This time last year…

Philip Galt is Superintendent Pharmacist and Managing Director at Lindsay & Gilmour.

 

This time last year, it would have been impossible for any of us to imagine just what challenges lay ahead in the coming months.

 

In truth, it’s hard to overstate what a significant year this has been for community pharmacy in Scotland. More than ever I have watched with pride as colleagues across the community pharmacy network have worked together tirelessly to offer nothing short of a lifeline to some of the most vulnerable members of our communities at a time they needed us most. And it’s not gone unrecognised.

 

National polling carried out by the National Pharmacy Association in June found that there is strong public support for a greater role for pharmacies within the NHS.

 

  • 74% want pharmacies to provide more NHS services.
  • 89% of people believe pharmacies play an essential role.

 

Yet at the same time, the survey reported that only 3 out of 10 people are “definitely aware” that community pharmacies are part of the NHS, despite the fact that pharmacies are the most visited of all settings where NHS care is offered. Indeed, throughout the pandemic community pharmacies were one of the few healthcare settings that kept their “doors open”, providing much needed, face to face convenient access to healthcare services to the public.

 

Community pharmacies provide a range of NHS services and pharmacy teams work with other professionals, such as doctors and nurses, to give you the best possible care as part of the local healthcare team.

 

Community pharmacists demonstrated incredible resilience and fortitude from the front line of the COVID crisis, ensuring that as many people with minor medical needs and long-term conditions were kept safe at home. At Lindsay & Gilmour, both our online prescription management service and free home delivery service grew in demand exponentially.

 

This, in turn, played a vital role in protecting hospital beds and secondary care resources available for those who were directly affected by COVID-19.

 

The recent introduction of NHS Pharmacy First Scotland means even greater access to your community pharmacist to discuss a wide range of health and healthcare issues, not just about medicines. Sometimes people go to a doctor or even a hospital for problems that could be sorted out more conveniently at the pharmacy. It’s estimated that up to 18 million GP appointments per year and 3.7 million A&E visits could instead be handled in a pharmacy.

 

So please, do remember to Ask Your Pharmacist for:

 

  • Advice and treatment for minor illnesses such as coughs, colds and earache
  • Advice on staying well and preventing disease
  • A range of vaccinations
  • Help to quit smoking
  • Personalised support to get the most from your medicines

 

Pharmacy teams deliver prompt, professional health care advice when and where it is needed. The community pharmacy network in Scotland and beyond is a precious resource. We are proud to be part of the NHS team and privileged to be able to serve our community.

 

Philip Galt is Superintendent Pharmacist and Managing Director at Lindsay & Gilmour.

 

 

Community pharmacy volunteer delivery service ‘doomed to fail’

 

Community pharmacy contractor Mike Hewitson has responded to the announcement of the essential and advanced delivery services in England on Good Friday evening last week. The services are to involve community pharmacy contractors engaging with volunteers to deliver medicines. 

 

“The pandemic community pharmacy delivery service is not worth the paper it’s written on.

 

“Essentially if you can find the one person in a thousand that probably qualifies for a funded delivery then you’re a better person than me.

 

“This is too little too late.

 

“This is a slap in the face to all the community pharmacy teams that have been working their socks off over the last four to six weeks.

 

“I’m fed up.

 

“I’m just fed up.

 

“This is just rubbish.

 

“The services urgently need a rethink. The plan to use volunteers in this way urgently needs to be reviewed. I think in its current form it is doomed to failure. The problems with volunteers have been widely discussed now. It’s not just me that feels like this.

 

“Essentially the only time we are going to be able to deliver to a patient is:

 

  1. If they qualify as shielded, which is only a tiny minority of people who are a) stuck at home at the moment and b) that want delivery.
  2. They have to be unable to get a friend, relative or a neighbour to collect their prescription for them and in the event that they can’t.
  3. They have to be a position that there is no volunteer available. That is not just the NHS national scheme but also local schemes and community schemes.

 

“The service is just a joke and this is going to create a massive additional workload because the obligation is on us.

 

“So, we have to go and find the volunteers.

 

“That means that you’ve either go to log on to one of the volunteer apps to source a volunteer and if you’re in a rural area like ours there is absolutely no guarantee you are going to find somebody when you want them.

