As the village pharmacist, I sell tickets for the local “am dram”, publish the local diary of events – and play a lead role in identifying and preventing dementia
I own the pharmacy in Wheathampstead, a village of around 6,500 people in semi-rural Hertfordshire.
On the face of it there are few problems: the population is healthy, wealthy – and wise.
But there is a small, isolated council estate housing single mothers with depression and other vulnerable people; a disproportionately high population of very elderly people; no rail link; and buses are infrequent.
We were all shocked in 2010, when the decaying, long-dead bodies of an elderly carer and her quadriplegic daughter were discovered. The reclusive mother had died suddenly of a heart attack and her daughter, unable to help herself or raise the alarm, had starved to death in her wheelchair. It had all gone undiscovered for months.
It is hard to convey, in a short article, the degree of social capital that is vested in our pharmacy. It plays a pivotal role in village life.
We sell tickets for the local “am dram”, publish the dairy of village events and have won several civic awards.
We support the local surgery’s patient participation group by publicising and participating in their events. At Christmas the pharmacy is stuffed with gifts of thanks – cards and chocolates galore – from appreciative patients.
We even get occasional mentions in the obituary columns when relatives thank us for the kindness and support we gave to them and their dying relative.
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“We are so lucky to work with such an excellent local pharmacy,” were the words the senior partner wrote in the Christmas card the local GP practice sent us.
It really is the sort of “Big Society” stuff of which prime minister David Cameron would approve.
So, when I was invited one evening to attend the launch of Wheathampstead as a “dementia friendly” village, I readily accepted.
The speakers in front of a surprisingly large village gathering were a local GP, a representative of the Alzheimer’s Society, a patient and a consultant.
‘Early diagnosis was key but effective treatment options are limited’
Between them they described the nature of the condition, the difficulty in arriving at a firm diagnosis, warning signs and symptoms, the profound effects dementia has on the person with the disease, and the knock-on consequences for their family.
Early diagnosis was key but effective treatment options are limited. Unprompted every single one of the speakers mentioned the pharmacy and the invaluable services it provides.
They invited me to say a few words so, slightly embarrassed, I conveyed that we are pleased to be able to make a small contribution to the life of such a special, friendly village, and that we would like to support the initiative in any way we could…
All of which got me thinking: in what ways could the pharmacy really help? It seems to me there are four discrete but related areas:
It is becoming increasingly clear that poor diet and lack of exercise play a huge role in the development of dementia as with so many long term conditions.
The same lifestyle issues that predispose towards developing hypertension, type 2 diabetes and metabolic syndrome – the combination of diabetes, hypertension and obesity – also predispose towards dementia. In fact I’ve even heard dementia described as “type 3 diabetes”.
‘We plan to train our health champions as dementia champions’
The NHS Five Year Forward View is heavily oriented towards disease prevention and early detection, with particular emphasis on diabetes.
Community pharmacy has the potential to play a pivotal preventive role in controlling diabetes and improving blood pressure control, which is key in this group. This clearly has implications for dementia that is vascular in origin.
As Public Health England director of health and wellbeing Kevin Fenton pointed out in a recent blog, more than a million people visit pharmacies every day. The Healthy Living Pharmacy initiative is proving itself with real world heath promoting outcomes. There are around 1,000 Healthy Living Pharmacies nationwide, employing more than 3,000 trained “health champions”.
So, in Manor Pharmacy, we plan to train our health champions as dementia champions, too.
2. Early detection and referral
With a little extra training pharmacists and their teams are well placed to spot the early signs of dementia. We see people on a very frequent basis and develop strong and trusted relationships. This is especially the case for people who have long term conditions for which they are taking regular medication.
We often spot warning signs such as behavioural changes or confusion. Is there any reason why we could not carry out specific dementia-targeted reviews and administer one of the simpler scoring tests as part of this when appropriate?
3. Medicines optimisation
Treatment options for dementia are few and limited. But many dementia patients also suffer other long term conditions, such as hypertension and type 2 diabetes.
‘Of every 10 hypertensives, four remain undiagnosed’
While smoking remains the number one killer, hypertension is number two. An astonishing one in four adults is hypertensive. Yet of every 10 hypertensives, four remain undiagnosed, two are treated but not to target, and only four are treated effectively.
Whenever we hold a “know your numbers” blood pressure testing day, this is exactly what we find – so early detection and case finding through the community pharmacy network is a no brainer.
But why stop there? Why can’t community pharmacists manage the entire pathway and treat to target by following evidence based protocols. Read and write access to the summary care record means GPs would be kept informed and outcome data would be generated.
In this way, with a little imagination, medicines use reviews could move from sideshow to centre stage, sharing data relating pharmacists’ inputs and outcomes with GPs as we go.
4. End of life care
This is still a taboo subject. Most people at the end of life are taking – or more likely failing to take – a complex and often conflicting cocktail of prescribed medicines.
These people need a full level 3 clinical medication review – a simple medicines use review will only scratch the surface.
While many patients at the end of life do have their medicines reviewed regularly either by their GP, their consultant or a hospital pharmacist, there will inevitably be those who fall between the cracks.
Community pharmacists can play a pivotal coordinating role. In fact we are often approached by carers, hospital pharmacy departments and GPs to provide medication in dosettes for dementia patients.
We do far more than this, providing a full medicines management service and weekly delivery when required. All without remuneration or evaluation, of course.
Duncan Selbie, Public Health England’s CEO, believes ridding the UK of tobacco, tackling uncontrolled blood pressure at scale, intervening pre-diabetes and taking down sugar consumption would save thousands of lives, at least halve the typical life expectancy gap of 10 years, and reduce demand on the NHS.
‘Community pharmacy is consistently locked out of the NHS’s complex commissioning processes’
By dropping weight to the levels of 1993 we could remove up to 1.8 million type 2 diabetics from the “forward order book” of the NHS.
NHS England has just published its business plan for 2015-16. Dementia is so significant it merits its own chapter, and tackling dementia addresses eight out of nine of NHS England’s mandate priorities
But the final word goes to Charles Alessi, who is dementia lead for Public Health England. In his recent blog he states that at nearly 60 he is keen to stave off the risk of developing dementia himself. He wants to be treated like a person, not a container for disease. Amen to that!
There is nothing I’ve suggested here that some community pharmacies are not already doing. But what is sorely missing is the necessary pace and scale.
Why? Because community pharmacy is consistently locked out of the NHS’s complex commissioning processes. NHS England and Public Health England must seize the day. Working together they need to make NHS commissioning processes deliver more for patients and the public by tapping the potential of community pharmacy.
Let’s work together to deliver the pace and scale that Duncan Selbie wants and let’s do it within Charles Alessi’s timescale.
Community pharmacists like me are up for the challenge. Is the NHS?
Graham Phillips is director and superintendent pharmacist of Manor Pharmacy Group