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.

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The new pharmacy

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 question. Could a pharmacy survive without an NHS contract? What would it do?

The first thing to suggest is that it won’t need its dispensing technician and ACT, but it will need a pharmacist and a team on the counter and the appropriate support staff. The overheads would still be £100 an hour, so it would need to put at least £300 into the till every hour to make a profit. Surely this is break –even, but you can probably can expect 30% margin on products, but higher on services.

So there you go – start thinking – here is your challenge for today.

  • Multi-professional location – I would rent out one of my consultation suites. Perhaps a podiatrist or a physio – something that will bring me an income and footfall of the type of customers that I am looking for.
  • Products – I need to sell £100 an hour – so I need to stock a different range, something that is specific to me, something that people might travel for.
  • Services – I need to sell £200 an hour. I can include public health services such as stop smoking and weight management, but I need to expand these.
  • Marketing – the customers that I need are not in the Pharmacy. I have to go out and find them, create awareness and draw them in.

When you start thinking about it, it might work. It might have to when the dispensing contract needs to be subsidised by other income and prescription numbers fall.

There is a question to Dr Ridge here. Could a Pharmacy operate under an NHS contract and not dispense NHS prescriptions? Could it opt out or have a restricted and specified element? Would it be able to deliver MURs and NMS services in association with a local GP practice and contract locally for Immunisation, minor ailment, domiciliary MURs and other public health services?

Will some Pharmacies become ‘health and wellbeing hubs’ and will we see new non-dispensing pharmacies opening?

 

Community pharmacy on the launchpad

So the first round of quality payments has been submitted and I understand that community pharmacy compliance will be outstanding. I am genuinely happy, both for the community pharmacies and for the Chief Pharmacist and his team who may have dragged community pharmacy into the 21st century.

What was that? What did I say? Did you hear me right? Yep – community pharmacy are on the Launchpad to greater things thanks to that little masterstoke introduced at the last contract imposition. A little unfortunate that it was hidden in the cut to core service payments and the pharmacy integration fund. And I hope that you don’t think of it as a box ticking exercise.

If you wake up tomorrow and find out that the NPA or PSNC has won their case, let’s not forget that an important job will have been done.

So every pharmacy will be delivering at least one advanced service. They have all updated their NHS Choices entry – although I never understood why they wouldn’t want to tell everyone about the services that they provide. They all have a secure NHS email address – so they can transfer information to and from their main paymaster securely and perhaps they will be more responsive to requests etc. And they are all using EPS.

Brilliant

Every pharmacy will now record and act on patient safety incidents and they will respond appropriately to national patient safety reports. Safeguarding for children and vulnerable adults – that sounds important for a community pharmacy to be fully aware of.

And you have to complete a patient questionnaire every year. That is actually a bit pathetic – for a business that thrives on the patient experience – it should have been more frequent. I know that some use mystery shoppers so they can sharpen up their act. Any business survives on customer loyalty and experience – I just can’t understand why you all weren’t doing this already.

Everyone is a healthy living pharmacy now. So you all are thinking about the skills and ability of your staff, the state of the premises and how you connect with your community and healthcare colleagues. Sounds sensible to me.

Using summary care records – not sure how you can operate a safe system without using them. And your NHS111 entry is up to date. You are all going to be dementia friendly and if someone is obtaining 6 consecutive relievers for asthma over 6 months you will refer them for an asthma review.

Should have included NUMSAS – it should be core, but we have to be a little patient with technology.

Of course most of you were tittering in the back – easy peasy lemon squeezy.

But now we have the majority of community pharmacies up to a simple standard. Most are now looking in the same direction and thinking the same thing……

What next. Well you are on the Launchpad – flick the switch – turn the boosters on – and head for the stars – and always aim to be better than the minimum that is expected.

 

The environment around community pharmacy

There is a time to be realistic and put away those rose coloured glasses. The Public Accounts Committee is probably a good place to start.

So they don’t believe that there is a clear and transparent transformation plan because everyone thinks that the STPs are just a mechanism for cutting costs. It is interesting to see that some STPs are already in ‘severe financial difficulty’ and are being asked for a recovery plan even before they start.

At last someone has realised that the local authorities have been cut to the bone and urgent action is needed to stop it all falling down and creating back pressure in the NHS.

And at last someone is asking about the consequences of the funding cuts and if the whole pack of cared will come tumbling down. Of course they realise that constant plundering of the NHS, for example removing the national insurance rebates, creates an unsustainable service.

