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.