Category: Opinion | Pharmacy in Practice

Why is pharmacy not integral to government mass vaccination plans?

Community Pharmacy should be an integral part of the government’s plan for a mass vaccination programme.

Why is it not?

It has become very clear that the only way the nation returns to some degree of normality is through an effective Covid vaccination programme. With this in mind, the key considerations for any such programme must be that of pace, scale and urgency.

It has become evident over recent days that the government’s own targets for vaccinations will not be met. The reasons for this current performance matter not, but it is important that the government now turns its attention to adopting a new approach and seeks support and assistance from those who can help.

Community pharmacy stands ready, willing and able.

The recent disclosure that one in four people in England live in an area without a vaccination centre is in stark contrast to the level of accessibility and localised provision of community pharmacy. Community pharmacies are situated in high street locations, in neighbourhood centres, and are often in some of the most deprived communities. Crucially, 89% of the population in England has access to a community pharmacy within a 20-minute walk.

There are approximately 14,000 pharmacies across the UK, all of which have a proven track record in supporting public health initiatives and in particular the very successful annual flu vaccine programme. Estimates suggest that community pharmacy could deliver close to 1.3M vaccines per week.

Pharmacists are skilled professionals with the right level of clinical training to undertake such a role, the network is well placed and has the required refrigerated supply chain in place to support. Pharmacists who currently deliver the flu vaccine each year have all undergone face to face training and will have met the necessary national standards and demonstrated appropriate competency. The annual flu vaccine programme has been successfully delivered for many years with community pharmacy playing a crucial role. In addition, the government’s own legislation in relation to the Covid vaccination programme enables pharmacists to administer the vaccine.

It is imperative that the government does not delay, ask community pharmacy for support now and you will get it.

You have a workforce which represents a fundamental part of the primary care network, a profession, that throughout the pandemic, has continued to provide care and advice to patients whilst ensuring the continued supply of valuable medication. When called upon, they will rise to the challenge once again. Making community pharmacy an integral part of this endeavour just makes good sense.

Nathan Wiltshire is Group Chief Executive at Cambrian Alliance Group. Cambrian Alliance Group represents the buying interests of over 1200 independent community pharmacies across the UK.

The great patient medication returns debacle

Johnathan Laird Serial Nudger

The amount of money drained from the NHS via the oversupply of medication must be staggering and largely unmeasured.

I’m talking about the at times mountainous piles of returned medicines that get handed into community pharmacy for disposal.

The great patient medication returns debacle.

If you’ve ever worked in community pharmacy you’ll know the routine. The bin bags approaching up the middle aisle usually unfortunately from a bereaved close relative. In my experience, these great excesses of prescription drugs handed back to the community pharmacy usually come to light after the passing of a patient. The sadness of the moment is balanced by the mortification of the family members returning said medicines.

The empathetic shake of hands happens as you try your best not to raise an eyebrow at the three bin bags of returned medication about to be handed over.

Insulin, inhalers and dressings are expensive patients returns but the winner is usually the unused diabetic test strips and lots of them.

This problem needs to be tackled. It’s a classic lose-lose situation all around.

At the beginning of my career, I really did get irate when this happened. And on occasion, I will admit this probably clouded my mood so that I did not provide the highest level of patient-centred care. These situations would often involve offering condolences which in my more formative years was difficult through a mist of outrage. I’m not really proud of these occasions because family members deserve the care of their community pharmacist at that moment shortly after a bereavement.

I’ve often wondered what the public would think if the amount of money that the NHS wastes in this way. What is the average prescription item value these days? Something like £10-£12 per item? I honestly think the general public don’t have any idea about the scale of this problem. Perhaps putting the problem into context might help.

And on the flip side the problem really is conveniently difficult to measure because the system assumes that every patient will be adherent to their medication all of the time.

Well as pharmacists we know that even the most engaged patients will struggle to achieve 100% adherence.

The causes will be multifactorial but no doubt free access to medicines drives a certain amount of volume. Market forces are at play too. There is also the trend towards ‘managed repeat’ services but that’s whole other opinion article altogether. I think any conversation about waste must bring the desire for pharmacy contractors to sign up loyal repeat prescription patients. A patient on a managed repeat prescription service will I’m told generate higher annual dispensing sales compared to those patients not using such a service. I guess it’s easy for me to pontificate given that I don’t currently own a community pharmacy that still depends on prescription volume for profit.

