| Over the past six months there has been a 28 per cent
increase in the number of pharmacy staff who are trained as intermediate
level smoking
cessation advisers. In September 2003, there were 49 trained advisers
among the 110 pharmacies in the three Manchester PCTs. There are now
63 pharmacy advisers.
One of the pharmacists involved is Paul Benson. At his pharmacy in Chorlton-cum-Hardy,
two pharmacists and one of the medicines counter assistants are trained
advisers. They take part in a voucher scheme designed to increase access
to nicotine replacement therapy. Accredited advisers can write these
vouchers, as well as redeem vouchers written by other advisers (eg, practice
nurses) or by staff at specialist centres.
The PCT-funded scheme, which is organised by the specialist smoking cessation
service of Manchester Health Promotion, allows up to six weeks’ supply
of NRT. Supply is free for prescription-exempt customers or £6.30
for each fortnight’s supply for non-exempt customers.
Mr Benson does not advertise his smoking cessation service, other than
in occasional window displays. Clients are recruited into the scheme
by self-referral or referral from the GP or practice nurse. Staff might
also pick up on cues, eg, purchase of a cough medicine, to ask if the
customer smokes and has thought about stopping. But he is cautious about
this approach: “We tread softly here as we don’t want to
alienate people by haranguing them. It is better to wait for them to
raise the issue.”
The first interview involves an assessment of whether the person is motivated
to make a serious attempt to stop smoking. “We make a judgement
on this, but tend to give them the benefit of the doubt,” Mr Benson
says. Clients are given advice on smoking cessation and are asked to
set a quit date.
Any of the P or GSL products can be supplied. Clients choose which formulation
they prefer, and the pharmacist will advise on the product strength,
based on an assessment of nicotine dependence. The pharmacy has a consultation
room but this is not often used, since most people are happy to talk
in a quiet area of the pharmacy. The first session takes at least 10
minutes, but subsequent visits are shorter. For the first two weeks,
supply is made on a weekly basis, then fortnightly. After four weeks,
smoking status is recorded. This is needed for central statistics.
Mr Benson emphasises that the whole pharmacy team can be involved. “A
counter assistant or technician who has received basic in-house training
on how to ask questions can do the initial paperwork, before handing
over to one of the trained advisers. This is a sensible use of available
staff.”
Counter assistant Joyce Mills recently undertook training as a smoking
cessation adviser |
He is pleased that one of his counter assistants, Joyce Mills, recently
undertook training as a smoking cessation adviser: she had been doing
much of the documentation and it was a natural next step for her to take.
Mrs Mills can now participate in all aspects of the service, unless the
client wishes to use nicotine inhalator (a pharmacy medicine) in which
case the pharmacist will become involved.
From the start, clients are advised that they might need to carry on
with NRT after their six-week NHS supply. Mr Benson comments: “We
encourage them to put aside the money they would have spent on cigarettes — both
to buy themselves a treat and also to ensure they will be able to afford
NRT and don’t undo all the good work by stopping too soon.”
It is, he says, essential to encourage people to report back, whether
or not they have been successful. Relapse is common and people need support
to try again. “I think this is where pharmacy scores above surgeries.
Given the easy access, clients are more likely to come back to the pharmacy
than make an appointment to go back to the GP.” There has been
no formal survey of user satisfaction but Mr Benson says that clients
are positive about the help they get and that the service definitely
shows pharmacy in a favourable light.
Limitations to the scheme
There are, however, some limitations to the pharmacy voucher service.
The pharmacy advisers cannot write NRT vouchers for under-18s or pregnant
women. (These groups can receive NRT from specialist clinics.) Also,
the pharmacists have been advised that supply to clients with coronary
heart disease should first be approved by the GP. Mr Benson finds this
disappointing, given that NRT is safer than continued smoking. “It
is a barrier, as the client might lose motivation if they are asked
to take a form to the GP before they can start on the pharmacy scheme.”
Combination therapy is another issue. “Some people might benefit
from use of a patch to give background nicotine level plus a quick-acting
formulation for breakthrough cravings. At the moment, I supply combination
therapy if requested on a voucher from a specialist centre but I don’t
initiate it.”
All these issues are currently being discussed, with a view to developing
pharmacy protocols to allow supply.
On average, Mr Benson’s pharmacy enrols one new client each day.
The pharmacy receives £6 per client, plus £13 payment (less
any patient contribution) for each week of NRT supplied. The voucher
scheme has been running for around four years and now has recurrent funding.
The latest data for Manchester pharmacies, covering July to September
2003, show a 36 per cent success rate (four-week cessation) among the
266 clients. Encouragingly, unofficial data indicate that the recent
increase in number of pharmacies taking part has been associated with
a significant increase in clients.
For the future, Mr Benson sees new opportunities when medicines management
and medication review schemes get under way. “We will be spending
more time with patients with CHD and diabetes, some of whom will inevitably
still be smokers, and we will be able to steer them towards the smoking
cessation scheme.” |
The
Pharmaceutical Journal