Anti-osteoporosis medication dispensing by clinical commissioning groups in England - an ecological study of variability in practice and of the effect of the Covid-19 pandemic.

PURPOSE: To investigate whether the rate of Anti-Osteoporosis Medication (AOM) dispensing was related to prevalence of risk factors and hip fracture incidence in the local population. METHODS: The Open Prescribing database was used to analyse dispensed AOM at the level of Clinical Commissioning Groups (CCGs) in England. Male Healthy Life Expectancy (MHLE), Female Healthy Life Expectancy (FHLE), the prevalence of smoking and active adults, the incidence of hip fracture and of alcohol related hospital admissions, and local dispensing of a comparator drug (atorvastatin) were considered as predictor variables. Linear and multilinear regression were performed. Using atorvastatin as a comparator, AOM dispensing was compared after the start of the Covid-19 pandemic with the same quarter the previous year. RESULTS: Rates of AOM per 1000 people aged over 65 years in a CCG area varied between 379.2 and 1129.1, with a mean of 670.3. Population risk factors were individually related to the amount of AOM dispensed in an area. Collectively, local activity levels in adults (p = 0.042) and local hip fracture incidence (p = 0.003) were significantly negatively correlated with rates of AOM dispensed. Rates of alendronate dispensing fell significantly at the start of the Covid-19 pandemic (p < 0.001), whilst atorvastatin dispensing rates significantly increased (p < 0.001). CONCLUSION: Lower rates of AOM dispensing were seen in areas with a higher proportion of active adults and higher incidence of hip fracture. Multidisciplinary services should be developed to address this care gap with consideration given to local population risk factors. Community pharmacists are ideally placed to play a vital role in osteoporosis management.

An Integrated Dyspepsia Module for First-year Pharmacy Students.

Objective. To design an integrated dyspepsia module for first year pharmacy students that combines clinical and professional practice with fundamental sciences in five different science subject areas. Methods. The approaches used in designing this module are described with emphasis on strategies adopted to integrate science and practice, and the new ways of working adopted by the design team. Students' views and experiences of the module and its integration were explored using questionnaires. Results. A high proportion of students reported positive views and experiences of the module, the integration and its impact (as self-reported) on their learning and practice. The assessment of student performance indicated learning and attainment was at an appropriate level for a first-year module. Both the student grades and research results indicate a positive student learning experience. Conclusion. The dyspepsia module provides a flexible and effective template for the integration of science and practice in theme-based modules, with students reporting positively about the integration, including their perception of its contribution to improving their learning and understanding. New and more collaborative ways of working are required when designing integrated modules.

The role of the pharmacist in the selection and use of over-the-counter proton-pump inhibitors.

BACKGROUND: Heartburn and other symptoms of gastro-oesophageal reflux occur in ~30% of survey respondents in multiple countries worldwide. Heartburn and acid regurgitation are common complaints in the pharmacy, where patients frequently seek relief through medication and advice. The growing number of proton-pump inhibitors available in the over-the-counter setting provides an efficacious choice to patients experiencing frequent heartburn. Pharmacists can assist patients in their treatment decisions whilst inquiring about alarm symptoms that should prompt a physician referral. Aim of the review Provide pharmacists with a review of current clinical research and expert guidelines on use of over-the-counter proton-pump inhibitors. METHODS: This narrative review was conducted to identify publications relevant to the following themes: overview of available treatments for frequent episodes of heartburn/acid regurgitation; treatment algorithms providing guidance on when to use over-the-counter proton-pump inhibitors; and the role of the pharmacist in the use of over-the-counter proton-pump inhibitors. RESULTS: Frequent symptoms of acid reflux, such as heartburn and acid regurgitation, can interfere substantially with daily life activities. Proton-pump inhibitors are the most efficacious treatment for frequent reflux symptoms and are recommended as an appropriate initial treatment in uncomplicated cases. Proton-pump inhibitors have varying pharmacokinetics and pharmacodynamics across the class; 20 mg esomeprazole has higher bioavailability and exposure than over-the-counter omeprazole, for example. However, differences in clinical efficacy for symptom relief have not been demonstrated. The safety and tolerability of proton-pump inhibitors have been well established in clinical trial and post-marketing settings, and use of a short regimen is associated with a very low likelihood of missing a more serious condition. Pharmacists can assist patients with accurate self-diagnosis by asking short, simple questions to characterize the nature, severity, and frequency of symptoms. Additionally, pharmacists can inquire about alarm symptoms that should prompt referral to a physician. Pharmacists should inform those patients for whom over-the-counter proton-pump inhibitors are appropriate on their proper use. CONCLUSION: Over-the-counter proton-pump inhibitors have a valuable role in the treatment of frequent heartburn. Pharmacists have the opportunity to guide patients through selection of the best treatment option for their symptoms.

