By Tom Morley, Candy Ho and Madeleine Stevenson

Advanced service Enhanced service(some examples)

Medicines Use Review (MUR)

Supervised administration

Prescription intervention service

Needle exchange

Minor ailment

EHC

Smoking cessation

In April 2005 Primary Care Trusts have been able to commission community pharmacies to carry out any one of the 19 enhanced services outlined in the contractual framework (DoH, 2005)

This should ensure that the enhanced services a community pharmacy provides are in tune with the requirements of the local population.

Area & National PSA target Pharmacy Contribution Impact

Reducing Smoking - to <21% by 2010 Opportunistic brief advice

No smoking campaigns

Specialist NHS stop smoking Service

****

Heart disease, strokes and cancer - reduce mortality rates from HD&stroke by at least 40% in 2010. Reduce mortality rates from cancer by at least 20% in 2010 (for <75’s)

Information and advice

Campaigns

Secondary prevention/risk factor monitoring and advice

***

<18’s conception rate - reduce by 50% by 2010, as part of broader stragty to improve sexual health

EHC under PGDs

Supply of condoms

Signposting

Sexual health advice and screening

***

Obesity among children - halt the rise in obesity in under 11’s by 2010

Targeted information and advice

Weight reduction programmes

**

Medicines Use Reviews (MURs) Smoking cessation CVD prevention CCF monitoring Diabetes Weight management EHC Needle exchange/ opioid supervisionKey - blue = advanced services, red = enhanced services

>5 million individuals living with asthma in the UK

AN average community pharmacy provides a service for >450 asthma sufferers◦ Large potential for contact

The AIRE study found that only 5.3% of the population met all the goals of the Global Initiative for Asthma (GINA) guidelines (Rabe et al,

2000)

There is a need for healthcare input

One study looked at increasing patient compliance via an MUR pharmacy service

(Portlock et al, 2009)

965 patients had an MUR in participating pharmacies

A total of 1,787 interventions were made Patients were happy with the advice they

received and the knowledge of the pharmacist There was good interaction with local GPs as

the study involved a range of health care professionals

Smoking cessation - is effective and cost-effective; training is essential to increase effect (Anderson, 2007)

Pharmacists in Scotland gave smoking cessation advice to the public (77% smoked >34 pack years) (Cramp et al, 2007)

◦ 65% said that pharmacists were their preferred healthcare professional for advice on smoking cessation

◦ At the end of week 4, 45% had stated they’d quit smoking

◦ Of those that didn’t stop, 19% reduced their smoking.

CVD prevention showed reduction in lipid levels and CV risk scores, which was sustained after 1 year.

RCT showed significant increase in Rx of antiplatelets, lipid-lowering medicines and smoking cessation treatments (Anderson, 2009)

Enhanced service commissioned across 250/300 community pharmacies within Greater Glasgow and Clyde PCT area (Cree 2010)

Community pharmacists trained annually by specialist pharmacists and r/v patients, advise on meds and lifestyle, can refer to other services, also direct specialist pharmacist clinical input

66% patients knew more about CCF, 72% knew more about meds, 48% more likely to seek help if symptoms worsened

PCT identifies health need and is willing to £££

Led/trained by specialist clinical pharmacists with no prospect of financial gain from the service

Service receives external referrals (by 2o care pharmacists and 1o care specialist nurses)

Limitation: 85% of those referred seen but only 42% had ongoing follow-up – time constraints?

Pharmacies showed 1% reduction in HbA1c levels compared to controls (Machado et al, 2007)

Community pharmacy services shows promise but more information is needed (Anderson, 2007)

2 out of 3 intervention studies showed a positive effect from community pharmacy services, but 3rd study found no effect (Anderson,

2007)

1,370 individuals who’d previously taken part in a community pharmacy based diabetes screening study (n=3,800) took part in lifestyle counselling - weight loss was between 0.6-1.9kg at 3 months (Anderson, 2007)

Counselling by pharmacists could help to reduce public obesity

Community pharmacies highly rated by women as a source of supply and advice (Anderson, 2007)

Large US trial of advance availability of EHC found no increase in risky sexual behaviour and no significant reduction in no. of pregnancies

(Rocca et al, 2007).

