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Cherry Bwalya is a primary care pharmacist from
Woking, Surrey
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The Department of Health consultation on the provision of stoma and incontinence appliances is a welcome and long overdue development. Although
I have always considered the issues being addressed in the consultation
from the perspective of a practising pharmacist I now have reason to
see issues from a patient’s perspective: recently I underwent surgery
that necessitated the creation of a colostomy. This experience brought
several issues to my attention including the support available to patients
with stomas, the accessibility of information and the supply of stoma
appliances and accessories.
The DoH consultation document details proposals for a reconfiguration
of the services provided in relation to stoma appliances. Two levels
of service, essential and additional, are proposed. Dispensing is an
essential service. The document states that when an appliance is dispensed,
appropriate advice should be given to enable patients to use the appliance
and to meet patients’ personal needs for general information on
products. Furthermore, it is proposed that the contractor should provide
access for patients to a telephone care line, staffed by suitably trained
and experienced people and, as a minimum, the care line must be open
between 9am and 5pm, Monday to Friday. Other proposed essential services
are the provision of complimentary supplies and product delivery. Essential
services are to be provided by all contractors, who may also choose to
provide additional services, which include
appliance customisation and making visits to the patient’s home
or place of residence.
In hospital, I was visited by two stoma nurses the day before surgery.
They explained the procedure and what to expect afterwards in terms of
appearance and care of the stoma. The nurses also visited on the day
of surgery and every day until I left hospital. The length of my hospital
stay depended largely on my ability to manage my stoma and change stoma
bags on my own. On discharge, I was referred to the stoma nurses at my
local hospital for follow up. The support that I received from them was
excellent and included telephone calls and home visits to ensure I was
coping well. The nurses are limited in what support they can give because
they are usually stretched to capacity but I was aware that I could call
the helpline of the company supplying my stoma bags if I needed to.
By the time patients are obtaining their bags from a contractor they
have already had the information they need about the products and how
to manage their condition. I wonder how many community pharmacists could
honestly claim to have the knowledge to provide the kind of advice that
stoma nurses provide, and that the consultation document implies. It
would be useful to know what level of information is expected by the
DoH document. For example, would completing an open learning pack on
the management of lower gastrointestinal disease, such as the one provided
by the Centre for Pharmacy Postgraduate Education, be considered adequate
and, if so, set the standard? As a patient I would feel more confident
asking for advice about my stoma appliance from a stoma nurse or an appliance
contractor than from my community pharmacist. However, I might seek my
pharmacist’s advice if I knew that he or she had received adequate
training.
Throughout, the document refers to a “suitably qualified person” without
defining what this means. The level of information that staff manning
carelines or making home visits are expected to have would require, in
my opinion, someone trained to the level of a stoma nurse. This presents
a challenge for pharmacists. With appropriate training pharmacist could
conceivably provide these services but we need to know what training
would be needed. Appliance companies have an advantage because they already
provide these carelines and employ stoma nurses. Could the proposed service
reconfiguration be an opportunity for community pharmacists and these
companies to form working partnerships?
There are few sources of information for people with colostomies who
want to know more about managing their condition. The stoma nurses and
the hospital colorectal
department provide some literature and
information before the procedure is performed. Sadly, I discovered that
the British Colostomy Association mentioned in the
information sheet from the hospital had shut down due to lack of funding.
A new association has risen out of the ashes but, in order for it to
be viable, it has to charge a membership fee. I believe strongly that
this should not have to be the case.
I then turned to the internet. The best source of information I found
about stomas was a website (www.ostomysupport.info/) set up by a “colostomate” who
was probably frustrated by the lack of information available. The only
other source of information available is from the companies that supply
the stoma appliances. Apart from providing helplines, some produce magazines
for patients living with stomas. Others also hold forums around Britain
for stoma patients. As a pharmacist who has, in the past, been sceptical
about appliance and delivery companies, I have to admit that this is
something that they seem to do well and, currently, many pharmacies do
not provide this type of service. However, pharmacists could easily signpost
patients to what information is available.
When I left hospital the stoma nurse arranged for delivery of my bags
and accessories via an appliance company. This could just as easily have
been arranged through a community pharmacy but the pharmacy would have
not been able to compete with the appliance company in supplying extras,
such as wet and dry wipes and skin cleansers, which are provided free.
In addition, most appliance companies can pre-cut the bag flanges to
fit the size of the stoma. They also provide patients with samples of
different types of bags to help them find the one most suited to their
lifestyle. The current consultation proposes that appliance customisation
become an additional service. I cannot see community pharmacists providing
this sort of service without some sort of arrangement with
appliance companies.
The additional services proposed favour appliance companies because they
already have the structures in place to provide them. I guess community
pharmacies have to calculate whether or not the income generated from
stoma supplies is worth the effort
required to provide these additional services.
Having been an avid supporter of the community pharmacy supply route
(and an equal playing field in terms of remuneration) I now find myself,
with my patient’s hat on, sitting on the fence. As a patient it
would not matter to me who provided the services as long as they were
prompt, efficient and easily accessible.
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The
Pharmaceutical Journal