Partnership in optimizing management of reflux symptoms: a treatment algorithm for over-the-counter proton-pump inhibitors.

BACKGROUND: Uncomplicated heartburn and acid regurgitation are increasingly treated and managed using over-the-counter medications. However, with over-the-counter availability of antacids, alginates, histamine 2 receptor antagonists (H2RAs), and proton-pump inhibitors (PPIs), consumers need guidance as to appropriate options and how to use them. METHODS: Relevant guidelines, studies, and reviews were identified via literature searches of PubMed/Medline and Google Scholar, as well as cross-referencing from the identified papers. RESULTS: Antacids, alginates, and H2RAs are best suited to management of occasional heartburn, taken either before provocative meals or other triggers or on demand when symptoms arise. Over-the-counter PPIs are appropriate options across the range of symptom severity/frequency typically encountered in the pharmacy, but may be particularly appropriate for treatment of those with frequent and/or very bothersome heartburn. A 2-4 week course of daily PPIs can lead to complete resolution of frequent heartburn. Counseling is important to ensure that patients understand that failure of symptoms to resolve or a rapid return of symptoms while taking a PPI is an indication to consult a doctor, whereas a return of symptoms after a period of months may be an indication for just another course of treatment. The need for effective communication and for ensuring use of the correct medication in the over-the-counter setting puts much of the responsibility for management of heartburn and acid regurgitation on the pharmacist. A proposed algorithm that details when and how to use available over-the-counter medications is presented. This algorithm also highlights alarm features and atypical symptoms indicative of other underlying conditions that should be referred directly to a physician. CONCLUSION: Implementation of a simple algorithm will empower pharmacists and consumers alike and ensure consistent and appropriate care.

Effectiveness of a community pharmacy weight management programme.

BACKGROUND: Obesity is a growing problem in England with one quarter of the adult population being obese and around 60 % being overweight or obese. Given the high costs of treating obesity-related conditions such as coronary heart disease and type-2 diabetes the UK Government aims to reduce obesity through public health services including those provided by community pharmacists. OBJECTIVE: To evaluate the effectiveness of a community pharmacy weight management clinic in assisting obese patients to reduce their weight. SETTING: Community pharmacies across four Primary Care Trusts in England. METHODS: Retrospective analysis of data collected by pharmacies providing weight management programmes. The service involved measurement with provision of advice and support. Data analysis consisted of frequency counts, percentages and means with standard deviations (SD) for demographic and biometric variables. Paired t tests were used to compare weight, waist circumference and blood pressure at 3 and 6 months. MAIN OUTCOME MEASURE: Weight change at 3 months. RESULTS: 281 patients attended the programme across four Primary Care Trusts. Three-quarters were female, mean age 52.8 years (SD ± 14.4) and mean baseline weight 96.3 kg (SD ± 15.7). At 3 months patients had lost weight (mean change = -3.07 kg) and waist circumference (mean change = -3.87 cm), but there was no difference in blood pressure. After 6 months weight and waist circumference were further reduced from baseline (mean change = -4.59 kg, -4.79 cm respectively) and there was a reduction in blood pressure (mean change systolic = -9.5 mmHg; diastolic = -4.7 mmHg). CONCLUSION: The study has demonstrated that reductions in weight and waist circumference can be achieved in patients who participate in a community pharmacy weight management programme.

What proportion of prescription items dispensed in community pharmacies are eligible for the New Medicine Service?

