NHS Direct: Focus on pharmacy’s role

NHS Direct is a 24-hour, nurse-led telephone helpline which provides an advice and triage service designed to help patients make the most appropriate use of primary care services. The aim is to provide callers with the advice, information and reassurance they need to treat themselves at home or, if that is inappropriate, to direct them to the best source of further professional help.

What happens?

Calls from the public are handled in the first instance by a “call handler” (See Figure 1) who is trained to give such basic information as the whereabouts of local hospitals and the opening hours of pharmacies. If the call involves more than providing this type of basic information, callers are asked if they want to speak to a nurse. Depending on the nature of the query and the nurse’s experience, she will either answer the query herself using the resources at hand or, if the inquiry concerns, say, a complex medication issue, the nurse can obtain information from the regional drug information service or poisons unit.

Having assessed the caller’s presenting symptoms – and she does this using a clinical decision support system (CDSS) – the nurse has several options, known as dispositions. Until now, there have been three formal dispositions as follows:

• Refer the caller to an accident and emergency department
• Refer the caller to a general medical practitioner
• Provide self-care advice

However, there is now a fourth disposition proposed:

• Refer the caller to a pharmacy

This fourth disposition is due to be piloted in Essex from March this year.

Callers have been referred to pharmacies on an informal basis as part of the self-care disposition since NHS Direct began, but the Essex pilot is the first to formalise a recommendation to visit a pharmacy as a separate disposition. Moreover, the project will be thoroughly evaluated, so allowing the pharmacy profession to show how effectively it is at dealing with minor ailments.

Pharmacy support

Pharmacy’s involvement in NHS Direct is nothing new, although it was slow to start with, and there was little pharmacy input into the three first-wave pilots that started in March, 1998. However, by the time the second-wave pilots came on stream in the early part of last year, many members of the profession, including local pharmaceutical committee secretaries and trust pharmacists, had identified the need to collaborate and a lot of effort has since been put in to catching up.

An early initiative – the NHS Direct Pharmacy Support Network – was established by Mrs Beth Taylor (pharmacy manager, Community Health South London NHS trust) to provide a mechanism for communication and mutual support for pharmacists involved in NHS Direct, and its first meeting was convened in November, 1998. The network is now chaired by the National Health Service Executive’s NHS Direct project team. It includes local pharmaceutical committee and drug information representatives from all the NHS Direct sites as well as representatives from the Department of Health, the Royal Pharmaceutical Society, the National Pharmaceutical Association, the Pharmaceutical Services Negotiating Committee and the poisons information services.

The NHS Direct Pharmacy Support Network aims to ensure that all NHS Direct call centres have access to comprehensive, high quality pharmacy support, and it recommends the involvement of both drug information pharmacists and community pharmacists in providing this support. In its core principles produced on January 10 this year, the network recommends that pharmacy support should include:

• Training for NHS Direct nurses and call handlers
• Access to drug information back-up and poisons information services
• Pharmacy representation on local CDSS review committees
• Up-to-date information on opening hours of community pharmacies and availability of specialist services.

Misconceptions

There have been many misconceptions about NHS Direct pharmacy support. It is important to realise that the support intended here is support to help the NHS Direct nurses in their job while they are on the telephone with a patient. The fourth disposition, in which a caller is referred to a pharmacy, is something that happens after the call has ended.

Pharmacy support to the nurses does not involve switching the call to a pharmacist – either a drug information pharmacist or a community pharmacist – while the patient is on the line. The nurse can, for example, telephone the drug information services for information while the patient waits, but the drug information pharmacist does not speak to the patient personally. It is always the nurse who answers the patient’s query.

Moreover, drug information centres do not become involved in many of the queries. Figures will vary across England, but in South London, according to Mrs Margaret Hewetson (head of regional drug information at Guy’s hospital) about 0.5 to 1 per cent of calls to NHS Direct reach the drug information unit with a slightly higher number reaching the poisons services.

Training

Training is a key component of pharmacy support for NHS Direct and both community pharmacists and drug information pharmacists are involved in this. A training group led by Mrs Hewetson with representation from the NPA and drug information and poisons services has produced a resource pack to enable pharmacists to conduct the training.

