From Mr D. V. Nandha, MRPharmS, and others
SIR,—As coronary heart disease (CHD) facilitators working in the Ealing, Hammersmith & Hounslow health agency, we were particularly interested to read your leading article and the update on fish oils by Pamela Mason (PJ, November 11, p720). The evidence for dietary intervention in disease prevention and chronic disease management is growing rapidly but the true value of nutrition in this area is perhaps still underestimated. At the same time, patients are becoming increasingly knowledgeable about health supplements and, therefore, pharmacists will need to keep pace with developments and current research to help them give the best advice to patient groups such as those with CHD.
As part of our role, which includes rolling out the joint British recommendations on the prevention of CHD to general medical practitioners and helping them to implement the national service framework guidelines, we also facilitate "healthy heart" clinics at GP practices across the health agency. Patients at risk with CHD are identified and invited to attend these clinics which are jointly run with a nurse and a community pharmacist. Blood parameters such as lipid profiles, glucose measurements, body mass index, family history and lifestyle assessment are made at these clinics. This information is then collated to obtain a CHD risk score. The role of the pharmacist is to review the patient's medication on the basis of best available evidence and address any pharmaceutical care issues. The session also focuses strongly on lifestyle advice, which is given both by the nurse and pharmacist. The results from the healthy heart clinic are presented to the GP at a subsequent meeting.
We are also actively promoting the use of the chronic disease register (CDR), which is a computerised system for collection of relevant data for calculation of risk scores. The system is currently undergoing data input from individual surgeries and already deficiencies in data collection at practice level are being highlighted. However, because data are stored conveniently in a central database, one major advantage will be the potential for assisting primary care groups and trusts in the management of chronic diseases.
An interesting development of the healthy heart project has been the inclusion of an exercise adviser (certified by the American College of Sports Medicine) who provides individual behaviour change counselling and advice on home-based and locally available opportunities for increasing physical activity in a manner beneficial to particular clinical conditions. (He has also undertaken study units in chronic disease and exercise.) This role has developed as a consequence of the exercise adviser's individual efforts to initiate the development of an exercise referral system. The involvement of the exercise adviser has helped to change the focus of this primary care intervention from the management of illness to the promotion of health, but his inclusion has only served to highlight the absence of dietetics — the inclusion of which, we feel, would really provide us with a holistic approach to primary prevention and chronic disease management.
Since CHD requires treatment from many angles, it would seem judicious to have a dietitian or nutritionist on board when running clinics. A pharmacist with a special interest in this field could also provide the service so that the therapeutic benefits of a chosen diet and/or health supplements are optimised alongside drug therapy. The Government has targeted CHD as a major area for health improvement and we have no doubt that nutritional advice has to be embedded firmly into the fabric of any disease management strategy.
Dipak Nandha Community Pharmacist Usha Shah Community Pharmacist Marianne Walmsley Nurse Practitioner Ealing, Hammersmith & Hounslow Health Agency