Strep A – enough is enough

In 2016 a third of GPs thought that the downward pressure on antibiotic prescribing was fueling the increase in cases of bacterial infections such as Scarlet fever. The recent report by Public Health England shoed that the number of notifications were double the average of the past 5 seasons. All nine regions in England are reporting an increase and the North East, North West, Yorkshire and Humber, the South East and South West reporting rates more than twice as high.

The reporting of invasive strep A infection is up 73% on last season. This is particularly worrying as the mortality in this condition is high at 15-20%. 14% of these are children under 10 and consequently an increase in the number of children dying is also expected to be higher than last season. In 2012 two children died. In 2016 twenty children died. Will it be thirty or forty this season? Every child is valuable – we should not accept this.

We are the only country in the western world, perhaps the whole world to be experiencing this high level of Strep A infection. Where many countries have introduced rapid tests, we have not. Is that a coincidence – I think not.

The good news is that no isolates have been found to be resistant to penicillin and general resistance patterns to other antibiotics has not changed.

The same bacteria cause strep throat, scarlet fever and invasive strep A. Transmission from person to person must be controlled. People with a strep A sore throat will remain infection for 14 days or more, returning to work or school and supporting the transmission of the bacteria. Within 24 hours of starting an antibiotic people cease to be infectious and can return to work or school without transmitting the bacteria.

Lord O’Neil in his report, commissioned by David Cameron, recommended that we should make better use of rapid diagnostics to cut unnecessary use of antibiotics. He went further to recommend that it should be mandatory by 2020 that the prescription of antibiotics should be informed by testing technology where available.

Where are we up to on this? Apparently NICE believes that there are some GPs that routinely test, but I am not sure where they are. The Birmingham Children’s Hospital routinely tests children and they have reduced antibiotic use by 70%. The use in community pharmacy was lauded into the NHS Innovation Accelerator and the local innovation networks, but as far as I know no CCG has commissioned it. NICE sticks with the clinical risk score FEVERPAIN – it is better than nothing, but it is hardly very sensitive, contributing to the unnecessary use of antibiotics and missing many patients with infections.

However, several community pharmacies have gone it alone. They have introduced testing to patients as a program of test and treat with advice to reduce transmission. Well done – it needs healthcare professionals to make a stand.

It is about time that Mr Hunt took a lead in this. He should insist that every GP and every community pharmacy that manages a patient with a sore throat completes a proper examination and uses a rapid antigen detection test to confirm the presence of strep A in the throat. In patients that are positive, appropriate antibiotics should be started immediately and the patient should be given information to reduce transmission.

Further more Mr Hunt should support the diagnosis and reporting of Scarlet Fever in community pharmacy.

We need to get on top of this. Indiscriminate downward pressure on antibiotic prescribing and the failure to use available technology as recommended in the report commissioned by the Government is not acceptable.

 

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How prepared is your A&E

What would you expect the NHS to do? Cancel all planned, but non emergency operations until February leaving thousands of surgeons with nothing to do.

The MMP Blog

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…

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Guest Blog: Is brushing your teeth more important than checking your feet?

GUEST BLOG BY SOLESEE

I have been to a few presentations and talks recently, raising awareness of Solesee to groups of podiatrists and people with Diabetes. Through listening to comments on feet and foot health I have had a few more thoughts about the importance of foot health within this sector.

The more people I meet, the more this has turned into a crusade.

My crusade is to change the way people think about the two parts of their body that are literally with them ‘every step of the day’.  From the moment we get out of bed in the morning to the moment we get back into bed in the evening, they are supporting and transporting us, every second of every day. They give us our freedom and our independence, the ability to work and provide for our families, and support us in our enjoyment of life.

Like all parts of our body we take them for granted…. until something goes wrong or we encounter a bit of pain. ‘My feet are killing me’ is a phrase most of us have used or heard before.

How does this relate to the title of this blog?

Do you think that brushing teeth is more important than checking your feet?

Do you brush your teeth every day?

Most people do to prevent – tooth decay.

Figures taken from the *‘NationalSmileMonth’ say that 75% of adults do brush their teeth twice a day. That is twice a day they take a few minutes to clean their teeth and check to see if there are any problems in their mouth.

Subsequently the number of adults with no natural teeth has dramatically reduced from 37% in 1978 to only 6% now. This increased awareness of good dental hygiene and regular cleaning has helped to improve the health of the nation’s teeth. This is reflected in the number of adults with 21 or more natural teeth which has risen from 68% in 1978 to 86% today.

If 75% of adults are cleaning their teeth twice a day it must be clear that this is an important task and should be done. A huge amount of education is distributed to new mums, children and to the general public as to the importance of good dental hygiene and these figures show that in the last 40 years, more and more people are retaining their teeth.

The habit of cleaning your teeth twice a day is established early on in life. Indeed, like most habits, guilt kicks in if you happen to get into bed at night without cleaning your teeth, so much so, that it kicks you out again to grab the toothbrush and give them a quick scrub!

Do you check your feet every day?

The majority of people will probably answer ‘no’ to this question.

“Why would I?”

“They are fine!”

“If there is a problem or I have trodden on something I would feel it and then deal with the problem.”

That is all very well if you are sure that your pain receptors are working correctly to alert you when there is a problem. Yes – then it is clear, if I have a blister I will feel it, take my shoe off and put a plaster on it – job done! And oh yes, replace my tight-fitting shoes once I have put a plaster on the blister and I can hobble back to work. In feet where there is no problem with circulation, these will heal quickly.

However, what about when you have diabetes?

What happens when those very special nerve endings that tell the brain you have hurt yourself by ringing the alarm bells of pain, so that you react and take action, don’t work very well?