The nurses (and call handlers) are, of course, trained in a number of areas, but the specific input on pharmacy and medication issues includes training on therapeutics and skills in finding and handling information.

Delivered by drug information pharmacists, the two-day therapeutics programme includes topics such as travel medicine, antibiotics, analgesics, drugs in pregnancy and breastfeeding, oral contraceptives and paediatrics – topics which, from experience on NHS Direct to date, produce a large proportion of the queries.

The nurses also have half a day’s training in community pharmacy related issues. This training is delivered by community pharmacists and includes the role of community pharmacists and the legal status of medicines. There is also one day’s training on poisons related issues, delivered by staff from poisons information services.

Essex pilot

Essex was part of NHS Direct’s second wave that started in February, 1999. Barking and Havering joined in November, 1999. A bid to run a pilot including pharmacy as the fourth disposition was approved by the NHS Direct central team, and this pilot is planned to go live in the next few months. The Society and the NPA are partners in this project and the LPC was instrumental in putting forward the concept.

As part of the development process for the fourth disposition, a team led by Professor Alison Blenkinsopp (department of medicines management, Keele university) has reviewed all the algorithims on the CDSS and the dispositions associated with them. All those algorithms that ended with “see GP in 72 hours” or “see GP in two weeks” or “self care” were identified as possibly appropriate for pharmacy referral. The review team identified 182 opportunities for pharmacy as the fourth disposition (see also
PJ, December 18/25, 1999, p983).

The fourth disposition is concerned with symptom-based queries, and not with questions about medicines. The nurse will answer medication-based queries herself, with or without referring to the drug information support services, depending on the nature of the query and her own expertise. If a caller presents with a symptom, the nurse enters this into the CDSS, and if the computer software takes her to the fourth disposition, she will recommend that the caller visits a pharmacy.

When the caller visits the pharmacy, the pharmacist will deal with the query in the usual professional manner, just as he or she would deal with every other query relating to a minor ailment. The only difference is that the query in this case will have been preassessed by a nurse.

For the patient, of course, having face-to-face contact with a pharmacist may lead to an outcome different from one resulting from a telephone conversation. For one thing, patients may say something different to the pharmacist than they did to the nurse. And for another, if the symptoms are visible – say, a skin rash – the pharmacist, having seen the complaint, may make a different recommendation.

Moreover, because the project is being evaluated, the caller will have been given a reference number by the NHS Direct nurse, and the caller should give this number (or failing that, his or her name) to the pharmacist. The pharmacist then records the person’s symptoms and the actions advised and taken. An in-depth evaluation will be conducted by Sheffield university, which is doing a similar thing, albeit in less depth, for the whole of NHS Direct.

All the pharmacists in the Essex pilot have been informed about the project and invited to a briefing session. The aim of the briefing is to provide information on NHS Direct and the role of the nurses and pharmacists involved. There is no clinical input, simply because pharmacists will be expected to deal with the callers who visit their pharmacies in the same way as they would with anyone else. The National Pharmaceutical Association has been working with the Centre for Pharmacy Postgraduate Education in developing materials to support the Essex pilot and the briefing sessions will involve community pharmacists and NHS Direct nurses learning together.

The future?

In the future, the NPA would like to see the pharmacist as an NHS Direct provider, using the CDSS to triage people on behalf of the NHS – with appropriate payment for doing so. Older people and people in deprived areas without access to telephones might be attracted to a face-to-face service, and the NPA also thinks that pharmacies could have an important role in the piloting of access points for NHS Direct on-line. The organisation would like to see access points in pharmacies, with the caveat that there would be some interaction with pharmacy staff where a member of the public or the pharmacist feels it appropriate.

In the meantime, the members of the Essex project team are excited by the pilot. They hope and indeed expect that it will lead to adoption of the fourth disposition nationwide with full recognition of the community pharmacist’s role in management of minor ailments. Mr John Stanley (chairman, pharmacy steering committee, NHS Direct Essex) believes that the project “offers pharmacists a great chance to prove that they offer consistently good advice to patients on minor ailments”.