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Pharmacists will play a more significant role in helping people lead healthier lives
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Pharmacists are set to have a major impact on improving public health.
So said health minister Rosie Winterton last week. “To date, pharmacists
have been
a major untapped resource for health improvement. The track record of
community pharmacists in areas such as stopping smoking, sexual health
advice and substance misuse is evidence of how integral they are to tackling
public health issues,” said Ms Winterton. “But we would like
pharmacists to do even more.”
Working out exactly what pharmacists’ roles in public health could
be falls to four
organisations. Pharmacy HealthLink, the Royal Pharmaceutical Society,
the Faculty of Public Health and the UK Public Health Association have
been awarded a joint contract to develop a public health strategy for
pharmacists in England.
Miriam Armstrong, chief executive of Pharmacy HealthLink, explains that
the consortium brings together a balance of input from both pharmacy
and public health. “The resulting strategy will be broader than
any other document in pharmaceutical public health published so far,” she
says. “This is a serious commitment by the Government to develop
pharmacists’ roles.”
Current agenda
The strategy that the consortium is developing will be published by
the Department of Health next year. Before that, a White Paper on public
health is expected this summer. Ms Armstrong explains that the pharmaceutical
public health strategy will build on this White Paper, a bit like Pharmacy
in the Future developed pharmacists’ roles in the NHS Plan.The
White Paper is being developed from work undertaken as part of the “Choosing
health” consultation which will close later this month.
Panel 1: Public health issues
The public’s health is not as good as
it should be as some of the following statistics show:
· Obesity has trebled in the past 20 years
· Smoking kills 13 people an hour
· One in five children does not eat any fruit
· One in 10 sexually active young women are
infected with chlamydia
· Death rates in some parts of England are the same as the national
average in the 1950s
· People living in the north-east are three times more likely to
be on sickness/disability benefit as those living in the south-east
· Since the early 1990s, the proportion of
primary school aged children who walk to school has fallen from
60 to 51 per cent |
However,
public health has been on the agenda for much longer. Work to improve
public health is already under way but there is still much to
do: the public’s health is not what is should be (see Panel 1).
In addition to it being high on the Government agenda, community pharmacists
have another reason for wanting to develop roles in public health. That
is the fact that their new contracts are expected to encompass public
health.
In England and Wales, basic public health roles are expected to form
an essential part of the new community pharmacy contract. Additional
public health roles could be offered as enhanced services (negotiated
locally with primary care trusts). In Scotland, the proposed new pharmacy
contract is built around four core services of which public health is
one.
Alastair Buxton, head of NHS services at the Pharmaceutical Services
Negotiating Committee, comments: “PSNC is committed to public health
being central to the new pharmacy contract.” Exactly where the
roles will fit is not yet agreed.
Gary Boorman, chairman of North East London Local Pharmaceutical Committees,
comments that many pharmacists want to provide services but a number
of issues stand in their way. “Finance is a problem that we hope
will be solved through the new contract. Then there are manpower shortages,
premises that have to be refitted and a need to increase communication
between pharmacists and PCTs. We have set up a forum at which pharmacists
can meet PCT representatives, something that otherwise can be hard to
do.”
However, it is not just about community pharmacy. Ms Armstrong emphasises
that the new strategy will be about pharmacy’s contribution to
public health in all sectors: community, hospital, industry and primary
care. Consortium aims
One of the difficulties pharmacists have faced in the past is that
the concept of public health services is vague. Many services that pharmacists
offer now — smoking cessation being the most obvious — fit
into the public health bracket but are not promoted as such.
John Foreman, a community pharmacist at Greenlight Pharmacy in north
London, who is involved in the new public health strategy’s development,
comments: “Public health is something pharmacists have been doing
forever on an ad hoc basis. It is the lack of structure that causes the
problem.” This is exactly what the new strategy aims to resolve:
pharmacists’ roles in public health will be structured. The strategy
will set out:
· The functions of pharmaceutical public health
· The framework within which pharmacists delivering public health should
work
· The contribution that the settings within which pharmacists work can
make
· The competencies that pharmacists and staff will need to deliver public
health
The consortium has six months to produce the strategy. An outline framework
for the strategy has already been produced by a DoH public health steering
group. “Our first task is to get together a group of people who
are strategic thinkers to look at this outline framework and start adding
the detail,” explains Ms Armstrong.
