Community pharmacy and NHS Direct in new team initiative

Since its creation and launch more than five years ago, NHS Direct has handled over 18 million calls and has become one of the world's principal providers of telephone-based health care advice. During the conception of NHS Direct it was not anticipated that medicines-related enquiries would make up a significant number of the calls being dealt with by nurse advisers; therefore input from community pharmacy was not initially sought.

NHS Direct receives many calls for advice on the treatment of minor ailments and these calls have traditionally been dealt with either by giving some form of home care advice, or advising the caller to see a GP for a routine appointment. Over time, the demand for advice on medicines by callers has become apparent. Research has shown that almost six per cent of calls are solely for advice about medicines and approximately 40 per cent of responses include advice about medicines (Jamieson and Joshua, 2002).

It was from this identified need that the community pharmacy project was born. It has since been rolled out across all NHS Direct sites. The aims of the project are:

- To provide a framework of training and knowledge, understanding and support for NHS Direct nursing staff to work within;

- To provide safe and appropriate information and referral to an appropriate health care professional (in this case a community pharmacist) following assessment of the caller using the Clinical Assessment System (CAS) tool. The CAS tool is a research-based, computerised, clinical assessment programme, which is one of the key tools used by the nurses to assess callers.

The disposition of 'contact pharmacists' was introduced across NHS Direct sites in 2002 following a pilot study undertaken in the Essex, Barking and Havering areas in 1999-2000 in partnership with the National Pharmaceutical Association, Essex, Barking and Havering NHS Direct, Essex Local Pharmaceutical Committee, the Pharmaceutical Services Negotiating Committee and the Royal Pharmaceutical Society. An independent evaluation of the results was undertaken at the University of Sheffield (Chaplin, 2002).

The CAS tool provides a research-based framework to guide the nurse during the assessment process. Some 250 algorithms were reviewed by a team of community and academic pharmacists, GPs and nurses convened by the Department of Pharmacy Education and Practice at Keele University. Of these, 182 opportunities were identified to refer the caller to a pharmacist (Chaplin, 2002).

The roll-out of this project was completed at NHS Direct, North Central London, by the end of 2002. However, like any change or improvement to practice, this is an ongoing process that aims to keep existing staff updated while training new staff.

NHS Direct, like community pharmacy, is a fundamental and integral part of the health service. Both are, in many cases, the first point of contact for the public when accessing health care, and provide ease of contact combined with accessibility to health professionals. Both services can and do play an important part in raising their own and each other's profiles in the public perception.

Forging links
Having worked both as a pharmacist nurse adviser and a pharmacy coordinator for NHS Direct at the North Central London site, I have seen closer links being forged since the introduction of the community pharmacy project among our NHS Direct, the Local Pharmacy Committee (LPC) representatives and community pharmacists in the areas we cover. This is reflected in feedback from pharmacists concerning nurses on clinical placements and after visiting the call centre.

The feedback on the clinical placements was very positive from both nurses and participating pharmacists. Closer links have allowed NHS Direct nurses and the community pharmacists to gain a greater understanding of each other's roles. This has been key in providing the public with a wider range of safe and appropriate treatment choices. It has also led to a more streamlined use of NHS resources through appropriate referral of members of the public to the relevant health care providers.

To support these links, a series of open evenings have been held to provide those community pharmacists who have not been able to facilitate a clinical placement or exchange. The open evenings are in addition to a service level agreement and regular meetings with the LPC representatives and those on clinical placements.

The open evenings allow the pharmacists to explore the CAS tool and see the call centre in action as well as learning about the role and function of NHS Direct when callers are referred to their local community pharmacists. The response from pharmacists who have attended has been positive. The open evenings have enlightened, informed and highlighted the differences in the service we each provide while emphasising the potential symbiotic relationship between NHS Direct and community pharmacists in providing the public with a safe and easily accessible source of health advice.

The joint working approach at North Central London NHS Direct
The three LPCs covered by North Central London NHS Direct are Kensington, Chelsea and Westminster; Barnet, Enfield and Haringey; and Camden and Islington. North Central London NHS Direct has been working closely with LPC representatives and the pharmacists they represent. From this a strong, supportive relationship has grown, providing a high level of support for the community pharmacy project.

