Paracetamol

So the NHS in England spent £87million on paracetamol last year (2015) – that is £7m more than the previous year or growth of nearly 9%. Looking behind this figure there were 22million prescriptions. If 20% of these were new then a GP entered paracetamol into their prescription system 4.4million times, printed a prescription and signed it. The remaining 80% were requested by patients, reviewed by the practice, printed out, signed by a doctor and handed to a patient, sent to a pharmacy or handled electronically. That is 22million dispensing fees, 22million prescriptions containing paracetamol bundled up and sent to the NHSBSA, 22million items processed, costed, repaid to community pharmacy and cross charged to the responsible CCG.

I haven’t started yet to include the 2.5million co-dydramol prescriptions and the 15million co-codamol that add another £100m in costs. There is a discussion to be had about the value of some of these combinations in terms of added efficacy, added side effects and flexibility of use. Personally I have tried to avoid them in favour of a paracetamol backbone with additional analgesics used flexibly, although some would argue that the long term use of paracetamol has its drawbacks.

I haven’t even considered some simple NSAIDs like ibuprofen which generates approximately 3.5million prescriptions each year. Or even 75mg aspirin which generates 27million prescriptions a year. Or the £20million we spend on sodium fluoride tablets each year

So a veritable empire built out of the humble basic pain killer – paracetamol. It remains a very effective painkiller – very safe in the right hands – and in the wrong hands very toxic. It is almost ubiquitous in our society and available in small quantities from petrol stations and newsagents – it is probably present in most people’s medicine chest or bathroom cabinet.

It is not just the money – although £80million would buy quite a few front line staff – but you have to consider the time taken to manage the 22million transactions from GP to community pharmacy reimbursement.

I have asked successive Health Ministers to think about Paracetamol and simply moving it to the non-reimbursible list in the drug tariff – in simple terms to stop the NHS paying for it. There would be no pressure on GPs to reduce prescribing and persuade patients to buy it – no unequal access to free medicines and a clear message to the population that self care is essential to keep the NHS running and you should visit your community pharmacy first.

I am reminded that the NHS has to make £22b of efficiency savings – did Mr Stevens tell the Health Committee that he is struggling to realise these savings at the front line, but has made progress with some central initiatives. Well here is one for him!

But they all nod sagely and write it down. And I wait……

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Engaging a Practice Pharmacist

Quite incredibly a GP asked me about employing a practice pharmacist. He had heard a lot of rumours and a practice nearby had just appointed one. The starting point was the question why. But an answer about additional skillmix, improved quality of patient care had little real impact so we started a different discussion:

  • Your practice gets 100s of letters and communications every day – perhaps 25 of these include additions or changes in medicines – do you put them on your clinical system yourself and do you ever feel that you need to check something? Do you have the time?
  • You issue 200 repeat prescriptions a week – each – do you ever wonder if they are OK, need reviewing or checking – is your system robust and reliable?
  • Do you ever spend time talking to patients about their medicines, sorting our queries, drug shortages or completing more structured medication reviews?
  • Do you have care homes with residents that might benefit from a medication review – some ‘deprescribing’ or setting up medicines action plans to avoid admissions?
  • Are you up to date with shared care arrangements and feel certain that high risk medicines are properly managed?
  • How many of your consultations are with patients with acute common conditions that could be managed by a pharmacist within the practice?
  • Do you have to complete audits/reviews as part of your contract or additional services?
  • Do you need help to achieve full QoF points or perhaps LES or DES payments? Are you missing out on potential income?
  • Are you fed up with being roped in to give flu or other vaccinations when it is busy?
  • Are you worried that the CQC are going to ask difficult questions about medicines management and expect to see evidence of delivery?
  • Are there chronic disease areas where the addition of a clinical pharmacist to the current team, might mean that they can manage a larger percentage of patients without referral to you? What value would an additional independent prescriber bring to the service?
  • Are you just tired of being in the practice late, unable to recruit GP help, can’t find practice nurses and not enough time to spend with patients that need your expertise. Is it just not fun anymore?

