Government policy

The creation of national healthcare schemes, such as the NHS has encouraged the general population to become more reliant on institutional bodies to look after their health. This has led to increased demand on services provided by these bodies, including the management of minor illness. For example, more than one in three GP consultations are for minor illnesses and an estimated 20–40% of GP time could be saved if patients exercised self-care. Similar findings have been recorded for patients attending hospital emergency departments. This dependence by patients on bodies such as the NHS has led to government policies which encourage and facilitate self-care. In the UK, the government agenda for modernizing the NHS was spelled out in its White Paper The NHS Plan (2000). Within this document the government made its intention clear to make self-care an important part of NHS health care. It stated that the front line of health care was in the home. Since that time the government has published numerous papers detailing why and how maximizing self-care can be achieved. The prominence placed on this government strategy is evidenced by the Department of Health having a dedicated website on self-care (http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Selfcare/index.htm). Included in these policy documents are specific papers looking at the role of pharmacy (e.g. A Vision for Pharmacy in the New NHS, 2003; Choosing Health through Pharmacy, 2005). It is clear that UK government policy centres on patient empowerment and utilizing all healthcare professionals to encourage patient self-care.

Widening access to self-care

The guiding principle of NHS modernization is to provide services that are best suited to the needs and convenience of patients. With regard to self-care, this can be achieved by encouraging patients to practise self-care themselves or by making better use of other healthcare professionals’ skills.

NHS walk-in centres and telephone help lines

The UK government has been proactive in facilitating self-care, most obviously by the formation of NHS walk-in centres and the telephone help lines NHS Direct (England and Wales) and NHS 24 (Scotland). The aim of walk-in centres is to improve access to health care that supports other local NHS providers. The service is nurse led but some employ doctors to work at particular times. The first NHS walk-in centre opened in 2000 and there are now approximately 90 operating in England. The Department of Health states that over 5 million people have used a walk-in centre with the main users being young adults. NHS Direct, launched in March 1998, has seen remarkable government investment and rapid and widespread expansion. It is a 24-hour nurse led service that receives over 500 000 calls per month. Although originally designed as a telephone help line service, NHS Direct now also offers an online service and direct interactive digital TV plus the publication of its self-help guide.

Deregulation of medicines

Less obvious, but arguably more important, has been the expansion of medicines available without prescription (Table 22.1). This has direct impact on community pharmacists and represents one of the major ways in which pharmacy can contribute to self-care. Widening access to medicines previously only available via prescription supply is a global phenomenon and not unique to the UK.

Table 22.1 Chronological history charting prescription only medicine (POM) to pharmacy (P) and P to general sales list (GSL) deregulation

The switching of prescription only medicines (POMs) to pharmacy (P) status is now well established. Loperamide and ibuprofen were the first POMs to be switched in 1983. The rate of POM to P deregulation after the initial two switches was slow, with only nine medicines deregulated between 1984 and 1991 (see Table 22.1). This was in part due to the bureaucratic process in place at the Medicines Control Agency (MCA; now known as the Medicines and Healthcare products Regulatory Authority, MHRA). In 1992 the MCA changed the process by which medicines were deregulated. Under the new system, changes to the product’s legal status could be made without requiring amendments to the POM Order, thus speeding up the process. This change was effective, with no fewer than 30 medicines being deregulated over the next 3 years.

Further streamlining took place in 2002 to encourage manufacturers to switch medicines from both POM to P and P to general sales list (GSL). At approximately the same time, the White Paper Building on the Best (2003) set a target of 10 medicine switches each year (both POM to P and P to GSL) which was endorsed in The NHS Improvement Plan (2004). Between 1983 and 2008, over 80 POM to P and 40 P to GSL switches were made, although, the target of 10 switches per year from 2004 has yet to be met.