One of the reasons I decided to write this article was the link from this topic I made with the charge that was initiated for plastic bags supplied from retailers in recent years.

I remember working in a community pharmacy in Scotland when the plastic bag charge was initiated. I found it absolutely hilarious the lengths some folk would go to to avoid the 5p investment in a bag to ensure their walk to the car was comfortable. Instead that first year there was some heroic resistance to splashing out on the bag charge. Things have moved on from then because any form of the plastic bag would surely be frowned upon now due to environmental considerations.

Now that’s all very interesting to you I’m sure but the bottom line about the plastic bag charge idea was that it actually worked. The number of bags used by the pharmacy absolutely plummeted. I’m guestimating here but I’d say in the six months after the charge came in the usage of plastic carriers bags in the pharmacy dropped by as much as 80%.

The difference before and after implementation of the charge was stark.

I think that was probably an example of nudge theory. I highly recommend the book, surprisingly called ‘Nudge’, where these ideas have been articulated.

The first chapter of that book involves a little story about a school headmaster. Basically this headmaster was tasked with improving the levels of healthy eating amongst the youngsters at lunchtime. The headmaster was given no extra budget and his brief required student choice to be respected. His solution was to rearrange the cafeteria. He put the fresh fruit, veg and healthy options at the front and the chips, burgers and other less healthy options behind the screen at the far end of the room.

Much like in the plastic bag example the plan worked and he began to ‘nudge’ the children towards making healthier options.

So what is the ‘nudge’ solution that could be applied to our patient medication return problem?

Well unlike our headmaster striving for healthier eating choices we can’t really make it more difficult for patients to access or re-order their medicines in the first place but perhaps we could disincentivise it. At the very least I’d like to support patient education to such an extent that the decision to order is at least considered. There has always been the argument that some kind of charge on prescriptions would be draconian and to be honest I agree.

But the lever in the plastic bag success story was a monetary one albeit a very low-level charge. Perhaps the solution could be something simple like making the price of the medicine really clear to our patients or enforcing a nominal 5-10 pence charge per item.

I’m not sure what the answer is but what I am fairly sure of is that things can’t get much worse. Wouldn’t it be great if we could stumble upon a low cost ‘nudge’ type solution that tackles this issue once and for all?

This amount of waste has to stop so come on clever people answers on a postcard, please.

Johnathan Laird is a pharmacist who likes to think he is a serial nudger but probably often doesn’t realise he himself is being nudged.

What next for community pharmacists managing people with asthma?

I know 2020 has been all about ‘you know what’ but with vaccine deployment happening my mind turned to the future and also the past.

The topic of asthma deaths used to literally keep me up at night.

I thought I would revisit it and reflect on how things have changed for me but also more widely for community pharmacy in Scotland.

Looking back now five years on from when I wrote the article below I am no less moved by the terrible findings of the National Review of Asthma Deaths (NRAD) in 2014. The truth is we [all health professionals] are still letting people with asthma down.

One of the highlights of running PIP recently was the fact that I got the opportunity to interview and collaborate with Dr Mark Levy. Dr Levy was very much involved in the original NRAD document and continues to be a tireless advocate for the involvement of community pharmacists in the care fo people with asthma. We were therefore very proud that he took the time to contribute to a recent PIP webinar.

I defy anyone to listen to Dr Levy and not be moved by the stories of some of the people who have sadly passed away as a direct result of poorly managed asthma. Many of these people are children. It really is heartbreaking and something must surely change.

But what must change and can community pharmacy help?

Five years ago I wrote about how the Chronic Medication Service (CMS) offered considerable promise in our collective endeavours to literally save the lives of people with asthma who are at risk. The brief intervention model using independent prescribing that I advocated for all those years ago doesn’t seem to have caught on although pharmacists like Anna Murphy have advocated for greater community pharmacy involvement. As I mentioned on a recent webinar with Anna, the Simple Intervention™ she pioneered was work many years ahead of its time.

Rather than significantly invest in community pharmacy across the UK there has been a rush to fund pharmacists to work in general practice.

Not all conditions can be managed optimally via a formal sit down the appointment-based system. Brief interventions are useful and people with asthma, particularly mild asthma (although I hate that term), can benefit greatly by ‘little and often’ interventions. I think this is particularly true when this activity is delivered by a community pharmacist who has the autonomy to make appropriate interventions. Although I need to caveat that by saying that any independent prescribing activity in community pharmacy must be properly resourced. It must not be an opportunity to dump more responsibility on pharmacists with no extra investment in them through training, supervision and financial reward to them.