If you have answered yes at least 10 times, then convert the above into a job description. Add some skills and knowledge, perhaps a few competencies – working in a team, but independent thinking – you know the sort of stuff. Think of a salary scale – perhaps band 7 or perhaps 8a if they have areas of specialism or are an independent prescriber. Write an advert and give it to your CCG – put it in a journal or on line. Ask the head of medicines management to help select and interview or another practice pharmacist and just get on with it. Open the interview with ‘what do you think you can contribute to my practice’ and you are away.

The only remaining question – is one going to be enough?

Pharmacy is changing

The Clinical Pharmacy Congress is over for another year. Another successful conference with over 2,000 pharmacists and pharmacy technicians attending – this must be easily the largest gathering of clinical pharmacists in the UK.

But what happened – what was the buzz? Actually that is difficult to explain. The so-called thought leaders offered presentations, some I could have seen last year and some delivered with the enthusiasm of a damp cloth. But not all – some were really interesting and got great feedback.

Networking was fantastic and the sponsors were great – although some large pharmaceutical companies were noticed by their absence – what are you guys thinking?

The leading clinical pharmacists did their stuff. Always on the ball and up to date, but now sharing with some case studies and more interaction than usual. A definite move that allowed the participants the chance to get closer to our profession’s experts and learn more.

However, there was something really different from the RPS. A more forward looking and joined up approach. The RPS is sounding more like a membership organisation that is interested in its members. There were great presentations from the ENB chair and a series of presentations from the faculty. Congratulations go out to Dave and Catherine – your hard work is paying off.

This is also the first time I noticed the academics and educationalists. They seem more engaged with the profession and more adaptive to the needs of pharmacists. There is a real feeling that they will be there to create the pharmacists of the future to fill the gaps that are created.

OK – I must admit that there was a selection of views on pharmacists in general practice. Views from the RPS, that were surprisingly up-beat and underlie the work that they have done behind the scenes and a much more conservative approach, recommended by those who, quite frankly, have never done the job. We heard from practice based pharmacists who have been doing the job for many years and a description of the roles. There is little doubt that this area will become a major expansion for the profession over the next few years.

The most exciting feeling came from the frequent discussion about team working and the benefits from all pharmacists, in every sector, pulling together for the benefit of the patient and the profession. I met pharmacists from all sectors of the profession – of course it is clinical pharmacy that really brings us together. The hastag #oneprofession has grown and so it should.

My biggest surprise is the introduction of the ‘celebrity pharmacist’ – I am not even sure what I mean by this, but if you were there, you would understand. I witnessed the growth of the pharmacy selfie – there was a dedicated selfie station – who ever thought of that one? And the first time I have seen a spontaneous standing ovation for a pharmacist.

There is a buzz in the profession – I am not sure I can put my finger on it – but it is definitely there and growing.

madness in the operating theatre

It was a few years ago that the High Impact Intervention – Care bundle to prevent surgical site infection guidance was issued. Just to remind everyone that the aim was to reduce the incidence and consequences of surgical site infection (SSI).

It all links together – surgical site infections increase hospital stay, are unpleasant and potentially dangerous to the patient, often requires additional healthcare expense and usually leads to the use of an antibiotic. We are constantly told that overuse of antibiotics lead to resistance, hospital beds are expensive and the patient should be our main consideration.

The high impact change within the Intra-operative phase is:

“Patient’s skin has been prepared with 2% chlorhexidine gluconate in 70% isopropyl alcohol solution and allowed to air dry”

That is simple enough isn’t it – and in the care bundle audit, successful achievement of this high impact change will be recorded.

On Friday, I think I had one of the most disappointing and frustrating discussions with a senior nurse in charge of an operating theatre. It went a little bit like this:

“I see that you aren’t using a 2% chlorhexidine in 70% IPA solution as indicated in the High Impact Intervention – care bundle to prevent surgical site infection.”

“No we use a 2.5% v/v solution in alcohol instead.”

“Why is that?”

“Because it is a stronger solution and it is less expensive than the licensed 2% solution.”

“In fact it is weaker. If you reread the label it is 2.5% v/v of a 20% chlorhexidine gluconate solution – meaning that it is only 0.5% chlorhexidine.”

