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Counter culture

Counter culture
23 April 2015

Results have shown that urgent and emergency care can be improved when pharmacists’ skills are utilised

There are more than 40,000 pharmacists and around 11,500 pharmacies in England. Ninety nine per cent of people can get to their local pharmacy within 20 minutes by car and 96% by walking or using public transport – so they are extremely accessible. Many pharmacies are open long hours, many are open when GP surgeries are closed. But the NHS is not making the most from this resource.

Results have shown that urgent and emergency care can be improved when pharmacists’ skills are utilised

There are more than 40,000 pharmacists and around 11,500 pharmacies in England. Ninety nine per cent of people can get to their local pharmacy within 20 minutes by car and 96% by walking or using public transport – so they are extremely accessible. Many pharmacies are open long hours, many are open when GP surgeries are closed. But the NHS is not making the most from this resource.

A key issue with the current growth in waiting times for A&E services is the number of people with conditions that could be treated elsewhere but who use A&E services as an alternative source of healthcare. Some people view A&E as a valid first point of contact with the NHS. Incorporating pharmacists more fully into the delivery of urgent and emergency care would have a substantial impact on A&E waiting times and improve the care for patients.

In 2012/13 there were 27.1 million attendances at emergency departments, minor injury units and urgent care centres and these attendances have increased by 32% since 2003/04. It is estimated that 8% of emergency department attendances could have been managed by a pharmacist equating to 1.5 million visits annually. Alongside this there were 5.2 million emergency admissions to England’s hospitals in 2012/13 and these have increased by 40% since 2003/04. [1]

Saving the NHS money
A recent study[2] looked at where people went when they, or a family member, had a common ailment. The results for the patient were equally as good wherever the patient was treated, be that A&E, GP surgery or community pharmacy. It is estimated that if all common ailments were treated in a community pharmacy, rather than a GP surgery or A&E, this could save the NHS around £1.1 billion per year. The cost of treating common ailments in community pharmacies was found by the study to be £29.30 per patient. The cost of treating the same problems at A&E was found to be nearly five times higher at £147.09 per patient and nearly three times higher at GP practices at £82.34 per patient. More than 51 million GP consultations, which is 18% of all GP consultations, are for common health problems such as coughs and colds, headaches, indigestion and skin problems, all of which could be dealt with competently in a community pharmacy.

Nationally, NHS England has raised public awareness of community pharmacies as a place to go for common ailments with its Feeling Under the Weather[3] campaign that is proving successful. Locally, some clinical commissioning groups (CCGs) have been running their own campaigns, for example CCGs across Northumberland, Tyne and Wear, Durham, Darlington and Teesside have been working together on a winter campaign, which uses the key message: “Keep calm and look after yourself.”[4] A key highlight of the campaign evaluation showed that 24% would change their behaviour as a result of the campaign and would start using NHS services appropriately. This equates to 24,000 people across the north east stopping using A&E inappropriately, a saving of nearly £1.4 million. For every £1 invested in the campaign, £16.38 was saved on inappropriate NHS use.

The role of the pharmacy
But pharmacists can do more to ease the pressure on urgent and emergency care (U&E) services. In a number of CCGs across the country, community pharmacies have been commissioned to deliver services that support people when they have run out of their medicines – commonly known as pharmacy urgent/emergency repeat medicines schemes. In West Yorkshire this service is linked to NHS 111, which refers patients to local pharmacies rather than to the GP out of hours (OOH) service. Results from this service show that if it had not been available patients would have gone without medicine (21%); contacted their GP practice (21%); contacted OOH service (38%), visited A&E or an urgent care setting (21%). Some patients did not answer this question. Bradford CCG also commissioned a Pharmacy First scheme where patients and the public are encouraged to use the community pharmacy as a first port of call for common ailments.

A similar scheme has been commissioned across 13 CCGs in the north east of the country. As well as patients being referred via NHS 111 there is also a walk-in element to this scheme. During the first month of this scheme 568 patients were referred from NHS 111 and 759 patients attended the pharmacy themselves. The total cost of three months NHS 111 activity in GP OOH service (if tariff based) is £107,914, whereas the total cost of three months NHS 111 activity in community pharmacy is £22,120, equating to potential savings (if contracts are tariff based) of £85,794 over three months alone. When patients were asked where they would have gone had the pharmacy service not been available 10% would have gone to A&E, 34% would have gone to an urgent care or walk-in centre and 48% would have gone without medication. So this service also eases pressure on other parts of the urgent care system.