The article below published originally in January 2015 is a trip down memory lane and describes how I was attempting to put these ideas into practice.

The chronic medication service (CMS) in my view is a necessary step towards securing a future role for pharmacists within the community pharmacy setting in the UK.

There are two sides to the chronic medication service. There is the repeat supply of medicine via serial prescriptions and also the clinical side of the service in which community pharmacists provide pharmaceutical care for the patient. Both have merit. However, if I am being positive neither side has reached its full potential yet.

With this in mind, I presented a positive take on CMS at the recent Scottish National Seminar focusing on the clinical side of the service.

Based largely on the findings of the National Review of Asthma deaths 2014 (NRAD) I decided to exploit the unprecedented access to patients I have as a community pharmacist in an attempt to deliver some clinical returns. Many asthma deaths are preventable so I set about creating a simple plan to first find and then begin to manage the high-risk asthmatics that were failing to properly engage with my local general practice team.

Relationships and co-operation are key to the success of any multidisciplinary service. I did a number of searches of the surgery asthma list kindly facilitated by the practice team and my GP colleagues. I generated three searches:

Patients who had been prescribed salbutamol in the previous 12 months or had a diagnosis of asthma who had failed to attend their annual asthma review in the practice in the previous 12 months.
Patients prescribed more than 12 beta-agonist inhalers in the previous 12 months.
Patients prescribed oral prednisolone in the previous 12 months.

I used these searches in the community pharmacy setting to identify, intervene and conduct a mini asthma review with patients. I found a significant number of higher risk asthmatics that certainly needed support and better management. As part of the CMS service, I fed back my findings to the practice team so that they could be recorded in the patient’s record.
I should make it clear that the patients who did attend the surgery regularly were extremely well managed locally. However, if the patient did not choose to attend the practice, like many others, the surgery team are in a tricky position if they intend to support these patients. My little enterprise was a success because I observed that asthmatic patients were required to visit the pharmacy to collect their reliever medication.

There has been much talk recently of pharmacists working in GP practices. I think this, along with any other scheme that utilises the unique skill set of the pharmacist, is an excellent idea. However, I am much more in favour of the profession encouraging pharmacists to work in pharmacies to deliver clinical returns for patients and be paid accordingly for doing so.

I am now in the final planning stages of planning independent prescribing clinics to manage, amongst other groups, asthmatic patients within the community pharmacy. Combining these clinics with the CMS case finding the activity of high-risk asthmatic patients I have described above, will hopefully mean that my clinical list will be comprised largely of patients who cannot be reached by the GP practice team. Therefore I am not duplicating the good work that already takes place.

On the contrary, I am going after the higher risk asthmatics that require additional support.

I am hopeful that by taking the best bits of community pharmacy, unprecedented access, and combining them with a little basic clinical work I can deliver positive results for patients.

Reading that again I reflected on the urgency in my words. Time has passed but I still feel very strongly that community pharmacy must get organised and deliver a coherent set of services with the aim of literally preventing the deaths of people with asthma.

If I’m honest, trying to innovate and seize any form of professional autonomy at that time was exhausting. And all this activity before I met Dr Levy five years later who thought what I was doing was absolutely excellent. The result of this exhaustion was my move into the arms of my local GP practice where I worked for three years shortly after this. It is possibly a topic for another article but the speed of my professional development rocketed in this supportive environment where professional development was seen as the norm. And there was the investment to support this which to this day I really appreciate.

Back in 2015 the leadership noises coming out about CMS nudged me towards the promised land of managing people with asthma in the community pharmacy.

But was CMS a roaring success?

No, I don’t think so but I do think it was a necessary step to enable community pharmacists like me and encourage us to think more deeply about how our role needs to change. Some aspects of the service were fabulous and I know those behind it worked tirelessly to make progress with it.

For example, the notion that a community pharmacy should develop a registered population of patients was groundbreaking. I think the clunky computer system and the lack of simple focussed objectives meant the service petered out and reverted basically to become a repeat prescription service.

The launch of the NHS Pharmacy First service is a clever move for a number of reasons and was not on the go back in 2015 when I wrote this original article. The ‘lie of the land’ has changed and for various reasons, the direction of travel has moved away from supporting people with long term conditions towards more of a responding to symptoms approach. There is nothing wrong with this approach and I hope it is a great success but I do think to deliver the ambition will require much more investment than what is being offered despite the fact that the funding in Scotland for this service and others is much more generous than other areas in the UK.