This could be something as simple as the pain you assume you would feel when you leave your feet too long on a hot water bottle on a cold winters night. This is the pain that would tell you that you need to remove your feet from the hot water bottle or you will burn them.

What happens when those ‘life saving nerve endings’ eventually stop working all together as happens with neuropathy?  How will you know when your foot is too hot and has been burnt or has been cut, or you have been walking around with a stone in your shoe for days which has created a nasty blister?

If the nerve endings stop working, the only way you will know you have a problem is when you actually look at your feet.  Or someone takes a look at your feet for you.

What happens if, at the same time as your nerve endings stop working properly, the blood vessels taking blood to and from your feet get damaged and therefore can’t transport blood as well as they used to?  When this happens, blood doesn’t get to all parts of our feet as well as it should which in turn means that blisters or cuts won’t heal as quickly as they ought, if at all.

With Diabetes, these complications can occur due to damage to the nerve endings and blood vessels. This results in cuts, blisters and breaks in the skin, which ordinarily will be healed quickly by the body, not healing at all.

Not only has the body’s defence mechanism of pain been damaged but also the body’s natural healing ability has been affected.

In these cases, a seemingly innocent cut can escalate rapidly to an ulcer, infection and potentially lead to amputation of the infected part, to stop the infection spreading to the rest of the body.

The Bare Facts of Diabetic Foot Disease                             

 

  • In England, according to the latest figures from Diabetes UK, there are now 160 lower limb amputations due to diabetic complications every single week. This figure was 140 this time last year so the situation is clearly getting worse.

 

  • Diabetes UK also state that 80% of amputations due to diabetic complications are preventable.

 

  • Figures show that 8 out of 10 people who have suffered an amputation will die within 5 years of surgery.

 

  • £1 out of every £140 spent in the NHS is spent on foot care for people with Diabetes

 

So why do you NOT check your feet daily but will brush your teeth daily – especially if you have Diabetes?

Is it simply that you are all aware of the risks associated with not cleaning your teeth every day? i.e. could end up losing your teeth.

If the motivation is vanity, surely losing your foot through amputation will have just as much effect on your day to day life as losing your teeth. I would argue more, due to the debilitating effect of losing a lower limb.

I think it is more the lack of knowledge and awareness of how devastating the effects of diabetes on your feet can be. I also feel after speaking to many podiatrists and people with diabetes, that there is an apathy to foot care, an assumption that someone else will look after them.

 

‘I see my podiatrist every 3 months, so I don’t need to do anything else’

‘I will start checking them regularly when I have a problem’

 

it is very common to hear that the relatives of people with Diabetes are also unaware of the potential danger to their loved one’s feet.

 

 Final thoughts

Why would you clean your teeth daily to help prevent 

but not check your feet daily to prevent ulcers and amputations

 

After reading this blog I hope that you agree that it is equally as important to check your feet daily, as clean your teeth daily. We don’t even question why we clean our teeth every day now – we just do it.

Establishing a habit of checking your feet daily will allow you to take responsibility of your foot health, just as you do your tooth health.

All I would ask you is “would you expect your dentist to clean your teeth every day?”

*NationalSmileMonth – http://www.nationalsmilemonth.org/facts-figures/

To find out more visit or follow us at:

www.solesee.com  info@solesee.com   twitter@soleseeUK  facebook.com/@soleseeUK

Sorting out influenza

The MMP Blog

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…

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Is the NHS chasing pavements?

The MMP Blog

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…

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The new pharmacy

The MMP Blog

It is a funny time.

All I hear are discussions about the term ‘clinical’, about supervision, about the law suites and about shortages of medicines. A Pharmacy isn’t a Pharmacy without a pharmacist and you can’t separate supply from clinical services. There seems to be a mist falling demonstrating the whole professions wish to move backwards into the good old times and reluctance to move forwards. The eloquent ask for one voice – but saying what, on behalf of whom, delivering which future? It might be time for a different voice talking about a different future.

I have heard chatter in the backroom about a new breed of pharmacy. The one without a dispensing contract with the NHS. It is not unheard of – the dentists did it – but despite the chatter and the goading – I have not seen a Pharmacy do it.

Now this is the real…

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Influenza – I’m sick of it

The MMP Blog

It is all go – the Chief Medical Officer and the Chief Pharmacist have issued the Central Alerting System saying that surveillance data indicates an increase in the number of influenza cases in the community so GPs and other prescribers in primary care can now start prescribing anti-virals at NHS expense.

OK – I didn’t think that PHE data actually identifies cases of influenza rather than ‘influenza like illness’, and it is only reported through GPs, but I won’t worry about that. I go to the PHE guidance and well – “GPs may only prescribe antiviral medicines for the prophylaxis and treatment of influenza at NHS expense when the Chief Medical Officer (CMO) has confirmed that influenza is circulating in the community. The CMO announcement is issued to the NHS through the DH Central Alerting System (CAS)”.

Hang on a minute – what about the community pharmacist?

So every poster…

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Influenza

The MMP Blog

I was interested to see that some people have influenza predictive tools. They measure whether we are going to have a light or heavy season and some are predicting that 2017/8 might be a bad season – so in many respects it may be that we have been lucky.

We currently have a system where most people with a viral or flu like illness would go to their community pharmacist for some help and I am sure that they get good advice and assistance. However, many patients go to their GP and will sit in their waiting room until called for their appointment. There is a scheme in place that supports some GPs reporting flu like illness and at a point in time the GPs are able to prescribe treatments at the expense of the NHS.

So why don’t we try changing this?

Still ask all people with a viral…

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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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