The role of pharmacists in preventing cardiovascular disease

By Dr Duncan Petty, Member of the English Pharmacy Board

It was great to see the news this week about how the NHS plans to make greater use of community pharmacy to help prevent 150,000 strokes, heart attacks and cases of vascular dementia, supporting earlier detection and management of cardiovascular risks.

Cardiovascular disease incidence can be reduced through better lifestyles and the optimisation of preventative medicines, such as antihypertensives and statins to prevent vascular strokes and ischaemic heart disease / myocardial infarction, and anticoagulants for stroke prevention in atrial fibrillation.

NHS plans will include using pharmacists in the community (community pharmacy and general practice-based) to work on identification of at-risk individuals; offering lifestyle advise and supporting long-term changes in poor lifestyle; offering or optimising preventative medicines, and helping patients remain on these medicines. Pharmacists having been doing this work around the UK for many years. The difference going forward is that these services will be done in a systematic way and on a wider scale.

The community pharmacy contract could see (subject to successful pilots and roll-out) screening services for hypertension and atrial fibrillation. In general practice pharmacists might already be familiar with using tools such as AlivecorR to detect AF and most pharmacist will be able to measure blood pressures. However, to advise patients on 10-year cardiovascular risks a cholesterol level will be needed as will skills in using risk calculators such as QRISK 3.

For patients with a high cardiovascular risk score, overall risk can be reduced through lifestyle (especially smoking cessation support); reduced blood pressure (from lifestyle changes and introduction on antihypertensives) and offering statins at an evidence-based dose. There are plenty of examples where pharmacist have been involved in case finding untreated and undertreated patients and offering medicines optimisation and lifestyle support, which you can read about in our roundtable report.

Offering oral anticoagulants (OACs) for stroke prevention in AF (SPAF) is more complex and requires skills and knowledge on what are true contraindications to OAC (actually there are very few); access to the full medical history and team work with the GP and specialist pharmacy anticoagulant services. Most patients when they have had risks and benefits of OAC explained to them are keen to accept therapy but pharmacists need to be skilled in running these types of consultations.

Once patients are prescribed OAC, statins and antihypertensives ongoing reviews are required. Community pharmacy will be well placed to support adherence and to offer patients ongoing advise on reducing bleed risks from OACs (e.g. using the HAS BLED tool) but to perform a full clinical review of most CV medicines access to the clinical record will be required e.g. to check monitoring parameters such as U+Es, full blood count etc). There is nothing to stop community pharmacists performing these reviews if they are given access to the patient’s clinical record. Whether community pharmacy access is granted or not is dependent on local arrangements and funding, but examples exist across whole communities such as in Fleetwood.

Cardiovascular medicines optimisation services are already running in parts of the NHS. What we need now is to share the learning and adopt standardised services at scale to help improve patient care, safety and value to the NHS.

Read our roundtable report on pharmacy and cardiovascular disease.

Community pharmacy: a gateway to health

by  Gill Hawksworth MBE, FRPharmsS and RPS Faculty Fellow

I have been trying to keep track of a gradual change in attitudes about pharmacy and public health and now,18 months on from when the Murray Review was commissioned, find myself asking ‘What does it all mean?’.

In September 2017, several key announcements began with the new Pharmacy Minister Steve Brine who said at the RPS conference that initiatives such as the work of (HLP) and flu vaccination services highlight pharmacy’s role in promoting public health and reducing health inequalities. Also at the Labour party conference, the Pharmacy APPG Chair  and Labour MP for Rother Valley, Kevin Barron, said they would like to see the HLP initiative included in the community pharmacy contract as it has a ‘role to play in improving public health’. This was encouraging, so the message must be getting through somehow to those who could influence change and this is backed up by the news that the Public Health England (PHE) report ‘Pharmacy: A Way Forward for Public Health’ has been published.

This new report sets out opportunities for commissioners, some of whom have previously decommissioned such services, to realise community pharmacy’s role in protecting and improving the nation’s health, flagging up growth in the HLP programmes since a quality payment is now available for attaining HLP1 status. The CPPE are supporting this with leadership for HLP workshops and the paper also looks at developing capacity in the workforce to support promoting health through pharmacy settings and lists smoking cessation among the menu of opportunities for community pharmacists to get involved, timely for the PHE Stoptober challenge.

PHE is working with the Pharmacy and Public Health Forum to collect case studies of promising practice to help identify opportunities to build on current learning and scale what is working and has been shown to have impact.  Interestingly there is already a move in Scotland (the vision of Achieving Excellence in Pharmaceutical Care) to expand the public health role with evidenced-based interventions, so pharmacy is at the heart of delivering national health and well-being priorities.

A further focus in September was on support for the role of community pharmacists in antimicrobial stewardship, highlighted in the RPS national campaign, and again during World Antibiotic Awareness Week this week.

There was also an article by Professor David Wright (who’s literature review informed the Murray Review) on the potential for revised Medicines Use Reviews (MURs). We must remember that a range of public health interventions are often part of an MUR. This can include looking after the mental health and wellbeing, as well as physical health, of elderly patients who may be lonely, supported by CPPE’s work on mental health. This also offers a chance for pharmacists to fulfil other roles such as in cancer awareness and screening referral.

Making every contact count and documenting public health interventions may be a good place to start and help to develop the evidence base, remembering that the Murray Review stated ‘we should note that the evidence for (or against) specific clinical services within the peer-reviewed literature is often relatively sparse’.

All this is developing within the context of RPS working with PHE and NHS England to promote the role of pharmacists in public health, with the support of the RPS Professional Standards for Public Health Practice for Pharmacy.

So as attitudes are gradually changing and funding of public health services are being considered in terms of the evidence available, I await, with interest, the public consultation I understand is coming soon on the work by NICE on community pharmacy public health interventions. This deals with the evidence, (RCTs as gold standard) therefore relying on documentation of public health interventions such as alcohol, sexual health and of course smoking. After all, community pharmacists I believe have a good track record in helping people stop smoking.

Pharmacists’ role in person-centred care

By Andrew McCracken, head of communications at National Voices.

For at least 20 years, policy makers have been aspiring to deliver ‘person-centred’ care.

There have been revised definitions of quality, national commitments, and phrases like “people at the heart” and “empowered communities” have become ubiquitous.

So what difference, if any, have policymakers’ stated ambitions made to the experiences of people who need and use services and support? We wanted to know. Read more Pharmacists’ role in person-centred care