Ade Williams, superintendent pharmacist and IP at Bedminster Pharmacy in Bristol, talks to Saša Janković about running a joint pain clinic.
Service type: Joint pain.
Name of pharmacy: Bedminster Pharmacy, Bristol.
Name of pharmacist: Ade Williams, superintendent pharmacist.
Why did you start offering this service?
I started offering this service in March 2019. When I was doing my IP course my GP mentor had an interest in joint pain, which is quite unusual for an IP to work with and certainly sparked my interest. We know, of course, that pain is very subjective, but joint pain is highly emotive as well, so I wanted to understand more about the evidence for the treatments that are already there for joint pain, and how we can best help and advise patients in this category.
Subsequently the RPS wanted to design a holistic pathway around joint pain because their research said pharmacy professionals lacked confidence in this area, which was an issue because joint pain is so prevalent in the population. Alongside the RPS I worked with a physiotherapist, dietitian, consultant rheumatologist and an MSK expert to determine what community pharmacy could do to support patients, and we came up with a holistic pain pathway, incorporating a broad range of ways to provide care and relieve the joint pain for customers in community pharmacy.
How much did it cost to set up the service?
It didn’t cost us anything except time, because the RPS produced training tools and quite a few resources for all the pharmacy team. This allowed us to upscale and bring consistency to our interventions – which is important for patients as they know that whichever member of the team they are speaking to we are working from the same framework and pathway.
What, if any, training did you or other team members have to undergo?
We read through the RPS resources and used their SOP template to create something that fit our team. For example, we know where each of us has specific clinical competencies and therefore can refer our customers to the appropriate colleague for support. This means that rather than it being a role-based service run only by the pharmacist, the SOP gives the whole team confidence in where they fit in the process. We also map limits of confidence for the service, so everyone knows the red flags for referral.
In a nutshell, what does the service involve?
Three things are making joint pain more common in our customers – it predominantly affects an older population; lifestyle issues such as being overweight, smoking and drinking alcohol have an effect; and the healthcare system itself does not have many access points for referral and onward treatment for patients with joint pain. Community pharmacy is the ideal place to address all of these issues, so I started using the holistic joint pain pathway tool with my team to help our customers.
If someone comes in with joint pain it enables us to have so much more than simply a product-centred consultation. Rather, it allows any member of the team to have a person-centred conversation which first lets them understand what is going on with the person, and the emotional toll their joint pain is having on them.
Next, we can explain to our patient what their interim options are. Many people with joint pain fear they will have to have surgery, or lose their independence and their income, but we can talk to them about all the holistic interventions they can make with diet and lifestyle, as well as the possible pharmacological interventions. The aim of any treatment is to manage the deterioration of the patient’s joint for as long as possible until at some point they may require a more invasive process, but along that path there are many other things they can do, such changing their diet or losing weight.
It’s a whole team service and we provide an evidence-led approach about what works and what doesn’t – but even if they want to try something like acupuncture, if they feel it offers them some relief then there’s no reason not to do it.
We find that – particularly because of the emotional burden of joint pain – the holistic approach is the least likely one that patients expect. For us, being able to provide evidence-based advice in a clinical setting means our patients go away with more than just a medication to try – we are part of the management of their pain.
Are there any opportunities to sell over the counter or prescription products during the consultation or after it?
Very much so, but always with health and lifestyle advice included. We are also mindful that part of the management of joint pain is NSAIDs, which carry a clinical risk. Using the holistic approach gives us confidence that our intervention is part of the solution, rather than leading the patient to think that if they simply keep using an NSAID they’ll get better, but instead they end with other problems such as ulcers and medication side effects.
How have patients responded to the service?
They refer other patients in to us! We are able to help them manage their pain very effectively and with NHS changes in stopping prescribing some OTC medicines the service fits really well into the self-care agenda, saving customers money and empowering them to take ownership of their health.
Because joint pain is a long-term condition, for us it’s about maturing that clinical relationship with our patients. The service is also a great way to build ongoing relationships with your local general practice because once the patient transitions on to them for further care the GPs know we have been looking after them for a while.
Roughly how often each month do you carry out the service?
We see at least two people a day – some new patients, some returning. There are different reasons people will present with joint pain, so we try to explore what going in with the patient – did they fall over, have they been over-exercising, etc – so we get a holistic view of who they are and how best we can help.
How much do you charge for the service?
The service is free of charge.
Roughly how much a month do you make from offering the service?
We don’t make any money from the service, but reputation-wise it’s great because it definitely brings in new customers, and it’s given us the opportunity to take something we were already doing, understand it more, align it to the evidence and do it even better. It doesn’t take much more effort: just a different approach and orientation.
Would you recommend offering this service to other contractors?
Yes, definitely, because if feeds into other services such as smoking cessation and weight management, for example. Ultimately, the aim is for local commissioners to see a joint pain service as a need that community pharmacy can provide care for in every locality, so it’s something worth commissioning. That’s the aspiration behind it, especially during Covid now that people who were less active are getting more active and dealing with joint pain they hadn’t experienced before. This service is another great example of how community pharmacy can raise the standards of what we already do.