Public health and pharmacy interventions
Pharmacy and its role in public health
Services that can be delivered by pharmacists to support the public health agenda
Introduction
Public health and its role in society has been described in Chapter 13. This chapter describes the part pharmacy plays in providing public health services to the public.
Traditionally, pharmacy has tended to work closely with health service commissioners to provide dispensing services. As the profession develops with time, it will need to work outside its traditional areas and increase its involvement in other areas, such as the provision of public health advice and services.
In many countries, the responsibility for public health sits between local government and health services. Pharmacists will, therefore, need to look towards local government in the future both as a commissioner of services and as the organization which will determine public health strategy.
Access
Community pharmacy has, traditionally, had the reputation as the only healthcare profession which is readily accessible to the general public without an appointment.
Over the past few years, as more pharmacies have opened in the UK, particularly pharmacies which open at least 100 hours each week, this accessibility has increased. For example, in England it is estimated that 1.8 million people visit a pharmacy every day, which means that in England, an average person will visit a pharmacy 14 times a year. Many of these will be people using the pharmacy for non-traditional purposes, i.e. not to have a prescription dispensed or to purchase an OTC medicine. These people will use the pharmacy to seek advice about general health care and to access other services. Because many of the people accessing pharmacies are not ill, pharmacists are ideally placed to offer advice to help people stay healthy. The profession’s unrivalled access to this portion of the population makes it extremely valuable in supporting general well-being and reducing the incidence of long-term health problems in the general population.
Thus, pharmacy is ideally located to be at the heart of the patient-centred health service.
Healthy living pharmacies
This is a concept developed in the UK in 2010. The aim is to increase the public’s awareness of community pharmacy as a centre within a neighbourhood, where anyone could go and access information to improve or maintain their health. These pharmacies do not necessarily offer more services than other local pharmacies but they do have ‘health trainers’. These people are usually identified from the medicines counter assistants and are people who are passionate about well-being. Their role is to proactively approach people in the pharmacy to help them with either current health issues or to help them make positive changes to their lifestyle. Health trainers are a recognized role in the NHS but this is the first time they have played a significant role in pharmacy.
Healthy Living Pharmacies are accredited by local commissioners. In the future, it may be that for a pharmacy to be commissioned for new enhanced services, it will have to meet the standards required to be a Healthy Living Pharmacy.
Services
Pharmacy is beginning to move away from dispensing as its sole purpose, and to offer other services, many of which are covered elsewhere in this book. This chapter looks at some of the services and interventions pharmacists and their teams can offer to support the public health agenda.
Smoking cessation
For many years, pharmacists and medicines counter assistants have been selling nicotine replacement therapies (NRT) as an aid to stop smoking. As perceptions of smoking have changed, it has become routine for many healthcare professionals to ask patients whether or not they smoke and this has also become routine for pharmacists. Encouraging a smoker to quit is probably the biggest positive intervention that can be made to their health. Since many smokers will use a pharmacy to buy products to treat minor illnesses (particularly coughs and colds), the pharmacy team is ideally placed to encourage a smoker to quit.
For some pharmacy teams, the intervention will be solely based around motivational conversations and the sale of an appropriate NRT product from the wide range available. In other pharmacies, the patient will be able to access a commissioned smoking cessation service. This may involve an in-depth consultation with a smoking cessation advisor (usually drawn from the medicines counter assistant population), during which there will be agreements about why the patient wants to stop, when they intend to stop, the support available (in some pharmacies this can involve groups of quitters meeting weekly to discuss progress) and decisions about the right NRT product for the patient. The patient will then be supplied with the product free of charge, if they are exempt from prescription charges.
In other pharmacies, the pharmacist may be involved in offering a smoking cessation service if they have been authorized to supply Champix® (a selective nicotine-receptor partial agonist) under a PGD (see Ch. 4).
Another group of pharmacies will process the vouchers issued to patients to obtain a free supply of NRT by smoking cessation advisors, who work elsewhere in the community, e.g. nurses in clinics.
Cardiovascular checks
In the UK, cardiovascular disease (CVD) is one of the main causes of premature morbidity and mortality. It is recognized that when cardiovascular disease has been diagnosed as a result of a cardiovascular event (such a minor stroke or myocardial infarction), effective treatments are available to reduce the risk of a second event. However, we do not have an effective national screening programme to reduce the risk of the first cardiovascular event happening.
Screening would be most effective if carried out for both male and females who are aged between 40 and 74 years of age. Often, this is a group of people who do not routinely access care from their GP, but who will access treatment for minor ailments from a pharmacy.
Some pharmacies have been commissioned to carry out CVD risk assessments, particularly in those areas where the target numbers for patients being screened has not been met by GP surgeries.
