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The effect of Advanced and Enhanced Community Pharmacy services

The effect of Advanced and Enhanced Community Pharmacy services. By Tom Morley, Candy Ho and Madeleine Stevenson. What are advanced and enhanced services?.

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The effect of Advanced and Enhanced Community Pharmacy services

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  1. The effect of Advanced and Enhanced Community Pharmacy services By Tom Morley, Candy Ho and Madeleine Stevenson

  2. What are advanced and enhanced services?

  3. In April 2005 Primary Care Trusts have been able to commission community pharmacies to carry out any one of the 19 enhanced services outlined in the contractual framework (DoH, 2005) • This should ensure that the enhanced services a community pharmacy provides are in tune with the requirements of the local population.

  4. Targets from Public Service Agreement (DoH, 2004)

  5. Services looked at: • Medicines Use Reviews (MURs) • Smoking cessation • CVD prevention • CCF monitoring • Diabetes • Weight management • EHC • Needle exchange/ opioid supervision Key - blue = advanced services, red = enhanced services

  6. Asthma 1 • >5 million individuals living with asthma in the UK • AN average community pharmacy provides a service for >450 asthma sufferers • Large potential for contact • The AIRE study found that only 5.3% of the population met all the goals of the Global Initiative for Asthma (GINA) guidelines (Rabe et al, 2000) • There is a need for healthcare input

  7. Asthma 2 • One study looked at increasing patient compliance via an MUR pharmacy service (Portlock et al, 2009) • 965 patients had an MUR in participating pharmacies • A total of 1,787 interventions were made • Patients were happy with the advice they received and the knowledge of the pharmacist • There was good interaction with local GPs as the study involved a range of health care professionals

  8. Smoking Cessation • Smoking cessation - is effective and cost-effective; training is essential to increase effect (Anderson, 2007) • Pharmacists in Scotland gave smoking cessation advice to the public (77% smoked >34 pack years) (Cramp et al, 2007) • 65% said that pharmacists were their preferred healthcare professional for advice on smoking cessation • At the end of week 4, 45% had stated they’d quit smoking • Of those that didn’t stop, 19% reduced their smoking.

  9. CVD prevention • CVD prevention showed reduction in lipid levels and CV risk scores, which was sustained after 1 year. • RCT showed significant increase in Rx of antiplatelets, lipid-lowering medicines and smoking cessation treatments (Anderson, 2009)

  10. Heart Failure • Enhanced service commissioned across 250/300 community pharmacies within Greater Glasgow and Clyde PCT area (Cree 2010) • Community pharmacists trained annually by specialist pharmacists and r/v patients, advise on meds and lifestyle, can refer to other services, also direct specialist pharmacist clinical input • 66% patients knew more about CCF, 72% knew more about meds, 48% more likely to seek help if symptoms worsened

  11. Why success in Glasgow? • PCT identifies health need and is willing to £££ • Led/trained by specialist clinical pharmacists with no prospect of financial gain from the service • Service receives external referrals (by 2o care pharmacists and 1o care specialist nurses) Limitation: 85% of those referred seen but only 42% had ongoing follow-up – time constraints?

  12. Diabetes • Pharmacies showed 1% reduction in HbA1c levels compared to controls (Machado et al, 2007) • Community pharmacy services shows promise but more information is needed (Anderson, 2007)

  13. Weight management • 2 out of 3 intervention studies showed a positive effect from community pharmacy services, but 3rd study found no effect (Anderson, 2007) • 1,370 individuals who’d previously taken part in a community pharmacy based diabetes screening study (n=3,800) took part in lifestyle counselling - weight loss was between 0.6-1.9kg at 3 months (Anderson, 2007) • Counselling by pharmacists could help to reduce public obesity

  14. EHC • Community pharmacies highly rated by women as a source of supply and advice (Anderson, 2007) • Large US trial of advance availability of EHC found no increase in risky sexual behaviour and no significant reduction in no. of pregnancies (Rocca et al, 2007). • A study in Manchester found that the EHC PGD was largely adhered to and that EHC was supplied appropriately (Anderson, Bissell, 2004) • Women felt that pharmacists had been polite, courteous and non-judgmental • Women had no concerns about confidentiality • Small study sample (2 secret shoppers)

  15. Services for drug (mis)users • Needle exchange, supervised dosing, opportunities for advice (inc wider health) • Predate current community contract for enhanced services - although RPSGB opposed NX 1982-6 (Bates 2002) • Pharmacy-based NX has been shown to be successful, with client satisfaction and in one study an 86% sharps returns rate (Cameron et al 2004);NX also clinically effective in reducing HIV transmission (McDonald et al 2003) • However: varied types of paraphernalia available, often limited (Abdulrahim et al 2006)

