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Further information
Further information is available at two websites:
· www.mmnetwork.nhs.uk includes examples of good practice, a frequently
asked questions section and a discussion group
· www.out-of-hours.info provides information about out-of-hours
care, including the medicines sub-group’s guidance |
Out-of-hours services are in the process of substantial change.
The days of the local GP being the sole provider of care in the community
setting
throughout the night are numbered. The introduction of the new GP contract
has resulted in doctors opting out of providing out-of-hours care. Instead,
the responsibility for these services falls to primary care trusts. On
one hand, this means that there are new opportunities for other health
professionals to become involved in out-of-hours care. But on the other,
it represents new challenges in terms of service organisation, resources
and finding professionals who are willing to work overnight or at weekends.
The process of change has its roots in 2000, when a review of out-of-hours
services was commissioned by the Department of Health. Known as the Carson
review, it set new standards for out-of-hours care. Since then, a team
at the DoH has been charged with implementing the standards. The Carson
review identified a particular problem with access to medicines. It recommended
that: “Other than in exceptional circumstances, patients should
be able to receive the medication they need at the same time and in the
same place as the out-of-hours consultation.” A medicines sub-group
of the DoH team, led by Helen Allanson, head of medicines management
at Cumbria and Lancashire Strategic Health Authority, was set up to find
solutions to meet this objective. Last week, a conference in London was
held to mark the publication of guidance produced by the sub-group (see
p135).
In order to understand how this guidance fits into the out-of-hours agenda,
it is worth bearing in mind the general recommendations of the Carson
review. Nicholas Reeves, a member of the DoH implementation team, says
there are three critical elements. “They are prompt easy access
to clinical assessment, prompt referral to the appropriate person and
a requirement to meet national quality standards,” he explains.
The model the DoH came up with is this: when a patient telephones a GP
out of surgery hours, the call is automatically rerouted to an out-of-hours
service provider. By the end of 2006, all calls will be answered by NHS
Direct. A call manager makes an initial clinical assessment and then
refers the patient to one of a number of services — for example,
ambulance, nursing, pharmacy, dental or social services — or for
a face-to-face appointment with a GP.
In fact, 40 per cent of patients who call out-of-hours services do not
need an immediate consultation and these patients can be reassured that
their symptoms can wait. But for the remainder, appropriate services
must be provided to meet their needs. “It is important to bear
in mind that these are patients with urgent needs. This has implications
for what kinds of medicines are required out-of-hours,” says Dr
Reeves.
Medicines provision
The traditional approach to the provision of medicines out-of-hours
was for the on-call GP visiting the patient to give a “starter pack” and
a prescription for the remainder of the course. But starter packs were
problematic. Dr Reeves explains: “They were often provided by
the pharmaceutical industry so were used as a form of promotion for
new or expensive drugs. And they were inconvenient for patients, many
of whom did not cash in their prescriptions so did not complete the
course.” This is why the guidance recommends that patients should
be able to receive the full course of the appropriate medicine at the
same time as the out-of-hours consultation.
What does the guidance mean for pharmacists? Opportunities and implications
exist throughout. A major point is its recommendation that, ideally,
out-of-hours medicines should be accessed through a one-stop primary
care centre in which the pharmacy service is co-located with other services. “However,
primary care organisations will have to be realistic and make the best
possible use of existing available resources and may need to use a nearby
pharmacy,” it adds. “Supply of medicines via a pharmacy (or
dispensing doctor) remains the preferred approach, even during the out-of-hours
period. But, where this is not practical, PCTs may need to make alternative
arrangements.”
The preferred options are setting up a new pharmacy or extending the
opening hours and services of existing pharmacies using local pharmaceutical
schemes or using the new pharmacy contract. If these are not feasible,
then the guidance says that other options are supply via NHS walk-in
centres, hospital pharmacies or by the out-of-hours service itself as
part of primary medical services. Another recommendation is that systems
need to be in place to call out a pharmacist. There are examples of good
practice in Panel 1.