A study in Manchester found that the EHC PGD was largely adhered to and that EHC was supplied appropriately (Anderson, Bissell, 2004)

◦ Women felt that pharmacists had been polite, courteous and non-judgmental

◦ Women had no concerns about confidentiality◦ Small study sample (2 secret shoppers)

Needle exchange, supervised dosing, opportunities for advice (inc wider health)

Predate current community contract for enhanced services - although RPSGB opposed NX 1982-6 (Bates 2002)

Pharmacy-based NX has been shown to be successful, with client satisfaction and in one study an 86% sharps returns rate (Cameron et al 2004); NX also clinically effective in reducing HIV transmission (McDonald et al 2003)

However: varied types of paraphernalia available, often limited (Abdulrahim et al 2006)

Most service users and pharmacists also positive about concept of supervised dosing (Bloor 2007)

However: Lack of privacy/confidentiality – with consulting-

rooms? Impact on self-image Lack of communication between pharmacists and

other members of “MDT”; unused skills e.g. safer injecting advice? (Bloor 2007)

Pharmacists’ training needs not always met (Cameron et

al 2006) – only 15% covered care of misusers at undergrad, limited awareness of motivational skills

Monetary targets for MURs are meaning that not all truly benefit the public

Some members of the public feel coerced into having an MUR - thus putting them off further ones or recommending to others

PCTs not commissioning enough enhanced services to community pharmacies

Still some barriers between GPs and pharmacists preventing true integration◦ Some GPs still do not see pharmacists as an equal

health care professional

Space constraints - e.g. for private consultation room

Opinions of the general public Time constraints on pharmacists Confidence of pharmacists - many still do not feel

confident in opportunistically advising members of the public on health care issues e.g. smoking cessation: mostly no formal training in motivational interviewing/”stages of change” psychological model

Poor GP response to MUR interventions The lack of growth of recent UK studies

Quarterly meetings between community pharmacists and PCTs

Increased communication between pharmacists and GPs

This may be improving with many pharmacies now operating in GP surgeries

More commissioning from PCTs to community pharmacies

This is also a way to help surgeries meet government statistics e.g. lipid targets

Joint educational sessions with GPs when a new enhanced service is started

A central ‘spine’ system to allow free flow of information between community pharmacists and GPsThis would be especially helpful in the case of

MURs

Specific time allocated to pharmacists by employer to spend on clinical duties, e.g. MURs, smoking cessation clinics, counselling and advice

Ways to improve the serviceResearch and development, develop long term strategic pharmacy practice program to produce evidence based community pharmacy services.

More public education about the skills of the pharmacist

Adequate education/ training for pharmacists e.g. on smoking cessation, and receiving support from PCT or academic institutions

Monitor GP response to MUR interventions

Collaboration between pharmacy enhanced/advanced services and secondary care: referrals from secondary care on discharge?

Advance booking of MUR, patient were informed about the nature and duration of MUR, and allow patients to prepare for MUR

Collaboration between specialist and “generalist” pharmacists

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Anderson C, Bissell P (2004). Using semi-covert research to evaluate emergency hormonal contraception service. Pharmacy World and Science 26(2): 102-106

Anderson C, Blenkinsopp A, Armstrong M (2009). The Contribution of Community Pharmacy to Improving the Public’s Health: Summary Report of theLiterature Review 1990-2007. PHLink

Bates P, 2002. Are needle exchange schemes ethical? Pharm J 269:214 Bloor R, 2007. Summary of a supervised methadone study in Staffordshire and Shropshire.

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Pharmacy-based smoking-cessation counselling and nicotine replacement therapy initiative. IJPP 15: 113-121

Cree N, 2010. Operating a specialist heart failure service in community pharmacies. Pharm J 284:450-1

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Pharmacists Interventons. Part I: Systematic Review and Meta-Analysis in Diabetes Management. Annals of Pharmacotherapy 41: 1569-82

Portlock J, Holden M, Patel S (2009). A Community Pharmacy asthma MUR project in Hampshire and the Isle of Wight 282:109-111

Rabe KF, Vermeire PA, Sorlano JB, Maler WC (2000). Clinical Management of Asthma in 1999: The Asthma Insights and Reality Europe (AIRE) study. The European Respiratory Journal 16:802-7

Rocca CH, Schwarz EB, Stewart FH, Darney PD, Raine TR, Harper CC (2007). Beyond access: Acceptability, use, and non-use of emergency contraception among young women. American Journal of Obstetrics and Gynaecology 196: 29