BACKGROUND: The payment structure for the New Medicine Service (NMS) in England is based on the assumption that 0.5% of prescription items dispensed in community pharmacies are eligible for the service. This assumption is based on a theoretical calculation. This study aimed to find out the actual proportion of prescription items eligible for the NMS dispensed in community pharmacies in order to compare this with the theoretical assumption. The study also aimed to investigate whether the proportion of prescription items eligible for the NMS is affected by pharmacies' proximity to GP practices. METHODS: The study collected data from eight pharmacies in Nottingham belonging to the same large chain of pharmacies. Pharmacies were grouped by distance from the nearest GP practice and sampled to reflect the distribution by distance of all pharmacies in Nottingham. Data on one thousand consecutive prescription items were collected from each pharmacy and the number of NMS eligible items recorded. All NHS prescriptions were included in the sample. Data were analysed and proportions calculated with 95% confidence intervals used to compare the study results against the theoretical figure of 0.5% of prescription items being eligible for the NMS. RESULTS: A total of 8005 prescription items were collected (a minimum of 1000 items per pharmacy) of which 17 items were eligible to receive the service. The study found that 0.25% (95% confidence intervals: 0.14% to 0.36%) of prescription items were eligible for the NMS which differs significantly from the theoretical assumption of 0.5%. The opportunity rate for the service was lower, 0.21% (95% confidence intervals: 0.10% to 0.32%) of items, as some items eligible for the NMS did not translate into opportunities to offer the service. Of all the prescription items collected in the pharmacies, 28% were collected by patient representatives. CONCLUSIONS: The results of this study show that the proportion of items eligible for the NMS dispensed in community pharmacies is lower than the Department of Health assumption of 0.5%. This study did not find a significant difference in the rate of NMS opportunities between pharmacies located close to GP practices compared to those further away.

Views and experiences of community pharmacists and superintendent pharmacists regarding the New Medicine Service in England prior to implementation.

BACKGROUND: The New Medicine Service (NMS) was introduced to community pharmacies in England in October 2011. The NMS aims to improve adherence to new medicines in patients with selected long term conditions. The service consists of two follow-up consultations within 1 month in addition to usual care. OBJECTIVES: This study explored community pharmacist and superintendent pharmacist views and experiences of the NMS in the 5 weeks prior to its implementation to identify potential facilitators and barriers to its success. The study also investigated participant experiences of the introduction and provision of existing pharmacy services in order to contrast with the implementation of the NMS. METHODS: This study consisted of four focus groups with a total of 15 community pharmacists representing locums and employees of small, medium and large chain pharmacies. In addition, 5 semi-structured interviews were conducted with superintendent pharmacists representing independent, small chain, supermarket and large multiple pharmacies. Data were audio-recorded, transcribed verbatim and thematically analyzed. RESULTS: Both pharmacists and superintendent pharmacists were positive about the NMS and identified potential benefits for patients and the pharmacy profession. Awareness of the service was high, however, some confusion between the NMS and changes to Medicine Use Reviews was evident in all focus groups due to their similarity and coincidental implementation. This confusion was not observed in the interviews with superintendent pharmacists. Participants identified pharmacists' positive attitude, the similarity to current practice and the self-accreditation procedure as potential facilitators to service implementation. Potential barriers identified included a perceived lack of interest and awareness by GPs of the service, and the payment structure. Participants were concerned about the speed of implementation, and the absence of some materials needed prior to the start of the service. CONCLUSIONS: Participants were enthusiastic about the potential of the NMS to benefit patients and the pharmacy profession. Participants were able to identify several potential barriers and facilitators to the provision of the service. It remains to be seen whether the factors identified affected the early implementation of the service.

A qualitative study exploring the impact and consequence of the medicines use review service on pharmacy support-staff.

BACKGROUND: Pharmacy support-staff (pharmacy technicians, dispensers and Medicines Counter Assistants) support the delivery of pharmaceutical and retail functions of the pharmacy. Workflow is supervised and at times dependent upon the pharmacist's presence. Policy makers and pharmacy's representative bodies are seeking to extend the community pharmacist's role including requiring the pharmacist to undertake private consultations away from the dispensary and shop floor areas. However, support-staff voices are seldom heard and little is known about the impact such policies have on them. OBJECTIVE: The objective of this study is to explore the impact and consequences of the English Medicine Use Review (MUR) service on pharmacy support-staff. METHODS: Ten weeks of ethnographic-oriented observations in two English community pharmacies and interviews with 5 pharmacists and 12 support-staff. A thematic approach was used to analyse the data. RESULTS: Despite viewing MURs as a worthwhile activity, interviews with support-staff revealed that some felt frustrated when they were left to explain to patients why the pharmacist was not available when carrying out an MUR. Dependency on the pharmacist to complete professional and accuracy checks on prescriptions grieved dispensing staff because dispensing workflow was disrupted and they could not get their work done. Medicines Counter Assistants were observed to have less dependency when selling medicines but some still reported concerns over of customers and patients waiting for the pharmacist. A range of tacit and ad hoc strategies were consequently found to be deployed to handle situations when the pharmacist was absent performing an MUR. CONCLUSIONS: Consideration should be given to support-staff and pharmacists' existing work obligations when developing new pharmacy extended roles that require private consultations with patients. Understanding organisational culture and providing adequate resourcing for new services are needed to avoid improvisations or enactments by pharmacy support-staff and to allow successful innovation and policy implementation.