  16. Issues with IDU care • Most service users and pharmacists also positive about concept of supervised dosing (Bloor 2007) However: • Lack of privacy/confidentiality – with consulting-rooms? • Impact on self-image • Lack of communication between pharmacists and other members of “MDT”; unused skills e.g. safer injecting advice? (Bloor 2007) • Pharmacists’ training needs not always met (Cameron et al 2006) – only 15% covered care of misusers at undergrad, limited awareness of motivational skills

  17. Current Issues • Monetary targets for MURs are meaning that not all truly benefit the public • Some members of the public feel coerced into having an MUR - thus putting them off further ones or recommending to others • PCTs not commissioning enough enhanced services to community pharmacies • Still some barriers between GPs and pharmacists preventing true integration • Some GPs still do not see pharmacists as an equal health care professional

  18. Current Issues • Space constraints - e.g. for private consultation room • Opinions of the general public • Time constraints on pharmacists • Confidence of pharmacists - many still do not feel confident in opportunistically advising members of the public on health care issues e.g. smoking cessation: mostly no formal training in motivational interviewing/”stages of change” psychological model • Poor GP response to MUR interventions • The lack of growth of recent UK studies

  19. Ways to improve the service • Quarterly meetings between community pharmacists and PCTs • Increased communication between pharmacists and GPs • This may be improving with many pharmacies now operating in GP surgeries • More commissioning from PCTs to community pharmacies • This is also a way to help surgeries meet government statistics e.g. lipid targets

  20. Waysto improve the service • Joint educational sessions with GPs when a new enhanced service is started • A central ‘spine’ system to allow free flow of information between community pharmacists and GPs • This would be especially helpful in the case of MURs • Specific time allocated to pharmacists by employer to spend on clinical duties, e.g. MURs, smoking cessation clinics, counselling and advice

  21. Ways to improve the service • Research and development, develop long term strategic pharmacy practice program to produce evidence based community pharmacy services. • More public education about the skills of the pharmacist • Adequate education/ training for pharmacists e.g. on smoking cessation, and receiving support from PCT or academic institutions • Monitor GP response to MUR interventions

  22. Ways to improve the service • Collaboration between pharmacy enhanced/advanced services and secondary care: referrals from secondary care on discharge? • Advance booking of MUR, patient were informed about the nature and duration of MUR, and allow patients to prepare for MUR • Collaboration between specialist and “generalist” pharmacists

  23. References • Abdulrahim D, Gordon D, Best D, 2006. Findings of a survey of needle exchanges in England. National Treatment Agency: London • Anderson C, Bissell P (2004). Using semi-covert research to evaluate emergency hormonal contraception service. Pharmacy World and Science 26(2): 102-106 • Anderson C, Blenkinsopp A, Armstrong M (2009). The Contribution of Community Pharmacy to Improving the Public’s Health: Summary Report of theLiterature Review 1990-2007. PHLink • Bates P, 2002. Are needle exchange schemes ethical? Pharm J 269:214 • Bloor R, 2007. Summary of a supervised methadone study in Staffordshire and Shropshire. National Treatment Agency: London • Cameron I, Matheson C, Bond C, 2006. A survey of community pharmacists' training needs in the management of opioid-dependent clients. Pharm J 276:601-3 • Cameron J, Gilchrist G, Roberts K, 2004. Needle exchange services: a profile of service users in community pharmacies and other settings. Int J Pharm Prac 12:211-5 • Cramp GJ, Mitchell C, Steer C, Pfleger S (2007). An Evaluation of a rural Community Pharmacy-based smoking-cessation counselling and nicotine replacement therapy initiative. IJPP 15: 113-121 • Cree N, 2010. Operating a specialist heart failure service in community pharmacies. Pharm J 284:450-1 • Edward D, Freeman T, Gilbert A (2006). Pharmacists’ role in smoking cessation: an examination to current practice and barriers to service provision • smoking cessation: an examination of current practice and barriers • to service provision. IJPP 14: 315–17. • Machado M, Bajcar J, Guzzo GC, Einarson TR (2007). Sensitivity of Patient Outcomes to Pharmacists Interventons. Part I: Systematic Review and Meta-Analysis in Diabetes Management. Annals of Pharmacotherapy 41: 1569-82 • Portlock J, Holden M, Patel S (2009). A Community Pharmacy asthma MUR project in Hampshire and the Isle of Wight 282:109-111

  24. Rabe KF, Vermeire PA, Sorlano JB, Maler WC (2000). Clinical Management of Asthma in 1999: The Asthma Insights and Reality Europe (AIRE) study. The European Respiratory Journal 16:802-7 • Rocca CH, Schwarz EB, Stewart FH, Darney PD, Raine TR, Harper CC (2007). Beyond access: Acceptability, use, and non-use of emergency contraception among young women. American Journal of Obstetrics and Gynaecology 196: 29

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