This column is the first of a regular series written by Eileen Neilson, head of the Royal Pharmaceutical Society's Policy Support Unit, to highlight topical issues on the national policy agenda. The PSU can be contacted on 020 7735 9141 ext 433, by email on psu@rpsgb.org.uk or by fax on 020 7793 1923
Now that this winter's influenza outbreak seems to have passed its peak, it may be time for a more considered look at how the Health Service might handle things differently next year, and make the best use of pharmacists in the process.
At the height of the 'flu outbreak, debate focused on the pressure on intensive care beds and the anti-influenza drug Relenza. NHS funding was once again declared to be insufficient (for what?) and the issue of health spending (how much should be spent and how it should be paid for) was reopened. But neither Relenza nor additional hospital beds, whether NHS or private, offered simple solutions. The "bed crisis" arose primarily from staff shortages exacerbated by absence due to 'flu. Additional private sector beds would not have produced more trained staff: they are all drawn from the same pool. The NHS is seeking to train, recruit and retain more qualified staff, but these measures will take several years to have an impact.
The Government had already decided not to make Relenza available under the NHS on the ground that it had not been sufficiently tested in the vulnerable groups most at risk from serious complications (older people and those with chronic diseases). It was not, as some newspapers claimed, simply "too expensive for the NHS". Shortly after the peak of the 'flu outbreak, a warning about side effects in people with chronic respiratory disease was issued. If Relenza had been approved for the NHS, GPs' surgeries could have been overwhelmed by otherwise healthy adults with 'flu, delaying access to treatment for the vulnerable who really needed it.
If we are to avoid a 'flu-induced "crisis" in the NHS every winter, a broader public health agenda must be addressed. Excess winter mortality in older people is a problem that the United Kingdom has failed to deal with, in contrast to some other European nations. A variety of risk factors have been cited. About one-third of older people in the UK have incomes below the poverty line, and many of these live in housing with poor basic amenities which is difficult and expensive to heat. Malnourishment is another factor. And there is relatively little health promotion activity targeted at older people, despite national standards for health promotion and work on their application to this age group. There may be scope for extending the role of health visitors into health promotion work with older people, which could produce considerable health gain. There could also be roles for a variety of health care professionals, including pharmacists, in providing health promotion and advice to care home residents.
So how might next winter's influenza outbreak be handled better? Prevention is more effective than cure, and a properly organised immunisation programme for the vulnerable groups, with annual recall and appropriate remuneration for GPs, would have the greatest public health impact. Immunisation of staff in hospitals, care homes, sheltered housing and domiciliary care would help protect service users from 'flu and help keep facilities open by reducing sickness absence among staff. Educating the public to use the most appropriate forms of care is also important, and both pharmacists and NHS Direct have a major role in this, encouraging normally healthy adults with uncomplicated 'flu to obtain relief for symptoms from pharmacies.
Longer term, the Government's public health strategy aims to reduce both premature deaths and health inequalities. Smoking is the most important avoidable cause of premature death in the UK, most commonly from heart disease and cancer. It is also a risk factor for chronic respiratory diseases. Pharmacists can make an important contribution to public health on a number of fronts including health promotion (eg, by helping people to quit smoking).
The accessibility of community pharmacists is a key aspect of the service they offer to the public, but more needs to be done to extend domiciliary pharmacy services to people living in nursing and residential homes and to frail older people living at home. New opportunities to take pharmacy services to service users will arise from the internet and the development of telehealth care. WebTV will be soon be available to the majority of the population. Webcams, video-conferencing equipment and the monitoring technology being built onto community alarm systems are other potential vehicles for virtual pharmacy services.
The Society's Policy Support Unit is taking forward two projects relevant to this debate, one on pharmacy' contribution to public health and one on the potential impact of e-commerce on pharmacy, which will look at information services as well as distribution and supply of pharmaceuticals.
The Society is keen to engage its members in the development of policy. Readers wishing to contribute views, experience or information on pharmacy research or practice to the Society's work on public health or e-commerce should contact the PSU (see introduction above for contact details).