The outline framework has not been made public. However, Mr Foreman is
on the steering group and his views provide a clue to what might be included.
He hopes that it will formalise the pharmacists’ role in the safe
and proper use of medicines and confirm pharmacists’ importance
as an integral part of stop smoking services.
“I think pharmacists will have a more active role in immunisation
and screening campaigns,” he says. This could include childhood and
influenza immunisation. “Public health is about preventing disease
and identifying people at risk,” he adds. Mr Foreman hopes that
the strategy will result in public health roles becoming core services
in the pharmacy, particularly smoking cessation and weight management
services. “The strategy should establish pharmacists as an accessible
expert in public health,” he says.
The consortium will use real-life examples of pharmacy practice to illustrate
the detailed framework. “We will be interviewing
pharmacists who are offering public health
services or who have an interest in pharmaceutical public health,” says
Ms Armstrong. “We need to find innovative practitioners.”
Panel 2: Contact information
Pharmacists who wish to contribute to the consultation
on the new pharmacy strategy, particularly with examples of local
work,
should contact the project’s director, Jenny Griffiths,
e-mail GriffHobbs@aol.com |
A
strong evidence base is an important aim of the strategy and pharmacists
are invited to contribute (see Panel 2). Already happening
Many pharmacists are already providing public health services. These
could be expanded to other pharmacies and it is hoped that broader
roles will develop too.
Where should pharmacists start? “Obesity is a really obvious one.
Pharmacists can play a big role in obesity and it is a national priority,” says
Ms Armstrong. “My advice to pharmacists is don’t wait for
the strategy when you could realistically contribute a considerable amount
to weight management right now. Get in touch with your PCT and find out
what you can offer.”
Panel 3: Smoking cessation
There are many examples of smoking cessation services across the
UK. One that was recently recognised as a best practice model by
the Health Commission is run by Barking and Dagenham PCT. A total
of 34 community pharmacies offer one-to-one support over five weeks
for people who are trying to stop smoking.
Nicola Hill, the smoking cessation lead, explains that at the first
appointment, the pharmacist assesses a patient’s motivation
to quit and recommends treatment. “We have a patient group
direction in place for nicotine replacement therapy so the pharmacist
can prescribe it there and then. If bupropion is more appropriate,
patients are referred to their GP.” Once started on a treatment,
the patient returns to see the pharmacist on a weekly basis for
the rest of the course. “The pharmacists have a phenomenal
success rate. The national average quit rate after four weeks is
52 per cent but, in our service, the figure is 68 per cent,” she
says. |
Smoking cessation is another obvious service
(see Panel 3). “In
hospitals, particularly, something that is often said but still not done
by enough pharmacists, is providing smoking cessation advice, especially
following a heart attack. We know it is effective so it shouldn’t
be an optional extra,” she says.
Nicola Gray, lecturer in pharmacy practice at the school of pharmacy,
University of Nottingham, suggests that pharmacists consider group sessions
for smoking cessation. “A big problem, particularly for young people,
is that giving up smoking might mean giving up a group of friends. This
puts people off.”
Other public health roles that pharmacists could consider are in substance
misuse. Dr Gray describes needle exchange as a “triumph for pharmacy” through
which the spread of blood-borne disease has been limited.
Then there is sexual health, immunisation (see Panel 4), and endless
opportunities to provide advice about chronic conditions, their prevention
(see Panel 5) and their treatment — coronary heart disease, diabetes
(see Panel 6), osteoporosis and asthma to name but a few. Disease screening
is another option, particularly blood pressure, blood glucose and blood
cholesterol. And many services, such as waste medicines disposal, have
a public health aspect.
