Hard to swallow?


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17 Mar 2017

Is NHS England’s proposed roll-out of a new sore throat ‘test and treat’ scheme a plus for community pharmacy, or a waste of time and resources, asks journalist Saša Jankovic

Each year, around 1.2 million people visit their GP with a sore throat. Recent studies from NHS England show that 62% of these visits result in the prescribing of antibiotics, but this staggering demand on GP time and antibiotic use could be set to change.

A sore throat ‘test-and-treat’ scheme piloted in 35 Boots pharmacies in 2014/15 has been named as one of eight schemes selected for this year’s NHS Innovation Accelerator (NIA) programme, which aims to fast-track the roll-out of new treatments and technologies across the country.

Designed to prevent antibiotic resistance and reduce GP workload, the pilot involved community pharmacists carrying out throat swabs to test patients for group A streptococci (strep throat), which cause bacterial infections in the throat. Patients would then be offered antibiotic treatment if necessary. They paid £7.50 for the test and an additional £10 if antibiotics were supplied, although it remains unclear if these charges will continue when the scheme is further rolled out.

A review of the pilot demonstrated that two-thirds of patients who would have seen their GP for a sore throat did not need to do so, according to Malcolm Harrison, senior manager of the project and contract development at Boots, and now fellow of the NHS England programme.

‘If this was extrapolated to the 1.2 million consultations that GPs see annually for sore throats, then an additional 800,000 patients could be potentially seen within community pharmacy,’ he adds. ‘Such a service should make sure that patients have a new access point of care to relieve the burden on GPs, while also making sure that antibiotics are only given when needed.’

[box type=”shadow” ]How the sore throat ‘test-and-treat’ service works

The sore throat test-and-treat service is a walk-in service at community pharmacies where patients can receive screening and point-of-care testing for group A streptococci, which cause bacterial infections in the throat. Pharmacists will be trained to recognise bacterial infection in adults and offer patients a swab test if they are displaying symptoms of a sore throat.

The results are available in five minutes, and patients who test positive will be offered antibiotics from the pharmacist without having to visit their GP. Those who do not need antibiotics will be given advice on the best course of pain management and other options to help them make a speedy recovery.[/box]

A question of timing

Much of the reaction to the news has been positive, with chair of the Royal Pharmaceutical Society’s (RPS) English pharmacy board Sandra Gidley (pictured overleaf) describing it as a ‘win-win all round’.

Bipin Patel, LPC chair for Bexley, Bromley and Greenwich, and owner of Broadway Pharmacy in Bexleyheath, is more cautious in his praise: ‘As with most things, there is always a downside or something to be careful about,’ he says. ‘But there is a place for this scheme as some people out there suffer quite a bit, especially with bacterial sore throats. Ultimately, it’s about giving the patient more information about their condition and empowering them to make their own decisions about treatment.’

The burning – and as yet unanswered – question remains why NHS England is bringing in a new service when it is also cutting funding to pharmacy.

As one of eight medical innovations to ‘mainstream patient care’ that will be introduced over the course of the coming year, the sore throat service is another long-term objective from the Government for reducing pressure on the NHS. However, the Pharmaceutical Services Negotiating Committee (PSNC) and Pharmacy Voice raise a note of caution.

Alastair Buxton, PSNC’s director of NHS services, says that while he welcomes the news, it should be noted that no central funding is being made available to commission this service and its adoption will be subject to local decisions made by clinical commissioning groups (CCGs).

Buxton also stresses that the announcement ‘seems to run contrary to the Department of Health funding cut, which will adversely affect the ability of pharmacies to provide patient care’.

Buxton is not the only one to notice the inconsistencies in the Government’s attitude towards the sector. Pharmacy Voice CEO Rob Darracott highlights the juxtaposition between introducing a new service at the same time as ‘undermining’ English community pharmacy through the funding cuts – which are likely to make pharmacists think again about the ‘scope’ of services they can continue to deliver (see pages 10-12).