A qualitative study exploring the impact and consequence of the medicines use review service on pharmacy support-staff / Estudio cualitativo explorando el impacto y las consecuencias del servicio de revisión de uso de medicamento sobre el personal de apoyo en la farmacia

Background: Pharmacy support-staff (pharmacy technicians, dispensers and Medicines Counter Assistants) support the delivery of pharmaceutical and retail functions of the pharmacy. Workflow is supervised and at times dependent upon the pharmacist’s presence. Policy makers and pharmacy’s representative bodies are seeking to extend the community pharmacist's role including requiring the pharmacist to undertake private consultations away from the dispensary and shop floor areas. However, support-staff voices are seldom heard and little is known about the impact such policies have on them. Objective: The objective of this study is to explore the impact and consequences of the English Medicine Use Review (MUR) service on pharmacy support-staff. Method: Ten weeks of ethnographic-oriented observations in two English community pharmacies and interviews with 5 pharmacists and 12 supportstaff. A thematic approach was used to analyse the data. Results: Despite viewing MURs as a worthwhile activity, interviews with support-staff revealed that some felt frustrated when they were left to explain to patients why the pharmacist was not available when carrying out an MUR. Dependency on the pharmacist to complete professional and accuracy checks on prescriptions grieved dispensing staff because dispensing workflow was disrupted and they could not get their work done. Medicines Counter Assistants were observed to have less dependency when selling medicines but some still reported concerns over of customers and patients waiting for the pharmacist. A range of tacit and ad hoc strategies were consequently found to be deployed to handle situations when the pharmacist was absent performing an MUR. Conclusions: Consideration should be given to support-staff and pharmacists’ existing work obligations when developing new pharmacy extended roles that require private consultations with patients. Understanding organisational culture and providing adequate resourcing for new services are needed to avoid improvisations or enactments by pharmacy support-staff and to allow successful innovation and policy implementation(AU)

Antecedentes: El personal de apoyo en la farmacia (auxiliares de farmacia, dispensadores, y ayudantes de mostrador) ayuda en la entrega de medicamentos y las funciones de venta en la farmacia. El flujo de trabajo esta supervisado y a veces es dependiente de la presencia del farmacéutico. Los políticos y los cuerpos de representación de los farmacéuticos buscan extender el papel del farmacéutico comunitario, incluyendo exigir al farmacéutico que realice consultas privadas fuera de la zona de dispensación y de las partes del público. Sin embargo, rara vez se oyen las voces del personal de apoyo y se sabe poco del impacto de estas políticas sobre ellos. Objetivo: El objetivo de este estudio es explorar el impacto y las consecuencias del servicio ingles de revisión del uso de medicamentos (MUR) sobre el personal de apoyo en la farmacia. Métodos: Diez semanas de observaciones de tipo etnográfico en dos farmacias comunitarias inglesas y entrevistas con 5 farmacéuticos y 12 personas de apoyo. Se utilizó un abordaje temático para analizar los datos. Resultados: A pesar de ver las MUR como una actividad que valiosa, las entrevistas con el personal de apoyo reveló que se sienten frustrados cuando se les dejó y tuvieron que explicar a los pacientes porque el farmacéutico no estaba disponible cuando estaba realizando una MUR. La dependencia del farmacéutico para completar las comprobaciones profesionales y la idoneidad de las prescripciones incomodaba al personal dispensador porque el flujo de trabajo de la dispensación tenía que interrumpirse y no podían hacer el trabajo solos. Se observó que los ayudantes de mostrador tenían menos dependencia cuando vendían medicamentos, pero algunos reportaron preocupaciones sobre los clientes y pacientes cuando esperaban por el farmacéutico. Se encontró un abanico de estrategias tácitas y ad-hoc que se desarrollaron para manejar las situaciones en las que el farmacéutico estaba ausente realizando una MUR. Conclusiones: Se debería tener en cuenta las obligaciones del trabajo actual del personal de apoyo y del farmacéutico cuando se desarrollan nuevos papeles ampliados en la farmacia, que requieran consultas privadas con pacientes. Se necesita comprender la cultura organizaciones y realojar adecuadamente los recursos para los nuevos servicios para evitar improvisaciones o actuaciones del personal de apoyo en la farmacia y para permitir innovación y la implementación de políticas con éxito(AU)

Medicines use reviews: a potential resource or lost opportunity for general practice?