Panel 1: Good practice
A range of models of pharmacist involvement in out-of-hours services
have been developed at a local level. Some examples of good practice
include:
Co-location of pharmacy service with out-of-hours
service provider In Warrington Primary Care Trust, local pharmaceutical
services
(LPS) funding has been used to co-locate a pharmacy with an out-of-hours
service provider. The pharmacy is open from 6.30–10.30pm
on weekdays and 10.30am–10.30pm at weekends and on bank holidays.
The service involves both dispensing and over-the-counter sales.
A bank of 12 pharmacists work in the pharmacy, which is expected
to dispense 18,000 items this year. A similar service is offered
at Hope Hospital in Salford where an out-of-hours pharmacy operates
via an LPS scheme. The hospital is planning to develop the services
further so that an “emergency village” is created consisting
of an initial triage point through which patients are referred
to accident and emergency (A&E) major, A&E minor, an NHS
walk-in centre, the GP out-of-hours service and the out-of-hours
pharmacy. Fylde Coast Medical Services has been running an integrated
out-of-hours service in Blackpool since 1994. Its pharmacists and
nurses deal with 20 per cent of consultations. The service has
found that involving pharmacists in the consulting team is essential
since the pharmacy would not be cost-viable on dispensing alone.
Pharmacy on-call scheme In Newcastle and North
Tyneside, a group of community pharmacists provide an on-call
service for dispensing
urgent prescriptions. They are on-call through the night and can
be contacted via a dedicated mobile telephone held by the pharmacist
on duty. The prescriber contacts the pharmacist to give details
of the prescription and then the patient’s representative
and a police escort meet the pharmacist at the pharmacy to collect
the prescription.
Palliative care scheme In Chorley and South Ribble PCT, five pharmacies
hold sealed boxes of palliative care drugs. The specialist palliative
care team can call on the service out-of-hours in order to access
these drugs. |
A new guide to safe practice in providing medicines
out-of-hours will be published soon. Its development is being led by
the National Pharmaceutical
Association, in collaboration with the other main pharmacy organisations.
Karen Homan, head of NHS service development at the NPA, says: “It
is a practical guide written in user-friendly language.” It contains
three sections: the first looks at safe and secure systems (such as buying
and supplying medicines, and dealing with errors), the second is Controlled
Drugs and the third is palliative care.
“The guidance has been delayed because it is had to be revised following
the Shipman Inquiry. However, it will be available on the NPA website
by the end of March,” explains Ms Homan. Out-of-hours formulary
Part of the medicines sub-group guidance is a national out-of-hours
formulary (see Panel 2). Having a national formulary is about consistency:
it
means that NHS Direct is able to provide advice about what medicines
are available out-of-hours regardless of where a caller lives.
Panel 2: Out-of-hours formulary
The new DoH out-of-hours formulary contains the minimum list
of drugs that should be available. They are:
· Analgesia: codeine or equivalent, diamorphine, a non-steroidal
anti-inflammatory drug and paracetamol
· Asthma: inhaled ipratropium, inhaled salbutamol or equivalent,
prednisolone and spacer devices
· Cardiac emergencies: adrenaline/epinephrine, aspirin, atropine,
diamorphine, furosemide, sublingual glyceryl trinitrate
· Allergy or anaphylaxis: adrenaline/epinephrine, hydrocortisone,
chlorphenamine, a non-sedating antihistamine
· Diabetic emergencies: glucagon injection, glucose
· Opioid overdose: naloxone
· Gastrointestinal: an antacid, domperidone, glycerol suppositories,
an antispasmodic agent, loperamide, metoclopramide, oral rehydration
sachets, phosphate enema, prochlorperazine
· Psychiatric emergencies: diazepam, haloperidol, procyclidine
· Obstetrics and gynaecology: levonorgestrel 750, syntometrine injection
· Palliative care drugs: diamorphine, cyclizine, dexamethasone, hyoscine
butylbromide, ketorolac/diclofenac, methotrimeprazine/ levomepromazine,
midazolam
· Antibiotics: local choice for cellulitis and other skin infections,
respiratory infections, upper respiratory infections, urinary tract
infections
· Infection: local choice for bacterial conjunctivitis, candidiasis
and Herpes zoster, plus benzylpenicillin for meningitis/septicaemia
· Miscellaneous: sodium chloride for injection/ infusion, water for
injections, testing sticks
· Oxygen (appropriate for some organisations) |
Ms Allanson
explains: “We had to make the formulary practical
so went for the minimum list of drugs needed. There are two groups
of medicines:
those that have to be started out-of-hours because evidence suggests
that it is better to start them immediately and those that provide immediate
symptom relief such as in palliative care.” Drugs in the first
category include emergency hormonal contraception and shingles therapy.
