Clinical skills training included in £100,000 Welsh pharmacy investment

 

Welsh Health Minister Vaughan Gething has announced a £100,000 funding package for pharmacist training.

 

The minister emphasised the importance of ensuring that the pharmacy workforce has the right skills to deliver A Healthier Wales, Welsh Government’s long-term plan for health and social services. The new backing will fund specialist clinical skills training for 50 pharmacists across Wales, to be delivered by Health Education and Improvement Wales (HEIW). It will focus on managing minor ailments, traditionally not included in initial pharmacy training.

 

The Health Minister also welcomed the Welsh Pharmaceutical Committee’s report ‘Pharmacy: Delivering a Healthier Wales’. The report sets out how the unique skills of pharmacy professionals in Wales could be used to improve health wellbeing and prevention, enabling the people of Wales to get the most from their medicines. Thanking the Committee for their important work, Mr Gething said the Welsh Government would now consider the proposals over the summer and work with the profession in taking forward this ambitious plan.

 

The announcement coincided with the launch of the pharmacy phase of Welsh Government’s Train, Work, Live campaign aimed at promoting Wales as a top choice for pharmacists.

 

Health Minister Vaughan Gething said:

 

“I welcome the efforts of Welsh pharmacy professionals in working to ensure that pharmacies meet the changing healthcare needs of the people of Wales. There is increasing potential for pharmacists to be seen beyond their traditional role of dispensing medicines. This focussed training on minor ailments will directly benefit patients by freeing up GP time. Our commitment, backed with significant new funding this year for training and continuing professional development, will ensure a sustainable and appropriately-trained pharmacy workforce in Wales. It will also offer pharmacists more varied and professionally rewarding careers.”

 

Andrew Evans, Chief Pharmaceutical Officer for Wales, said:

 

“The Welsh Government and the profession have already achieved a great deal through working together. It is important that we continue to respond to the changing needs both of the people of Wales and our healthcare system. Seeing the right person, at the right time, to help them to stay fit and well, lies at the heart of that.”

 

 

Interview with Ade Williams

 

Ade Williams is the lead pharmacist at Bedminster Pharmacy, a Healthy Living Pharmacy in South Bristol. He actively works to increase public understanding of community pharmacy’s work and roles within the NHS whilst also highlighting ways to broaden access to the extensive expertise offered by the whole pharmacy team.

 

He was good enough to join me on the podcast and we got under the skin of community pharmacy. We discussed some of the tougher aspects of working in community pharmacy today but also some reasons to be hopeful.

 

Ade really is an inspirational pharmacist and a very humble leader. I thoroughly enjoyed chatting to him and would encourage anyone to listen to find out how he is shaping community pharmacy in south Bristol.

 

 

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Should over-the-counter opioid sales be banned in the UK?

 

As pharmacy professionals, it is our duty of care to ensure that patients receive treatment suited to their needs, in order to provide optimal benefit. An issue that is well known in pharmacy practice is that of over-the-counter pain relief. These consultations can be difficult as it is often hard to determine whether the patient is receiving the correct drug and dose for their pain and that there are no underlying dependency issues.

 

To address this issue, the student-led Pharmacy Law and Ethics Group at Robert Gordon University held a debate in March this year with the title:

 

“Is it in the patient’s best interests to ban the sale of OTC opioids to reduce addiction and harm?”.

 

The debate was led by Annamarie McGregor from the Royal Pharmaceutical Society who gave an unbiased background on the issue of OTC opioid dependence. There is a current estimate that 3-28% of patients on chronic opioid therapy have opioid analgesic independence (OAD), which can stem from predominant comorbidities such as mental health issues and a history of substance misuse. (5) Whilst OAD is a threat to public health, as professionals, we must be aware that pain must still be managed by the use of appropriate treatment. (4) By understanding the balance between benefit and risk of opioid prescribing, patients can be treated with the confidence that their medication will not lead to dependence or adverse events.

 

Following Annamarie’s introduction, two pharmacy student speakers from the University argued for or against the debate title. Ewan Hardie, a fourth-year student, gave an opposing view and touched on mortality with regards to prescription-only opioids. He explained that deaths involving opioids appear to occur more frequently in those taking prescribed opioids in comparison to OTC users. (3) He also discussed that the majority of OTC opioid users are infrequently purchasing products like co-codamol for short term pain relief. It is these patients who would be impacted by an OTC opioid ban, unable to self-manage ailments whilst adhering to the guidance given by their community pharmacy. (3) Ewan explained that these patients would require to see a GP, impacting on the NHS and increasing their waiting time for acute pain management.