More recent POM to P switches have seen new therapeutic classes deregulated (e.g. proton pump inhibitors, triptans) and further deregulation of medicines from different therapeutic areas seems likely. The profession has played its part in this process, with the Royal Pharmaceutical Society of Great Britain (RPSGB) producing a consultation document on future candidates for POM to P switching (2002), some of which are now deregulated or being considered (e.g. tranexamic acid in 2007). Perhaps the largest area for future growth of deregulation centres on chronic disease management. Government policy toward self-care now embraces both acute and chronic illness (Supporting People with Long Term Conditions to Self Care: A Guide to Developing Local Strategies and Good Practice, 2006) and in 2004, the deregulation of simvastatin paved the way for further medicines to be available to manage chronic illness. This now enables UK consumers to purchase a medicine which government agencies have declared too low a priority to fund on the NHS (coronary heart disease risk of 10–15% over 10 years). This move therefore puts the emphasis squarely on the shoulders of the consumers to decide for themselves whether they want to initiate primary prevention.

Minor ailment schemes (MAS)

One barrier to patient self-care is the NHS system itself. Over 85% of prescriptions dispensed are exempt from the prescription charge (NHS statistics 2004). Therefore patients entitled to free prescriptions are likely to seek a doctor when they have minor illness, as any prescription issued will be free of charge in contrast to purchasing potentially the same product from the pharmacy. In response to this, a scheme dubbed ‘Care at the Chemist’ was established in Merseyside in 1999. It involved eight pharmacies and one GP practice and allowed patients free access to medicines through the pharmacy to treat 12 self-limiting conditions. Of the 1522 patients who used the scheme, only 21 patients were referred back to the GP. A 30% reduction in GP workload was observed for the 12 conditions included in the scheme. The scheme was subsequently replicated elsewhere and similar findings were observed. Consequently, the government called for widening participation of MAS, and the new pharmacy contract for England and Wales has seen MAS incorporated into the enhanced service specification and in Scotland it is included as a core service. MAS are designed to meet the needs of the local patient population. Consequently, different models exist throughout the country although many bear much similarity to the ‘Care at the Chemist’ scheme. However, there are some primary care trusts and health authorities that now use a common scheme and there is growing support for a national scheme to be implemented in England. In some schemes, patient group directions (PGD) have been incorporated to allow pharmacists to prescribe POMs to treat conditions such as urinary tract infections and impetigo. A useful resource is the National Prescribing Centre (NPC) website (http://www.npc.co.uk/mms/SIGs/minor_ailments/#HELP).

The public’s view on self-care and access to deregulated medicines

The public’s attitude toward self-care and its actual actions are contradictory. A King’s Fund study (2004) found that almost 90% of respondents believed they were responsible for their own health and a Mintel report (2004) found that 8 out of 10 people said they had to be ‘really ill’ to visit a doctor. However, it is estimated that upwards of 40% of GP time is spent dealing with patients who present with minor illness and only 25% of people who suffer minor illness self-treat with a purchased non-prescription medicine. It appears then that the government’s message on promoting self-care is understood by people but is not being translated into action. Of some comfort to the government are findings from 2003 and 2004 Mintel lifestyle surveys that show increasing numbers of people consulting a pharmacist while the number of GP consultations is slowly falling. These latter studies cite convenience as a major contributory factor to pharmacy consultation rather than waiting for a GP appointment. However, patient attitudes over being questioned before medicines are sold are seen as a barrier. A study by Morris (1997) found most consumers had a degree of awareness of why pharmacy staff might require information but almost two-thirds had expected to make their most recent purchase without being questioned. Cantrill et al (1997) also found that pharmacists reported more than 10% of consumers unwilling to answer questions.

