Pharmacists see urgent need for NRT patient group directions

Pharmacists are drafting patient group directions for supply of nicotine replacement therapy in advance of the withdrawal of the voucher scheme. Joanna Lumb reports

Confusion surrounds the future of the supply of nicotine replacement therapy (NRT) by pharmacists, following the Government's decision to make NRT available on NHS prescriptions from next month. The Department has indicated that the scheme will be phased out from April, 2001, although arrangements are being made to continue some of these schemes in the short term.

The voucher scheme has allowed free supply of NRT to patients who are exempt from prescription charges and started in health action zones in 1999. It has since been extended to other areas. It involves supply of four to six weeks' NRT, with vouchers written by accredited smoking cessation counsellors (eg, pharmacists, general practitioners, technicians, nurses). Supply in this way requires counselling and patient follow-up.

The Department of Health has announced that NRT is now to be prescribable again on FP10s. This could happen by the end of April (with the regulations expected to be laid before Parliament this week). Another new supply route is nurse prescribing — for this, NRT needs to be added to the Nurse Prescribers' Formulary but the Department says that this could be done quickly.

So what should pharmacists do to protect their role in smoking cessation?

Next step

The development of a patient group direction (PGD) is an obvious next step for pharmacists and there is a belief that there is no need to wait for the National Institute of Clinical Excellence appraisals of NRT and Zyban, which are expected later this year.

At a meeting in Birmingham organised on March 23 by Pharmacia for pharmacists with a special interest in smoking cessation, one of the working groups drew up a “first draft” PGD for NRT (see Panel) using the Royal Pharmaceutical Society's template.

Part of suggested PGD

Supply — List whole range on one PGD
Outside terms of SPC — Yes
Clinical situations in which medicine used — Aid to smoking cessation
Criteria for inclusion — All smokers (10 or more a day) who want to give up smoking
Criteria for exclusion — Adverse drug reactions to NRT
Referral — For Zyban
Follow-up — Consultation/phone/e-mail, once a week for first four weeks
Period of administration — Within licence but for a maximum of 12 weeks

Karen O'Brien (prescribing adviser, Central Manchester primary care trust), who led the group, said: “A lot of people may be preparing these documents. It seems sensible to produce one document, which can be tweaked for local use.” She said that putting a PGD together was easy — the difficult bit was managing the project, training, and following the audit trail. She suggested that it was important for the PGD to be multidisciplinary and that it would be useful to involve practice nurses.

One issue raised was the need to provide feedback to GPs. Unlike the PGD for emergency hormonal contraception, which provided for a confidential service, with NRT there would have to be feedback so that GPs could record a change in smoking status on their practice computers (accurate data are needed for monitoring for national service framework targets).

The pharmacists suggested that PGD supply should not be restricted to the conditions on the summaries of product characteristics. So, for example, it should allow issue of NRT in pregnancy and in coronary heart disease. “GPs can prescribe outside the licence, and we would want to be able to make a PGD supply outside the licence too,” said Gillian Hawksworth (community pharmacist, Mirfield). Approval for non-licensed indications would depend on the views of local clinicians, and might meet opposition. “Our gynaecologists seem likely to approve PGD use of NRT in pregnant women but use in patients with coronary heart disease is still to be confirmed,” Mrs O'Brien said.

Age group

Another issue discussed was whether to stick with the SPCs' lower age limit for use of NRT or to allow supply for, say, 15-year-olds. Ann McNeill (independent consultant in public health) said that efficacy of NRT in young people was unclear but even if it did not work in all people, it was a safer way of using nicotine.

Weekly follow-up for the first four weeks, with pharmacists giving one week's supply at a time, was suggested. The PGD would name individuals permitted to supply NRT, ie, those who had undergone training and were accredited (by the health authority or PCT). This would be pharmacist-specific and not pharmacy-specific. Mrs O'Brien said that, in this instance, the first people to be accredited might be pharmacists who were already trained as level 2 intermediate advisers (for the voucher scheme) who then had additional specific training. With a PGD, patients paid prescription charges in the normal way, and pharmacists received a professional fee, which was negotiated locally.

Where was funding for a PGD scheme to come from? The Department had announced that it was providing extra money to health authorities (within the unified allocation) for NRT and Zyban prescribing, but it had not specified the amount.

Graham Phillips (community pharmacist and prescribing lead, Harpenden and Villages primary care group) said that his local GPs were worried about cost and workload with NRT going back on prescription. They had welcomed his proposal to write a PGD, letting pharmacists and practice nurses handle the issue, which would reduce their workload, control costs and have auditable outcomes. “There is a huge problem out there. If we can present a solution there is all to play for,” he said.

Andrew McCoig (community pharmacist, and secretary of Croydon local pharmaceutical committee) agreed that GPs were worried about workload implications. “If they write a prescription for NRT they are morally bound to hold some sort of consultation with the patient. They don't have to do this at the moment because it is done by other services.”

Added value

Dr McNeill applauded the decision to get NRT back on prescription. But she emphasised that the aim was to attract more people — not just to move from OTC sale to prescription. As to the proposed new GSL licences, she said that it was difficult to argue against this given the wide availability of the “dirtier” form of nicotine. But pharmacists supplied added value and were able to “signpost” further support for smokers.

Alison Williamson (marketing manager, Pharmacia) thought that overall use of NRT would increase. “People go in and out of quit attempts and might go back to the pharmacy to buy NRT, without always using an NHS counselling service or prescription,” she said.

Terry Maguire (community pharmacist, and president of the Pharmaceutical Society of Northern Ireland), who chaired the meeting, said that PGDs were very much part of the new NHS and pharmacists were going to have to get to grips with them. He said that pharmacists should not limit themselves to a supply function, ie, to selling NRT. “Professionally, smoking cessation is a requirement of us and it is also a business opportunity,” he said. The evidence base was there, with robust work showing the impact of pharmacy intervention, and there were several practical models for pharmacy smoking cessation services.

Correction Terry Maguire is a past-president of the Pharmaceutical Society of Northern Ireland.

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Joanna Lumb is a freelance journalist