 

Secondly, Vivien Yu, a second-year student, argued for the debate title. Vivien compared the UK’s current OTC codeine sales to Australia, who banned OTC codeine on the 1st of February 2018 due to research showing low-dose codeine-containing products offered little additional pain relief to non-opioid analgesics. (2) She also explained that by making OTC opioids prescription only, patients would require to have a sit-down conversation with a healthcare professional to ensure that the treatment was the most appropriate for their pain management. (1)

 

Overall, the debate offered in-depth insight into both the benefits and the risks of prescription and OTC opioid use. A motion was passed involving opinions of those attending the debate. The motion was as follows: “The RGU Pharmacy Law and Ethics Group believe that better safeguarding should be in place with regards to OTC opioid sales, rather than proposing an outright ban. A Pharmacy First approach should be adopted for acute and chronic pain management”. This motion was agreed on as, after a full discussion, it was decided that OTC opioids are required for short-term use to manage acute pain. However, it was suggested that a more in-depth consultation through community pharmacies would benefit patients, ensuring that their pain management is tailored to their needs to reduce the risks of adverse effects and dependence.

 

Katie Waghorn is a 4th Year MPharm RGU, PLE Group Leader 18/19.

 

The PIP team would love to know your views on over the counter opiates. Answer the questions below and with your permission, we will publish your response to this story as a letter to the editor.

 

 

 

References:

 

[1] ANDALO, D., 2016. Survey of UK public reveals extent of over-the-counter drug misuse and abuse. [online] London: The Pharmaceutical Journal. Available from: here [Accessed May 15th 2019]

[2] KLEIN, A., 2017. Australia bans non-prescription codeine to fight opioid crisis. [online] London: New Scientist. Available from: here [Accessed May 15th 2019]

[3] KOLODNY, A. et al., 2015. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. The Annual Review of Public Health, 36, pp. 559-74

[4] LYAPUSTINA, G. and ALEXANDER, C., 2015. The prescription opioid addiction and abuse epidemic: How it happened and what we can do about it. [online] London: The Pharmaceutical Journal. Available from: here [Accessed May 14th 2019]

[5] SHAPIRO, H., 2015. Opioid painkiller dependency (OPD): An overview. London: DrugWise.

 

On average it takes 13 years to get a diagnosis of coeliac disease

 

With only 3% of British adults aware that the symptoms of IBS (irritable bowel syndrome) are also common symptoms of coeliac disease, national charity Coeliac UK, is calling on greater awareness of the similarity of symptoms and urges anyone with IBS to ask their GP for a coeliac disease blood test, if they have not already had one. (1)

 

As many as 1 in 4 people with coeliac disease were previously misdiagnosed with IBS as many of the symptoms for IBS such as bloating, stomach pains or cramps, diarrhoea or constipation and feeling exhausted are the same as the symptoms of coeliac disease.

 

Norma McGough Coeliac UK director of policy, research and campaigns said:

 

“It is essential that awareness of the similarity of the symptoms increases and that GPs adhere to the NICE (National Institute for Health and Care Excellence) guideline which states that anyone with IBS symptoms should be tested for coeliac disease before a diagnosis of IBS is made.”

 

Coeliac disease is not an allergy or an intolerance but an autoimmune disease where the body’s immune system damages the lining of the small bowel when gluten, a protein (found in wheat, barley and rye) is eaten. There is no cure and no medication; the only treatment is a strict gluten-free diet for life. 1 in 100 people in the UK is estimated to have coeliac disease but of these, only 30% are currently diagnosed, meaning there are nearly half a million people in the UK with undiagnosed coeliac disease.

 

The average time it takes for someone to get a diagnosis is 13 years from the onset of symptoms; by which time, they may already be suffering with added complications caused by the disease. If left untreated, coeliac disease can lead to a number of serious complications, including anaemia, osteoporosis, unexplained infertility, neurological conditions such as gluten ataxia and neuropathy, and although rare, there is an increased risk of small bowel cancer and intestinal lymphoma.