 

“Then you have to manage those logistics so you’re going to have to make additional phone calls. You’re going to have to then make an assessment when the patient comes in.

 

“This is the real cherry on the cake which I can’t believe.

 

“The pharmacist has to make a decision as to whether they feel that person is an appropriate person to do delivering medicines.

 

“It’s not clear what happens if we don’t think they are so what do we have to do?

 

“Find another volunteer?

 

“Deliver ourselves at that point?

 

“It doesn’t specify. This is just nonsense. This is a complete waste of everyone’s time and effort. I can’t believe we’ve waited a month for this.

 

“From where I’m sat this looks like a bad deal. Personally, I think I’d rather the powers had be had left it to be honest because it just leaves us in a whole worse situation that we were in before.

 

“Now we’ve got an obligation to deliver to people, though in my case as a rural contractor we’ve got some people that are seven or eight miles away and your taking about a 14-mile round trip potentially to deliver one urgent antibiotic to somebody.

 

“Well you know you can forget this service being anything other than a massive loss to contractors.

 

“Now I obviously understand that these are difficult times, I understand that there are people in a lot worse positions than us but likewise, I don’t want to have to fund everything from the patients that don’t qualify for the NHS funded delivery through to the ones that do.

 

“It’s just unbelievable.

 

“So where do we go from here?

 

“I don’t know.

 

“The obligation is now in our terms of service so we’ve been stitched up like a kipper on that one. I honestly feel like telling them to go shove it. You know we’re all reasonable people, we all put our patients first I know that.

 

“If anyone has an answer to this impossible question please let me know because I honestly don’t understand how I’m going to make this work.

 

“And of course, it was dropped on us at 7:30 pm on Good Friday. Absolute disgrace.

 

“We’ve been left in an impossible spot where we’re being the last line of defence and we’re the ones that are going to end up picking the deliveries no one else wants to do.

 

“And we’re going to end up doing that at a massive loss.

 

“I’m sorry that this service continues to be a shambles.

 

“I can’t really say any more than that.”

 

Mike Hewitson is an independent pharmacy contractor. He is also a Councillor for Stoke & Norton Sub Hamdon, South Somerset District Council. His views are his own. 

 

We previously spoke to solicitor Andrea James on the PIPcast about this very topic. You can access that conversation here.

 

To read more about the new essential and advanced community pharmacy delivery services click here.

 

 

 

Dr Edward Snelson on examining childrens’ throats during the pandemic

 

As increasing evidence comes out of the countries hit worst by the COVID-19 pandemic, there is growing concern about the number of healthcare workers being affected. A large number of COVID-19 positive tests in Italy (currently about 10%) have been healthcare workers.

 

It is important to emphasise that these statistics will inevitably have at least some bias. Healthcare workers are much more likely to be tested for COVID-19.

 

It is a concerning figure nevertheless and it is well known that healthcare environments are inherently risky when it comes to acquiring an infection.

 

There are three main ways to avoid getting an infection as a healthcare worker. The first is to avoid patient contact where possible. The second is to use appropriate personal protective equipment as per guidance. The third is to minimise the risk of the clinical encounter.

 

Over the past few weeks, there has been a growing discussion amongst frontline clinicians about a radical cultural change in clinical practice.

 

We have been asking the following question:

 

Should I stop examining children’s throats?

 

Like any such suggestion, the first time the question was asked out loud was probably in a one-to-one conversation in a closed room after checking that the General Medical Council hadn’t bugged the place. Then, as the question was asked more and more, it became quickly apparent that there was a large proportion of frontline clinicians who felt that this was a sensible move in the current situation.

 

On 25th March 2020, the RCPCH published guidance stating that in the current situation “the oropharynx of children should only be examined if essential.”

 

Never before in my career have I seen such a change in practice go from whispers between colleagues to official college guidance in such a short period of time. Well done RCPCH! For the first time since the introduction of FAOMed, you’re ahead of us!

 

While this move is entirely intended to reduce the risk of clinical contact during the COVID-19 pandemic, clinicians will at the very least have questions. When something is part of our routine and then taken away from us it will cause anxieties. As acute clinicians, our intuitive thinking relies on a reasonably consistent approach and in most paediatric encounters, we are used to looking in the throat.