BACKGROUND: Patient non-adherence to medicines represents a significant waste of health resource and lost opportunity for health gain. Medicine management services are a key health policy strategy to encourage patients to take medicines as they are prescribed. One such service is the English Medicines Use Review (MUR) which is an NHS-funded community pharmacy service involving a patient-pharmacist consultation aiming to improve patients' knowledge of medicines and their use. To date the evidence for MURs to improve patient health outcomes is equivocal and GPs are reported to be sceptical about the value of the service. This paper presents the patient's perspective of the MUR service and focuses on the importance of GP-pharmacist collaboration for patient care. Suggestions on how MURs may have value to GPs through the delivery of increased patient benefit are discussed. METHOD: A qualitative study involving ten weeks of ethnographic observations in two English community pharmacies. Observations were made of all pharmacy activities including patient-pharmacist MUR consultations. Subsequent interviews with these patients were conducted to explore their experience of the service. Interviews with the pharmacy staff were conducted after the period of observations. A thematic approach was used to analyse the data. RESULTS: Fifty-four patients agreed to have their MUR observed of which thirty-four were interviewed. Seventeen pharmacy staff were also interviewed. Patients reported positive views about MURs. However, there was little evidence suggesting that pharmacists and GPs were working collaboratively or communicating outcomes resulting from MURs. MURs were conducted in isolation from other aspects of patient care. Patients considered GPs to have authority over medicines making a few wary that MURs had the potential to cause tensions between these professionals and possibly adversely affect their own relationship with their doctor. CONCLUSIONS: This study reveals the potential for effective GP-pharmacist collaboration to improve the capacity of the MUR service to support patient medicine taking. Closer collaboration between GPs and pharmacists could potentially improve patients' use of medicines and associated health care outcomes. The current lack of such collaboration constitutes a missed opportunity for pharmacists and GPs to work together with patients to improve effective prescribing and optimise patient use of medicines.

Understanding the patient perspective of the English community pharmacy Medicines Use Review (MUR).

BACKGROUND: Health policy-makers and pharmacy's representative bodies seek to better utilize the skill of community pharmacists so as to support patients' use of medicines and associated health care outcomes. The English Medicines Use Review (MUR) is an NHS-funded community pharmacy service that aims to improve patients' knowledge of medicines and their use. MURs represent an opportunity for patients to gain additional help with their medicines as well as fostering inter-professional collaboration between pharmacists and general practitioners (GPs). OBJECTIVE: To describe patients' perspective of the MUR service and their understanding of the value that they derive from it. METHODS: This study employed a qualitative approach involving 10 weeks of ethnographic observation in two English community pharmacies. It employed observations of 54 patient-pharmacist MURs consultations and subsequent interviews with 34 patients. A thematic approach was used to analyze the data. RESULTS: All patients reported feeling comfortable speaking with the pharmacist, who they saw as a knowledgeable expert on medicines. They appreciated the time spent with them in a private consultation. The MUR provided patients with reassurance about their medicines, that they were "doing the right thing." Despite these positive views, when asked to describe the purpose of their MUR, patients provided ambivalent accounts and reported that the consultation did little to improve their knowledge of medicines or affect how they used them. CONCLUSIONS: Patients' accounts of MURs suggested they held broadly positive views about the service. However, evidence that MURs were fulfilling their formal policy aims and intentions was limited. Policy-makers and those seeking to promote community pharmacy's professional agenda should note the patients' perspective, assessment and perceived value of MURs in order to develop services, which are better tailored to patient need.

Information sources used by parents buying non-prescription medicines in pharmacies for preschool children.