We need to find ways to drive additional investment into community pharmacy in Scotland.

The confidence and competence required for a community pharmacist to work autonomously is significant. It takes time to develop consultation and clinical skills. As an optimist, I’m sure the structures around this will develop over time.

Much like the outset of CMS, I think NHS Pharmacy First is a necessary step and it is a very positive step in the right direction.

For me, pharmacy practise is about impact. What positive impact or contribution can I make to the patient in front of me? As a community pharmacist, you have the opportunity to keep hundreds of people safe, give sound advice, refer as appropriate and manage their condition if you are competent to do so.

Five years on I hope the next Chief Pharmaceutical Officer for Scotland looks again at the community pharmacy estate and leads them towards focussing on supporting people with long term conditions in the community.

I was wondering what I would like to achieve in five years and revisit this article again then. I think the answer to this is the fact that we currently have very little idea of what happens to medicine after it leaves the dispensing bench. The relationship between medicine and the patient still remains a mystery in my view.

In five years I would like to think pharmacists will have real-time data about how medicine is being used. Sure, this data will be patchy and incomplete, to begin with, but we need to use the community pharmacy network to go in search of these insights together and democratise that information.

There is no point identifying a high-risk asthmatic, making an intervention like increasing their inhaled corticosteroid dose if, in fact, their adherence is poor. Wouldn’t it be interesting to intervene months later and reengage that patient about their inhaler digitally if necessary.

Pharmaceutical care is no longer enough. The world has changed but the community pharmacy section of our profession is developing too slowly in my view. The shiny ideas like remote consultations benefit are the ‘red herrings’.

The future must involve a new speciality in pharmacy practise.

Technaceutical Care™.

Johnathan Laird is a pharmacist, independent prescriber, occasional agitator and eternal optimist.

Dropping the pre-reg exam – an overview of arguments

Greg Lawton

A rundown of some of the arguments advanced for dropping the pre-reg exam. In no particular order.

1. In employment law, you’re a pharmacist if you’ve worked as one.

Answer: In employment law, if you’ve had certain arrangements for a period of time, you can acquire the status of ’employee’ or ‘worker’. It doesn’t change your profession and has nothing to do with regulation.

2. There’s a global pandemic.

Answer: This is unrelated to the need for an exam. Other professions are not campaigning for their exams to be scrapped. They have sat them and understand why they’re needed.

3. Provregs will have practised for months, so surely it would be safe.

Answer: Absence of evidence of risk is not evidence of absence of risk. You’d have also been practising to be a pharmacist for 12 months as a pre-reg, but still some 25% fail the exam.

4. Provregs will have practised for months so surely they’d be competent.

Answer: In that case, the exam shouldn’t be a problem, and if they completed it, it would give the public the assurance that it deserves.

5. It’s been really challenging during Covid.

Answer: Everyone understands that, and they sympathise and empathise. But it’s not about you, it’s about patients and the public. The public.

6. The exam is just parroting the BNF, so it’s not required.

Answer: The content of the exam is a separate discussion. But if it was really just parroting the BNF, it shouldn’t be a problem as all you have to do is demonstrate that you can use the reference source.

7. Pharmacists are saying “we had to do an exam, so should you.”

Answer: Have any really said that, or is that what you think they think? If they have, they’re missing the point. It’s about the public, not what they had to do.

8. Pharmacists won’t treat us the same if we don’t sit the exam.

Answer: See the last sentence in no. 7.

9. There are pharmacists on the register who didn’t sit an exam.

Answer: Practice evolves. Before 1868, people didn’t need to be pharmacists or have a degree to sell dangerous drugs. So by extension of your logic – if it was once okay then it must be now – we could do away with the degree and the profession too.

10. I’m busy, I don’t have time to sit it.

Answer: Working life do be like that, but it’s not about you. It’s about the public. The public. The people you’re joining a profession to care for and protect.

11. They shouldn’t have put us on the register in the first place if they were going to insist on an exam!

Answer: Necessary or not, it was always provisional, a balance of risks in a global pandemic. You accepted this, along with other conditions, when you voluntarily applied to join the register, and have been paid for your role.

12. There haven’t been any FtP issues to date, so what’s the problem?

Answer: Evidence of this? FtP cases can take two years to progress. Also, it’s not about immediate FtP issues being apparent, but risk.