It appears that some sectors of the public are unhappy to be questioned by pharmacy staff. This group poses difficulty for pharmacy staff but asking questions ensures responsible purchasing of OTC medicines by consumers. There is also a small body of research both in the UK and USA that indicates that the public regards OTC medicines as inherently ‘weaker’ than prescription medicines. OTC status in itself may lead to a perception that the medicine cannot be harmful. For example, 40% of people in a US study believed that OTC medicines were ‘too weak to cause any real harm’ (Roumie & Griffin 2004). That doses of medicines switched from POM to P may be lower than those used on prescription is likely to reinforce such beliefs and could influence why people believe that they should not be questioned.

First impressions

It is said that you never get a second chance to make a first impression. When we meet somebody for the first time we make assumptions about that person. We often put people into categories and the assumptions lead to expectations of their behaviour, jobs and character. This initial judgment of a person is often based purely on what we see and hear and includes appearance, dress, age, gender, race and physical disabilities. It is important that we are aware of these assumptions in order to avoid stereotyping people. For example, the impression we have of a person wearing a denim jacket may be very different from our impression of the same person wearing a suit. As you get to know a person better, initial impressions are either reinforced or discarded, but in the context of dealing with patients who want advice about minor illness, this could be the first and last time you see them. This first impression works both ways and pharmacists who create a friendly approachable impression are more likely to find patients receptive to what they say.

From the perspective of deciding what the patient’s problem is, this ‘first impression’ can be very helpful in giving you clues to their state of health. Assessment of the patient begins the moment the patient enters the pharmacy. Most pharmacists will probably do this at a subconscious level but what is important is to bring this to the conscious level and build it into your consultations. Many visual clues will be apparent if they are actively looked for. How old are they? Many conditions are age-related and this will help narrow down the number of conditions that need to be differentiated from one another. What is their physical appearance? Is the patient overweight or showing signs of being a smoker? Are there any signs of confusion, pain or systemic illness? For example, does the patient look well or poorly? For people who appear in discomfort or look visibly poorly, this might influence your decision to treat or refer – they might have a self-limiting condition such as viral cough but have marked systemic upset which necessitates referral. How did the person present to the pharmacy counter? Did they walk over in a normal manner or did they appear nervous, shy or reluctant? It might mean that the person who appeared nervous wants advice but is embarrassed to ask or they are intimidated by the environment and atmosphere. These ‘cues’ can be picked up by the pharmacist and appropriate action taken to make the person more at ease. The key is to observe your patient. Take time to assess what they look like, how they move and how they behave. This initial assessment will provide useful information which shapes your thinking and actions and is the first step to reaching a differential diagnosis.

Questioning

Arriving at a diagnosis is a complex process. In medicine it is based on three kinds of information: patient history; physical examination; and the results of investigations. Currently, physical examination and using diagnostic tests are rarely used in community pharmacy practice. Pharmacists rely almost exclusively on questioning patients when deciding whether to offer treatment or perhaps refer the patient for further evaluation. Studies have shown that an accurate patient history (gained from asking questions alone) is a powerful diagnostic tool. Supplementary examinations and diagnostic testing do improve the odds of reaching a correct diagnosis, but only by 10–15%.

The pharmacist’s diagnosis will, in many cases, be a differential one; the signs and symptoms are suggestive of a particular condition but it is difficult with absolute certainty to label the exact cause. For example, someone who presents with acute cough is likely to have a viral self-limiting cough but it could possibly be bacterial in origin. Advice and treatment might well be the same but an exact diagnosis cannot be made. Of course, in certain circumstances this can be done, for example head lice, eczema caused by a watchstrap or psoriasis on a knee, etc.

The ability to ask good questions to gain the appropriate information is therefore critical. The type of question and the way in which it is asked will dictate the level of response given.