“Does that matter?”

“Yes. It means that you have been completing the care bundle audit incorrectly and using a solution that is less effective. You are also routinely adding a red-staining solution to the product which is not covered in the label – so you should have been dealing with this off-label use of a medicinal product.”

“What does that all mean?”

“Well – you have been saving some money, using a product weaker than suggested by the high impact intervention document and telling porkie pies on the audit sheet. What’s more you have been using it off-label, without assessing the risk or informing your patients.”

Silence…….

“And although the evidence is limited to a poster, when this research is fully published, it is highly likely that you have contributed to an increase in surgical site infections.”

It is a little difficult to offer advice at this point. And to be honest, I am not sure how the department/hospital has got them into this position. It looks like a systemic failure, but who am I to comment. I am not sure where this fits within the Code of Practice on the prevention and control of infections, CQC monitoring and the new patient safety agenda. It is a mess – an opportunity to save a few quid without the proper assessment that comes before writing policies and taking action.

I am rarely at a loss – its madness!

Community Pharmacy – time to change?

Is it still now or never – or has the rush passed and are we still calling to action? All I know is that we have to think differently in community pharmacy. We are where we are, some might say, but it is neither where we want to be nor what the population or the NHS wants from us.

So let’s start with the negatives. We have a community pharmacy contract that is dispensing focussed. The DH believes that there are too many pharmacies and that dispensing is not economical. The provision of clinical services is hugely variable in volume and in quality and we are losing our way. There is money in the system, but it is not going to flow in a manner where it could end up in owners’ pockets. The politicians are not confused as to the role that they want community pharmacists to play in the future, but they can’t see a path.

And the positives. The government seem hell bent on driving patients to the pharmacy before booking an appointment with the GP or out of hours provider. Areas have built new services against the trend and many community pharmacists are providing services that are above and beyond our basic expectation. Community Pharmacists are engaging more, but are still a way from building integrated multi-professional services within primary care other than in PM Challenge Bid Projects. The government will invest in pharmacists to support primary care or at least in GP practices.

One sad fact always comes to mind. A procurement pharmacist in a multiple can make more money for the company in one trade than a whole team of clinical specialists over the year. Remember this as this is important.

If there is little new money, then it may be about trading and compromise, working towards a new definition of community pharmacy that suites the population, the government, the profession and the owners. Perhaps the owners are the key to change – have we understood this?

So what are we going to do about dispensing? Here is just one suggestion. We split prescriptions into acute/first or repeat – it is easy to do. We slightly increase the dispensing fee of all acute/first prescriptions and reduce significantly the fee for all repeat prescriptions. The money saved goes into two separate pots. The first is an establishment payment that supports any pharmacy to upgrade to a ‘Healthy Living Pharmacy’ or ‘Self Care Pharmacy’ – I don’t care which, but these pharmacies have additional features and additional standard services. We can bundle ‘Pharmacy First’ or MASchemes into this, along with staffing and training requirements. The second is a clinical services pot which supports the pharmacies becoming a clinical service point within the system – it might only need to be a pump-priming fund and could sit under the control of the Chief Pharmacist. No more dabbling in asthma or pain management – a fund that can support pharmacists to develop and deliver specialities in the pharmacy.

Yes it is about a choice – repeat dispensing will be less profitable and factories may take a larger role – but community pharmacies have the chance to develop and provide additional services. And yes CCGs and LAs that already invest in community pharmacies must embrace this move and we work out how their commitment is rewarded. A community pharmacy must be able to survive dispensing fewer repeat prescriptions (or sending them to a factory) and increased clinical services.

Community pharmacy also needs to think independently and locally. Joining as members of federations they can play an active role in the delivery of multi-professional providers within primary care. Through this route, community pharmacists will bid alongside GPs, Optometrists, Dentists, Community Service providers and the voluntary and charitable sectors for contracts. This is the way forward and if it doesn’t work then hospitals will take it over (whatever that will mean).

I am hearing that the multiples are split – some see that dispensing is their future and some see that clinical services hold the key. That’s fine – there is room for both views and perhaps, in the future, owners will be able to make a choice, knowing that both can thrive.