Panel 4: Flu immunisation
Community pharmacists in Aberdeen have been offering influenza
immunisation for two years. Under an initiative set up by Grampian
Primary Care Trust, six pharmacists use a patient group direction
to provide the immunisation either on the NHS, if the person falls
into one of the identified at-risk categories, or privately.
Caroline Hind, pharmacist facilitator at the PCT, explains: “The
pharmacists are trained in giving the immunisation and also in
how to use an EpiPen in the case of anaphylaxis,” she says.
The pharmacies hold immunisation clinics at which patients book
appointments. Clinics were necessary in order to plan for two pharmacists
to be at the pharmacy. Another requirement is that the premises
must have a separate room for the clinic and an area in which patients
can sit after the immunisation. A particular success is that some
clinics are offered during lunchtimes or on Saturdays which is
ideal for people who find it difficult to visit their GP during
working hours. |
Panel 5: Education
Camden PCT uses public health assistants to
offer lifestyle advice at a number of settings including Greenlight
Pharmacy in Euston.
The assistant, who is from the local Bangladeshi community, provides “health
MOTs” and then helps people to make step-by-step changes
to improve their lifestyle. This is a role that could also be taken
on by the pharmacist or pharmacy staff. |
Panel 6: Diabetes
A new pharmacy-based service for people with diabetes was launched
in Alloa, Clackmannanshire, this week. It aims to encourage people
with the condition to develop healthier lifestyles. Pharmacists
at four community pharmacies will provide a health assessment,
medication review and ongoing advice to people with diabetes.
Liz McGovern, specialist in pharmaceutical public health for NHS
Forth Valley, says that pharmacists will explain what health improvements
the patient should consider and then asks them to choose one to
tackle first. “It could be weight reduction, smoking cessation
or fitness improvement,” she says. The patient is then given
a voucher to try something out for a month, such as aerobics, swimming
or nicotine replacement therapy. The pharmacist reviews the patient
a month later and gives another voucher. “The idea is that
people get a chance to try a healthier lifestyle, feel its effect
and then go on to continue it themselves,” she says. |
But pharmacists could go much further. Dr Gray
believes that pharmacists need to think more broadly about public health,
beyond what would be
considered a traditional pharmacy service. They should also think about
what specific services their local community needs. For example, some
people choose to ignore public health advice and this needs to be understood.
Dr Gray cites research she undertook in a deprived area of Manchester
where a commonly found attitude was that people did not want to live
until the age of 70 because they lacked hope and did not like living
there. “To close the mortality gap, we need to do something about
economics, housing and providing people with something to live for,” she
explains. Similarly, she points out that not all teenage pregnancies
are unwanted.
“In many deprived areas, pharmacies are one of only a few businesses
that survive. These pharmacies should be seen as a beacon of success, talking
to local schools about what can be achieved through qualifications and
training,” she says. This is what the broader role in public health
is all about. “Pharmacies in deprived communities can become a
focal point for the community. One possibility is to bring other services
into the pharmacy, such as nurses, counsellors and even things like the
Citizens Advice Bureau.”
In Dundee, a community pharmacy that specialises in health promotion
has demonstrated exactly this. It was refurbished two years ago (PJ,
24 August 2002, p240) and
the outcomes seen so far are positive. A survey found that 30 per cent
of customers used the pharmacy more frequently
since the new services were introduced and 80 per cent are comfortable
about talking to pharmacy staff about health promotion. Among the services
the pharmacy offers are blood pressure monitoring, testing peoples’ inhaler
technique, group smoking cessation, glucose monitoring meter servicing
and drug misuse services. It also offers chiropody clinics and welfare
rights’ surgeries. A large section of the pharmacy has been sectioned
off for health promotion where over 500 customers a month access touch-screen
health information.
Pharmacy’s accessibility is a key strength in providing public
health services to as large a proportion of the general public as possible.
The roles pharmacists could play seem endless: the pharmaceutical public
health strategy will help pharmacists transform the ideas into tangible
services. |
The
Pharmaceutical Journal