 

So the question is, is it OK to stop doing that routinely?

 

Here are a few common questions in response to this radical change.

 

What if I need to know what the focus of infection is?

 

Good question.

 

This has always been a hugely subjective issue. Even before this pandemic, the majority of clinicians and organisations have been trying to encourage self-care for uncomplicated febrile illness in children. If a clinical confirmation of infection focus was essential, health care organisations would be getting the message out.

 

“Never give your child fever medicines without seeing a doctor to check what the problem is.”

 

That’s not a thing.

 

A snotty febrile child has an upper respiratory tract infection (URTI). URTI does not exclude other infections nor does it exclude sepsis so the redness of the throat should not reassure us if we think a child has another probable diagnosis such as UTI, LRTI or sepsis.

 

The important question has always been, “does this child have signs of serious bacterial infection or sepsis?”

 

If the answer is no then the throat exam won’t really change things (see below).  If the answer is yes, you’re looking for a source and it probably isn’t in the throat.

 

 

When might I need to examine the throat?

 

The necessity for this is probably going to be mainly to look for evidence of a significant pathology such as peri-tonsillar abscess.  I would suggest that such a possibility can be all but excluded clinically if a child is well analgesed and is able to eat or drink.
If you do feel that examining the throat is important to do, you must wear eye protection.

 

Don’t I need to determine if the child has tonsillitis?

 

Tonsillitis in children can always be treated symptomatically. The NICE guidance for treating sore throats attempts to direct the clinician toward cases where a symptom benefit from antibiotics is more likely but does not mandate the use of antibiotic in any uncomplicated URTI or tonsillitis. The reason there is no mandate is that there is no evidence that in this era in the UK, antibiotics prevent the rare complications of URTI/tonsillitis.

 

Regardless of clinical findings, the symptom benefit from antibiotics is poor. The lack of evidence for the significant benefit has led the Children’s Hospital Melbourne to recommend no prescription of antibiotics in any case apart from high-risk children or signs of complicated URTI.

 

So if the child is low risk (99.9% of children) and has no signs of complications from the infection, the visualisation of the tonsils is non-essential.

 

Should I, therefore, prescribe antibiotics empirically?

 

In the interests of openness and honesty, I need to say first that the RCPCH does advocate this. There is a reminder that under the age of three years old, FeverPAIN should not be used. Over the age of three, it is proposed that in the current climate we prescribe antibiotics as follows.

 

“If using the feverpain scoring system to decide if antibiotics are indicated (validated in children 3 years and older), we suggest that a pragmatic approach is adopted, and automatically starting with a score of 2 in lieu of an examination seems reasonable. 

 

Children with a total feverpain score or 4 or 5 should be prescribed antibiotics (we suggest children with a score of 3 or less receive safety netting advice alone)”

 

I’m going to stick my neck out and suggest that this approach is wrong, for the following reasons:

 

  1. First and foremost, it contradicts the public health approach to containing the COVID-19 pandemic. People are being told that if they have a fever without signs of something that looks like a serious illness (difficulty breathing, poorly responsive etc.) they should stay at home, self-medicate and not seek a face to face clinical contact. This is for their benefit, to protect the health service and to reduce the spread of COVID-19. Lowering a threshold for prescribing antibiotics for sore throat at this time goes against that move.
  2. Secondly, the RCPCH has misquoted the NICE guidance. In their speediness to protect clinicians from unnecessary risk, they have missed a word. Just the one but it the word from the guidance that frequently goes unnoticed. That word is consider’. It doesn’t say give’ antibiotics for a FeverPAIN score above 4. It says consider. I consider that question every time and in most cases the answer is “The likelihood of benefit from antibiotics does not justify the risks.”  

 

I feel (personal opinion) that since there is no mandate to treat low-risk children who have no signs of complications of their URTI or tonsillitis, we should default to not prescribing antibiotics in these cases. To lower our threshold for prescribing instead of raising it at this time of such a high-risk clinical environment feels wrong. It seems contrary to the need to protect children and their carers from the risks of a visit to a GP or hospital and it feels contrary to the drive to reduce the number of people bringing COVID-19 with them to those places.