Acronyms

Acronyms have been developed to help pharmacists remember which questions should be asked. WWHAM (Who is the patient? What are the symptoms? How long have the symptoms been present? Action taken? Medication being taken?) is the best known and simplest acronym to remember and has been advocated by many as a useful tool in gaining information from patients. Other acronyms have been subsequently developed and include ENCORE, ASMETHOD and SIT DOWN SIR. The difficulty with using acronyms is that they are rigid and inflexible – a ‘one size fits all’ approach. In addition, there is a tendency to ask questions for no reason – it is part of the acronym so the question has to be asked even though there might be no relevance or underpinning reasoning for asking the question. This is especially true of WWHAM, and because it is simple to remember it also means it provides the least information. Other acronyms do provide more information but because they are longer they become almost impossible to remember. Acronyms can be helpful in gaining some information from the patient but pharmacists should not rely solely on them. Each patient is different and it is unlikely that an acronym can be fully applied, and more importantly, it might miss vital information.

Current prescription workload and staff skill mix in most pharmacies makes pharmacist intervention in requests for advice or product selection impossible on every occassion. Up to 75% of patients are first seen by a counter assistant. The standardization of their questioning by using an acronym via a standard operating procedure (SOP) might be appropriate to ensure basic information is obtained from all patients.

The funnelling technique

A funnelling technique can be used to allow direction and focusing of ideas on a specific topic. This involves initially asking background open questions to provide basic information, then asking specific closed questions to provide specific detail and clarify points. In these circumstances, it can be useful to paraphrase comments made, to ensure that the understanding of the information being obtained from the patient is accurate. This checking procedure allows the pharmacist to check understanding and minimizes misinterpretation. It is possible during any one conversation to use more than one ‘funnel’, e.g. establishing a patient’s current medical condition, then going on to suggest appropriate action or medication available. In a pharmacy setting, where time can be a limiting factor, using the funnelling technique can be useful for directing and focusing a conversation to enable an end point to be achieved more quickly.

Clinical reasoning

Clinical reasoning relates to the decision-making processes associated with clinical practice. It originates from medicine in determining the best way physicians solve diagnostic problems. It is a thinking process directed towards enabling the practitioner to take appropriate action in a specific context. Based on these principles, the encounter with a patient in a community pharmacy is no different. It fundamentally differs from using acronyms or the funnel approach in that it is built around clinical knowledge and skills which are applied to the individual patient. Various models have been used to explain the process and include hypothetico-deductive reasoning and pattern recognition.

Body language

Body language can be broken down into several component parts which include gestures, facial expression, eye contact, physical contact, body posture and personal space. It is the combination of all these components which gives the overall impression. It is important to ensure that they are all compatible. If a mixture of messages is portrayed it will cause confusion to observers.

Gestures

Hand gestures in particular are useful when emphasizing a point or to help to describe something. Used appropriately, they can greatly enhance communication and improve understanding. Observing the patient’s gestures can give useful information on how concerned they might be or where the problem is. For example, someone presenting with abdominal pain might say they have stomach ache but point to the lower abdomen. In these cases, the non-verbal hand clue is much more informative than the spoken word. Also the person might point to a specific region, as the pain is very localized (e.g. appendicitis), or they might move their hand over a larger area (e.g. irritable bowel syndrome).

Gestures are also useful for the pharmacist to use as they can emphasize or reinforce a point or describe a particular procedure. However, it is important not to overuse them, as this can detract from the spoken word and become a distraction to the listener. Do some ‘people watching’. It is amazing how much information about people you can pick up just by quietly observing their gestures.

Facial expression

Facial expressions are a very important part of communication. Facial expression says a lot about mood and emotion, with the eyes and the mouth giving the dominant signs. As well as ensuring that facial expression is encouraging and welcoming, it is important for pharmacists to be able to read the meaning of facial expressions. In this way important points regarding a patient’s level of comprehension or receptiveness can be judged.

Eye contact

Avoiding eye contact is a very successful way of avoiding communication. This can be very well illustrated by observing a class of students who have just been asked a question by a lecturer!

The maintenance of eye contact during a conversation is vital to ensure the continuation of the process, because it indicates interest in the subject and is also useful as a means of determining whose turn it is to speak. However, care must be taken. Holding eye contact for too long can be off-putting and will reduce the success of the communication. Anyone who has been stared at will know how uncomfortable this can be.

