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Chiltern region lecture

Responsible self-medication: the changing dynamic in managing everyday illness

The annual Chiltern Region lecture was given on November 27 by Professor Peter Noyce (professor of pharmacy practice, School of Pharmacy and Pharmaceutical Sciences, Manchester university)

It is important to know how the public choose and use over-the-counter medicines

The National Health Service was looking to manage demand arising from minor ailments, Professor Noyce said. Consumers were becoming better informed, fuelled by the media. Ensuring responsible self-medication was a significant and integrated component of the community pharmacist’s professional and merchandising activities. It was, therefore, important to know how members of the public dealt with minor ailments, whose advice they sought and how they chose and used over-the-counter medicines.

The topic was commonly regarded as trivial, in that it covered symptoms encountered in peoples’ everyday lives. This attitude led to potential conflict in the consumer-pharmacist relationship, especially when it came to the perception of risk. To the consumer, the biggest risk was not having the symptoms relieved, whereas to pharmacists risk was more associated with safety in using a particular type of product.

A recent study had put pharmacists at the bottom of a list of information channels that influenced product choice by young adults. Consumers were now better informed from other sources about their conditions and treatment options. Consequently their perceptions about need tended to be more product specific by the time they arrived at a pharmacy. Nevertheless, they expected pharmacists to be able to provide reassurance that products were good. Earlier work had identified five types of advice that consumers regarded as helpful: product recommendation, reassurance, instruction, information and referral.

Referring to a “Care at the chemist” project undertaken at Bootle, Manchester, Professor Noyce said that most general medical practitioner consultations or prescription requests involved minor ailments, principally cough, sore throat, hay fever, thrush and head lice. Under the scheme, consultations for 12 minor ailments had been transferred to pharmacies.

Patients’ views on the operation of the scheme were positive. The main reported benefit was the time saved for both patient and doctor. Accessibility, convenience and access to treatment were also regarded as important factors. However, resistance to change could be expected where symptoms were new or severe, involved children, if previous self-treatment had not worked, if another condition was also involved or if there was a perceived need for an antibiotic.

Professor Noyce set out four possible next steps:

• (i) re-examination of consumers’ access to and use of pharmacies, taking into account the influence of NHS Direct and walk-in centres;
• (ii) exploration of the scope for the transfer of patients from surgery to pharmacy among more traditionalist GPs;
• (iii) exploration of opportunities for PCG/PCT transfer campaigns; and
• (iv) comparison of GP, nurse and pharmacist led clinics for minor ailments.

In this regard he said: “The people who are really making the running are the nurses.”

A number of issues needed to be tackled in rolling out such schemes. First was the question of patient access and recruitment. Then, should patient selection be condition-specific or employ a more generic minor ailment approach, should pharmacists confine recommendations to pharmacy medicines and should there be a formulary or non-formulary approach? Patient group directions also had to be assessed. Monitoring, surveillance and documentation would be required in any event. Finally, what options would there be for payment. In Scotland, a commitment to roll-out had been gained in two localities.

Discussion

Asked how to handle the accusation that the professions tended to treat their clients as children, Professor Noyce said that the challenge was to isolate those patients who really needed advice. That was not simple, bearing in mind that a range of advice might already have been gathered from elsewhere.

Further discussion centred on the inevitability of pharmacists becoming more involved in treating influenza and providing post-coital contraception and their need for appropriate remuneration. Professor Noyce acknowledged a lack of consensus on financial aspects. However, he considered that consultation time needed to be considered when looking at the professions’ relative costs. Nurses spent longer with patients than either doctors or pharmacists and were therefore not necessarily cheaper. NHS Direct needed to guess ahead four years or so, when it would increasingly encounter wider issues, such as the care of the elderly.

Invited to look 10 years ahead and to comment on the pharmacy role, the professor envisaged a range of diagnostic tests being available that patients could use for themselves. A good deal of extra money was now being put into the NHS to upgrade its reputation, but how long that might continue was a matter for conjecture. He cautioned his audience that the Government remained to be convinced of the need to maintain a comprehensive pharmacy network and that voices in the European Union were questioning the length of training required before one could practise as a pharmacist. On the other hand, GPs and pharmacists had a generally closer rapport in the UK than on the continent.

Professor Noyce was asked whether he really believed that patients might in future be more likely to take their symptoms to pharmacists than to other health care professionals. It was his opinion that unless patients saw doctors or nurses providing access that pharmacists did not, patients would generally first want to approach a pharmacist. There would be exceptions. For instance, in the Bootle project it had become clear that pharmacists were not regarded as having adequate skills to manage earache. Also, there were differences among pharmacists when it came to referring customers to doctors and this might raise questions about competence. One area where pharmacy practice was regarded as being tailor-made, however, was in the management of long-term medication.

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