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Shot in the arm

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Shot in the arm

Winter ailments are the mainstay of OTC consultations at this time of year, and even more so with the arrival of a national flu vaccination service in England. 

Pharmacy is good at getting on with things. While GPs and hospitals seem to hit the headlines every week for one reason or another, pharmacy quietly goes about its business of dispensing prescriptions and advice, and looking after the health of anyone who walks through the door.

One such example is flu vaccination: while last year’s seasonal jab was blasted in the media for not targeting the viral strains that were in circulation (see ‘The seasonal flu jab’ box below), what didn’t make the news was the fact that a London-wide pharmacy scheme run the previous winter had resulted in a huge surge in immunisation uptake. This pattern was replicated elsewhere in the country.

In some areas, pharmacies supplemented GP provision of influenza vaccination, with many patients commenting positively on the fact that they could pop in when convenient rather than being tied to rigid clinic times. Whereas in other parts of the UK, patient group directions were put in place so individuals who were not eligible for an NHS jab could opt to pay for one on a private basis. Nobody made a big song and dance about it.

Pharmacies just got on with helping customers protect themselves against an illness that is debilitating for a few days at best and is potentially life threatening to some. But someone, somewhere, sat up and paid attention to the difference that community pharmacy had made to literally hundreds of thousands of people. So much so that in July 2015 came the announcement that NHS England had commissioned a service allowing pharmacies across the country to offer seasonal influenza vaccinations to patients in at-risk groups.

Pharmacist-led but not pharmacist-only

Pharmacist Pembe Hassan-Hicks is excited about the opportunity the national flu vaccination service is providing to the pharmacy profession: “I qualified this summer and it is really exciting to have entered the profession at a time when the role of pharmacy is really expanding. This new service sends a message to everyone in the country that you can walk into any pharmacy at any time to get your flu injection, which is giving patients a real choice.”

A lack of experience in injection technique doesn’t worry Pembe too much: “I’ve done the full Numark course so I can provide the service from the two branches of Regent Pharmacy on the Isle of Wight where I work, and while I know the first patient I see will be very different to when I did the training, I am confident I have done everything I can to prepare.”

Pembe is keen to emphasise the fact that while only pharmacists are allowed to administer vaccinations, a whole team approach is needed to make the service a success. Kathryn Moffitt, pharmacist at Whickham Pharmacy in Tyne and Wear, is in full agreement:

“The service may be pharmacist-led, but support staff are fundamental to identifying and recruiting patients. The counter staff are great at engaging customers in conversation and finding out who may be eligible for an NHS jab, and the dispensary staff fix stickers to bags of prescription medicines so we can pinpoint likely candidates – for example, those with diabetes or over 65 years of age.”

The teamwork doesn’t stop there, Kathryn continues: “The staff get patients started on the paperwork, meaning it is much quicker for me when I see them in the consultation room for their actual vaccination. Everything has to be recorded on PharmOutcomes [a web based audit and management system] in order for us to be paid, and this is another thing that the staff do that helps free up my time to do even more vaccinations.”

 

What you need to know

  • England’s national flu vaccination service runs until 29 February 2016, but the sooner someone is vaccinated, the sooner they are protected
  • Pharmacy contractors must have notified the NHS Business Services Authority of their intention to provide the service and have a standard operating procedure (SOP) in place, which all staff must be aware of
  • Only pharmacists who have downloaded, read and understood NHS England’s patient group direction on flu vaccine administration and completed a competence declaration can participate in the scheme, and all staff involved must have received appropriate training relevant to their role
  • Only certain groups are eligible for an NHS-funded flu jab. This includes all over 65s, pregnant women, care home residents and carers, plus those aged between 18 and 65 years who have chronic respiratory disease such as asthma or COPD, diabetes, a learning disability or neurological condition such as Parkinson’s disease, splenic dysfunction such as sickle cell disease, chronic heart, kidney or liver disease or an impaired immune system, for example as a result of chemotherapy or HIV infection. Household contacts aged 18 years and over of immunocompromised individuals are also eligible
  • Vaccinations must take place in a consultation room. If the service is being provided at a care home, a room should be used that allows conversations to take place that are not overheard
  • Written patient consent must be obtained, and the patient asked to complete a questionnaire after the vaccination has been administered
  • The patient’s GP must be notified, by the following working day at latest
  • The national PGD that allows pharmacies to vaccinate people against flu as an advanced contractual service does not enable them to provide a private service to individuals who do not meet the eligibility criteria. For more information, click here.

