Community pharmacy ‘must provide consistent care’ for cold and flu

On 24 June 2019, ten representatives from across pharmacy came together at a roundtable event at the Royal Pharmaceutical Society’s (RPS’s) London headquarters to discuss the management of cold and flu in community pharmacy.

The panel, chaired by Angela Kam, careers editor at The Pharmaceutical Journal and editor of Tomorrow’s Pharmacist, included preregistration trainees, pharmacists, managers and technicians from community and primary care, and representatives from Public Health England (PHE) and the RPS.

The event marked the start of a new editorial campaign for The Pharmaceutical Journal, in partnership with GSK, aimed to identify new ways for pharmacy teams to engage with patients presenting in community pharmacy with symptoms of cold and flu. By challenging existing behaviours and viewing self care, infection prevention and symptomatic relief in the context of antimicrobial stewardship (AMS), the campaign will support the implementation of a pharmacy standard for patient care through the production of related articles and support materials.

“We know that patients consider pharmacy as the first port of call when feeling unwell from cold and flu,” said Tony Scully, publisher of The Pharmaceutical Journal. “What we want to do is identify new ways to support the pharmacy team provide key advice to patients in the context of infection control and discouraging inappropriate prescribing of antibiotics.”

Prior to the roundtable, The Pharmaceutical Journal sent a survey to UK pharmacy teams to gain an insight into their knowledge and current practices, and help inform the day’s discussions.

A total of 1,169 pharmacy professionals responded to the survey between 24 April 2019 and 17 May 2019 — 499 (43%) of whom were community pharmacists working across large multiples, small multiples and independent pharmacies.

Responses were also gathered from pharmacists working across other sectors, pharmacy technicians, preregistration trainees and students.

Prioritising cold and flu

Respondents were first asked to rank common minor ailments according to their perceived clinical priority.

Cold and flu was ranked fourth highest clinical priority overall.

Allergy was found to be of the highest importance to community pharmacist respondents, with 17% ranking it as their highest clinical priority. Eye conditions and cough were ranked second and third highest priority, respectively, while sore throat was ranked as having the lowest clinical priority.

During the data presentation and discussions, the panel agreed that, although they are both common ailments, cold and flu should be of a higher clinical priority to pharmacists as they can become serious, or even fatal, if  not properly managed.

There are 600 deaths from complications associated with flu each year in the UK, compared with 20 deaths from anaphylaxis. However, it was pointed out that the focus should not be on the prioritisation of minor ailments in community pharmacy by condition, but instead priority based on the needs of the individual patient.

What is the patient’s priority? It might not be the same as the pharmacist’s

Olutayo Arikawe, superintendent pharmacist at The Priory Community Pharmacy, Dudley, said that the priority given to a condition was dependent on the patient’s symptoms, and consequently an “in-depth” consultation was important to find out more.

Babir Malik, northern lead at the Green Light Campus and teacher practitioner at the University of Bradford asked: “What is the patient’s priority? It might not be the same as the pharmacist’s.”

Consistent messaging

On average, most community pharmacist respondents said they saw six to ten patients with cold and flu symptoms per day during the cold and flu season.

General self-selection, seeking advice and purchasing an over-the-counter (OTC) product were the most common modes of cold and flu presentation in the pharmacy. Product marketing and promotion also ranked highly as a driver of patient presentations.

These results drove discussions about OTC medicines and how patients are often not provided with an indication of how long their symptoms may last before feeling better, meaning patients consequently end up at the GP surgery.

Malik highlighted that manufacturers of OTC cold and flu products can often present patients with a range of different messages through their advertising.

David Russell, pharmacist manager at Well Pharmacy and chair of Community Pharmacy Sheffield, added “packaging and licensing doesn’t allow OTC products to be used for that long [— you should only use them for] three days and then go and see your GP [if problems persist].

“We need to have confidence in recommending alternative treatments.”

Aimi Dickinson, pharmacist professional support manager at Boots, agreed and added that pharmacists need to be able to balance out what a patient needs in terms of length of treatment and self care, alongside what the licensing of an OTC product allows.

The panel concurred that, to avoid confusion among patients, there was a need for more consistent messaging across community pharmacy around symptom duration, pharmacological and non-pharmacological options for self care, and when to revisit the pharmacist or seek advice from a GP.