Body posture

We can usually control the words we say, but it is more difficult to control our body language. It is possible, therefore, to send out mixed messages by having a positive verbal message but a negative body posture. This will only serve to confuse the patient and it is likely that the outcome of the interaction will be poor. There are several classic body postures which have been identified as having significant meanings:

Physical contact

This is an important aspect of any communication process and can be used to enhance verbal communication. A sympathetic touch on an arm can often say far more than any number of words. However, physical contact is governed by broad social rules which vary greatly between cultures. The British are identified as one of the least ‘touching’ nations, while in many cultures touching between the sexes is unacceptable. An awareness of this is important for pharmacists who will come into contact with people from a wide variety of social and cultural backgrounds. What is considered acceptable behaviour in one culture could be unacceptable in another.

Personal space

We all have our own space in which we feel comfortable. Personal space varies between cultures and its extent depends on the situation. An awareness of personal space is important for pharmacists as it can play an important role in the success or otherwise of communication. If you carry on a conversation with someone at too great a distance it may be difficult to build up any rapport. However, if you are so close to people that they feel uncomfortable and threatened, no meaningful dialogue will occur. The different space zones are generally divided into four main areas.

Vocal communication

Vocal communication, sometimes called paralanguage, concerns the vocal characteristics, the quality and fluency of the voice. The quality of the voice refers to the tone, pitch, volume and speed. Tone in particular can convey more meaning than actual words. ‘Thank you for asking the question’ said in a harsh voice contradicts the words and indicates that it is not meant. The same words in a warm tone show sincerity. The volume must be adjusted to the circumstances and can emphasize key words. The speed of speaking must enable the listener to understand. Varying the speed and pitch can make the words more interesting and hold the listener’s attention. Effective use of vocal communication requires that we become proficient at speaking with a warm confident tone of voice at an appropriate speed and volume and without interruptions or vocal mannerisms.

Timescales

One of the key things a patient needs to know is what is the best course of action to take. Obviously this will depend on a number of factors including the patient themselves, the differential diagnosis and the severity of the condition. As a general rule, all patients should be advised on a timescale when they need to consult further medical help, whether they return to the pharmacist or see another healthcare practitioner. This allows the patient to understand the nature of the problem and know when they should seek further help. This will have to be gauged on a person-to-person basis. For example, take three patients all presenting with viral cough. Although the condition is self-limiting the timescales given to each patient can vary. If the first person presents after 7–10 days then you might tell them to see the doctor in the next 5–7 days if symptoms do not improve. The second patient has only had symptoms for 2 days, in which case you would give them a longer timescale. The third person might have had symptoms for 5 days but compared to the first two patients they have severe symptoms which would warrant automatic referral for a second opinion. This process is known as a conditional referral.

Treatment and advice

Once a full assessment of the symptoms has been made, and a decision made that the patient does not require immediate referral, appropriate recommendations should be made. Selection of an appropriate treatment for a condition involves application of pharmacology, therapeutics and pharmaceutics knowledge. The first step will be to choose an appropriate therapeutic group to recommend. The next step would be to assist the patient in the choice of product within the therapeutic group. For many therapeutic groups there is a wide variety of products available, often in various combinations. The pharmacist should take into account the efficacy, potential side-effects, interactions, cautions and contraindications. With regard to efficacy, pharmacists should be aware that many OTC medicines have little or no evidence base. This does not necessarily mean they are not effective, but in today’s climate of evidence-based health care then products with proven efficacy should constitute first-line treatment.

