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Urgent supply patient group direction extended
for two years
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Community pharmacists have a crucial role to play in what is called “unscheduled
care”, but it is a role that has yet to be fully exploited. A couple
of years ago, NHS Scotland decided to change that.
The first step was to put in place the tools that pharmacists need to
take on the new role. Central to these are the new community pharmacy
contract, the urgent supply patient group direction and the out-of-hours
direct referral mechanism. The importance of each will be explored later.
Now the tools are being brought together as a recognised role for pharmacists
in unscheduled care. Within the next couple of weeks, NHS boards will
send pharmacists a folder containing a guide to pharmacy’s role
in unscheduled care.
What is unscheduled care?
Unscheduled care is urgent care that can be required at any time of
the day or night: this differentiates it from out-of-hours care, which
is unscheduled but only takes place outside normal working hours. The
importance of unscheduled care was recognised in the Scottish Executive’s
2005 publication “Building a health service fit for the future”.
This report set out the future of the NHS in Scotland and recommended
that care should be delivered in local communities (as opposed to distant
hospitals).
Bill Scott, Scotland’s chief pharmaceutical officer, explains: “The
purpose is to develop a stratified unscheduled care system which will
improve integration, quality and productivity.
Part of this will mean a much greater emphasis on providing the majority
of unscheduled care at local and community levels in a planned and co-ordinated
way. Hospital and community pharmacists will have an active part to play
in both the development and delivery of these services.”
The tiered model of unscheduled care described in “Building a health
service fit for the future” put community-provided services in
the first level, the level at which patients make contact with the health
service. Within level one are the services provided by GPs, pharmacists,
NHS24 and the Scottish Ambulance Service. It is through this model that
community pharmacies are becoming regarded as Scotland’s NHS walk-in
centres. Level two comprises locally provided “community casualty
units”; these are effectively accident and emergency services for
outpatients. The third tier of the model is made up of inpatient services
for patients who require an emergency admission to hospital. In the final
fourth tier are specialised hospital units.
Lindsey Devlin, regional pharmacy adviser at NHS24, explains: “Services
within tier one are the patient’s first point of contact with the
NHS Scotland unscheduled care system. All services within this level
are expected to be harmonised. In other words, it doesn’t matter
who initially assesses the patient, the outcome should be the same — referral
to the most appropriate part of the service.”
Clearly pharmacists’ role as one of the first points of contact
can only be delivered if they can directly refer patients to the most
appropriate professional. And this is exactly what is now allowed. “Pharmacy
is in a unique position in that it is the only profession that can refer
patients directly to the out-of-hours service, without the patient having
to go through NHS24 first,” says Ms Devlin.
Mr Scott comments: “The fact that community pharmacists can now
directly refer a person to the local out-of-hours service significantly
improves the patient’s journey and makes community pharmacy a valued
partner in the provision of both local out-of-hours services and unscheduled
care.”
Two types of professional-to-professional referral telephone line have
been introduced. NHS24 operates a central line and there are local procedures
in place for contacting each health board’s out-of-hours service.
Full details of the telephone numbers — which should never be given
to patients — are included in the unscheduled care guide about
to be distributed to pharmacists.
“Direct referral is a big change for pharmacists and something pharmacy
needs to embrace. There is no point in pharmacists telling patients to
contact NHS24 when the pharmacist can make a direct referral on the patient’s
behalf and they have already made a professional assessment,” says
Ms Devlin.
The professional-to-professional telephone lines are more than just a
referral mechanism. They can also be used to contact out-of-hours service
providers who issue prescriptions, for example, in the case of a query
on a prescription.
Alison Strath, principal pharmaceutical officer, Scottish Executive,
explains: “The
professional-to-professional number also provides an opportunity to discuss
a patient’s condition with another health care professional before
reaching a conclusion on the most appropriate course of action.”
Another use is for pharmacists to access a patient’s emergency
care summary. The emergency
care summary was introduced earlier this
autumn and is basically an electronic summary of the patient’s
medical record (PJ, 2 September, p267). For each patient, it
lists both chronic and acute medicines prescribed in the previous year,
plus any
known allergies. Pharmacists can access the emergency
care summary by contacting the NHS24 professional-to-professional line,
providing the patient has given consent for this access.