 

“The first step to diagnosing coeliac disease is a simple, inexpensive blood test done in primary care, but thousands of people are not getting the necessary testing and are being left undiagnosed including those with IBS symptoms. This not only causes years of unnecessary suffering but also wasted costs to the NHS with repeated appointments and investigations. We urge anyone who has symptoms such as ongoing bloating, diarrhoea or constipation and has been given a diagnosis of IBS but not been tested for coeliac disease to ask their GP to test them for coeliac disease. However, it is essential to keep eating gluten until all tests are completed as otherwise these tests may give a false negative result,” continued Ms McGough.

 

Coeliac UK’s online assessment www.coeliac.org.uk/isitcoeliacdisease, based on the NICE guideline NG20, gives people greater confidence to seek further medical advice from their GP. Upon completion of the assessment, the respondent will receive an email with their results, which will indicate whether their symptoms are potentially linked to coeliac disease. Coeliac UK Awareness Week 13-19 May 2019 www.coeliac.org.uk/AW19.

 

Reference

 

  1. YouGov Survey – When answering the question: ‘What do you think are common symptoms of coeliac disease?’, only 3% of
    respondents answered IBS symptoms. All figures, unless otherwise stated, are from YouGov Plc. The total sample size was 8423 adults. Fieldwork was undertaken between 20th December 2018 – 2nd January 2019. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+).

NHS to take a firmer approach to deter prescription fraud

 

NHS England and NHS Business Services Authority (NHSBSA) are now starting to take a firmer approach to deter fraud.

 

In early 2018, NHSBSA started trialling an approach with people who have received five or more penalty charge notices (PCNs) in a 12-month period but had made no attempt to pay. Selected repeat offenders are now interviewed under caution at a police station and to date, NHSBSA has submitted five cases to the Crown Prosecution Service to consider for criminal proceedings. NHSBSA began a debt collection process for dental cases in January 2019 and is seeking approval for one for prescriptions.

 

NHSBSA is developing a system to reduce the likelihood of fraud or error occurring in the first place by allowing pharmacists and dentists to check peoples’ eligibility for benefit-related exemptions at the time the transaction occurs. A pilot is underway, in four pharmacies, to check health exemptions in real-time, which if successful, could significantly reduce the amount of fraud and error that occurs, and therefore the number of PCNs NHSBSA needs to issue.

 

The NHS estimates that it lost around £212 million in 2017-18 from people incorrectly claiming exemption from prescription and dental charges. However, rules around entitlement are overly complicated leading to genuine mistakes and confusion for many people, according to the National Audit Office.

 

Each year, the NHS dispenses around 1.1 billion prescription items in the community and undertakes around 39 million courses of dental treatment. Around 89% of prescription items dispensed and around 47% of dental treatments are claimed as exempt from charges. NHSBSA administers the distribution of PCNs to those who, either fraudulently or in error, have claimed a free prescription or dental treatment when they were not entitled to do so; or have a valid exemption which cannot be confirmed at the time of checking.

 

Recently, there has been a significant increase in the exemption checks and the total value of PCNs issued. For example, the number of prescription checks has risen from 750,000 in 2014-15 to 24 million by 2018-19. Over the same period, while the number and value of prescription PCNs have risen, the proportion of checks resulting in PCNs has been declining. In 2014-15, one in four checks resulted in a PCN, compared with one in 20 checks by 2018-19. Over this period the value of PCNs issued has risen from £12 million to £126 million per year for prescriptions and from £38 million to £72 million per year for dental treatments.

 

Since 2014, NHSBSA has managed the distribution of 5.6 million PCNs with a total value of £676 million. Of these £133 million (20%) were collected, £297 million (44%) were resolved without a penalty charge being paid, and £246 million (36%) remain outstanding.

 

Since 2014, around 1.7 million PCNs, 30% of those issued, with a value of £188 million, have been issued but subsequently withdrawn because a valid exemption was confirmed to be in place following a challenge. PCNs might also be cancelled where the claimant cannot be identified and located based on the details provided on the prescription or dental form. The penalty charge element of the PCN might also be removed following communication with the individual concerned, although the cost of the prescription or dental treatment will remain payable.