Ravi Sharma, director for England at the RPS and senior GP pharmacist, highlighted that ‘healthy living pharmacies’ were already facilitating conversations around self care, but Arikawe said it was a role for all community pharmacies, with Dickinson adding that the challenge was to get everyone across community pharmacy doing the same.

Self care is going to get bigger and bigger, but we need to ensure quality is high when having those conversations

“We need to use specific routes and channels [and provide guidance] about how to start these conversations,” said Dickinson. “We need to be clear about how to do this across each and every pharmacy — not just [put] a poster on the wall.

“Self care is going to get bigger and bigger, but we need to ensure quality is high when having those conversations.”

It was agreed that providing consistent self-care messages was the responsibility of the whole pharmacy team.

Russell said that messaging needed to be as simple as possible so that it can be used by every patient-facing staff member.

“It needs to be achievable across the profession — short messages [that are] easy to remember and to deliver during a short consultation — for example, three things to look out for … we all need to be trained to the same standard.”

He added that the pharmacy team also needs to have confidence in recommending alternative treatments if the OTC product chosen by a patient is unlikely to be effective.

Arikawe agreed, saying that opening with a simple question, such as ‘What are you taking?’, ‘How long have you had the symptoms?’ or ‘What have you tried?’ will lead to a other, deeper conversations with patients.

Confidence and training

In terms of training, The Pharmaceutical Journal survey revealed that a large proportion of pharmacists from small multiples and independents (63% and 54%, respectively) had not received training within the past year, while 50% of pharmacists from large multiples had. A sixth of respondents (16%) had never had any training on cold and flu.

Dickinson and Laura Reed, a clinical training manager at McKesson, the parent company of LloydsPharmacy, both confirmed that dedicated online training was available for staff working for large multiples at least once per year.

“If you don’t regularly enforce learning then it can easily be lost,” said Reed.

“It’s not just about training, but ensuring that that training is reinforced.”

Respondents from large multiples reported higher levels of confidence when differentiating between symptoms of a cold versus symptoms of flu and in differentiating between cold and flu and allergy.

But Sharma highlighted the lack of protected learning time and the practicalities of releasing community pharmacy staff for training.

“[It is an] issue in community pharmacy — access to education and training is a struggle,” he said. “Employers need to release employees for this training.”

Diane Ashiru-Oredope, lead pharmacist in the healthcare-associated infections and antimicrobial resistance division of PHE, said: “Training needs to be short, to the point and quick, and you need to be able to show that it has a purpose.”

For pharmacy technicians, confidence and competence was lower, highlighting a need for training to be delivered with a focus on the whole pharmacy team.

Although training provision is the responsibility of employers, the panel agreed that, as the clinical lead for their respective community pharmacy, pharmacists need to recognise the importance of updating their knowledge and fulfil their responsibility to upskill their team as needed, focusing on the quality, rather than quantity, of training.

Role of the pharmacy team

The survey found that, generally, pharmacists provided counselling to adults wishing to purchase cold and flu products, and respondents appeared to be good at recognising red flags for referral for medical review, such as blood in sputum, difficulty breathing and sudden chest pain.

When asked which healthcare professionals they had referred patients with symptoms of cold and flu to in the past, it was found that pharmacists mainly referred to GPs, while pharmacy technicians mainly referred to pharmacists, although a small number referred directly to a GP or nurse.

However, the panel had differing views about the role of different members of the pharmacy team and whether, with the right training, other members of the team could provide patient counselling.

Malik highlighted the importance of considering the skills and competencies of individual pharmacy staff members before setting any rules about who should do what.

“Very few things are ‘always’,” he said.

“If my technician referred, I would want them to tell me — but I would be happy for them to do that within their level of confidence.”

Re-education of patients

Survey respondents said that lack of time, lack of remuneration and patients declining a consultation were the major barriers that prevented them from conducting in-depth consultations with patients about cold and flu products.

Most patients see what they want to buy on TV and do not think they require any input from healthcare professionals

One respondent said that most patients see what they want to buy on television advertisements and do not think they require any input from healthcare professionals, “regardless of the suitability of the product or possible red flags”.

This prompted a discussion about how pharmacy teams can re-educate or reach those patients who decline a consultation.

“[We have a] responsibility to make sure that [pharmacy medicines] are used safely and appropriately and we need wider education of how patients see the role of pharmacists and the pharmacy team,” Dickinson said, adding that that there was work to do to discover whether patients actually understand the information they are given.

Ashiru-Oredope said that behavioural change was necessary so that when patients come in to buy a medicine, they expect the pharmacy team to give them information.