The CVD risk screening covers the following:
Using the information obtained from the screening tests, the pharmacist calculates the risk of a cardiovascular event occurring in the next 10 years, for the patient. Depending on the level of risk the pharmacist and patient agree either lifestyle changes to reduce risk or referral to the GP for other preventative measures (e.g. medication).
Alcohol intake screening
It is believed that at least one in three adults in the UK drinks more alcohol each week than is regarded as safe. It is also believed that a large number of these people do not realize that their alcohol consumption is at a level that is anticipated to cause health problems in the future.
Pharmacists are being encouraged to include discussions about alcohol intake as a normal part of the conversation with a patient. Currently, this seems very alien and intrusive to many pharmacists. This matches the feelings experienced in the 1990s when pharmacists were first asked to start including discussions about smoking status as part of most conversations. It would be unusual now not to be questioned about smoking status when asking for medication for a cough or cold in a pharmacy and so pharmacists can now plan to increase their patients’ awareness of the problems caused by drinking alcohol to excess.
In some places, pharmacists have been commissioned to provide services to increase awareness of safe drinking levels. Pharmacists can target ‘at risk’ patients, who may include:
Patients accessing emergency hormonal contraception through the pharmacy
Customers who buy hangover cures or products for indigestion
Customers are asked to complete a questionnaire or use a scratch card to identify their drinking patterns. Depending on what the questionnaire/scratch card highlights, the outcome may be:
Services for drug-user clients
Pharmacists play an important public health role with the services they provide for drug-user clients. They can include:
Observed, supervised consumption of prescription medicines
Needle and syringe supply and exchange
Supply of other injecting equipment
(These are covered in more detail in Chapter 50.)
Screening for chronic disease
Pharmacists can also be involved in screening for long-term (chronic) disease/conditions, e.g. screening to identify patients with, or at risk of, developing Type 2 diabetes.
It is estimated that one in four people with Type 2 diabetes are, at any one time, undiagnosed. The consequences of this delay in diagnosis are:
Patients may have symptoms without being aware they have diabetes so do not know why they are feeling unwell
Patients are often diagnosed late as a result of a preventable complication of the disease being found. These complications would include retinopathy identified during a routine sight test or peripheral neuropathy being identified after a series of falls
Early diagnosis means that patients are less likely to develop complications resulting in a better quality of life and less support required from the NHS.
Pharmacists have been commissioned to provide a service in certain parts of the UK with a high rate of undiagnosed diabetics. The service targets patients through:
After identification of the ‘at risk’ patient, the patient is asked to complete a lifestyle questionnaire. The pharmacist or a trained colleague then carries out the following tests:
Depending on the results obtained, the pharmacist will either:
Recommend lifestyle improvements to reduce risk factors for Type 2 diabetes (e.g. weight management programme, smoking cessation programme)
Refer to a GP for confirmation of a diagnosis and treatment.
Treatment and prevention of infectious disease
A key public health requirement is to monitor and reduce infection from what are termed ‘communicable diseases’. While all infections have the potential to be passed on, public health priorities focus on the infections or diseases that tend to spread easily and have serious health consequences. Both the common cold and influenza are such types of infections. In particular, the health consequences of influenza can be serious, may require hospital admission and can cause death.
Pharmacy has a role to play here, in four areas:
Provision of vaccination to prevent infection
Screening to identify specific infections
Provision of treatment of specific communicable diseases
Increasing patient compliance with medication for a communicable disease with a long treatment period.
None of these are part of key or essential services, but like many of the other services given in this chapter, they are commissioned in response to a local need.
Provision of vaccination
Vaccination is only effective as a widespread infection control if a large percentage of the population is vaccinated. For some infections, vaccination is designed to ensure that patients with other conditions/diseases, that make them susceptible to complications from the infection, are vaccinated. This is the case for the influenza vaccine, where the NHS vaccinates groups of people with underlying medical conditions such as asthma or heart disease.
Pharmacies provide vaccination as a way of increasing access. Patients will access vaccination services through pharmacy, rather than from a GP surgery, for one of two main reasons:
The opening hours of pharmacies tend to be over more days and more hours per day than those of a GP surgery. This is particularly relevant for patients who work and would have to take time off to be vaccinated. Pharmacy plays a substantial role in both identifying patients who should be vaccinated and also vaccinating those patients who are unwilling to be vaccinated at their GP surgery
Pharmacy is seen by some patients as more anonymous than attending the GP surgery. Some pharmacies provide human papillomavirus (HPV) vaccination for older female teenagers, whose age means that they missed the national vaccination programme at school. Some of these patients will not wish to be vaccinated at their GPs, as they perceive information about their sexual activity will be recorded in their patient record.