 

Again, huge respect to the RCPCH for cutting through the red tape and rapidly producing guidance to protect healthcare workers.  Whenever something is done in that sort of timeframe, it is likely that detail gets missed.  That’s where we come in.  We notice the typos and consider the implications.  We ask questions that deserve answers after the fact in lieu of the consultation period that couldn’t happen due to the timescale needed.

 

Edward Snelson
@sailordoctor

 

You can view Edward’s excellent blog by clicking here.

 

 

A pre-registration year of uncertainty, concern and turmoil

 

Who knew that ‘coronavirus’ would become a serious disrupter to my pre-registration training?

 

Not one person, except Bill Gates, could have predicted or imagined this novel global outbreak. The pandemic is here to stay for some time and this is a cause for concern to everyone. For me, my future in community pharmacy and qualifying as a pharmacist is now uncertain.

 

What, where and when will my role be later this year?

 

Evidently, COVID-19 is a cunning virus and spreads like fire across the world. Its impact has brought unmanageable psychosocial, educational and economic disruption globally. COVID-19 mortality rates are currently exploding. I and many thousands of trainees from all four countries that make up the United Kingdom are now feeling the uncertainty with regards to the lockdown on our current training cycle.

 

One evening, in March I vividly recall looking out my bedroom window. Whilst, heavy rain was hitting my window I could hear the raindrops.

 

What was echoing in my ear was will this virus hit my goal to be a registered pharmacist in 2020?

 

Everything seemed so troublesome and the chances of me joining the pharmacy register were diminishing. I felt that this ‘virus earthquake’ was going to send rippling shock waves to my training events and it was becoming a cause for concern. Thousands of trainees and I were sitting on the edge of our seats for a decision. I sought pharmacist support from the middle east and got hope. On Thursday afternoon, the big news I was waiting for came my way.

 

A joint statement from the PSNI and GPhC said:

 

”The GPhC and PSNI are now working as quickly as possible to develop plans for the period between now and the rescheduled assessments, including the possibility of a form of provisional registration for current preregistration trainees”.

 

Further, to this, the statement from the Royal Pharmaceutical Society, Gail Fleming, Director for Education and Professional Development said:

 

“We fully support the decision by the GPhC to postpone the forthcoming registration assessments in June and September. We support the concept of provisional registration which will enable trainees to progress without adversely affecting workforce numbers”.

 

So what is the future for us pre-registration pharmacists? Should we now call ourselves pandemic provisional pharmacists?

 

This news was the right move by the regulators to postpone the registration assessment due to the outbreak. Clearly, we trainees can’t control the situation we are facing. Nevertheless, we can support the profession in the coming months we joined many years ago. This summer, we won’t be qualifying and any plans to have the provisional status launched will require strong supporting mechanisms in place from the professional organisations, regulators and our tutors.

 

The key questions for me are as follows:

 

  1. How will I be protected?
  2. What support will I have?
  3. Based on reaching competencies?
  4. What will my scope of my practise be?

 

Hopefully, if the plans do go ahead, regulators and professional bodies would need to provide us guidance of our provisional ‘job description’. Maybe, bring in support to tutors to helps us facilitate the planned transition. Any proposed action ought to be soon so we can be fully prepared and use the current time to discuss this with our supervising tutors. March was an uncertain month.

 

Now, we need the certainty of our future role and to march forward to support pharmacy.

 

This article was written by pre-registration pharmacist S. Singh. 

 

 

New York pharmacist on how COVID-19 is killing his patients

 

Dear Pharmacy in Practice Editor,

 

SARS-CoV-2 has officially infiltrated my life.

 

Outbreaks, epidemics, and pandemics…those are events that only occur in third world countries or movies, right?

 

Well, that is what I thought when I used to hear those words thrown around in the past. In the last two weeks, it feels as though my world and everyone else’s has been flipped upside down due to COVID-19, and this pandemic has hit too close to home.

 

The types of patients in the intensive care unit (ICU) in which I practise has significantly changed.

 

The ICU has literally converted from a Cardiac ICU into a COVID-19 ICU.

 

In just a week, my service has gone from having just two COVID-19 positive patients to 16. Almost all of the patients with the virus who become critically ill have ended up with severe respiratory failure, shock, multiorgan failure, and in some, death.

 

Management of these patients has been challenging from every aspect of their care because there are many unknowns when it comes to optimal medication therapy, environmental precautions, and shortages of both medications and personal protective equipment.