Is dying safe in the operating theatre

Today I have asked several people their views and they are perplexed at the question. It is simple, but it questions routine practice.

In one hand I have a bottle of chlorhexidine 0.5% in alcohol that says – to be used undiluted – you can look on the MHRA website to verify this.

In the other hand I have a bottle of red-staining solution that says – mix with chlorhexidine 0.5% in spirit. You can’t look on the MHRA website for this as it is not a licensed product as it does not make in its own right a medicinal or therapeutic claim. It simply stains the skin so you know where the medicinal product has been applied.

So should I mix them?

  • Well the medicinal product says no – it is not within its license – so this would be an ‘off-label’ use
  • And the MHRA doesn’t know that this happens, have never dealt with a licence variation and has never looked at safety and efficacy – cos I asked them
  • So I am adding a highly concentrated solution of an anionic dye to a cationic antiseptic – does that sound right?
  • A text book published in 2001 says that precipitation of chlorhexidine is likely at the concentrations necessary for skin delineation – and if I add it to the 200ml unlicensed 2% solution I go way above this
  • An Australian paper comparing a licensed 2% product (stable dye included) with an unlicensed 2% product with this dye added suggests that there is a 3.4 increased risk of positive bacterial swabs and they don’t sound surprised – you should read it
  • A poster at ECCMID from a team in the West Midlands compared licensed 2% to licensed 0.5% with the added dye and showed a clear difference in colony forming units and surgical site infections in an early interim analysis – the manuscript is submitted for publication. What drove their results – was it the lower concentration of chlorhexidine or that they might have precipitated it before application – who knows. What’s your bet here a 10% difference in surgical infection rates – higher or lower?

So here is the million dollar question – the little bottle of dye which has no regulatory status within the UK says you can, but everything in your head says hold on a minute.

What’s the majority decision in the NHS today – the double whammy – have an unlicensed product and add an unlicensed dye and don’t tell any patient what you have done – brilliant!

The safety of chlorhexidine

The MHRA has reminded healthcare professionals of the risks associated with chlorhexidine solutions, particularly in neonates. This is not the old problem of allergy, but an issue that many neonatologists and surgeons know well. Overuse on the skin, pooling and the soaking of materials left in contact with the skin, combined with more fragile skin has left some neonates with severe caustic burns that they have either been the cause or the contribution to the neonate’s death. It is also not only neonates as I have heard similar issues in children and the elderly in particular.

The MHRA’s advice is sensible – take care – do not allow the solution to pool and remove any material that might be soaked with the solution and left in contact with the skin. They recommend that single use containers should be used when possible. They choose not to mention sterility despite it being a condition of licensing for the last 10 years or more. And yes, any adverse events should be reported through the yellow card scheme.

Of course the MHRA have assumed that everyone uses products that are licensed medicines and naturally any product used to disinfect the skin before the insertion of a canula or a minor surgical procedure would come under their jurisdiction.

They know that their thinking is flawed. Two products listed in their review are not licensed medicines. And because of this, they are unable to ask for feedback on more adverse events. And because of this, those products do not come under standard systems of pharmacovigilence. So how many neonates, infants and children have been harmed through unlicensed medicines – well we don’t quite know apart from the two cases that the MHRA identified from the literature.

I applaud those clinicians who published these reports for their honesty. They used products intended for general hygiene (clearly labelled not for therapeutic application) or for wiping medical devices on the skin of frail neonates before inserting a cannula. I wish them well.

Perhaps the MHRA could have mentioned….. Products to be used in this manner – on the skin as a disinfectant prior to an invasive procedure are for us to regulate and monitor their safety and performance. Could we politely ask all clinicians to use licensed medicines in this situation – so we have a chance of doing our job to keep patients safe? They could also ask ward and theatre managers to keep disinfectants well apart from medicines and be clear about which product should be used for which purpose.

Oh and of course – all of the changes in label etc only applies to the products that are licensed.