13. Employers would support this too! They’d sign off the provregs!

Answer: I’m sure they would, they’d have a vested interest in it.

14. Provregs have done a stellar job during the pandemic.

A: Notwithstanding their commendable efforts during the pandemic, this is unrelated to the need for an exam.

15. I’ve worked in hospital, I’m confident I’ll pass.

Answer: Think beyond yourself. The discussion is about the entire cohort.

16. I’ve had pharmacists telling me I’m right. In fact, they’ve even liked and retweeted what I said!

Answer: Welcome to pharmacy Twitter, where some people’s self-interest, self-promotion and narcissism know no bounds!

The points from 17 onwards were added on 28.9.2020 in response to the counterpoints made by Jonny Blatchford in a letter to the editor that you can access here.

17. The exam is just about memorizing information.

Answer: The exam is partly about memory. The same is true of your Uni exams, A-Levels etc., but that doesn’t devalue them. More significantly, the exam also tests your ability to use reference sources, understand scenarios and apply knowledge. It’s part of assessing whether you’ve met the learning outcomes for pharmacists’ initial education and training.

18. Memorizing information doesn’t reflect practice.

Answer: Clearly, memory plays an important part in practice. It is by no means the only important facet for pharmacists, but knowledge without needing to refer to reference sources on every occasion is important.

19. It is inaccurate to say that other professions have sat exams.

Answer. My understanding of the regulatory requirements for the UK and overseas doctors, dentists, nurses, solicitors and barristers is that the usual exams will remain a requirement before full or permanent registration.

20. The exam should be scrapped but we will prove competence in a different way.

Answer. How? It seems that a signoff of competencies wouldn’t be appropriate as this has already been done – 25% fail AFTER this signoff has been made. The tutor’s friend in the same business or organisation may be influenced to sign you off such assessments are subjective in any event. Not all pre-regs receive the same experience, training and opportunities, so the exam provides a fundamental baseline to ensure all candidates meet core criteria at the point of registration.

21. People could cheat if it was done online!

Answer: Online proctoring may be an appropriate solution. You use your webcam to show your ID and demonstrate that the room is empty, and are observed throughout. The exam can be done in a controlled software environment which prevents other applications from running at the same time. I understand that some providers can proctor large numbers of students (e.g. 2000) simultaneously, but due diligence would be needed on the provider. It may be that the exam needs be done in person when safe to do so, and socially distanced (c.f. the approach being taken in schools) with PPE as necessary.

22. If I sat the exam, I’d have to sit with 1000s of students during the Covid crisis!

Answer: Is it done surrounded by thousands of people, normally?

23. I have anecdotes from lecturers who recall that they sometimes worry about the ones who pass.

Answer: The system may let some people through who have FtP issues. This doesn’t mean that the exam (and, by extension of your logic) the pre-reg and the degree should all be scrapped.

24. Practice has evolved so maybe we shouldn’t have to sit it.

Answer: The reason you didn’t sit is Covid. Practice has not evolved so substantially since August (the date of provisional registration) that the exam is now no longer necessary for your cohort all of your training up to this point was tailored and geared towards an endpoint, on the understanding it would be supplemented by a pre-reg exam at the end – and you can’t change your earlier training retrospectively.

Greg Lawton is a pharmacist specialising in patient and medicines safety, staffing, data protection, privacy and healthcare policy. This piece is short and concise because it originally appeared on Twitter as a thread and has been reproduced with permission. You can find Greg on Twitter here.

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Resilience initiatives deflect blame

Initiatives focusing on resilience as a solution to workplace stress suggest that the person experiencing the stress wouldn’t suffer so much if they were more resilient.

The blame for the stress, therefore, is placed on the individual for not being resilient enough. It’s not helpful at all to sufferers and in fact, may make them feel worse.

We need to tackle the root causes of workplace stress, but doing so is often against the interests of those responsible for the working environment. Some people or organisations keep the focus on resilience deliberately.

If any questions are asked of how they’re tackling workplace stress, a shiny document focusing on “resilience” deflects the blame back on to the sufferers, and away from their own responsibilities to address the root causes.

Where people and organisations spend enough time around others who take that approach, they can become infected with the same mentality.

They may become willfully blind to the root causes – essentially, captured by those with vested interests in keeping the focus on resilience. Or, they may simply not care what it does to the sufferer.