Barnet, Enfield and Haringey's representative, Michael Levitan, has observed the benefits of joint working: 'Like most professions, both community pharmacy and nursing are probably quite introspective. I think it really helps to get two professions working together. Not only does it benefit the professions concerned, but in this particular project, the patients are the real winners, being counselled to find a more appropriate, and possibly quicker resolution to their problems.'

Mr Levitan firmly believes, through his own experience of working with NHS Direct, that nurses and pharmacists could do a lot more joint work, in a variety of settings, such as walk-in centres, out-of-hours primary care centres, and even A&E. He argues for a more appropriate, more accessible, but equally acceptable route to treatment and care, and a common standard of quality.

The impact of the project
Before the introduction of the CAS tool, contact pharmacists at NHS Direct were advising callers to consult their local pharmacist (after the primary referral of the caller to another health care provider such as his or her GP). There was no formalised referral to a community pharmacist.

Jamieson and Joshua (2002) outline the impetus for the development of the community pharmacy project, its subsequent roll-out and the current level of input into NHS Direct. At North Central London the training included the structured learning package developed by the CPPE (Centre for Pharmacy Postgraduate Education) and the National Pharmaceutical Association, and the nurses undertaking a clinical placement within the pharmacy setting.

Senior nurse for NHS Direct North Central London, Sara Perry, is also the NHS Direct network D clinical coordinator. She states: 'We have enjoyed excellent support from our local pharmacists over the past year and have a robust training programme in place, which is always well evaluated by our staff'.

Since January 2003, an average of 250-300 callers per month have been assessed and then referred to the community pharmacist. After the introduction of the contact pharmacist and the simultaneous roll-out of training, the number of patients being referred was low. But as nurses undertook clinical placements with the community pharmacists, the number of referrals increased - reflecting an increased knowledge and confidence in referring callers to community pharmacy. The number of referrals to community pharmacy is monitored on a monthly basis, as is the type of calls by clinical reason.

Feedback
The pharmacy-training package developed by the CPPE and NPA has been well received by nurses and has allowed them to safely and appropriately refer callers to a community pharmacist. In addition, the evaluation feedback from both pharmacists and nurses participating in the clinical placements has been both positive and enthusiastic. Both groups have an increased personal and professional awareness of the other group's role, skills and function (Williams, 2002).

The future
The success of the community pharmacy project has also had the advantage of being a significant factor in raising the public and professional profile of both NHS Direct and community pharmacists. Supporting this, in his article 'How should the profession respond to pharmacy's poor public image?', Lloyd Matowe suggests that the pharmaceutical profession's profile could be raised through pharmacist-led campaigns to promote the notion to the public that pharmacists do more than simply supply and dispense medication (Matowe, 2002).

This is where NHS Direct, in collaboration with the community pharmacy project, can work with community pharmacists. The introduction and development of the 'contact pharmacist' referral reflects the affinity that the two services have. It highlights the key role that community pharmacists play in providing safe and appropriate advice on the management of minor ailments and medicines as well as being readily accessible and providing a rich source of advice, treatment for minor ailments and a wealth of experience to the public.

The secretary of Camden and Islington Local Pharmaceutical Committee, David Kent, has been working closely with staff at the NHS Direct site at North Central London. Mr Kent admits that he was sceptical about the concept and the implementation of NHS Direct until he visited the call centre environment and saw first-hand how NHS Direct functions. His appreciation and awareness of the scope and high level of skill involved in running the service has increased and he has become a vocal advocate of the service. Mr Kent has since become a trainer of NHS Direct nurses for the community pharmacy project.

Conclusion
Both NHS Direct and community pharmacists have an essential role to play in the government's health strategy. This can be achieved by providing the public with ease of access to services while reducing inappropriate referrals and/or access to NHS resources. By working together, NHS Direct and community pharmacy can provide the public with a health care resource that is safe, appropriate and meets their needs.

FURTHER INFORMATION
For further information on the community pharmacy referral scheme with NHS Direct, please contact:

Peter Williams, pharmacy coordinator, NHS Direct, London Tel: 020 8962 7600;

Ash Pandya, national pharmacy projects manager, NHS Direct, North East London Tel: 020 8924 6800/07980 261065.

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