If, after reading this, just one clinician or nurse holds up a product before they slosh it over a patient and asks “excuse me – is this product licensed for this”, the MHRA will have increased their chances of protecting patient safety. Of course, you healthcare professionals and patients can always read the label.

Message to General Practice – come and get me!

This is a simple message from us clinical pharmacists to all you GPs out there.

When you are looking to make a change in your practice, when a partner leaves, a nurse retires or you don’t feel that you can afford the current locum or salaried GP rates – come and talk to me.

I am a pharmacist – I have additional clinical qualifications to pharmacy and have spent most of my life working with patients, their conditions and their medicines. I am logical and organised – almost to a fault – and like you am used to working within a very busy team where we all throw our efforts together. OK – I may ‘think’ I know more than you about medicines, but you are streets ahead of me on other areas. I may need lots of help, but it may all be mutually beneficial.

If you would like me to – I can join your practice as an employee and do the following:

  • Manage your repeat prescribing system and deal with all the queries (implement electronic prescription management)
  • Handle all of the clinic letters and discharge letters
  • Review your patients who are on complex medicines
  • Help deliver your QoF, LES and DES services
  • Ensure that the whole practice knows the systems that are in place and about new medicines and guidelines etc
  • Work with the CQC inspectors who are asking about medicines management and ensure your practice passes this aspect of their inspection

To me, this is all quite simple. I know plenty of fairly young pharmacists who are already doing this. However, I could also do the following:

  • See some of your patients with common conditions who present at your practice, offering routine and emergency appointments – a bit like a nurse practitioner
  • Work with a specified GP and your practice nurse to manage long term condition patients. I have done hypertension, cardiovascular risk, respiratory (asthma and COPD) and diabetes clinics before, a bit of complex pain management, ostomy and wound care (I learnt pressure bandaging at St Georges’ in the day)
  • Run your anticoagulant service and other near patient testing services – I even do dopplers and recommend on post DVT management
  • I will even roll my sleeves up and do some vaccination clinics

Where I am yet to train as an independent prescriber, you can help me with this, although many of my colleagues are already independent prescribers. I know my limitations, accept my responsibilities and can work effectively with colleagues in a team.

If you would like to talk to a pharmacist already working in a GP practice or to the GPs that have employed them – please let me know – there are some cracking good examples around – one that might win an HSJ award next week!

If, unfortunately I am not able to join you, it is estimated that several thousand of my pharmacist colleagues will be available over the next few years – strictly on a first come first served basis.

On the other hand – you could always work harder or close

Only pharmacists can save General Practice

I share the pain of General Practice. An independent contractor small business, dogged by increasing demand and paperwork. Punished by constrained reimbursement at a time when it is increasingly difficult to find GPs and practice nurses to employ with the necessary experience and at a reasonable rate. Pressured by politicians as both the cause of and the solution to issues within the NHS. And then ridiculed by those politicians who dangle a carrot of recruiting thousands of additional GPs when they know that they aren’t there and take a decade to produce.

Many commentators have called General Practice the jewel in the crown of the NHS – they may be right – the envy of the world. But they are experiencing difficulties that we need to pay some attention to. Many people look to their family practice to know them and look after them from birth to death.

The reaction from General Practice, however, is to group together, federate and share precious resources. Is this just circling the wagons? Will General Practice lose the personal touch? Will we all lose our family practice? Will it disappear into private company hands?

There is another way, based on sound military tactics. When faced with an overwhelming force, you divide it up and reinforce your front line troops.

The issue that General Practice faces can be solved by pharmacists.

Workload – the overwhelming force. We hear statistics that suggest that as much as half of all GP appointments may be filled with patients with common conditions that could be suitably managed by community pharmacists away from the practice. But these services (often called minor ailment services) are variably commissioned and often poorly supported by General Practice. A national contract or framework with local support and implementation would work. If these services could take away 10% of the current General Practice workload it would create some breathing space. 20% and the GP practices would have headroom to think, plan and deliver even better care.