Those that fall into the second are analgesics and antiemetics.
Alex Yeates, a GP and member of the out-of-hours medicines sub-group,
points out: “Prescribing out of hours is different: long-term management
is best done in daytime.” To illustrate this, he suggests considering
depressed patients needing antidepressants. “It is far better to
send them to their GP the next day. If the depression is so severe that
they need immediate treatment then they should be in hospital because
of the suicide risk and, in any case, antidepressants take 10 to 14 days
to work,” he explains. New GP contract
The closure of GP surgeries on Saturdays that has occurred since GPs
have been able to opt out of providing out-of-hours care has had a
knock-on effect on community pharmacy. Although NHS Direct is to become
the single point of access to out-of-hours services next year, in Scotland,
nearly all calls made to GPs out of surgery hours are already answered
by NHS24. Harry McQuillan, national pharmacy director, says that since
GPs opted out of out-of-hours care, the volume of calls to NHS24 has
risen. “The call volume on Saturday mornings is greater than
anticipated,” he says. “A high proportion of all calls
relate to pharmacy — data from last March indicate 34.6 per cent
and we expect that figure to be significantly higher now. The vast
majority of these calls are about running out of repeat medicines.” The
problem is that since surgeries have closed on Saturdays, pharmacies
suffer reduced prescription business and so are forced to consider
closure, putting additional pressure on out-of-hours services.
In Scotland, Mr McQuillan hopes that the problem will be overcome by
the removal of dependence on prescription volume in the new contract.
The Scottish Pharmaceutical General Council is also negotiating funding
outside the global sum to help contractors meet the demand resulting
from new GP working hours. Meanwhile, the new pharmacy contract in England
and Wales allows contractors to tell their PCT, within 30 days of the
contract starting, what hours they intend to open. If a pharmacy’s
business has been made unsustainable through the closure of local surgeries
on Saturdays then it should come as little surprise that pharmacies will
also close.
Steve Lutener, head of regulation at the Pharmaceutical Services Negotiating
Committee, says that if a PCT finds it has insufficient cover then it
could negotiate with pharmacies to open for additional hours. “Pharmacies
may require payment or the contractors may be willing to open if the
PCT commissions a minor ailments scheme or some other service that is
going to make opening worthwhile,” he says. “If the PCT cannot
agree with one or more pharmacies then they will have the long stop position,
as now, of being able to direct the pharmacy to open. Unlike now, however,
the PCT would be required to pay an appropriate amount.”
In addition to opening hours, emergency supply of medicines has presented
a particular problem to NHS24. “Pharmacists are the only profession
who can make an emergency supply but it is an individual pharmacist’s
professional decision to make that supply: it is a private, not an NHS,
transaction,” Mr McQuillan says. “We have run into some difficulties
when we have suggested a patient goes to a pharmacy and then the pharmacist
doesn’t make a supply.” He suggests that pharmacists need
to ensure that they understand what the current emergency supply regulations
are, as stated in “Medicines, Ethics and Practice”, particularly
the removal of the requirement for patients to have had the medicine
in the past six months. “Pharmacists should also think about the
consequences of not making a supply,” he adds.
The PSNC is discussing changes to the emergency supply provisions with
the DoH and the Royal Pharmaceutical Society. “Our proposal is
to remove the five-day limit so that the pharmacist could, in the exercise
of his discretion, supply up to a complete patient pack,” says
Mr Lutener.
The proposal also suggested that the NHS should pay for the service. |
The
Pharmaceutical Journal