Bear in mind that the sufferers will include those with clinical mental health conditions. So when you think about it, taking an approach which places the blame upon them at a time they’re looking for help is pretty sick.

Point these issues out to the proponents of resilience, and they may insist that it’s a good thing – benign. But such insistence does nothing at all to change the impact on the sufferer.

I recently read the following:

“When things come into your head, take out a notebook and jot them down, then forget about them until it’s worry o’clock… At a specified time in the day, allow yourself time to worry; this should be no longer than an hour.”

Let’s just break that down.

Instead of asking why professionals are stressed in the first place, it’s asking them to *actually schedule in time to worry*. And to take time out of their probably-already-busy-day to do it.

Far from addressing the root causes of workplace stress – the workplace or environmental factors – this approach normalises stress and places responsibility for planning to be stressed on the sufferer.

It appears to be a new low.

The suggestion that all their worries can be contained into a 1-hour slot each day betrays an absolute lack of understanding of stress and mental health issues. Hopefully, nobody reading this would provide such advice to a depressed or anxious patient.

It’s not necessary to name the proponents of this stuff, but it needs calling out publicly because it risks damaging the cause they’re meant to represent.

Because here’s the irony: it hasn’t come from those with a vested interest in shifting the focus, but rather, some of the proponents of this actually have a responsibility for helping people to address workplace stress.

Which means that not only is the workplace broken for the sufferer, but the advice is broken too.

What hope have they got?

Before anyone suggests “have you emailed the proponent privately about it” – check yourself. It’s against the interests of an organisation to withdraw something like this and apologise for it when it’s pointed out.

Also, once they’ve published it, they’ve made it public themselves – so that’s where the debate needs to be, so that any sufferers thinking “what the actual…” know that they’re not alone in finding it ridiculous.

This is an opinion piece by Greg Lawton who is a pharmacist.

How 56 community pharmacies helped to eradicate hepatitis C

In response to the following article:

“Community pharmacy key to hepatitis C eradication in Tayside”

Dear PIP Editor,

56 community pharmacies across three Scottish Health Boards from Tayside, Grampian, Greater Glasgow and Clyde, took part in the evaluation of a community pharmacy pathway.

The community pharmacies invited people attending their pharmacies and who were prescribed opioid substitution therapy to take a test for Hepatitis C, Hepatitis B and HIV.

The pharmacists diagnosed on-going Hepatitis C infection using a PCR test and reviewed of a panel of blood tests including liver function tests. They performed a liver fibrosis risk assessment test (FiB-4) from these test results and determined whether the patients could start treatment.

Prescriptions for the direct-acting antiviral medicines were either written by independent pharmacist prescribers or provided using a Patient Group Direction. The pharmacies then administered the treatment each day alongside the patient’s methadone or buprenorphine prescription.

Our evaluation of the views and perspectives of the staff taking part showed that they thought the opportunity to provide this care was a valuable addition to the range of services they offer. Pharmacists appreciated the opportunity to provide a wider range of clinical services and to help the patients attending their pharmacy practice to a greater extent.

The studies that evaluated this pathway showed that approximately twice as many people accepted the offer of a test from a pharmacy than from other services. And these patients were approximately twice as likely to achieve a cure for their hepatitis C infection than from other standard routes of care.

Our evaluation showed that the long-term trusting relationship with pharmacy staff, the local situation of the pharmacy within a community and the on-going reason to attend the pharmacy were key factors in this success. Patients did not need to find the money for bus fares or navigate their way around an unfamiliar hospital.

As a consultant in public health pharmacy, my role is to maximise the value that we achieve from the pharmacy and medicines resource.

Working with Professor Dillon’s Liver Group at Dundee University has created a range of opportunities for our work to showcase the health gain that can be achieved by investing in pharmacies and empowering pharmacists to deliver clinical services. My role was as Principal Investigator for the SuperDOT-C study that was led from NHS Tayside and to work closely with community pharmacy colleagues responsible for delivering this care.

NHS Tayside has a reputation for innovation and for pioneering new ways of caring for its population. The hepatitis C work has demonstrated that strong clinical leadership and multidisciplinary working, harnessing the contribution of the wider team, can provide world-beating outcomes.

Community pharmacies are present in each community and provide an accessible point of care for local people. We have shown that by utilising the community pharmacy resource, many of the barriers that prevent some of our most vulnerable groups accessing effective healthcare can be reduced.