OBJECTIVE: Parents are exposed to many different information sources about children's medicines, including recommendations from other people, the media, and their own previous experience. The aim of this paper is to explore the influence of different information sources upon their non-prescription medicine purchases for children aged 0-4 years. SETTING: The setting was thirty-nine community pharmacies across four Primary Care Trusts in England. MAIN OUTCOME MEASURE: We explored the type and range of information sources used by parents in purchasing non-prescription medicines. Methods A self-completion survey and a subset of semi-structured telephone interviews were undertaken with parents/carers buying oral medicines for children aged 0-4 years. RESULTS: One hundred and thirty-four surveys and thirty-eight interviews were completed: most participants were 25-44 year-old women. Recommendations from other people, both from health professionals and family members, were most often cited as influencing parents' and carers' choice of medicine. Advertising, and well-known brands of children's medicines, were also influential. The Internet and other media were less often cited as sources. Medicines leaflets and packaging were found to be useful: a significant minority admitted difficulty in understanding all the information therein. CONCLUSION: This study explored the information sources reported at the point of a specific medicine purchase, thus reflecting actual behaviour rather than general perceptions of useful sources. Parents and carers of pre-school children reported a number of professional and lay influences on their medicine purchase choices. Pharmacists and staff should consider these influences when advising children's medicine purchasers. A combination of spoken advice and written reminder information would meet the preferences of most purchasers.

Interactions between parents/carers of pre-school children and pharmacy staff when buying non-prescription medicines.

OBJECTIVE: Little is known about the interactions between pharmacy staff and parents/carers who buy nonprescription medicines for children. Responsibility for choice and administration of children's medicines falls to the parent/carer. Pharmacy advice should support safe and effective use of medicines for children. This paper explores the interactions between pharmacy staff and purchasers of children's medicines, in terms of questioning and advice giving. SETTING: Thirty-nine community pharmacies across four Primary Care Trusts (PCTs) in England. METHODS: A self-completion survey and a subset of semi-structured telephone interviews were undertaken with parents/carers buying oral medicines for children aged 0-4 years. MAIN OUTCOME MEASURE: Frequency and type of questioning and advice given by pharmacy staff to parents purchasing nonprescription medicines. RESULTS: One hundred and thirty-four surveys and thirty-four interviews were completed: most participants were 25-44 year-old women. The majority (85%) reported being questioned, most often by medicines counter assistants, to establish the safety and suitability of the medicine. Three key questions (whether the medicine had been used before, the age of the child, and concurrent medicines), however, were not always asked. Interviews revealed self-perceptions of 'expert' and 'novice' users, depending on experience with the medicine purchased. This seemed to affect their perception of their need for questioning and advice from pharmacy staff. CONCLUSION: Interactions in the pharmacy involving the purchase of medicines for young children are varied with regard to questioning and advice given. This study has found that key questions are not always asked before a medicine is sold, and advice about using the medicine was given in just over one-third of encounters. Parents/carers also identified a range of additional information they would like to have received with their medicine: there was, however, no clear pattern to the type of information they would like. Parents reflected on the questioning and advice in terms of their self-perception of expertise with the medicine. Both pharmacists and their assistants should adopt a flexible questioning approach based on parents/carers' advice and information needs that respects expertise, but does not assume it.

The contribution of the Medicines Use Review (MUR) consultation to counseling practice in community pharmacies.

OBJECTIVE: To understand the contribution of the Medicines Use Review consultation to counseling practice in community pharmacies. METHODS: Qualitative study involving ten weeks of observations in two community pharmacies and interviews with patients and pharmacy staff. RESULTS: 'Traditional' counseling on prescription medicines involved the unilateral transfer of information from pharmacist to patient. Over-the-counter discussions were initiated by patients and offered more scope for patient participation. The recently introduced MUR service offers new opportunities for pharmacists' role development in counseling patients about their medicines use. However, the study findings revealed that MUR consultations were brief encounters dominated by closed questions, enabling quick and easy completion of the MUR form. Interactions resembled counseling when handing out prescription medicines. Patients rarely asked questions and indeterminate issues were often circumvented by the pharmacist when they did. MURs did little to increase patients' knowledge and rarely affected medicine use, although some felt reassured about their medicines. Pragmatic constraints of workload and pharmacy organisation undermined pharmacists' capacity to implement the MUR service effectively. CONCLUSION: Pharmacists failed to fully realise the opportunity offered by MURs being constrained by situational pressures. PRACTICE IMPLICATIONS: Pharmacist consultation skills need to be reviewed if MURs are to realise their intended aims.

A multi-method evaluation of the Pharmacy First Minor Ailments scheme.