Healthy competition

Satyan Kotecha, pharmacist proprietor of K&K Healthcare Ltd, which has pharmacies in Nuneaton and Leicester, applauds his NHS local area team for investing in PharmOutcomes for all Arden, Hereford and Worcester pharmacies: “There is an anonymised league table which has really motivated people.”

“You can see where your pharmacy is in relation to others, so those who are at the top try and do more to stay there and the others lower down do everything they can to try and catch up. It’s literally healthy competition that saw an increase from 4,500 vaccinations in one season to 14,500 the next, and also seemed to spur on GP surgeries.”

In Satyan‘s area, staff members are so crucial to the success of flu vaccination schemes that pharmacists are required to bring a member of the pharmacy team with them when attending training to provide the service. “Having a strategy of upskilling in this way means pharmacists feel able to trust their staff to recruit patients opportunistically, which is the main reason that last year 10 per cent of those we vaccinated had never had the flu jab before, even though they may have been eligible,” he says.

Pharmacy’s strength lies in its relative informality compared to GP surgeries, believes Satyan. Patients don’t usually have to make an appointment, and they are able to ask questions. “The number of times I have heard ‘nobody has ever explained why it is important for me to have it’ and ‘that’s the first time I’ve understood how it works’ is incredible,” he says.

Satyan adds that K&K Healthcare Ltd owned Kasli Pharmacy has its nearby GP practices fully on board. “Initially, I think they were worried that we’d be taking patients away from them, but I feel that generally we see the people who slip through the net. We always ask if someone has an appointment to have a flu jab at their GP surgery and won’t do them at the pharmacy if that is the case. It’s great partnership working.”

Whickham Pharmacy’s Kathryn concurs, saying: “The victory for pharmacy is to pull in patients who otherwise wouldn’t get vaccinated, and then make it so easy for them that they come back year after year.”

 

Symptom relief

Coughs, colds and flu can cause troublesome symptoms and they’ll be some of the most common reasons for customers to visit your pharmacy this winter. Here’s what you can suggest:

Sore throat

A sore throat often marks the start of a cold or flu, but can also be caused by a localised infection or irritation resulting from coughing or mucus running down the back of the throat. Sore throat infections are spread from person to person via airborne droplets, hand holding or kissing. Most sore throats tend to get better on their own and as they are caused by a virus, do not require antibiotics. 

Pastilles and lozenges containing soothing ingredients such as honey and lemon can stop the throat feeling dry and relieve irritation. Products containing antiseptic ingredients, a local anaesthetic or a painkiller are also available.

Nasal congestion

Sneezing, runny nose and nasal congestion are common symptoms of colds and flu. Decongestants such as pseudoephedrine and ephedrine can be used to relieve these symptoms and are often available in a combination product with a painkiller. Nasal decongestant sprays containing xylometazoline and oxymetazoline can also offer relief, but shouldn’t be used for more than seven days at a time.

An inhalant or vapour rub containing menthol, eucalyptus, peppermint, pine oil or camphor can help to relieve blocked noses or sinuses – especially for children, as many other products have age restrictions and are not suitable.

Aches, pains and fever

Aches, pains and fever can be relieved with painkillers such as aspirin (adults only), paracetamol and ibuprofen or by taking combination cold and flu remedies, which might also include a decongestant.

Cough

There are two main types of cough – productive (chesty, may bring up phlegm or mucus when coughing) and nonproductive (dry, no mucus or phlegm, often starts as a tickle in the back of the throat) – and there are different products to relieve them. Cough expectorants such as guaifenesin, ipecacuanha and squill can be suggested for a chesty cough. These help to reduce stickiness of secretions in the airways, making phlegm and mucus looser and easier to cough up.

Cough suppressants such as dextromethorphan help by blocking the natural coughing reflex and are suitable for dry coughs. These types of products are only suitable for adults and children over 12 years of age. For younger children, soothing ingredients such as glycerol, honey and lemon can be suggested. If a customer has a productive cough, it is important to find out if the mucus is greenish, yellow or brown in colour as this could indicate a bacterial infection and they should be referred to the pharmacist.

