical terms, to prevent one prostate cancer death, the number needed to screen (NNS) was 1,410, and the number needed to treat (NNT) was 48.

At this point it is worth considering a number of factors. Prostate cancer is one of the most common cancers in men with approximately 40,000 new diagnoses each year so screening would need to be widespread. Generally, prostate cancer is slow growing and, from the point of diagnosis, clinical trials comparing active treatment to watchful waiting have taken 8 years before the two mortality curves start separating and at 10 years there is still no statistically significant difference. However until these data mature further we won’t really know what effect delaying treatment has on later quality of life and survival at perhaps 15 years. Just because we know that after diagnosis of non-aggressive prostate cancer in an early stage most men will survive to 10 years – it doesn’t help me plan for 20 years.

When you roll forward the data from the European study to 13 years then the NNS falls to 781 and the NNT to 27. It is unknown how much further these numbers will drop with additional years of follow-up, but it seems likely that the observed magnitude of screening benefit to reduce prostate cancer mortality will continue to improve as data from this study continue to mature.

It is interesting talking to men about this issue. In reality a proportion of the men I speak to don’t know where their prostate gland is, yet they all seem to know of someone who has prostate cancer or who has died from prostate cancer. I might be a supporter of watchful waiting, but I can’t exercise that option until I have a diagnosis.

It is clear that men need to understand the facts as they stand and then think about it – evidence to wisdom. And they need to think about themselves, understand their risk and whether they want to know or not. There will be men that would rather not know and will not see a doctor even if they have severe symptoms. I don’t understand this approach. Nor do I understand people saying – don’t worry about the PSA, but watch out for symptoms and go and speak to your GP.

I think that the risk benefit balance has already shifted significantly. We can’t really stand still because the PSA is not a perfect screening test and wait for a better screening test to become available. It may be significantly more expensive and the risk benefit analysis may lurch to the point where it is still not considered cost effective.

I abhor the general view that I might get worried – so it is better not to tell me about screening. It is my prostate and my money. Better to be honest and say that for the few patients we might find and what they might have to go through to get a proper diagnosis – it will require a lot of organisation and it’s not worth spending tax payer’s money on it.

Perhaps community pharmacy has the answer by offering a simple qualitative non-diagnostic PSA screen at the man’s expense. It is my responsibility to look out for myself and if I have prostate cancer then I will get to know early.

 

Antiseptics – a must read

Over the years I have heard some strange views about antiseptics. I am usually stunned by the sincerity in which they are said. It demonstrates a total blind spot in knowledge and belief. Here are a few – with the answer I might have given if my jaw hadn’t hit the ground…..

Antiseptics are important, but washing hands and wearing a mask is more important during surgery.

Well I can’t disagree with the importance of handwashing and need to prevent transmission by wearing a mask, but the truth is that most bacteria infecting a wound have come from the skin – so the appropriate selection and use of antiseptics is important. Although there are few studies that are head to head, some do show a significant difference from one antiseptic to another and all guidance that I am aware of recommends using chlorhexidine 2% as a first line choice.

We are quite happy using an unlicensed medicine as our pre-operative antiseptic of choice.

Unfortunately there is no such thing as an antiseptic unlicensed medicine. It is either a medicine regulated by the MHRA or a biocide controlled by the HSE. They are two complimentary sets of regulations that form UK law – it is either one or the other. Any product containing an antiseptic that is not a medicine or a medical device is a biocide and controlled under the biocide regulations. It is an offence to use a biocide outside of its label. There is no legal framework to use a biocide in the place of a licensed medicine.

Where there is a possibility of confusion the MHRA has insisted on a label which tells the user that it is a biocide and not for a therapeutic application.

Patients are not informed – it is accepted as part of the operative procedure, but not specified on the consent form

This isn’t quite how I see it. As a patient I think it is part of the duty of care that I am owed to be treated with proper medicines. Actually I don’t even think that a hospital would use look-alike medicines that they have bought because they look the same, but are cheaper. However, I can just see the conversation –

Nurse or surgeon: ‘We use antiseptics to reduce the chance of you having an infection after your operation. I could use a proper licensed and evidence based medicine that is sterile and comes in a single use container, but I have one that is a bit cheaper and contains the same ingredients. Unfortunately it isn’t sterile and it isn’t in a single use container, but we will be very careful and try not to set you or the theatre on fire. Is that OK?

Me: Is it the same.

Nurse or surgeon: probably, we have no published studies to say it is, but the good thing is that there are no published studies to say that it isn’t.

Me: So there is nothing published at all

Nurse or surgeon: no, but I am sure it will be OK- would you sign here?

We use 0.5% chlorhexidine for our hip operations and use two coats.

OK firstly 0.5% chlorhexidine is a licensed medicine, but the indication is for minor surgery – so you are planning to use the product off-label. If you know that applying one coat is insufficient and off-label – how do you come to the conclusion that two coats is OK?

We add a little bottle of dye to the bulk bottles of chlorhexidine to show the surgeon the area of skin that has been prepared.

There is nothing on the label that says that this is an acceptable action. It is not included within the license of the bulk bottle and therefore the MHRA has not approved this. There is little evidence published to support this process except a small article which suggests that adding the red dye reduces the antimicrobial effectiveness of the antiseptic. A basic knowledge of chemistry would question the sense of adding an ionic dye to a cationic antiseptic.

It doesn’t matter what strength of chlorhexidine you use.

Chlorhexidine has the special property of substantivity. It adheres to tissue, preventing antimicrobial colonisation over time. The time appears to be concentration dependent so you should expect that the stronger the chlorhexidine the longer it works for. This has been demonstrated in two clinical studies.

