Issues of current professional and public interest were discussed in parallel hot topic sessions at the British Pharmaceutical Conference on September 12. The following reports have been received by The Pharmaceutical Journal
Self-care was a requisite step towards improving compliance and concordance,
Mr SULTAN DAJANI said, opening the hot topic session on “The expert patient”.
Public access to information was increasing but some sources were inaccurate.
Patient information leaflets focused on products and not disease management.
Excellent information could be obtained from other patients but this source
remained relatively unused.
Mr ROY JONES (service policy consultant, Arthritis Care) explained that although
the term “expert patient” was relatively new, it was part of some
established self-management programmes. The ethos of expert patient programmes
was to complement and provide added value to existing health care provision
and not to replace it. Indeed, as the programme leaders were not the experts,
participants were always referred back to the health care team when necessary.
He cited the American national arthritis plan as an example of a public health
policy which indicated that self-management was an integral part of coping with
a chronic condition as well as substantially improving the patient’s quality
of life. Studies suggested that patients involved with a self-management programme
could have up to a 30 per cent reduction in symptom presentation. Feedback from
health care professionals was favourable, since such programmes created active
and informed groups of patients who were willing to participate in consultation
on purchasing decisions and the development of medical provision.
He ended his presentation by quoting the Long Term Medical Conditions Alliance
which said: “Care is best delivered by an active partnership between the
individual and professionals. Only by using the expertise and knowledge of patients,
users and carers will the modern National Health Service be able to support
them in living as full and active lives as possible.”
The improvement in crop plants brought about by using gene-modifying technologies
would be as significant for our quality of life today as advances in medicine,
Dr NIGEL HALFORD (Institute of Arable Crop Research) said, opening a session
on genetically modified products.
Farmers had always changed crops, whether by simply selecting mutant plants
to breed or, more recently, by bombardment with radiation to induce mutagenesis.
The advent of gene technology had made it possible to select and modify single
genes, rather than the unfocused and unknown changes brought on by other methods.
The use of terminator genes, which deliberately made the produce of a GM crop
infertile, was questioned. Dr Halford said that a key example of the necessary
use of these genes was in producing GM edible plant vaccines. In this process,
infertility was used as a method of controlling the production of a therapeutic
substance. Farmers who chose GM seeds, however, were asked to buy them each
season, and to pay regular fees to license the technology.
GM products which might be useful in therapeutics included cereals fortified
with vitamins and minerals, such as the “golden rice” enriched with
vitamin A which was already being used in developing countries. Enhanced oil
production within GM crops was increasing evening primrose oil yields and might,
in time, lead to less expensive products for consumers.
Questions from the audience reflected the concerns of pharmacists and their
customers. One pharmacist had been asked: “Do you think it is safe?”
Dr Halford asserted that the human gut had never absorbed modified genes from
GM ingredients. Long-term safety could not, however, be guaranteed.
Mr MIKE KING (assistant secretary, Pharmaceutical Services Negotiating Committee)
led a discussion on pharmacists and primary care trusts.
Local pharmaceutical committees were the focus of efforts to secure representation
on primary care trusts’ boards in England. The places being targeted were
those on executive committees reserved for “community health care professionals”,
a definition which included pharmacists.
Mr King said that, in theory, once names had gone forward the candidates were
to be shortlisted against a list of competencies set out by the National Health
Service Executive. The NHSE’s guidance stated that candidates should have
a good understanding of strategy, be articulate and self-confident, have political
intuition and the ability to work as part of a team. Candidates were expected
to be available for five days a month and a total remuneration package of around
£12,000 was available (to include locum cover and a fee).
However, things were not so straightforward in practice, Mr King said. Some
PCTs were interpreting “health care professionals” to mean professions
allied to medicine or those working directly for PCTs or community trusts, such
as physiotherapists and podiatrists. In other cases, PCTs had not been convinced
of the benefit of having a pharmacist on the executive committee and although
names of pharmacists had been put forward they were not getting past the shortlisting
stage.
It was suggested from the floor that the arrangements in Scotland and Wales
were slightly different but that the key issue was to ensure that people with
the right skills were being identified.
It was also pointed out that it was vital that potential nominees involved themselves
in local health communities in advance of seeking inclusion on PCTs. Successful
candidates would be those who could represent a wider community. The need for
support of successful nominees was also recognised along with of appropriate
training.
Mr WARWICK SMITH (director, British Generics Manufacturers Association) led
a disucussion on the use of generics. He said that, in general, the pharmaceutical
industry and community pharmacy had coped well with shortages in the generics
market last year, ensuring that patients did not go without.
As a result of the problems, Oxford Economic Research Associates (OXERA) was
helping the Department of Health with a fundamental review of the generic pharmaceutical
market. The review would cover tendering, licence trading, limits on discounts,
fixed margins and mark-ups. It only involved those companies which were willing
to co-operate and had a limited remit. OXERA had admitted that it did not understand
what went on last year, Mr Smith said.
Stop smoking guidelines to be reviewed
Revised national smoking cessation guidelines were due to be published in December,
said Dr ANN McNEILL (a freelance consultant in public health and author of the
guidelines) opening a discussion on smoking cessation guidelines. The new guidelines
would cover amfebutamone/ bupropion (Zyban), amend the presentation of evidence,
and take account of feedback on the original guidelines and issues emerging
from the new National Health Service smoking cessation services. The first version
of the guidelines had been published in December, 1998.