 

The health care system is already getting strained, supplies are running low, personnel are being forced to work remotely to prevent the spread of the virus, and people are dying.

 

My daily routine has changed significantly and I’ve experienced some of the most emotionally difficult days I’ve ever had in my life in such a short period of time. One thing that has not changed is my passion for providing patient care to critically ill patients and educating the future of pharmacy.

 

Although most of the news regarding the struggles of healthcare workers such as physicians and nurses have been highlighted in the media, pharmacists in the community, hospital and academic settings have also been gravely impacted. As quickly as the virus has spread over the globe, the number of changes that have occurred in my life as well as many other pharmacists’ lives, have spread just as fast.

 

Academic and medical institutions in New York have been scrambling to come up with policies and procedures in order to be prepared to keep healthcare workers and students safe from the virus, as well as to provide care to the increasing number of patients that have been flooding the hospital systems. Cases of COVID-19 positive patients have been at least doubling every day, and many patients are requiring ICU level of care to support them.

 

Over the last two weeks, recommendations, policies, procedures, and etc. have been changing constantly, which has made coming up with contingency plans for myself, my students, and my patients very challenging. A plan that had been finalized one minute was necessitating either modification or complete overhaul the next.

 

Many hospitals have suspended experiential education of all disciplines.

 

Universities have converted to online teaching for the rest of the academic year. As you can imagine, this has resulted in immense stress and frustration for clinical faculty such as myself who both practice and teach. COVID-19 has forced me to become a remote clinician and educator, which was an unthinkable thought before the pandemic. Developing contingency plans for my students and maintaining my clinical services at my site has been both challenging, stressful, and emotional.

 

As a critical care clinician, physically being at the bedside of my patients and rounding in the ICU with my team is what I love to do and how I believe optimal patient care should be provided.

 

As an educator, I believe that modelling and teaching pharmacy students and other healthcare professionals or students in person is the most ideal way to improve knowledge and clinical skills. All of my ideals and morals have been tested in the last couple of weeks.

 

Allowing the challenges that I faced prevent me from continuing to teach my students and continue to provide care to the patients that need it most, would just allow COVID-19 to win. I could not imagine being completely removed from my practice site for a prolonged period of time so I felt fortunate enough to obtain remote access to the hospital’s electronic medical record for myself and my students, in order to continue to provide patient care and experiential learning.

 

I believe that going remote was the best plan that I could come up within this very difficult and constantly changing situation in order to make sure that my students, other healthcare providers, and ultimately patients remain safe.

 

If I can teach you anything from my recent experiences, COVID-19 should not be taken lightly or considered a joke.

 

Please stay safe, stay home, and stay positive.

 

Sincerely,

 

Peter Nikolos, PharmD Assistant Professor of Pharmacy Practice Arnold & Marie Schwartz College of Pharmacy & Health Sciences, Long Island University Clinical Pharmacy Manager – Cardiac Critical Care NewYork-Presbyterian/Weill Cornell Medical Center.

 

 

 

Decisions, decisions

 

Learning about branding and marketing seems like a rabbit hole with no end. I’m aware that there is always more to learn about both subjects on a surface level.

 

I’ll be at it a lifetime.

 

Not least because the tactics available, the ways we can communicate with each other, are forever changing and that change is accelerating. Just when you think you are reaching a point of clarity, or perhaps just after you have done so, it can suddenly become fuzzy with new questions popping up demanding answers.

 

This has happened to me recently. Having completed one of the most advanced Brand Management courses anywhere on planet earth, performing near the top of the cohort in the assessment and building on earlier learnings about Marketing, I felt like the mists had lifted. A calm clarity settled on me. I can tell the wood from the tress. I can sort the wheat from the chaff. The worthwhile from the pointless.

 

So why, very soon afterwards, am I left with a nagging sense that there is still something deeper, still something more to learn?

 

Following some half-formed notion in my mind, you’ll understand where that came from by the end of this article, I followed a train of thought and began studying psychology. A new wave of revelation washed over me. Through branding and marketing, we seek to influence the actions of humans. That relies on understanding what drives those actions – the human mind. Oh my. The rabbit hole suddenly became a whole lot deeper.

 

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