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Promotion of healthy lifestyles is an essential service of the community
pharmacy contract in England and Wales. In particular, the service specification
requires pharmacists to promote, when it is appropriate, public health
messages to patients from four key groups when they present a prescription.
The Regulations underpinning the contract say that when someone who has
diabetes, is at risk of coronary heart disease, smokes, or is overweight
presents a prescription “the pharmacist shall, as appropriate,
provide advice to that person with the aim of increasing that person’s
knowledge of the health issues which are relevant to that particular
person’s personal circumstances”. This is described in the
service outline as a “prescription-linked
intervention.”
This requirement was introduced into the contract to reinforce the crucial
role pharmacies can play in
promoting public health. The value of
this role was recognised by all parties
when the contract was being negotiated, Barbara Parsons, head of pharmacy
practice
at the Pharmaceutical Services Negotiating Committee, says. “The
PSNC, the Department of Health and the NHS Confederation all recognised
the importance of using community
pharmacies for public health and promotion of healthy lifestyles. There
was no dispute about the need to include this as an important element
of the essential service,” she explains.
Examples of service provision
Patients with diabetes can be easily identified by their prescriptions,
and pharmacists can use their judgement and patients’ other prescriptions
to help identify those who are at risk of heart disease or are overweight.
Public health messages include advice on healthy eating, exercise and
stopping smoking.
Jim Jiwa, a pharmacist at Alliance Pharmacy in St Austell, Cornwall,
tries to give advice on healthy living whenever he can, particularly
to people with heart disease or diabetes. “I talk about diet and
the importance of a low cholesterol diet,” he says. “I also
speak to people about the importance of taking care of themselves. For
instance, I talk to people with diabetes about the need to look after
their feet — not just treating them as anyone else would if they
cut or injure them, but making sure they know how to look after them
properly and when they need to see a health professional.”
Irene Gummerson, a community pharmacist in Wakefield, West Yorkshire,
with a special interest in diabetes, tries to take time to talk her patients
with diabetes whenever their medicines change. “When a person comes
into the pharmacy for the first time with a prescription for testing
strips or diabetes medicines, or for a change of diabetes medicines,
I always take a few minutes to talk to them about their strips or medicines
in the context of diabetes. If I see that they are
interested, I ask if they would like a more
detailed chat in the counselling room.” If she is busy with prescriptions
then she asks if they could wait a few minutes. “I check what has
been said in the clinic and expand on this,
answering questions as I go along. I explain briefly why the doctor or
nurse is recommending low sugar, low fat diet; the link
between increased waist measurement and
diabetes and the value of increasing physical activity, such as that
it helps reduce cardiovascular risk. Whichever medicine is used, I
explain briefly how it acts and and how to take it.”
Talking to these patients about adopting a more healthy lifestyle need
not be difficult, says Mrs Gummerson. “It is not rocket science.
It is saying the right thing at the right time, in the right way,” she
says. For example, the word “exercise” can often be off-putting.
Instead, Mrs Gummerson explains to people that if they increase their
level of activity, within their capabilities, so they are slightly breathless,
but can hold a conversation, for 10 minutes, two or three times day,
a few times a week it will significantly help their health.
When appropriate, Mrs Gummerson will turn the discussion into a prescription
intervention (a medicines use review) and discuss the
patient’s other medicines as well. “Examples where patients
can get things wrong include mistiming when to read their urine testing
sticks, not taking amitriptyline 25mg (prescribed for neuropathic pain
in their feet) because they have read the leaflet, which mentions depression,
not taking metformin with or after a meal, not realising that they should
give more attention to reducing their cardiovascular risk, and not knowing
how to read labels on food containers to work out sugar and fat content,” she
says.
Overweight patients
The requirement to provide advice to
overweight patients collecting prescriptions can pose particular problems.