The £1.8b bail out of hospital trusts has helped some, but it has not cleared the debt as intended – there may be £1.2b left to find. CCGs have been asked to create a 1% surplus to help this. And we know that many trusts out there are struggling to even identify enough possible cuts to balance their books – nothing is safe. And another £1b is being transferred from capital to revenue – so don’t expect any new buildings or maintenance or new technologies to be implemented soon.

One might suggest that it has become a world where we partner successful organisations with failing ones to cover debts and fines become one way of recouping money at the expense of other areas of the NHS. However, I am not one that suggests that this is a route to privatisation – there is just not enough money to tempt sensible companies to enter the fray.

Please don’t think that integration of health and social care is the best way forward – the National Audit Office could not find any compelling evidence that it worked. It is the stuff of leaders who have lost their way and need to find a horse to ride.

But things for the Pharmacy Profession is not all bleak. We have pharmacists in large numbers taking up roles within General Practice. We see some results from the PIED project putting Pharmacists in Emergency Departments – well done Mr Terry and co.

However, we must think a little about community pharmacy as it becomes clear that the current NHS contract will need cross-subsidising by private and retail services. It will introduce a bright new world where community pharmacists (who have always been clinical) take on even more exciting roles in the diagnosis and treatment of a wider variety of conditions. There are huge opportunities to drive better outcomes for patients through enhanced self-care and offering direct care.

So welcome to the bright new world where pharmacists are becoming ever more valuable healthcare professionals and community pharmacy can develop in leaps and bounds

 

What does self-care mean?

Many experts bandy around the term self-care as if it is the panacea solution for health and social care. But do we know what it means and how to encourage it?

Many might say that self-care are the elements of care that we deliver ourselves – our activities of daily living, such as my ability to get up, washed, dressed and make breakfast. Some may go further to talk about  the ability to go to work, make friends, have conversations and sort out some of the other aspects social inclusion. We all recognise that health creation starts with the individual and their family and local community.

But many just talk about the ability to look after your own health without the need for medical oversight. How many times have I heard the phrase ‘you have to just look after yourself better’.

There is a truth out there that suggests that many people just don’t want to look after themselves and then, even if they did, they are still forced to rely on the health service. So the NHS tells you to look after yourself, but it has to be on their terms and when they want to do it.

This has to change.

Some community pharmacists are starting to support that change. With the advent of the internet and various groups, many people know what they should be doing and what measurements should be collected to monitor their progress. Women in the peri-natal period have always carried their records around with them, but in other areas the records are not so accessible and the results are often ‘hidden’ in a computer somewhere. I worked with a GP who had a personal diabetes record for every patient in his practice – several used it as a tick box (I have to have these tests done or the Doctor would be unhappy), but many used it to monitor their own progress and drive the consultation.

These community pharmacists provide physical measurements and biochemical tests to patients. So the patient can build their own picture of how well they are doing and do something about it with the support of their medical team. There may be a charge, but the patient is in control of what measurements they want and when and where they are going to get them.

The advantages are clear. The individual takes more responsibility for their care. They can visit their doctor/pharmacist/nurse and show a series of results and ask for support in achieving a change. The dynamic of the consultation can change and can be patient directed.

One day the NHS will issue patients with self-care vouchers that are redeemable against a range of tests to monitor he complications of the condition.

Community Pharmacy – because we can

The best thing about community pharmacy is that it is an independent contractor to the NHS. And we must never forget this. It allows us to operate a business that not only fulfils an NHS contract, but an unofficial contract to the community that we serve. Next time someone walks into you pharmacy – remind them that you are a there to provide solutions to their healthcare needs. No not just dispensing a prescription, but that too.

Connect2pharma understands the importance of this concept and the need to develop a new way of thinking within community pharmacy.

The NHS is always hung up on population numbers and statistics. They think mainly about large populations of people and what would represent value the masses. Over 200 community pharmacies now offer private Strep A sore throat Test and Treat services. It may not add up on a national level to make it worth commissioning, but on an individual level it becomes much more important. From a personal point of view, if I had a sore throat and a Centor score of 3 or 4, I would go to a pharmacy and ask for an assessment and a test. The rapid antigen test is highly specific and highly sensitive and would provide a definitive diagnosis. If the test was positive I would ask the pharmacist to supply an antibiotic on a PGD. Having started a course of antibiotics I will stop being infectious within 24 hours and can carry on with my normal life.

It is my responsibility to make sure that I do not spread strep A to my relatives and friends, and my responsibility that I do not take antibiotics when there is no clear indication.