The original guidelines had said that opportunistic and brief advice in primary
care had a low efficacy but could reach many people; intensive specialist cessation
support (where appropriate) was more effective but reached fewer people. The
Government’s White Paper on tobacco included an investment of £60m
over three years to provide new NHS smoking cessation services. These included
the provision of specialist clinics, intermediate interventions and one week’s
free nicotine replacement therapy for smokers entitled to free prescriptions.
As with the previous guidelines, the cornerstone of cessation advice remained
the provision of opportunistic advice in primary care (for example, linked with
the sales of cough medicines, smokers’ toothpastes and related products).
Pharmacists could also provide specialist intermediate support (involving an
initial consultation and weekly follow-ups for a month), signposting NHS services
and helplines and advice on medicines.
Future developments, as part of the NHS plan, included: the dispensing of NRT
products on NHS prescription; the National Institute for Clinical Excellence
to advise general medical practitioners on the most appropriate and cost-effective
prescribing regimens for NRT and amfebutamone/ bupropion; and consideration
by the Committee on Safety of Medicines of whether NRT could be made available
on as a general sale list product.
In the discussion that ensued, there was concern that freely available NRT might
produce dependence. However, the dependence potential of NRT products was said
to be relatively low compared with that of cigarettes and the abuse potential
of NRT products had been shown to be very low. It was illogical that the most
dangerous form of nicotine delivery, cigarettes, was more widely available than
the safer forms.
The problem of lost sales from pharmacies was also highlighted. Having pharmacists
who were able to give advice and support as well as providing NRT would increase
smokers’ chances of giving up. Behavioural support was also necessary for
the success of products like Zyban.
Mr PETER CURPHEY opened a session on pharmacists and sexual health by reminding
participants that the Society had published its strategy for sexual health last
year (PJ, June 19, 1999, p873).
Ms CATHY HAMLYN (head of the teenage pregnancy unit, Department of Health) said
that the Government’s teenage pregnancy strategy was one of three linked
strategies for England. The strategy had been launched in June, 1999, and the
teenage pregnancy unit had been set up in the autumn of 1999 to implement it.
The linked strategies for sexual health and HIV/AIDS were to be issued for consultation
in the next few months.
Ms Hamlyn said that part of the strategy was new ways of providing advice and
treatment, including using NHS walk-in centres, NHS Direct and other helplines,
young people’s centres, the internet, outreach and local pharmacies.
The situation regarding strategies in the four home countries was clarified.
Northern Ireland was watching closely the developments in England as part of
its planning process. The Society’s Scottish Department was working with
the Scottish Parliament to point out what pharmacy could do in the context of
overall sexual health. The National Assembly for Wales, having consulted on
a strategy to promote sexual health, was now implementing its recommendations,
one of which was to run a public education campaign on emergency contraception.
Another was to make condoms more widely available, both to prevent unintended
pregnancies and to reduce the incidence of sexually transmitted infections.
It was stressed that pharmacists needed to be on the local implementation groups
charged with putting these strategies into practice.
The discussion was dominated by emergency hormonal contraception, reflecting
both enthusiasm from pharmacists to become involved and caution caused by some
of the ethical implications.
The point was made that it was better to promote the pharmacist’s role
in contraception — to have teenagers accepting this as normal — rather
than single out teenage pregnancy.
Issues around the need for privacy were hotly debated. It seemed that for the
pilot projects for EHC provision in London, users did not want to go into a
separate room, and an area of the pharmacy where a private conversation could
not be overheard had proved acceptable.
An important part of the provision of advice was to have a local directory of
services available so that inquirers could be referred on to other services.
Pharmacist needed to contact their local sexual health strategy lead to get
hold of this information (in England these were the local teenage pregnancy
co-ordinators who could be contacted through the health authorities).
Therapeutic cloning in five years?
Dr HARRY GRIFFIN (Roslin Institute, Scotland) opened a session on therapeutic
cloning by defining it as being when stem cells were used to produce specific
cell types for use in certain therapeutic conditions. Leukaemia, diabetes and
Parkinson’s disease were examples of medical conditions which were due
to failure of cell types. Stem cells could be produced from embryos or from
egg cells where the DNA had been removed and substituted with DNA from a patient.
Research might ultimately identify how to awaken silent genes in standard cells
without using egg cells or embryos which were likely always to be in short supply.
Stem cells could be cultured, when they readily multiplied and divided indefinitely.
Under the influence of certain growth factors they could be turned into specific
cell types. Currently experiments had been conducted only on animal cells due
to restrictions on the use of human embryos and cells. A report on potential
changes to these restrictions had been placed before Parliament, where it was
expected that a full debate would ensue. Considerable resistance to the changes
was expected.
The implications for the drugs budget of using expensive drugs to harvest human
egg cells was discussed, along with potential postcode prescribing, but it was
pointed out that the research was in its infancy and actual use was still many
years away. Transfer of diseases was raised as a concern, but this was said
to be unlikely since the strict rules and regulations which already applied
to the transfer of human cells, such as by blood transfusion, would be applied
to any use of stem cells. Cultured cells could transform and mutate, but tests
could be carried out before giving cells to patients.
The moral implications of using embryos were discussed. Nobody in the session
objected to the use of embryos on religious grounds. However, it was felt that
confidence would be needed in the regulatory process for preventing human cloning.
The potential, but unlikely, risk of human cloning might not outweigh the potential
benefits to many people if research was allowed.
Current European regulations were restrictive and the United States had conflicting
and confusing rules. The new proposals, if agreed by Parliament, might provide
the clarity of law necessary for research in the United Kingdom to develop and
lead the way.
Within five years it was expected that hepatocytes would be cultured for drug
safety testing and, perhaps in five to 10 years’ time, some simple procedures
such as islet cell transplantation in diabetes might be undertaken.