Ms Devlin comments: “If a patient is unsure what medicines he or
she is taking and the pharmacist needs this information, then it would
be appropriate to access the emergency care summary by contacting NHS24.
But if the patient knows exactly what medicines he or she is on, then
there is no need to contact NHS24. The emergency care summary should
not be used as a way of validating what medicines a patient is taking.” Pharmacy’s role
Referral works in both directions. Now pharmacy’s role in unscheduled
care has been formalised, both NHS24 and GPs will routinely refer patients
to pharmacists. So it is important to understand what the NHS expects
pharmacy to deliver. The roles are:
- Treatment of minor illnesses
- Urgent supply of repeat medicines
What does an NHS24
pharmacist do?
NHS24 is a nurse-led service, but it employs
15 pharmacists across Scotland. Their main role is to deal with
patients’ complex
medicines enquiries. A nurse answers the initial call and, if it
is a detailed medicines query, the patient will be referred to
one of the pharmacists. Sometimes the pharmacists will also deal
with
minor ailment consultations but these tend to be dealt with by
nurses, who use specific algorithms.
The pharmacists also offer support to the nurses. Part of this
is induction training about medicines but they also provide day-to-day
support on medicines queries, for example, about the licensed indications
of over-the-counter medicines so nurses can tell patients what
can
be bought from a pharmacy. |
Disallowed items on MAS
Prescribing data from the first month of the
minor ailment scheme — July — has
now been analysed. The Scottish Pharmaceutical General Council
wrote to contractors last week to highlight some prescription-only
medicines
that had been incorrectly prescribed (mainly due to pack sizes).
Some of the more common disallowed items were:
· Mebeverine 135mg tabs: not allowed as the
generic, only allowed as “Colofac IBS”
· Ketoconazole 2 per cent shampoo: not allowed as the generic,
only allowed as “Nizoral”
· Opticrom and sodium cromoglycate eye drops: 13.5ml pack size
is a POM, only the 5ml and 10ml packs are allowed
· Lamisil cream: 15g size is a POM, 7.5mg “Lamisil AT” cream
is allowed
· Adcortyl in Orabase: 10g size is a POM, 5g size is allowed
· Anusol HC 30g: this is a POM, “Anusol HC Plus” is
allowed (15g size)
· Voltarol Emugel: 100g size is a POM, smaller sizes are allowed |
It is the introduction of pharmacy’s new contract that has enabled
the NHS to refer patients to pharmacists for treatment of minor illness.
Until the minor ailment service (MAS) — one of the core services
within the new contract — was in place, medicines could only be
purchased over the counter. This presented difficulties for people on
low incomes who could not afford to buy medicines and meant the NHS could
not always refer patients to pharmacy.
The MAS allows people who do not pay prescription charges to receive
treatment for minor illnesses direct from the pharmacy, free of charge.
And for people who pay for prescription charges, medicines can still
be purchased over the counter as before. With this more equitable system
in place, the NHS can refer patients to pharmacies.
“
MAS is an important element in part of the overall strategy to shift
the balance of care to the most appropriate setting and professional.
In the future the community pharmacy should be the first port of call
for the NHS treatment of all common clinical conditions within the competence
of the pharmacist,” says Ms Strath. According to NHS24, part of
becoming the first port of call involves adopting an “assess and
treat” mentality. This means assessing the patient, diagnosing
and treating in the pharmacy if possible or,
if not, making a specific referral to another professional.
Urgent supply of repeat medicines can be met in two ways: the urgent
supply patient group direction and emergency supply. The urgent
supply PGD was introduced a year ago and allows pharmacists to supply
a usual quantity of a patient’s repeat medicines (PJ, 3 December 2005,
p682).
“The urgent supply PGD has been a great success,” says Mr Scott. “It
has been particularly beneficial on Saturdays and over public holiday
weekends when practices can be closed for up to four days. As it currently
stands, the PGD is wide-ranging and it is then down to the professional
judgement of the pharmacist and the clinical circumstances to determine
the most appropriate action.”