“Medicines are important and it is my job to give [patients] the information [they] need,” she said.

“Most people think that what they buy OTC is safe … they wouldn’t collect their prescription without getting [information] on how to use that — but with paracetamol they expect to walk away without any advice.”

Cold and flu in the context of antimicrobial stewardship

A 2017 Ipsos MORI survey asked more than 1,700 people aged 16 years and over what they would do if they had a respiratory tract infection.

The results, which were presented to the panel by Ashiru-Oredope, showed that only 34% would reach for an OTC medicine and just 11% would approach the pharmacy for advice.

The survey also revealed that almost 40% of patients said that they would expect to be given an antibiotic on presenting to their GP, NHS walk-in centre or out-of-hours healthcare service.

“We need to be able to manage infections so that patients don’t have this expectation,” said Ashiru-Oredope. “By prescribing antibiotics we are reinforcing that expectation.”

AMS needs to be about a “system approach” as well as individual contributions, with the focus on preventing infections in the first place, she said.

One respondent said that the survey was the first time they had come across the term ‘AMS’

Almost 90% of community pharmacist respondents to The Pharmaceutical Journal survey said they thought they had an important role in AMS. However, 17% said they did not feel that they had the resources to support this role.

One respondent said that the survey was the first time they had come across the term ‘AMS’, while others said they did not feel empowered to challenge prescribing.

“The general public still think of antibiotics as the ‘cure all’ [medicine] … there needs to be greater public awareness campaigns and resources sent to all healthcare settings to [correct this]” another respondent said.

Ashiru-Oredope brought the panel’s attention to the range of resources available to community pharmacy to aid conversations about antibiotic adherence and self care. She also mentioned the patient-facing ‘dancing antibiotics’ advertisement campaign in 2017 which aimed to spread the message about the dangers of antibiotic overuse.

In further discussions, it was agreed that instead of pharmacists seeing AMS as just being about challenging appropriate prescribing, community pharmacy teams can also play a major role in the prevention of infection and promoting self care for cold and flu, right from the initial contact with the patient.

However, Dickinson said it was also important to consider a patient’s personal circumstances: “Patients with a lower socioeconomic background are more likely to go to their GP practice, particularly when children are involved.”

“How can we start to target that population and drive them to pharmacy? We need to hinge on where community pharmacy can add value.”

Malik highlighted his experience of patients from Europe who expect to be able to buy antibiotics OTC.

Ashiru-Oredope said that consistency was needed to embed AMS into the everyday practice of pharmacists. This, she said, included the involvement of organisations such as the RPS and NHS England.

“Everyone has a role in tackling antimicrobial resistance … management of respiratory tract infections is an area pharmacy can lead on — [but it is] really important to educate pharmacy teams,” she said.

Sharma agreed: “Not everything requires a pharmacological intervention … we need to be looking at prescribing data and challenging [prescribing]”.

Moving forward

In order to make progress, Ashiru-Oredope said there needed to be wider implementation of existing resources, rather than the creation of new ones, alongside evaluation and testing of those resources in community pharmacy.

Dickinson drew the panel’s attention to an approach developed by Boots to achieve consistency and higher quality in patient consultations.

“The consultation with a patient is either product-led or symptom-led,” she explained.

“If they come in for a product, you take an advice-led approach — counselling on the dose, highlighting the indication and encouraging them to read the leaflet.”

Although progress is slow, she said patients are starting to realise and expect that level of care from Boots pharmacies.

Sharma highlighted that many patients want complete confidentiality, adding: “You won’t convince everyone — [some] may be [embarrassed] and they may not want to disclose information in a busy pharmacy”.

Concerns were raised about getting every pharmacy on board with changing the standards of practice around AMS and cold and flu. But Sharma said that the development of primary care networks, as well as increases in NHS 111 referrals to community pharmacy through the NHS Urgent Medicine Supply Advanced Supply Service, and the Digital Minor Illness Service, could provide the opportunity and momentum to help pharmacies transform.

Overall, the roundtable discussions highlighted that any new cold and flu management resources should acknowledge the need to educate the entire pharmacy team and include simple, consistent and easy-to-deliver messaging to “put self-care conversations into the spotlight” in community pharmacy.

In September 2019,The Pharmaceutical Journal will launch a set of practical materials to support best practice and implementation in pharmacy teams to improve cold and flu management in the context of AMS.