General Practice needs reinforcement through skill mix. There is little doubt that the current skill mix must be altered, but the government’s idea of a physician’s assistant is plainly silly. We already have healthcare assistants and we have practice nurses. There are many examples, however, where practices have introduced clinical pharmacists into the team to both improve systems and deliver clinical care to patients. If you need examples there are plenty around. If you need pharmacists there are plenty around – we currently train more than we have jobs for. Yes we need to increase the profile so all GPs see the value or working alongside a clinical specialist pharmacist and yes – the profession with the NHS England management team just needs to get its act together creating the proper support for a career structure for pharmacists in general practice and we could fill thousands of positions in practice.

So my conclusion is simple. If we want to save General practice we need to call in the pharmacists. Divert patients from General Practice who can be suitably managed by clinical pharmacists within community pharmacy and introduce more clinical specialist pharmacists into General Practice to build the workforce in a cost-effective way.

Urgent and Emergency Care

I was invited to speak at the future of urgent and emergency care services. It is unusual for a pharmacist to be invited to this sort of event – well I wasn’t directly, but Dr Michael Dixon felt that I would answer the brief about pharmacy to compliment his opening. As expected, there wasn’t a single pharmacist in the audience. The first batch of speakers talked exclusively about new ways of working in A&E and urgent care centres – somehow I didn’t expect anyone to mention that pharmacists are employed in these services, as well as out of hours and General Practice to provide care for patients with common acute conditions, but as usual community pharmacy was not mentioned.

Feathers slightly ruffled from the start. I had to explain that there was slightly more than General Practice within Primary Care – General Practice is only one of the four independent contractor contracts within primary care – and they all provide urgent care for patients. I had to explain that within NHS England’s report they clearly suggested that a shift all the way down the line was needed with increased focus on self-care and community pharmacy to relieve the increasing pressures up stream. And, with more than 438million healthcare interventions in community pharmacy (2008/9 data) – this was more than any other profession added together. You do realise that the community pharmacy estate is huge – more premises and open longer than GPs and often more convenient for patients.

I mentioned data around the symptom checker – just to remind people that most members of the public who used the symptom checker were young and female. And that 44% still went for a consultation. There is a hint there, that putting symptom checkers in unsupported environments, like libraries might just increase demand on general practice and other services.

I offered a solution of putting NHS Choices symptom checker into community pharmacy, backed up with access to an assistant or technician that can support navigation and a pharmacist should further explanation or an intervention be necessary. Link this to the Healthy Living Pharmacy initiative with qualified health trainers and you could really start to change behaviour and attitudes towards better health.

I talked about minor ailment services – renaming them ‘common acute condition services’ and despite over 1,000 pharmacies being open 100 hours a week and many more open 80 hours a week, this service was commissioned in only 10% of pharmacies. There was service specification variability and access to medicines was generally poor. Access to medical records is still zilch, although access to the summary care record is on the horizon and will help in the future. As a side comment, if I had £1 for every patient that had been passed over to the GP for a prescription, I would have retired long ago! It is also sad that a pharmacist at 21.55 in the evening can’t book a patient into the GP next day or skype call to an out of hour’s service for support – so you can guess where those patients go.

I mentioned that the first minor injury training program, specifically for pharmacists was to be delivered this summer. Not requested by the NHS, I might add, but by pharmacists who, no doubt, will pay for their own training to deliver a higher level of service to their patients.

I was openly critical of the lack of working together in these services and suggested that it should be a basic requirement that GPs and Community Pharmacists work together to develop these services to the level that they need to be. In my opinion this is a serious flaw and limits the success of services. If the GP, Practice Nurse or receptionist simple enquired – “what did the pharmacist suggest” to patients with common acute conditions, perhaps we could turn this tanker around.

I questioned the use of NHS 111 where I am still not sure offers community pharmacy as a disposition. And the very few CCGs that underwrite the supply of medicines from a pharmacy in an emergency situation. There is no more of a heartsink moment in A&E when a patient turns up and says – “I am on holiday and I’ve forgotten my medicines and I’ll die without them”.

Those professions at the ‘bulk’ end of the scale –  General Practice, Community Pharmacy, Optometrists and Dentists must work together to create capacity and deliver more effective and more integrated care. We must share the load, and support more effective self-care to give those clever people at the top end of the system a little more space and time.