This month, it was decided that the PGD would be extended for a further
two years, and an updated PGD will be sent to pharmacists within the
unscheduled care folder. The new PGD is largely the same as the older
version with two main exceptions:
- Supply of all appliances on repeat prescription will be allowed
- Dihydrocodeine and codeine oral preparations will no longer be excluded
Harry McQuillan, chief executive officer, Scottish Pharmaceutical General
Council, says that in the first seven months of the PGD being available,
pharmacists used it to supply 18,100 items. This is less than 1 per cent
of the overall prescriptions dispensed. “Use of the PGD is variable
among pharmacists,” he says. Familiarity with a new tool is bound
to be one reason with some pharmacists apparently sticking to the emergency
supply route or even “lending” the patient medicines in advance
of a prescription.
Deciding to make a supply, whichever route is used, is a professional
decision and pharmacists have the right to refuse to make a supply. Some
pharmacists argue it is too risky, with increased likelihood of supplying
the incorrect product (eg, if a patient asks for the wrong strength)
or of the patient abusing the system (eg, repeated requests for salbutamol
inhalers). The opposite argument is to consider the consequences of not
making a supply. Sometimes, missing one dose of a medicine such as a
statin is unlikely to cause any ill effect. But if a pharmacist refused
a supply and the patient became seriously ill as a consequence, where
would this leave the pharmacist?
Pharmacists’ refusal to make supplies gives NHS24 cause for concern. “Pharmacists
now have the same access to information about a patient’s medicines
as doctors and nurses within out-of-hours services. Pharmacists are the
experts in medicines so shouldn’t be passing the problem on to
another health professional,” comments Ms Devlin.
Recognised role
There is a perception among pharmacists that since GP surgeries began
closing on Saturdays prescription business has reduced with knock-on
financial consequences for pharmacies. Giving pharmacists a recognised
role in unscheduled care is one way to tackle this.
“It is about a shift in workload. Rather than having the prescription
volume on a Saturday, pharmacists have a patient consultation volume
instead,” says Mr McQuillan. “The SPGC recognised this in
the new contract negotiations so there is a specific element in recognition
of the increased workload for providing out of hours services. This is £105
per month per contractor.”
Is that enough? “We are monitoring it,” says Mr McQuillan. “We
would encourage contractors in Scotland to adopt the ‘assess and
treat’ mindset and to use the tools provided, such as the PGD,
direct referral and the MAS.” And when unscheduled care is considered
as a whole then payments for other services like MAS have to be included.
Pharmacists have to prove to the NHS that they are willing to take responsibility
for their role in unscheduled care. Ms Devlin says that telling patients
to contact NHS24 is opting out. “For example, I recently spoke
to a patient who wanted to buy ibuprofen for knee pain. The patient had
stomach problems so the community pharmacist had intervened in the sale
and told her that the ibuprofen was unsuitable. That was great but, instead
of suggesting an over-the-counter alternative or phoning the direct referral
line for something stronger, the pharmacist just told the patient to
go away and contact NHS24.” This is exactly what NHS24 wants to
avoid. It is unhelpful for all parties: the patient gets pushed from
pillar to post, NHS24 has to repeat the consultation from scratch, and
it does little for the public perception of pharmacy.
What referrals does NHS24 want from pharmacists? “The simple answer
is we don’t want any,” Ms Devlin says. “If it is a
request for a medicine that the pharmacist cannot supply or the patient
has symptoms that need to be seen urgently by a doctor, then the pharmacist
should phone the direct referral line. There is no need for that patient
to go through the triage system again at NHS24 when the pharmacist has
already done it.” The future
And what of the future? Mr Scott sees pharmacists’ roles developing
through prescribing. “Extended prescribing powers gives the potential
to further develop the pharmacist’s role in the delivery of both
scheduled and unscheduled care,” he says. “This will unlock
the pharmacist’s clinical skills and allow them to play an even
greater part in the providing care to the Scottish population. For example
it will extend the treatment options available from pharmacists through
MAS to include a wider range of products. Looking at it another way,
it will give the NHS a further 2,500 clinicians providing care which
is quicker, more personal and closer to home.” |
The
Pharmaceutical Journal