OBJECTIVES: To evaluate whether the Pharmacy First Minor Ailments scheme achieved its objectives in terms of improving access to medicines and reducing doctor workload for minor ailments by enhancing the role of community pharmacists in the management of minor ailments. SETTING: Nottingham, the United Kingdom. METHODS: A mixed-methods study was conducted, including semi-structured interviews with key stakeholders, a patient survey, and an analysis of the Nottingham City Primary Care Trust data. MAIN OUTCOME MEASURES: Stakeholders' acceptability of the scheme and scheme users' satisfaction with the scheme. RESULTS: Most health care professionals were positive about the implementation of the scheme, although they reported some problems, such as the restricted formulary. The majority of stakeholders perceived benefits of the scheme for both patients and health care professionals. The level of patient satisfaction with the scheme was high, particularly in terms of ease of access and convenience. The current structure of the scheme appears to be an acceptable way to run the scheme. Since its commencement the scheme has enabled the transfer of a substantial number of minor ailments consultations from general practices to community pharmacies. CONCLUSION: It appears that the Nottingham City Primary Care Trust is successful using community pharmacies to improve access to medicines and provide a greater choice in primary care for patients with minor ailments. Thus, the Primary Care Trust should continue the scheme, although there are some important issues (e.g. the restricted formulary, the lack of privacy in some pharmacies) that need to be addressed to improve and develop the service further. The Nottingham City Primary Care Trust should build on this success to further utilise the pharmacy in their primary care service development.

Epidemiology of insomnia: a longitudinal study in a UK population.

STUDY OBJECTIVES: To investigate the incidence, persistence, and consequences of insomnia and their associations with psychological health and pain. DESIGN: A population based, longitudinal, cohort study using postal questionnaires at baseline and 12-month follow-up. Sleep problems in the past month were assessed using 4 questions: insomnia was defined as having at least 1 of the sleep problems "on most nights." Questions about psychological health, presence of pain at different sites, and demographic details were included in the questionnaire. SETTING: Five general practices in Staffordshire, UK. PARTICIPANTS: The questionnaire was mailed to a random sample of 4885 adults aged 18 years and over registered with these practices. There were 2662 questionnaires returned. RESULTS: Of the responders, 2363 completed all 4 sleep questions at baseline: 870 (37%) had insomnia and 1493 (63%) did not have insomnia. Of those without insomnia at baseline, the incidence of insomnia at 12 months was 15%, and this was significantly associated with baseline anxiety, depression, and pain. Of those who did have insomnia at baseline, 69% had insomnia at 12-month follow-up; persistence of insomnia was significantly associated with older age. Insomnia at baseline was significantly associated with incidence of anxiety, depression, and widespread pain at 12-month follow-up. CONCLUSIONS: Insomnia is common and often persistent. Older people appear more vulnerable to persistent symptoms. Our results provide evidence that the common problems of insomnia, pain, and psychological distress are intertwined and suggest that combined approaches to treatment may be needed to reduce the onset and persistence of these problems in the community.

Why do older people report fewer headaches?

BACKGROUND: We have previously confirmed a clear decline in headache prevalence with increasing age. This parallels the pattern in other painful conditions but the age-related decline in prevalence is greater for headache. OBJECTIVE: To investigate whether the decline in headache prevalence with age was associated with the elimination of work-related factors, increases in other health problems or concomitant use of pain-relieving medicines. We discuss these and other possible explanations from the literature. METHODS: Cross-sectional postal survey to a random sample of 5,000 adults with follow-up by (i) consultations with general practitioners and prescriptions issued during the 12 months subsequent to the survey and (ii) a follow-up postal survey at 12 months. RESULTS: Headache prevalence was similar in working and retired respondents within age strata. Headache sufferers were more likely to consult their general practitioner for any reason (excluding headache) compared with non-sufferers and this was true for each age group. Headache sufferers were also more likely to be frequent consulters compared with non-sufferers in all except the oldest age group (age 66 years and over) where there was no difference. There was a clear increase in prescriptions for analgesics and non-steroidal anti-inflammatory drugs issued with increasing age. There was no difference in the percentage of daily medication users among headache sufferers compared with non-sufferers. CONCLUSION: Neither retirement from work nor the presence of other health problems account for the decline in headache prevalence with age. Whilst the data on concomitant use of pain-relieving medicines suggest this is also not a major factor in the age-related decline, the high use of such medicines in older age groups means we cannot rule out a link. Evidence from the literature suggests that there may be a number of age-related factors involved including changes in reporting of headache, biochemical changes, and the development of strategies to prevent and manage headaches.