Self care tips

For all symptoms of coughs and colds, the following tips can be suggested to customers:

  • Help prevent viruses from spreading by using tissues correctly and washing hands
  • Rest and stay warm
  • Inhale steam to help loosen and bring up phlegm
  • Drink plenty of fluids. Warm drinks containing lemon juice and honey can be soothing
  • Don’t smoke
  • Gargle with soluble aspirin (adults only) or warm, salt water
  • Don’t share drinks, cutlery, etc.

Care in the community

One feature of the new flu service is that unlike medicines use reviews (MURs), for example, it can be delivered off-site. This means pharmacists are able to vaccinate residents of long-stay care facilities, who are one of the groups eligible for flu jabs on the NHS, subject to approval by the local NHS England team. K+K Healthcare Ltd’s Satyan is delighted he will be able to continue to provide this service as he did last winter.

Not only does it mean people who find it difficult to get out and about are protected against what can be a nasty infection, but the Numark member explains that it has also helped his pharmacy build a relationship with those who work and live in local residential homes, meaning that they have been able to do more to improve the health of what is often a vulnerable but overlooked sector of the community – for example, by providing advice on nutrition.

 

The seasonal flu jab

A new flu vaccine is developed each year so that it best fits the viruses that the World Health Organization has identified to be most likely to cause people to become unwell that winter. There are many strains of the flu virus and they are constantly changing – usually in small ways that a particular season’s product will protect against, but occasionally in an abrupt and significant way that results in the emergence of a new subtype.

These are the virus forms that can cause many people to become very unwell, often referred to as an epidemic or, if it is more widespread, a pandemic. This year’s jab contains three influenza strains, including those that caused the swine flu pandemic of 2009 and the avian flu furore of 2011. The nasal spray flu vaccine is also reformulated each year, with this year’s protecting against the same three virus forms that are in the injectable product plus an additional strain that was active in 2008.

The 2014/15 product hit the headlines as being ‘barely effective’. While it was true that one of the flu viruses circulating that winter had mutated to the point that the strain that had been included in the vaccine to protect against it offered little protection, having the injection still immunised effectively against swine flu and influenza B. Flu was certainly about last season, but it didn’t get anywhere near epidemic levels.

It is important to remember that while the flu jab is an effective way of reducing the number of people who succumb to the infection, it doesn’t offer 100 per cent protection. Not all viruses are protected against – particularly new subtypes – and individual responses to the vaccine vary. The ever-changing nature of influenza viruses means that, unlike other immunisations such as tuberculosis or rubella, annual vaccination is a must for those at risk of the disease’s complications.

To do list

All pharmacy services require a degree of preparation, but none more so than a flu vaccination scheme – whether new or established, NHS or private. Demand is likely to be high, and the bulk of the work will be done during what are often busy months in terms of both dispensing and OTC consultations. John Urwin, pharmacist and co-director of Urwin Cumbria Ltd, which runs three pharmacies in North West of England, recommends that staff members do the following to help get ready:

  • Look at your consultation room with a critical eye. Is it tidy? Does it look clinical and professional? Is there a sharps bin, soap next to the sink and a supply of hand gel?
  • Make sure everyone knows what to do if a patient collapses. Where are adrenaline injections kept? Is there a notice beside the phone explaining what to do if an ambulance needs to be called?
  • Vaccines are kept in the fridge, so make sure you know how to check the temperature is okay, and what to do if it isn’t
  • How will your pharmacy create awareness? Consider using posters, leaflets and bag stickers, but also ask people to tell their friends and family – word of mouth is the best recommendation!
  • Make sure all staff understand who is eligible for an NHS injection. A reminder card on the pharmacy counter can be a helpful prompt
  • Know how to complete and submit paperwork such as consent forms, payment claims and GP notifications.

Ultimately, it isn’t just the public’s health that will improve as a result of pharmacy flu vaccination schemes, it is their perception of what the sector can offer at a broader level. Whickham Pharmacy’s Kathryn often delivers MURs to eligible patients after administering a flu vaccine. “I’ve already got most of the information I need and they have to wait for a few minutes anyway,” she says, adding that the feedback has been overwhelmingly positive.

Satyan agrees that such services have fuelled the public’s growing confidence in pharmacy: “When someone rolls up their sleeve and lets you inject them, just think of the amount of trust they have placed in you. From that point, you have a solid base to build on.”

It is vital that this opportunity isn’t squandered.

 

To test your knowledge on this topic, complete the team training learning module.

  

The victory for pharmacy is to pull in patients who otherwise wouldn’t get vaccinated

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