Speakers at sessions held on September 12 discussed ways in which the national service frameworks for coronary heart disease, cancer, respiratory disease and mental health might be implemented
Many simple things could be done that would help make the big changes required
by the national service framework (NSF) for coronary heart disease, said Dr
Roger Boyle (national coronary heart disease director, NHS Executive).
The NSF had been put together because heart disease was a major problem in the
United Kingdom, there was a five-fold difference in the performance of health
authorities when it came to tackling this disease and current commissioning
did not target those at greatest risk.
The factors that had been taken into account when compiling the NSF included
evidence for the efficacy and cost-effectiveness of interventions, the variation
in service provision and quality, and regional differences in mortality from
the disease. Overall mortality from coronary heart disease in the UK had decreased
in recent years but this was largely because of reduced deaths from myocardial
infarction. It was alarming that the prevalence of the disease had increased
and that there more patients now suffered from unstable disease.
The immediate national priorities when tackling this disease were to:
There was much to do but there were big opportunities for all health care professionals to become involved.
Pharmacists should take up the challenges presented by the NSF for oncology
and tackle high death rates, inequalities in prescribing and inequity of care,
said Mr Andrew Stanley (director for oncology and palliative care pharmacy,
City hospital, Birmingham).
This was all the more urgent as UK survival rates were rated 18th in Europe
and were equivalent to those achieved in Poland and Latvia. Each year £168m
was spent on paracetamol in the UK but only £67m was spent on cytotoxics.
The essential role of pharmacists in oncology had been recognised and the profession
should be ensuring that an optimal service was provided, with more emphasis
on the patient.
This might be achieved by the Royal Pharmaceutical Society setting up specialist
accreditation, with mandatory requirements for continuing education. The undergraduate
curriculum for pharmacists currently included less about oncology than that
for dentists and this should be increased.
Hospital pharmacists needed to move away from an obsession with workload figures
and focus on how to give the best care to the patient. Pharmacists were well
on the way to being at the forefront of non-medical prescribing, as many protocols
were already in place. It was important to consider risk management, because
mistakes made with cytotoxic dispensing and monitoring were those most likely
to result in litigation.
Community pharmacists should be asking themselves what they are doing for cancer
patients. It was important to become more involved with the provision of care
to patients, with prevention strategies (such as encouraging smoking cessation)
and with improving survival by encouraging compliance.
Health authorities and primary care groups had to move away from the provision
of services that were convenient for the providers but not the patient, which
included community-based treatment. In addition, patients should not be denied
the best treatment for them. It would be helpful when planning cancer service
provision for primary care groups to "map" the local cancer burden
in terms of numbers of patients and types of cancer.
Pharmacy had to be ready for this challenge in order to improve the lot of the
patients who relied on the profession.
Medicines are a big issue in mental health, said Mr Steve Bazire (pharmacy
service director, Helesdon hospital, Norwich), who asked the audience whether
they would be willing to take any of the drugs used in this therapeutic area.
Psychotropics were badly used, education of health care professionals was poor,
pharmacists tended not to be up to date in this area and, consequently, were
not assertive about asking for changes to be made to prescriptions, he said.
However, mental health was an area where pharmacists could shine; supply was
not the end of the service, it was the beginning. Pharmacists were fully trained
health care professionals, who could become involved in agreeing the treatment
strategy for inpatients. They could provide counselling and education to patients
thereby motivating them to take their drugs. Pharmacists were in a good position
to give patients practical advice rather than information. They could give consistent
advice once patients were back in the community and provide support directly
or by means of helplines.
Specialists needed advice on drug interactions and side effects, dosage regimes
and information on new drugs. There was also scope to help specialist psychiatrists
to write policies relating to drug treatment, to help put together proper discharge
packages and to be the liaison with primary care groups.