Community pharmacies can be used to provide flu vaccinations to patients who are eligible for a vaccination under the NHS criteria. They can also provide a private service to patients. CCGs across London have commissioned their local community pharmacies to provide flu vaccinations in order to help them meet their targets. During 2013/14 community pharmacies provided just over 10% of the flu vaccinations locally across five CCGs. Patients find services provided by pharmacists more convenient as they do not have to get appointments and can just walk in and get their flu vaccination.[5]

The role of the CCG
CCGs also need to support community pharmacies to ensure that the services they provide, particularly during the out of hours period, are fully integrated with the local NHS 111 providers and are an end point as part of the Directory of Services. For example, people requiring emergency hormonal contraception could go to their local community pharmacy and receive a quick, convenient and high-quality service, rather than being referred to an OOH GP or A&E, which will involve a delay in receiving treatment.

So there is a lot community pharmacies could do to help ease the immediate pressure on the urgent and emergency care services. CCGs need to work collaboratively with their community pharmacy colleagues to make this a reality across the country.

Pharmacists working in secondary care also have a role to play. Health Education England (HEE) West Midlands have conducted pilot work with pharmacist prescribers in a number of West Midland emergency departments. Early evidence suggests that a significant number of patients coming into A&E may be dealt with by a pharmacist prescriber who has been trained in advanced U&E care.

It has been demonstrated that pharmacist prescribers in urgent care settings such as walk in centres could see and deal with 43% of patients.
HEE has announced a national pilot of pharmacists working in A&E and a large number of hospital trusts applied to be part of the pilot. Around 53 hospitals have been selected to take part.

One of the other problems that affects the provision of U&E care services are the issues around discharge, explained well in a King’s Fund animation.[6]  Pharmacists have a significant role to play in preventing hospital admissions by providing medicines optimisations services such as medicine use, reviews on discharge, and assessment of patients experiencing polypharmacy etc to prevent admissions and readmissions. There is also much pharmacists can do to provide healthy living advice and support for long-term conditions (LTCs) to prevent LTC urgent/acute admissions. Some of these are outlined in the Royal Pharmaceutical Society briefings[7] ((Improving pharmaceutical care in) care homes, (Pharmacists and) GP surgeries, (Pharmacist-led care of people with) long-term conditions and Improving urgent and emergency care through better use of pharmacists).

CCGs and pharmacies talking
So, how can CCGs engage with their local pharmacists to start conversations about the delivery of urgent and emergency care services? Currently, every area team has a local professional network (LPN) for pharmacy. The chair of the LPN would be a great person to engage with to start these conversations and a list of contacts can be found at:

The LPNs engage across the pharmacy profession, including with pharmacy contractors, hospital trusts, local universities and individual pharmacists working in primary care, community pharmacies and secondary care.

Pharmacists, particularly those working in community pharmacies, can significantly contribute to the bottom line and deliver better patient care. If you are considering redesigning urgent and emergency care pathways locally don’t forget the role that pharmacists can play across the system.

Heidi Wright is a registered pharmacist and is now practice and policy lead for England at the Royal Pharmaceutical Society.

1.    National Institute for Health and Care Excellence (NICE) Acute Medical Emergencies, Service Guidance. (accessed 26 March 2015).
2.    Pharmacy Research UK. Community Pharmacy Management of Minor Illness (accessed 26 March 2015).
3.    NHS England. Feeling Under the Weather (accessed 26 March 2015).
4.    NHS Choices. Keep Calm and Look After Yourself  (accessed 26 March 2015).
5.    Claire Anderson and Tracey Thornley (2014) “It’s easier in pharmacy”: why some patients prefer to pay for flu jabs rather than use the National Health Service  BMC Health Services Research 2014, 14:35.
6.    King’s Fund An Alternative Guide to the Urgent and Emergency Care System in England (accessed 26 March 2015).
7.    Royal Pharmaceutical Society (accessed 26 March 2015).

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