‘If the NHS and Government are serious about working with the community pharmacy sector to develop and embed this type of initiative, then we need partnerships, not cuts,’ he says.

Stuart Gale, chief pharmacist and owner of the Frosts Pharmacy Group, says: ‘Why this is being introduced at the same time as the funding cuts is unclear.’

He says the pharmacists he has spoken to are also conflicted in their opinion about the proposed scheme: ‘On the one hand it is seen as a positive move, utilising the pharmacist’s expertise and encouraging behavioural change among the general public that will ultimately work towards alleviating some of the pressure in GP surgeries. At the same time, however, the question of how the additional need will be met when funds are being cut by 12% remains unanswered.’

Calls for clarity

So is the scheme a positive move for community pharmacy and patients, or a time and money waster that lacks sufficient proof that it will have the intended effect of reducing the use of antibiotics?

Gale is supportive, but calls for more clarity on the service. He says: ‘Each year, around 1.2 million people visit their GP with a sore throat. Of the 1.2 million visits, 62% result in the prescribing of antibiotics. However, tests have shown that fewer than 10% of people who present with a sore throat actually have a bacterial infection that warrants the prescription of antibiotics. This scheme is aimed specifically at these patients, although undoubtedly there will be some element of people seeking out the service who may not have considered a visit to their GP.

‘Because the swab test is designed specifically to identify the type of infection, the theory is that the patient will be guided by the expert and the best course of treatment will be prescribed. However, those opposing the test-and-treat service question how many of those who visited their pharmacist would have actually taken the time to book in to see their GP. Questions have also been raised over the efficacy of the test itself.’

Gale would like to see this as ‘a properly funded national service, which is how we feel pharmacy should be used – to take pressure off primary care in the current NHS crisis.’

However, he stresses that if it is rolled out nationally by NHS England, like the national flu vaccination service, then ‘CCGs will only have a role in monitoring and supporting the service’. If it is left up to individual CCGs to commission the service locally, he warns ‘there will be a risk of a postcode lottery developing where some patients have access to the scheme and others do not’.

At this stage, there doesn’t appear to be much detail about where the service will now appear. When contacted for comment on this issue, few CCGs replied. Of those that did, NHS Lambeth CCG said it ‘has not discussed commissioning this scheme’.

Debbie Jackson – head of engagement, communications and marketing (North) at NHS Arden and Greater East Midlands commissioning support unit – said neither she nor the CCG knew anything about the scheme. Although she added that Derbyshire is about to roll out a Pharmacy First scheme, encouraging patients with certain minor or common ailments who are exempt from prescription charges to use their local pharmacy rather than making an appointment at their GP practice.

Nevertheless, Patel thinks ‘CCGs should be looking to commission the scheme’, and says he ‘will be asking if it is something that will be coming to our area, as anything that gives more options to patients is good’.

[box type=”shadow” ]GP view: It will lead to an increase in antibiotic scripts

‘My concern is that this will lead to an increase rather than a decrease in antibiotic prescribing by encouraging patients to seek interventions for what is a minor, self-limiting illness. For years and years, sore throat has simply been viewed as an inconvenience that could be treated with OTC anti-inflammatories, but this scheme is reversing that. By encouraging people to attend a GP for a test, those who would have self-treated then get tested, and that leads to an increase in antibiotic prescribing.’

Dr Andrew Green is a GP in East Yorkshire, British Medical Association General Practitioners Committee representative for East Yorkshire and Lincolnshire, and UK Prescribing Policy Lead[/box]

Positive for pharmacy?

Despite all the current unknowns, the scheme will have obvious positive effects of driving more footfall into community pharmacy and reminding the public about pharmacists’ extensive skills, as well as taking pressure off already squeezed GP services.

And Gale supports this view: ‘Services such as this will no doubt have a positive role to play in shifting people’s perception of pharmacists from “checkers of pill boxes” to the health professionals that we are.’

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