Apart from providing convenient dispensing services, community pharmacists could
make sure that they provided consistent packaging or brands when it was important
to the patient. It was important to let community health care trusts know who
was open late, so that it was easy for patients to collect prescriptions. In
addition, community pharmacists could look out for interactions with other medicines,
monitor for side effects and keep an eye on the patient's general health. Often
patients were given a care plan and had a care co-ordinator, who would be a
good contact for community pharmacists to know.
Pharmacists could provide education to patients, carers, the primary health
care team and volunteer workers.
At the same time, no-one could be an expert on everything. Mental health was
a specialist subject and it was important that pharmacists knew their limits.
Pharmacists were the best people to sort out major problems that related to
prescribed drugs and primary care groups should ensure that local specialist
pharmacists were available.
Pharmacists have an important role in implementing strategies for treating
patients with asthma or chronic obstructive pulmonary disease (COPD), said Dr
Gillian Hawksworth (member of the Council of the Royal Pharmaceutical Society).
She illustrated this using case studies, in which greater communication between
pharmacists and doctors had led to improved patient care.
Emergency supply request A man visited a community pharmacy
and requested an emergency supply of a salbutamol inhaler. When questioned by
the pharmacist, it became clear that this was how the patient often obtained
his inhalers. He was a travelling salesman and found it difficult to visit his
general practitioner. Further conversation revealed that his symptoms had worsened
recently and he was using his salbutamol inhaler regularly.
The pharmacist recommended that the patient see his GP for a review of his medication.
The patient subsequently went to an asthma clinic and his symptoms improved.
Dr Hawksworth said that the Society's guidance on asthma and COPD included a
referral form that had been endorsed by both the Society and the Royal College
of Physicians (PJ, September 16, p390). This case was a good example of when
the form might be useful.
Incorrect diagnosis A 65-year-old man, who had been diagnosed
as having asthma was referred to his GP by a community pharmacist because he
had had many repeat prescriptions for both salbutamol and beclomethasone and
his symptoms were not being controlled. In addition, he had asked the pharmacist
for information on giving up smoking. The pharmacist was uncertain that the
patient really had asthma and thought it advisable to have the diagnosis checked.
Helping the patient to give up smoking was another priority for the pharmacist,
who discussed the options available to help the patient.
Childhood asthma The mother of a 5-year-old visited a pharmacy
asking for a cough syrup that the child could be given at night. She returned
for a further supply one week later. The woman had said that the family all
had a history of atopy and the child had always been "chesty". The
pharmacist referred the woman to their general practitioner, who prescribed
the child antibiotics.
When the woman next visited the pharmacy, she said that the child was no better
and had "little puff". With some trepidation, the pharmacist wrote
the woman a referral letter for the GP, explaining that the child had nocturnal
cough, was a frequent attender at the pharmacy and was requiring a large amount
of over-the-counter cough remedies. The GP subsequently prescribed asthma medication
for the child and referred him to an asthma clinic for assessment. The child's
symptoms began to improve.
Two months later, the woman revisited the pharmacy. She had not been attending
the asthma clinic and had not been giving her child his brown inhaler because
it had steroids in it. She had been given a spacer to help administer the inhalers
to her child but she seemed not to understand how or why it should be used.
The pharmacist explained the rationale behind the use of blue and brown inhalers
for asthma and explained how important it was to use them correctly. In addition,
the pharmacist explained why spacers could be helpful. Three months later, the
child was greatly improved and the mother seemed more confident and knowledgeable
about using both inhalers.
In this case, Dr Hawksworth said, the pharmacist had been important at several
stages. Action had been taken that had resulted in a correct diagnosis of the
child's illness being made and had provided information to the mother that had
helped her to understand her child's treatment and led to better compliance.
In the future, the pharmacist could continue to help by monitoring the child's
symptoms, checking inhaler technique and giving advice on peak flow measurement.
The barriers to this kind of intervention included pharmacy's tradition of isolation from other health care professionals, a defensiveness about workload and a lack of understanding about the working constraints of other health care professionals. Things were improving and now that a form that allowed pharmacists to refer patients to their GP was available, it would be easier for pharmacists to know the best approach to take when contacting doctors.