A survey of the provision of clinical pharmacy services in relation to existing published standards.

OBJECTIVE: To investigate the provision of clinical pharmacy services in hospitals in one NHS region in UK, and to measure the delivery of these services against published standards. METHOD: The study comprised two phases. Phase 1 was a postal questionnaire to hospital chief pharmacists seeking information on the provision of clinical pharmacy in their hospital. Phase 2 involved a semi-structured interview with hospital chief pharmacists to obtain a detailed understanding of clinical pharmacy services in their hospital and factors influencing the provision of these services. RESULTS: Ninety-four percent of all hospitals surveyed were providing a clinical pharmacy service. However, only two thirds provided a service to all wards, and the main reason given for not doing so, was lack of resources. There was a divergence of opinion amongst chief pharmacists whether it was better to provide a limited service to all wards or a good service to some wards. Thirty-seven percent of hospitals did not meet the minimum standard of frequency for visiting acute wards, whereas, 58 were meeting the optimal standard of frequency of visits for non-acute short stay wards and 67 for long stay wards, primarily because the latter required less frequent visiting. The study showed that hospital pharmacies were influencing prescribing decisions in a variety of ways other than ward visiting. CONCLUSION: Although hospital chief pharmacists see clinical pharmacy as a core service, published standards for these services are not being met. As a result of staff shortages, managers are using a variety of approaches to maintain clinical pharmacy services. There is scope for further devolvement of duties to pharmacy technicians in order to release valuable pharmacist time.

Psychological, sleep, lifestyle, and comorbid associations with headache.

OBJECTIVE: To investigate the associations of headache occurrence, severity, and frequency with psychological, sleep, and lifestyle characteristics, and comorbid conditions. BACKGROUND: Whilst associations for individual headache types, particularly migraine, have been investigated, possible associations between headache of all types and general health characteristics have not been explored. METHODS: Cross-sectional postal survey in an adult general population sample registered at five general practices in North Staffordshire, UK. RESULTS: Headache occurrence was associated with anxiety (odds ratio 4.09, 95% confidence interval 3.0, 5.6) and sleep problems (moderate sleep problems OR 3.60, 95% CI 2.5, 5.0), and the strength of the associations increased with higher levels of anxiety and sleep problem. Whilst depression showed an association with headache, this was not seen in respondents with depression in the absence of anxiety. Headache occurrence was also associated with comorbid pain anywhere in the body (OR 2.12, 95% CI 1.7, 2.6), with the strongest associations being for the neck and upper body areas compared with other areas. There was no overall link with alcohol or caffeine consumption. Increasing severity and frequency of headache resulted in stronger associations, and there were strong associations between the occurrence, severity, and frequency of headache, and both sleep problems and psychological distress. CONCLUSION: Poor sleep and anxiety appear to make a substantial contribution to the impact of headache on sufferers' lives in the general population.

One-year follow-up of headache in an adult general population.

OBJECTIVE: To investigate variation in headache occurrence and characteristics over 1 year. BACKGROUND: Headache is a common condition which can affect the work, home, and social lives of sufferers, yet surprisingly little is known about how headache changes over time. METHODS: Postal survey to a random general population sample of 5000 adults aged 18 years plus, with follow-up survey to all baseline responders at 1 year and a subsample of 500 being surveyed at 3-monthly intervals between the baseline and 1-year surveys. RESULTS: A total of 1589 (74% response) responded to the 1-year follow-up and 282 of the subsample responded to all five surveys at 3-monthly intervals. Among 1-year respondents with recent headache at baseline (defined as occurring during the previous 3 months), nearly all (94%) also reported headache during the follow-up year. One-third of respondents without recent headache at baseline reported a new episode of headache during the follow-up year. Most (85%) respondents with recent headache at both baseline and 1-year follow-up reported a variation in at least one headache characteristic. These findings were replicated in the sample completing the 3-monthly surveys. Although most of this subgroup reported their headache occurrence status was unchanged during each 3-month period, only a few (3%) respondents with headache in each period reported no variation at all in headache characteristics during the study. CONCLUSIONS: While prevalence of recent headache was stable over time for individuals, there was considerable variation in headache characteristics.