However this is where the numbers do not add up. There are about 5,000 reported cases of scarlet fever in England each year and almost 700 cases of the much more dangerous invasive Strep A each year. It would probably cost the NHS too much to implement a national test and treat service and the payback in reducing a few scarlet fever and invasive strep A cases is both too small and not quantifiable and evidence based.

Fortunately I don’t need that sort of evidence – it just seems like common sense and personal responsibility. The test costs less than a tenner and the antibiotics about the same. So £20 – boom – I have done my duty and can enjoy mixing with my family, friends and work colleagues. I live in London and I know where to go and I won’t be bothering my GP for something my pharmacy can sort out for me.

Why doesn’t every pharmacy do it?

This year I met two women who had experience of strep B infections during delivery. One baby died within a week and the other is profoundly deaf. The families will never be the same. But again the numbers don’t add up – lots of expense to save just a few families from this sort of heartache every year. So once Connect2pharma has the service up and running in some like-minded community pharmacies, I will be their first customer and my niece will have a pack coming in the post.

It will soon be a New Year and every new year needs a resolution – look after yourself.

 

Influenza – I’m sick of it

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 or communication from the DH/NHS tells patients to go to their pharmacy first for winter illnesses. But only GPs are trusted to make a diagnosis and report the PHE and then issue prescriptions for treatment at NHS expense. So, put simply, if you think you have flu you had better see your GP.

So what is the strategy? Ask all patients with influenza like illness to sit in a crowded GP waiting room – see the GP – who does not have point of care testing – and get the GP to issue a prescription for a suitable medicine and then send them to the pharmacy to have it dispensed at NHS expense. Seems a bit dumb to me, particularly when GPs are already overworked and there is extreme pressure on appointments and their waiting rooms bulge.

How about letting the community pharmacist play a part. Patients would walk in – no wait. Pharmacy teams can make a provisional diagnosis of influenza. The Pharmacist could confirm and offer a point of care influenza test on the NHS. If positive then the Pharmacist could manage the supply of anti-viral medicines through an NHS PGD for all uncomplicated patients and just refer the complicated ones to the GP. And PHE might have a better grasp on actual influenza patient numbers if they allow pharmacists to report.

So what might be the result? It isn’t coughed and sneezed around a busy GP waiting room full of ‘at-risk’ patients. GPs only get to see 5% of the patients with influenza like illness that might need their expert care. Patients get a more accurate diagnosis and rapid access to anti-viral medicines.

What is the problem with a little innovation in the NHS?

Community Pharmacy and Infection Control

I have always shouted that the game is not to give influenza vaccines, but to create community immunity where everyone takes personal responsibility to reduce the risk of getting infected and infecting others.

In some places – well just one that I know about – the GP practice and the community pharmacies have come together to set joint immunisation targets. The GPs don’t send out costly reminder letters and everyone works together to immunise as many people in the at risk groups as possible. It is the way to do it and the way that NHS England should have incentivised the contracts years ago.

Community pharmacy should go further and, seeing as a lot of people seek their advice about influenza like illnesses, look at ways of reducing the spread and impact of such illnesses in the communities that they serve. Within every conversation the pharmacy team should mention the “catch it, bin it, kill it” campaign and ask whether they have some tissues and if they have thought about using an alcoholic hand product. This is not a situation where self-selection is applicable – it should be an active recommendation in line with the NHS campaign.

Community Pharmacists could also offer a point of care test to differentiate between influenza A and B and other viruses. I appreciate that the treatment may be similar, but we shouldn’t be fooled into thinking that these two conditions are the same – they are not. Influenza can lead to complications, particularly lower respiratory tract infections and there should be enhanced precautions to reduce spread.

I was talking last night about rapid antigen tests for strep A sore throats. Again the game is to limit the spread of Strep A sore throats throughout our community. It is a nasty little condition that leads to absence from work and school. I was informed that a patient with an untreated strep A sore throat would remain infectious for up to 14 days – so there is a clear advantage to the community if people are properly diagnosed and treated.

There is a fine balance to find. We don’t want antibiotics used unnecessarily, but we don’t want to leave strep A infections untreated. I am told by Phil Howard from NHS England that resistance to penicillin in falling, but PHE says that the occurrence of scarlet fever and invasive strep A infections are rising.

So I think that test and treat would be a valuable service to be offered by community pharmacies around the country. The feasibility study shows that it is feasible, it will reduce unwarranted antibiotics and it will reduce unnecessary GP appointments through a time when they will be full to bursting.

Well I am off to meet a colleague for coffee. Stop in at a pharmacy and buy a pack of tissues and some hand gel – because he has a cold and I have no intention of catching it.