 

NHSBSA spent £11.2 million (31 pence per £1 recovered) in 2017-18 on managing the PCN process. This cost, which includes the cost of the Capita service provided to NHSBSA (Capita manages part of the dental checking service), is covered by the income generated by PCNs, with the surplus paid to NHS England. The NHS Counter Fraud Authority has acknowledged that NHSBSA’s work led to a £49 million reduction in prescription fraud from £217 million in 2012-13 to £168 million in 2016-17.

 

Between September 2014 and March 2019, 114,725 people have received five or more PCNs for prescriptions, indicating a pattern of incorrect claims. However, until recently NHSBSA had taken no action against these people. The NHS Counter Fraud Authority said in 2019 that the focus of NHSBSA’s PCN strategy had been on recovery of losses and charges from penalty notices.

 

NHSBSA accepts that the rules around entitlement, which are set by the Department of Health & Social Care, are complicated and recognises that genuine mistakes and confusion happen.

 

There are a number of factors which may cause mistakes and confusion. These include Universal Credit where claimants are only eligible for exemptions if their monthly earnings are below a specified level; and prescription forms that do not yet include Universal Credit as an option. Confusion can also arise where people need to understand the difference between benefits. For example, a claimant who receives income-based Jobseeker’s Allowance is automatically eligible for free prescriptions and dental treatment, whereas a claimant who receives new-style Jobseeker’s Allowance or contribution-based Jobseeker’s Allowance is not. Furthermore, a person’s eligibility for exemption may vary between prescriptions and dental treatments. Also in some circumstances, such as pregnancy, the person must apply for an exemption certificate to obtain free prescriptions. The length of time that exemptions apply varies according to the circumstances.

 

NHSBSA is unable to identify all vulnerable people in advance of issuing a PCN but will try to limit the impact where such people are later identified. This arrangement relies on the vulnerable person challenging the PCN, and not all vulnerable people may feel able to do so.

 

NHSBSA has only recently undertaken its first national advertising campaign to inform people about PCNs even though it has been significantly increasing its checks since 2014. It also began to develop online support tools to help people determine whether they are eligible for free prescriptions and dental treatment in 2017.

 

Amyas Morse, the head of the NAO, said today:

 

“Free prescriptions and dental treatment are a significant cost to the NHS, so it is reasonable to reclaim funds from people who are not exempt from charges and deter fraud. However, the NHS also needs to have due regard to people who simply fall foul of the confusing eligibility rules.  It is not a good sign that so many penalty charge notices are successfully challenged.

 

Chair of the Royal Pharmaceutical Society in England Sandra Gidley said:

 

“The National Audit Office has highlighted some important issues around prescription charge fines. It is important that we protect every single NHS pound so it can be spent on caring for the public. Pharmacists understand and support this. However, the NAO identifies there’s plenty of room for improvement and the current system is too complicated and bureaucratic. The system needs to be simplified before we start to criminalise those that make a genuine mistake navigating it.

 

“Pharmacists should not be the prescription police – they want to spend their time helping people with their medicines rather than checking their exemption status. It would be much simpler to have free prescriptions for everyone, as is the case in Scotland, Wales and Northern Ireland because then no-one would have to worry about filling out a form of declaration. They would always have the medicines required, without having to make payment decisions.  It would also enable the investment in issuing and monitoring penalty charge notices to be spent on patient care.

 

“The consequences of the relentless rise in prescription charges are well-known. Surveys* show that 1 in 3 people have not collected their prescription because of the cost. If you can’t afford your medicines, you become iller, which leads to poor health and expensive and unnecessary hospital admissions.

 

“Every day pharmacists are asked by patients who are unable to afford all the items their prescription which ones they could ‘do without’.  Patients shouldn’t have to make choices which involve rationing their medicines. No-one should be faced with a financial barrier to getting the medicines they need.”

 

What do community pharmacists need to know to care for people with coeliac disease?

Fiona Headridge

 

We were lucky to catch up with dietitian Fiona Headridge. Fiona is a specialist dietetic practitioner for Coeliac Disease. She works for the NHS in Tayside, Scotland. She was one of the dietitians who pioneered the Scottish community pharmacy gluten-free service and joined us to give an insight into how the service was developed initially. We also talk through how subsequent evaluations of the service have gone. Fiona also shares some top tips for pharmacists working with people who require gluten-free products.

 

 

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