Screening to identify specific infections
Some pharmacies are commissioned to screen for sexually transmitted diseases and blood-borne viruses which are transmitted when drug-users share needles.
Since pharmacies are accessed by sexual health services and by drug-user clients, they are ideally placed to discuss infection risk and then test (usually using dry blood spot testing) for infections such as HIV, syphilis, hepatitis B and C. For these infections, the pharmacy is then unlikely to provide treatment but will help the patient identify how they would like to access treatment elsewhere in the health service.
For infections such as Chlamydia, pharmacists can be commissioned to provide testing kits and then if infection is confirmed, can be trained to provide antibiotic treatment under a PGD.
Provision of treatment of specific communicable diseases
Pharmacists have been trained, in some parts of the UK, to supply drugs to patients who have tested positive for MRSA as a result of hospital pre-admission tests. Since the test results are not available on the day of the pre-admission tests, a patient who tested positive for MRSA would normally have to return to the hospital for treatment. To ensure that patients are completing their treatment before they return to the hospital, some areas have increased access by transferring the treatment to the patient’s local pharmacy.
Increasing patient compliance with medication for a communicable disease with a long treatment period
Tuberculosis (TB) is a disease that has increased in incidence due to changes in migration. The treatment involves a medication regime that lasts many months. If the patient fails to complete the regime, there is an increased risk of drug-resistant TB developing.
In areas with higher than average levels of TB infection in the population, pharmacies have been commissioned to provide increased support for patients to improve compliance with their drug regime. This can include:
Public emergency support
In a public emergency, such as a pandemic, some legislation is temporarily suspended to allow the emergency to be dealt with quickly and effectively. The legislation affected can include that which governs the supply of medicines. This may mean that:
some medicines can be withdrawn from the supply chain so that the best use is made of limited supplies
some medicines can be supplied against an order rather than a prescription. This can reduce the time to supply some drugs and also ensures that some drugs are only issued under specific guidance (e.g. antiviral drugs in an influenza pandemic will be available in limited quantities and cannot be given to every infected person)
some medicine supply functions can be carried out by people other than pharmacists (in the case of an epidemic, there may be too many pharmacists ill to continue with providing the population with drugs so registered technicians may be authorized to undertake some supply functions).
Although there was little need to put these options into operation, during the H1N1 influenza pandemic of 2009/2010, some pharmacies were commissioned to provide antiviral drugs against an authorization form rather than a prescription.
Sexual health services
Sexual health services available through pharmacies can be grouped into three main areas:
Most pharmacies will play some role in providing sexual health services from selling condoms and pregnancy testing kits to commissioned services to supply regular hormonal contraceptives. Many emergency hormonal contraception (EHC) services are commissioned to try to reduce the incidence of teenage pregnancy and so will be available to girls under 16 years of age. In the UK, girls under 16 who access contraceptive services have to be assessed under the Fraser Guidelines, and their competency recorded.
Contraception
Pharmacies will provide a variety of contraception services:
The sale of condoms and kits to predict ovulation to help couple using natural methods of contraception
Distribution of condoms to young people under the c-card scheme
Provision of free of charge emergency hormonal contraception (EHC) under a PGD, or if the patient is not suitable for EHC, referral to another provider to discuss other emergency contraception options
In some areas, pharmacists have been trained to provide a full family planning service for hormonal contraception (combined pill or progesterone only pill) – this includes assessment, supply and follow-up.
Prevention and treatment of sexually transmitted diseases
As well as the information covered earlier in this chapter, pharmacists will also supply condoms to women being supplied with EHC and in many cases, it is a requirement of the service to discuss whether the women needs to consider screening for sexually transmitted infections and in particularly Chlamydia.
Pregnancy testing
Pharmacists have traditionally carried out pregnancy testing or sold pregnancy testing kits. With more effective and accurate testing kits available to purchase, more women are purchasing testing kits to use at home.
However, in some areas, pregnancy testing in the pharmacy has become a commissioned service as a way of increasing the number of women who access midwifery services early in pregnancy. This is particularly important in areas where a lower than average proportion of the population is registered with a GP.
Conclusion
Pharmacy has the potential to be involved in many areas to support the public health agenda. To be successful at this, pharmacists need to be prepared to engage with commissioners and to explain what services they can deliver to support the public health agenda.
Key Points
Pharmacists are the most readily accessible healthcare professionals
The public health agenda is one that has been supported by pharmacists in the past but the services provided have rarely been thought of as public health services
Public health service provision must be decided by local need
Key areas are prevention of long-term conditions, drug-user services, sexual health services, disease prevention and treatment
Healthy Living Pharmacies are a concept that helps pharmacists and their teams to provide a wide range of public health interventions