In support of strep A testing

It has been a funny day. My support of Strep A testing in community pharmacy has been challenged to the point where I have been called unprofessional for my views. Me and strep A go a long way back and I have absolutely no love for the little bug.

It started for me as a baby – prone to strep A throat infections – except that the associated temperature led to febrile convulsions. After several trips to the A&E – fortunately we lived less than 100 yards for UCHL – they decided on a partial tonsillectomy. Operation went fine, but as a 2 ½ year old I pulled a heavy stool over on my hand in the ward. I remain grateful to the surgeon who fixed my fingers. Slightly fewer infections and fewer fits, growing out of this, but left on phenytoin and phenobarbitone as an infant. So grateful to a headmistress called Miss Herbert who was happy to take me into mainstream education, while the antiepileptics were discontinued or my life may have been very different.

I would add that I still have a love of black cherry yogurt from my childhood, but only front line pharmacists would understand this!

Roll on 10 when dear old strep A infected both my throat and chest and led to scarlet fever. You never quite forget the 48 hours in an elderly care side room, covered in calamine lotion, waiting for a side room on the paed ward to become free. I am told that the strep A infection was probably responsible for precipitating chronic urticaria. That lasted about six years – I could explain what it is like to have chronic urticaria as a teenager before selective anti-histamines and medicines like omalizumab, but you have to have it to understand. I recently met a clinical immunology specialist pharmacist at HPE Live – I told her my experience and she understood.

Fortunately I haven’t had a strep A sore throat for years. I haven’t forgotten or forgiven strep A. I appreciate that most people with a strep A sore throat would get better without treatment, but they remain infective for around 14 days. It is 2016 and we have the ability to make a proper diagnosis using a highly effective rapid antigen test and give a course of penicillin that will eliminate the organism and reduce the period of infectiousness to 24 hours. Why wouldn’t we?

Some shout antibiotic resistance, but the truth is that resistance to penicillin in strep A pneumonia has fallen by 14% over the past 4 years – thanks Phill for this.

Others ask whether there is an increase in strep A sore throats and to be honest I don’t know. However some strep A infections are reportable and from this we know that scarlet fever went through the roof a few years ago and continues to rise. Invasive strep A was up 45% last year. There are no new strains.

I can’t help it – I believe that anyone who has a sore throat should pop down to the pharmacy and ask the pharmacist. If the pharmacist considers it appropriate then they can offer a rapid antigen test, make a proper diagnosis and get you some penicillin. Go back to work or school after 24 hours knowing that you are not spreading strep A around.

I don’t know whether the NHS should fund this or if it should be considered a personal responsibility under self-care, but however it comes in I will give it my full support.

And while I am on the subject of streptococci – I am not a great fan of the group B variety. I met a lady whose life was devastated by this bug. Very soon I will be asking colleagues to help me stop this little bug from infecting babies – because we can.

Diabetes and Community Pharmacy

I don’t have to say that the NHS is struggling to look after people with diabetes, but I met one pharmacist who intends to change that. He has made one important observation.

‘Most people with diabetes have never seen the bottom of their feet’

It is an old joke isn’t it.

  • Doctor: you must inspect your feet every day
  • Patient: I haven’t seen my feet for 10 years

So one pharmacist in South London has bought a special mirror for his neighbouring practice. It is unbreakable and stands on the floor at an angle so the patient can easily see the bottoms of their feet while sitting down on a chair. It is crazy that doctors, pharmacists and nurses in that practice who recommend daily foot inspection can only now help the patient to see their feet and explain what to look out for. I know that the world isn’t perfect and some people with diabetes don’t see too well and some would be unable to part their toes, but it may well represent a revolution in diabetes footcare.

If the patient wants a mirror then they are on sale in the pharmacy next door. When the patient buys one, the pharmacists emphasises ‘inspect-moisturise-prevent’ explaining what to look out for and when to go back to the practice. The pharmacy team also talks the patient through a selection of suitable moisturisers that they could easily apply and would be acceptable. This pharmacy has a referral pathway to a podiatrist and can offer advice about specialist socks and shoes.

All around the country healthcare professionals give important advice – like inspect your feet daily – knowing that their patients have not seen the bottoms of their feet for years. There is actually no point in giving advice knowing that the patient cannot comply.

However in one practice in South London, the Healthcare Professionals offer advice and actually shows the patient what the bottoms of their feet look like and how they can inspect daily. They say ‘inspect-moisturise-protect’ and the community pharmacy delivers the support.

Community Pharmacy – supporting best diabetes care.