The difficulty in establishing efficacy has many explanations and includes: products that are available OTC predating clinical trials, a general lack of trial data or poorly conducted trials, the placebo effect seen with some OTC medicines and the nature of self-limiting conditions – is it the medicine working or the symptoms resolving on their own? Despite this, patient demand for a medicine to treat their symptoms is strong. Recommending an OTC medicine despite inadequate evidence of its efficacy is justifiable because many patients have a desire to try something to give them symptomatic relief. A negative or dismissive response by the pharmacist to a request from a patient can be harmful in that such patients may lose faith in the pharmacist and exercise self-care elsewhere where there is no qualified person to assess their symptoms. When selecting a product, the patient’s needs should be borne in mind. Factors such as prior use, formulation and dosage regimens should be considered. For example, antacids are available in both tablets and liquid form. Liquids tend to have a quicker onset of action than tablets but can be inconvenient for a patient to carry around with them or take to work.

Non-drug treatment should also be offered where appropriate. For example, providing medication for motion sickness can be supplemented with advice on how to reduce symptoms, for example focusing on distant objects, not overeating before travel or sitting in the front seat in car journeys will help to reduce symptoms. Advice on increasing dietary fibre and fluids is an essential part of the management of conditions such as constipation and haemorrhoids. Certain situations where pharmacists are being consulted by patients for advice on symptoms are ideal opportunities to promote health education (see Ch. 5). For example, someone who is asking for advice about a cough could be asked about their smoking habits.

Children and the elderly

These two patient groups have the highest usage of medicines per person compared with anyone else. Care is needed in assessing the severity of their symptoms as both groups can suffer from complications. For example, the risk of dehydration is greater in children with fever or the elderly with diarrhoea. Invariably, lower doses are used in children, and because the elderly suffer from liver and renal impairment they frequently require lower doses than younger adults. Children should be offered sugar-free formulations to minimize dental decay and elderly people often have difficulty in swallowing solid dose formulations. It is also likely that the majority of elderly patients will be taking other medication for chronic disease and the possibility of OTC–POM interactions should be considered.

Pregnancy

The potential for OTC medicines to cause teratogenetic effects is real. The safest option is to avoid taking medication during pregnancy, especially in the first trimester. Many OTC medicines are not licensed for use in pregnancy and breastfeeding because the manufacturer has no safety data or it is a restriction on their availability OTC. Table 22.2 highlights those medicines where restrictions apply.

Table 22.2 Medicines to avoid during pregnancy

1 Briggs GG, Freeman RK, Yaffe SJ 2008 Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk, 8th edn. Lippincott Williams & Wilkins, Philadelphia. (This is one of the standard reference texts used by medicine information centres in answering medicine suitability during pregnancy.)

Interactions of OTC medicines with other drugs

Medicines that are available for sale to the public are relatively safe. However, there are some important drug–drug interactions to be aware of when recommending OTC medicines. These are listed in Table 22.3.

Table 22.3 Interactions of OTC medicines with POMs that can be significant

ACE, angiotensin converting enzyme; GI, gastrointestinal; MAOI, monoamine oxidase inhibitor; NSAID, non-steroidal anti-inflammatory drug; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.

Providing advice (patient counselling)

The service specifications of the pharmacists’ Code of Ethics provides some guidance on the content of the counselling role of pharmacists. The specification on the supply of dispensed medicines states ‘Pharmacists must ensure that the patient receives sufficient information and advice to enable the safe and effective use of the medicine’. The sale of OTC pharmacy medicines is similarly covered by the service specifications and the pharmacist is required to provide ‘advice relevant to the product and the intended customer’.

Counselling should take place in a thoughtful, structured way. Pharmacists must have the ability to explain information clearly and unambiguously and in language the patient can understand. The counselling process should not be a monologue by the pharmacist giving a long list of information points. To be successful, it must be a two-way process. There should be ample opportunity for the patient to ask questions. Rapport is built up between the pharmacist and the patient and a much more meaningful dialogue can take place. What information to give to the patient will vary from case to case and will depend on a number of factors such as prior use and knowledge, the age of the patient and their comprehension level. However, as a general summary, patients should know: