Diverting care of minor ailments

The old model of healthcare provision in Ireland is in flux; the powers-that-be are advocating a shift to treatment at ‘the lowest level of complexity’ with GPs being asked to man the front lines in the care of chronic diseases as our hospital services creak at the seams.

As at least 20% of a GP’s daily workload is taken up treating minor health problems, it can be difficult for a doctor to find more time to focus on those patients with complex conditions who really need their input. The solution, according to the Department of Health, is to encourage people to take control of and responsibility for their health through self-referral to the most appropriate primary care team member.

For a number of minor ailments, the first port of call is usually the community pharmacist, who is trained to deal with minor illnesses and already spend a good proportion of his or her time advising on these self-limiting conditions.

Minor health complains are every day aches and ills that generally require little or no medical intervention, such as hay fever, constipation, dyspepsia, minor skin irritations, pain and inflammation, coughs and sore throats. A survey by the Irish Pharmacy Union (IPU) confirmed that almost 60% of people regularly rely on their pharmacist’s advice to solve their minor ailments.

By giving appropriate advice and recommending effective over-the-counter (OTC) products, community pharmacists have an important role to play in diverting minor illnesses from the GP surgery. Pharmacists are also trained to distinguish between minor illness and major disease so they can act as a filter for referral where a GP consultation is needed.

Rory O’Donnell

“All community pharmacists, to one degree or another, provide this service to their customers. Every pharmacy has a consultation room in Ireland, some of these consultations require a one-to-one conversation in private and, for other consultations it is just as appropriate to have them at the counter or to one side of the counter. It just depends on the circumstances and on the patient,” says Rory O’Donnell, who runs a busy pharmacy in Derrybeg, Co Donegal. He is also President of the IPU.

Pharmacists in Ireland provide approximately 15 million items of advice on minor health problems each year – a number that is growing annually as more individuals struggle with the cost of attending their GP, particularly for minor illnesses. Now, more than ever, there is considerable scope to develop the current level of professional services delivered by local pharmacists into a more comprehensive and structured service to the community.

Both the IPU and the Pharmaceutical Society of Ireland have long advocated for the introduction of a National Minor Ailments Scheme in community pharmacies, as currently exists in other countries including Scotland and the UK.

A minor ailments scheme works by providing non-prescription medication, where appropriate, to medical cardholders free of charge, without them having to go to their GP for a prescription.

“Under the current system, a medical cardholders with minor complains, such as a cold sore or hay fever, has to make an appointment with their GP and sit around in the waiting room so that their doctor can prescribe Zovirax or an antihistamine. This is time consuming for both the patient and the doctor and is an unnecessary drain on GP resources,” explains Rory. “A more progressive attitude to community health care would see pharmacists providing these medicines with appropriate advice on their use.”

At the IPU National Pharmacy Conference in Galway recently, union officials called on the Minister for Health James Reilly to actively engage with them on establishing a National Minor Ailment Scheme. The Minister was reminded of the IPU survey (2006), which revealed that 86% of medical cardholders are in support of this initiative.

In March this year, the Welsh Government announced plans to introduce a minor ailments service in community pharmacies across Wales. The first services will be in place by March 2013 with phased rollout beginning later that year.

Lesley Griffiths.

“By visiting pharmacists rather than GPs for minor ailments, patients will not need to make an appointment, but they will still be able to get any necessary medicine without charge. This will free up GP time for dealing with more complex conditions, and may also decrease waiting times for appointments,” remarked Welsh Health Minister Lesley Griffiths.

This endeavour to promote a more appropriate use of GP and community pharmacy skills has proved successful in Scotland and the UK. Under the Scottish system, which was introduced in 2006, patients register voluntarily in a pharmacy of their choice and the patient's GP is informed. This enables individual patient usage to be monitored through the pharmacy. There is a potential patient safety benefit and the risk for abuse of the scheme is removed, since patients can only use one pharmacy.

Payment is on a capitation basis determined by the number of patients registered, plus reimbursement for the cost of medicines supplied.

After just two years in operation, a review of the service found that there were 70,000 consultations per month in Scottish pharmacies that previously would have taken place in GP surgeries, and the average cost of medicines prescribed by pharmacists under the scheme was lower than those prescribed by GPs under the same circumstances.

In the UK, the public has been able to access free NHS treatment at local pharmacies in a large number of Primary Care Trusts for some minor conditions since 2005. Key features of existing minor ailment schemes is that the community pharmacist supplies the medication for a set list of minor ailments from a limited formulary and patients exempt from prescription charges receive these medicines free of charge.

According to research in the UK, this service has proved particularly beneficial in areas of deprivation, since patients in socially disadvantaged areas are more likely to receive OTC medicines on prescription than patients in more affluent areas.

Some members of the medical community have voiced concerns that there may be a real potential for excessive use of medicines where a health professional is both prescriber and dispenser. However, when the ‘Care at the Chemist’ study, conducted by the School of Pharmacy and Pharmaceutical Sciences at the University of Manchester, evaluated a minor ailment service in a deprived area of Merseyside, researchers found its introduction did not lead to an increase in medicine costs.

Rory O’Donnell points out that one of the biggest barriers to setting up a minor ailments service in Ireland is the limit of non-prescription medicines that are available to Irish patients through their pharmacy.

“This is only opening up gradually for us here in Ireland – they’re way ahead in the UK where there is a whole plethora of extra medicines available without prescription for a wide variety of minor medical conditions. The availability of the morning after pill without prescription from pharmacies was a welcome addition but, needless to say, we would welcome and call for a greater extension of switches like that - medicines such as fluconazole for thrush and sumatriptan for migraine.”

But, he says, in terms of the ability of Irish pharmacists to deliver this service, they are absolutely capable and willing.

“I believe that pharmacists have the skills, it’s part of our core competence already but any extra training that may be required would certainly be provided,” he suggests. “Firstly, we would have to agree the parameters of this service, involving all key stakeholders at an early stage - protocols and standard operating procedures for the scheme would need to be developed by a multi-disciplinary working group.

“As well as deciding on the list of formulary drugs, consideration would need to be given to what guidelines and advice should be included in the formulary, such as inclusion and exclusion criteria for treatment with the drug, and when to refer to the GP.

“We’re ready to engage at any time in that discussion. The package would have to be a win-win for everybody: The patient would have greater access to healthcare advice; it would reduce congestion in GP surgeries; the health service would benefit by targeting resources and making savings, and of course, schemes such as this promote the role of the community pharmacist not only as a medicines expert but as professionals who are trained to recognise and treat minor ailments and give healthcare advice.”

Fighting Cancer Fatigue

“I'm like a Lexus with a one-gallon tank: Wherever I go and whatever I do, I run out of gas while others - even my 81-year-old mother - are still going strong. It's more than just being sleepy; I am headachy and irritable. By mid afternoon, my IQ seems to be slipping 10 points per hour…if I keep pushing past my limits, I get flustered easily and appear angry when I'm not. It's hard to think, act or be like the real me,” says Dr Wendy Harpham - a well-known American doctor, author and cancer survivor – describing her daily experience living with what she calls ‘post-cancer fatigue’.

Patients expect to feel tired, weak or exhausted while undergoing rigorous cancer treatment, such as high-dose radiation or chemotherapy requiring bone marrow transplant, and they are cautioned that these symptoms may persist for a year or more.

But many are unprepared for the reality that about one-third of cancer survivors will continue to experience severe chronic fatigue for many months and even years after curative treatment.

Numerous studies have demonstrated that fatigue is a significant issue long into survivorship; ranging from five to ten years in 34% of breast cancer survivors to between six and18 years in more than half (56%) of long-term survivors of bone marrow transplantation.

Fatigue is also identified as one of the three most negative issues affecting quality of life in post treatment survivors.

While there are numerous theories to explain the etiology of fatigue in the patient undergoing treatment, and to describe the impact of that treatment on quality of life, many do not apply to the post-treatment population. Nonetheless, chronic fatigue for the cancer survivor can have a serious impact on normal life, preventing people from returning to work, leisure activities and socialising with friends.

It may also trigger a range of negative emotions including sadness, anxiety, irritability and, in some cases, guilt or depression.

Cancer-related fatigue is a common problem seen by Dr Sonya Collier, Principal Clinical Psychologist and her colleague Dr Anne-Marie O’Dwyer, Consultant Psychiatrist, at the Psycho-oncology Department in St James’ Hospital – the first multi-disciplinary service of its kind in Ireland, opened in 2003, which pioneered an innovative model of care to address the psychological problems that can emerge when a patient is diagnosed with cancer.

Over the course of almost ten years helping many thousands of patients, they identified long-term fatigue in cancer survivors as a major issue that is frequently under reported, under diagnosed and under treated.

Drs Sonya Collier (left) and Anne Marie O'Dwyer 

The pair responded by developing the first known self-help programme for persistent cancer-related fatigue in the world, which was launched earlier this year.

Entitled “Understanding and Managing Persistent Cancer-Related Fatigue”, the easy-to-use manual and accompanying DVD is structured on cognitive behavioural therapy (CBT) techniques and is made up of eight different chapters tackling issues such as inactivity, low mood, sleep problems, worry and reclaiming life after cancer.

Irish rugby star Gordon D’Arcy and well-known TV personalities Eddie Hobbs, Rachel Allen, Kathryn Thomas, Miriam O’Callaghan and Pat Kenny, along with cancer experts and former patients from St James’s Hospital, all contributed to the accompanying DVD to introduce, summarise and explain each chapter of the manual. 

“When we first set up the psycho-oncology service in St James’s, patients were being referred to me for a variety of problems, such as low mood, anxiety or body image problems, as would happen in a cancer setting, but there was frequently this common denominator which was a problem with persistent fatigue,” explains Dr Collier.

“In CBT, often one of the first exercises we do is we work with the patient to create a ‘problems and goals’ list, then we look at how we might try to solve them. Repeatedly fatigue was coming up on these lists and it was quite clear that the problems were overlapping – there were cases where the fatigue was actually causing the low mood and other times the depression was causing the fatigue.

“It was quite clear to me that some of the problems that I was use to working with, such as persistent worry following cancer - fear that it was going to come back - when I started treating those problems a lot of the fatigue issues would lift. The same with insomnia; 50% of breast cancer patients suffer from insomnia, but again, when I started working on their insomnia, the fatigue started to lift. Treatment in one area was impacting positively on the fatigue and we became very aware that this is a multi-factorial problem.”

The absence of textbooks and relative dearth of published research in the then embryonic subspecialty of psycho-oncology meant that Dr Collier had to adapt techniques from within established psychotherapeutic practice in devising strategies that worked for her patients. Over time, she could see which approaches worked on particular patients and on specific difficulties to help alleviate the ever-present and often debilitating fatigue.

“It was through working individually with patients that we developed this programme, and we could see that it was working very well, to the point that we felt the next logical step was the development of a home-based intervention for patient with mild to moderate problems,” she says.

“It’s interesting, when I started looking at this area first, back in 2003, the only real suggested intervention was medication for patients with persistent fatigue following curative treatment,” Dr Collier adds. “But treatment guidelines have since changed and now the first level intervention in the National Comprehensive Cancer Network’s (NCCC) guidelines is exercise and psychological therapy, namely CBT.”

She highlights a Dutch study that was pivotal in the re-evaluation of the NCCN guidelines. Researchers from the Radboud University Nijmegen Medical Centre in the Netherlands were among the first to demonstrate the effectiveness of CBT especially designed for fatigue in cancer survivors. Clinically significant improvement for the CBT group compared with the waiting list group was seen in fatigue severity (54% versus 4% of the patients, respectively) and in functional impairment (50% versus 18% of the patients, respectively). The study was published in the Journal of Clinical Oncology, 2006.

“We are a national centre here in St James’s and people come to us from every corner of the country – Cork, Kerry, Donegal, and the Aran Islands. These are people who have very limited amounts of energy in the first instance and they are using huge amounts of that energy to get up to Dublin and get home again, on the train or trying to battle traffic. Some have not been able to attend because they simply couldn’t manage the journey.

“The problem we were struck with was we felt their persistent fatigue was very treatable, it was something that we could help with, yet psycho-oncology is still a relatively scarce resource in Ireland. So we felt that if we could develop our programme into a self-help version it would be an effective intervention for people with mild to moderate problems,” says Dr Collier, pointing out that patients with more severe difficulties would still require one to one therapy.

The resulting and recently launched self-help programme consists of two main components - a workbook-style manual and a DVD - that are used in conjunction, chapter by chapter.

Dr Collier elucidates: “The patient is to use the manual and the DVD in a very structured way, which is made clear in the introduction to the manual. The entire programme is eight chapters long. Each chapter on the DVD has a corresponding chapter in the manual, similar to a distance-learning programme.

“Each chapter has myself and Ann-Marie explaining the programme. We also have one of the cancer consultants talking about the particular problem, and we have a contribution by an Irish celebrity that has some connection with the topic. For example, Rachel Allen does the section on good nutrition following cancer, Gordon D’Arcy does the stepped return to activity following injury or illness, and Eddie Hobbs does the energy economics piece. We’re hoping this approach will help engage people in the programme and make it more interesting for them.”

Although many studies document the incidence of fatigue in those who are no longer receiving cancer treatment, the specific mechanism of fatigue remains unknown. Researchers have suggested that such fatigue may be due to persistent activation of the immune system or to other factors such as late effects of treatment on major organ systems.

“It’s one of those problems that is hard to unpick, it is multifactoral; for different people it can be different things. In some people there may be a medical problem related to anaemia, for example, which can be treated once diagnosed by a doctor. For other patients, there are a whole host of factors that are feeding into it, some of those factors are psychological and that’s where our programme comes in,” she says.

“Most patients become very unfit and de-conditioned as a result of their treatment and being out of action for so long. Some are anxious to reclaim their old lives and try to do too much too soon; they wait an arbitrary period of time - it could be one month, six months or a year, depending on the person - and then they hurl themselves back into action and expect to be able to perform in the way that they did before, but of course their bodies can’t cope.

“Others sit and wait very patiently for their energy to return. They’re sitting, minding their energy so carefully but the more they do that the more they become deconditioned, getting less and less fit - we call this ‘use it or lose it’ economics - their beliefs are interfering with getting back and getting active again.

“In the self-help programme we try to educate people around this concept of energy economics and really encourage people to go back to activity in a stepped approach, little by little.”

She says it’s universal that cancer survivors ask why, now that their disease is gone, can they not return to their ‘normal’ life. “Questions like this are a huge part of what the manual focus on. Our beliefs, expectations and how we think about things can actually feed into vicious cycles of fatigue, anxiety and low mood, which can all negatively impact our quality of life. Each chapter in the manual offers cognitive behaviour techniques to help the patient overcome these.”

The self-help programme has already received praise from international experts in the field of psycho-oncology. Professor William Breitbart, Chief of the Psychiatry Service at the world’s oldest and largest private cancer centre, the Memorial Sloan Kettering Cancer Centre in New York described the programme as “incredibly comprehensive and extraordinarily helpful, full of practical information and interventions”.

Specifically designed for patients who are disease-free and who completed their treatment for cancer at least six months previous, the manual and DVD package is being distributed to regional oncology units and their patients nationwide, thanks to a funding from Roche Products Ireland.

Dr Collier and Dr O’Dwyer are hopeful that their home-based intervention will provide cancer survivors with information and strategies that may help them to better understand and manage their fatigue.

Dr Wendy Harpham

In her book After Cancer, Dr Harpham, who was diagnosed in 1990 with non-Hodgkin’s lymphoma and has since struggled with limited stamina and fatigue, reminds each patient that their recovery pattern is unique.

She advises survivors to work towards developing a new sense of well being and good health, as opposed to trying to get back to where they were before cancer, and to focus on ways to improve energy levels:

“Post cancer fatigue is one of the after effects that requires patience and hopefulness.”