Although it may be obvious that someone is overweight, unless he or she
is collecting an anti-obesity drug, raising this as an issue for discussion
and
introducing the importance of a healthy lifestyle needs to be handled
carefully. Graham Phillips, a community pharmacist in Hertfordshire,
comments: “If you think someone is overweight and might benefit
from a weight management class, blood pressure or cholesterol measurement,
you cannot simply say ‘Would you be interested in our weight management
service?’. You need to be more tactful.”
Mr Phillips offers a weight management service in his pharmacy and he
and his staff tend to advertise it in a broad-brush way and give out
leaflets to a wide range of people. “It may be that even if someone
is not overweight, they may have a relative who would be interested in
the service. It also helps to give people an idea of the sorts of services
we can offer in the pharmacy. Part of that is about placing information
where people can access it for themselves in a way they feel comfortable
with. For instance, we have an in-store television running in our pharmacy.
None of the information on it is about
advertising products — it is all about our services. Clients watch
while waiting for their prescription, so they become aware of the services
we offer and then ask about them,” he says. “We provide blood
pressure measuring, smoking cessation, diabetes testing
(including HbA1c) — and it is often
overweight people for whom all of those might be relevant. So if they
ask about one service because they have seen a leaflet or poster, then
you can take the opportunity to talk to them about other lifestyles issues,
such as cholesterol, dietary sodium or exercise,
and people usually self-identify at that point and ask about our weight
management
service.
In Mr Phillips’s Letchworth pharmacy, there is a Wellpoint station
where customers can measure their weight, blood pressure and pulse, and
calculate their body mass index. “It is a bit of a toy, but that
does encourage people to use it. However all you really need is a tape-measure
since the key concern for health is simply the waist measurement.”
Information and records
The service specifications say that, although information promoting
healthy lifestyles should be primarily provided verbally, this should
be backed
up, as appropriate, by the provision of written material, such as leaflets
and by referring people to other sources of information or advice (see
p20). As well as being a source of additional information for patients
to take away with them, leaflets can also provide the starting point
for discussions about healthy lifestyles or an MUR, Mr Jiwa says. “We
also have leaflets about healthy living and the services available
to people around the pharmacy,” he says. “So people can
pick them up and ask for advice about anything they would like to know
more about.”
Leaflets are available from organisations such as primary care trusts
(especially for health campaigns) and PharmacyHealthLink and, according
to Barbara Parsons, many informative leaflets are provided by patient
groups and these can be used for prescription-linked interventions if
the pharmacist believes this would be helpful.
Under the contract, prescription-linked interventions must be recorded
so that the pharmaceutical services provided by the pharmacy can be audited
and the follow-up care given to patients can be assessed. For patients
presenting prescriptions, such records are easily made, Denise Laidlaw,
a community pharmacist in Gateshead, Tyne and Wear, says. “We record
interventions with patients whose details we have on our system, because
we can do that on an individual patient’s notes,” she says. “Just
as we can type in the names of new drugs that have not been put on our
system yet, we can type in interventions and the nature of the intervention
using that system.”
Mr Phillips uses a similar system. “We have set up a tag on our
patient record system, which means I can dispense public health information
as if it were a drug on the system,” he says. “We can then
use the free text field to include details of the intervention. So when
the primary care trust comes to look at our records, we can call up ‘public
health information’ and show them a list of which patients we have
provided what information to. Because the details are tied to the patients’ details,
this also means, he explains, that he can see how many patients with
diabetes and how many with coronary heart disease public health information
has been provided to, and of what sort.
Engaging the patient
Pharmacists’ unique relationship with patients means that they
are often able to talk to
patients about lifestyle matters in a way that other health professionals
may not, Mr Phillips says. “I know patients will come into my pharmacy
and when we get into a discussion about their lifestyle they say ‘Well
I told the doctor I smoke 15 a day, but actually it is 25’ or ‘I
said I drink 21 units a weeks, but it is more like 35 most weeks’.
That means we can have an honest conversation. We need to make sure we
develop and maintain that kind of relationship and also that we provide
pharmaceutical care in an environment that looks like it is a health
care setting,” he adds.
However, the ease with which discussions can be initiated can depend
on when people come into the pharmacy, Mrs Laidlaw has found. “We
are based in a supermarket and find people are more willing to take the
time to listen to advice when they are buying medicines before they go
to do their shopping,” she says.
Although the service specifications focus on four groups, when attempting
to give advice, it is important not to consider them in terms of each
diagnosis separately, Mr Phillips argues. “What it is important
to realise with public health is that for almost all the big issues — obesity,
heart disease, smoking, diabetes, sexual health — you are dealing
with the same people,” he says. “You need to tackle the problem
holistically, rather than trying to tackle each patient as a patient
with diabetes and then as a patient with hypertension. You need to think
more strategically about the whole thing and consider the person’s
whole lifestyle and work towards synergistic improvements.”
Time management
People who are pressed for time will return
or make an appointment if they are interested in hearing more,
Mr Phillips says. “The
public have to realise that sometimes we will have enough time
to do support them there and then and but that at other times we
will be rushed off our feet and they will have to make a mutually
convenient appointment.” Many, but certainly not all, are
happy to make an appointment, he says.
One skill pharmacists have to learn, he argues, is how to deal
with missed appointments. “GPs are much more used to dealing with
DNAs [“did not attend”s] without it causing enormous
problems.” Pharmacies should learn from GP colleagues which
approaches work and which do not, he urges. “You can help to
minimise DNAs by issuing appointment cards or by sending text reminder
messages. This looks more professional and is good for pharmacists’ image
as health professionals.”
In addition, he says, pharmacists do not appreciate that, in many
ways, they already have the skills needed. “Pharmacy really
does offer an unbelievably fast, efficient and overwhelmingly safe
service. To be able to offer a service whereby a patient can come
into any pharmacy with a prescription for virtually any drug and
we can fulfil it usually within less than 12 hours really requires
an incredible mix of skills. So pharmacists have those skills, but
they need to learn how to adapt them so that they can manage the
time needed for tasks other than dispensing,” he added. |
Other interventions
Although the community pharmacy contract focuses on giving advice
to those presenting with prescriptions who are at risk of coronary
heart disease, have diabetes, smoke or are overweight, pharmacists
can also use prescriptions for other conditions or over-the-counter
sales to initiate discussions of healthy lifestyles.
Mrs Laidlaw says that a number of regular scenarios leads her
to promote healthy lifestyles to the public. “One opportunistic
intervention we make quite often is with effervescent co-codamol,” she
says. “A lot of people are taking that fairly frequently
and do not realise how much salt it has in it. So when someone
comes
in to buy that it is a good opportunity to talk about salt intake
and healthy eating and suggest they switch over to the non-effervescent
formulation.
“Also, if people come in with recurrent problems we try to link that
to what may be an underlying problem. So if a woman was coming
in with recurrent thrush, that might be because of sugar in her urine,
and so we might ask whether she would like to have a test for diabetes.
When I am asked to recommend vitamins, such as in pregnancy or
for children, I always use this to spread the five-a-day message, explaining
that supplementary vitamins are often unnecessary if sufficient
fruit and vegetables are included in the diet.
Services that are up and running Mr Jiwa runs
a smoking cessation service. “We can introduce the service to smokers who come
in to buy cough medicines and we can give lifestyle advice to the
people using the service,” he says. Mr Phillips also introduces
his stop smoking service through over-the-counter sales. “Our
pharmacy staff are all trained to ask, every time they sell a cough
mixture, ‘Do you smoke? Would you like to quit?’,” he
explains. “All the evidence is that such brief opportunistic
interventions can play an important part in helping people give
up smoking,” he adds. “There can’t be a pharmacy
in the country that doesn’t sell cough mixture. If we could
achieve a 1 or 2 per cent quit rate, just by asking people buying
cough medicine whether they smoked and whether they had thought
about quitting, that would — in terms of the improvements
in public health and health inequalities it would bring about alone — almost
justify the existence of the entire community pharmacy network.” |
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The
Pharmaceutical Journal