We use alcoholic povidone iodine and this is more effective than aqueous

Can’t fault that thinking – but do you really use an alcoholic product. The product that you are actually using has only a small concentration of alcohol. At that concentration it is there to support evaporation, but would need to be 50% plus to have an antiseptic effect. You should not expect better results than with an aqueous product.

You don’t get resistance to chlorhexidine

This is not completely true. We have known for many years that bacteria, particularly gram negative bacteria like Klebsiella activate a pump mechanism which allows then to survive in increasing concentrations of chlorhexidine – it is adaption rather than resistance, but the end is the same – the bacteria survive apparently without harm. What is worse is that we have known for some time that this process caused the upregulation of genes associated with antimicrobial resistance, but now we know that in Klebsiella it is associated with colistin resistance.

Resistance to chlorhexidine is not important

That is very hard to say – we don’t really know the extent of chlorhexidine adaption in gram negative bacteria. We continue to slop varying concentrations of chlorhexidine around in a wide range of situations with very limited control – some would say an ideal situation for adaption and growing Klebsiella resistance. We have not properly considered recommendations to use sterile and single use antiseptics in surgery.

What we do know is that resistance to Klebsiella is a worldwide issue and there is an absolutely urgent need to try to reduce resistance within this and other bacteria. The UK may not be in big trouble yet, but European colleagues such as those in Italy are and we are following hot on their heels.

And just remember – when the antiseptics don’t work and cause bacteria to be resistance to antibiotics – we have no chance.

Don’t worry there are other antiseptics

Yes well – we have had one new antiseptic medicine launched this century – It can’t have been easy to get through the regulations and produce a sterile product in a single use container. Just when was the last new antiseptic chemical entity was launched in the UK as a medicine – can anyone remember? No I thought not- I can’t either. It is a serious problem- that demands governmental action.

 

What do we have to do

This is undoubtedly the easiest and most sensible question. Two things are necessary:

  1. Implement the existing law
  2. Initiate an antiseptic guardian program as part of the wider antibiotic guardian program and start talking about it

The Disney style Urgent and Emergency Care Centre

If anyone has been to a Theme park they know exactly what I mean. Whatever the ride or experience that you choose – you always end up walking through a shop. You are attracted to sections and usually end up buying something. Have you also stood in one of two parallel queues – one for those who love thrills, have no back problems are not pregnant or of a squeamish disposition – and the other for those who take life with more caution?

I sat yesterday hearing about the great work of pharmacists in urgent and emergency care centres and wondered why we can’t take a reverse Disney approach?

Why don’t we build a Community Pharmacy as the entrance and the exit to all urgent and emergency care centres? At least the patients will know where to find a pharmacy with long opening hours in the evenings and weekends. Perhaps we could ask one of the 1,000 pharmacies already open 100 hours a week to consider relocation.

As they walk through the Pharmacy they can be attracted by signs offering symptomatic relief to common conditions. We could try to deflect minor acute conditions to the pharmacy and let the others walk through knowing that they might face a 4 hour wait. We are told that 8% of patients attending A&E could be managed in a community pharmacy – it would make good sense.

But we also learnt that with increased training in clinical examination, some point of care testing and IP qualifications a pharmacist with enhanced skills could look after up to 20% of patients who attend A&E and with minor injury training perhaps another five percent as well.

And that is not all – if the patients that actually get through to the GP or Urgent care specialist has to leave through the pharmacy, then the remark – ‘pick up some paracetamol from the pharmacy on your way out’ – has some real meaning.

So perhaps this Disney inspired approach has some real benefits:

  • Patients can find a pharmacy when they need to, buy symptomatic relief or sort out missing prescriptions (the pharmacist would have access to the shared care record)
  • An enhanced pharmacy service including minor injury management could remove a further 20% from the queue
  • The availability of a pharmacy on exit may save time and money in the Urgent Care service supply of medicines
  • If this is commissioned with pharmacists working on rotation then the expertise can be shared with more pharmacies taking on additional roles

Could anyone drop Walt a call……. Or just chat with the LPC and local pharmacists – is this something for the STP plan?

Would you treat a Strep A infection?

Over the past couple of weeks I have met several people with very polarised opinions on the treatment of strep A infection.

Yesterday I met a senior GP who said that she wouldn’t treat everyone with a Strep A sore throat with an antibiotic. Even if she had the result of a rapid antigen test and was 98% sure it was a strep A infection she still wouldn’t treat everyone. The basis of the stance was that most people would get better without treatment and the treatment might reduce the symptoms by half a day, but that was all – it wasn’t worth it. She was clear that she had to reduce the use of antibiotics to reduce the risk of resistance.

That was all very well, but questions on how to reduce spread within the community was less convincingly answered. No thought about washing hands, alcoholic hand gel and staying away from schools and older people for a couple of weeks.

A week ago I met a lady from Public Health England who was very convinced that every GP who had a patient with a definitive diagnosis of Strep A would treat it. She was knowledgeable about the reporting of scarlet fever and invasive strep A infections and dealing with serious outbreaks – of which there are about 90 a year. She spoke about the risk of transfer and the value of antibiotics in reducing spread, allowing people to return to school, work or normal social interactions after 24 hours.

When I asked about resistance – she looked aghast and informed me that there has been no isolate of strep a found that is resistant to penicillin.

I do wish that people would talk. Mix evidence with knowledge, wisdom and a smattering of common sense and come up with a consensus.

So would you or would you not treat a confirmed case of strep A sore throat? And if not what advice would you give about infection control and prevention of spread.