Government policy

The creation of national healthcare schemes, such as the NHS has encouraged the general population to become more reliant on institutional bodies to look after their health. This has led to increased demand on services provided by these bodies, including the management of minor illness. For example, more than one in three GP consultations are for minor illnesses and an estimated 20–40% of GP time could be saved if patients exercised self-care. Similar findings have been recorded for patients attending hospital emergency departments. This dependence by patients on bodies such as the NHS has led to government policies which encourage and facilitate self-care. In the UK, the government agenda for modernizing the NHS was spelt out in its White Paper-The NHS Plan (2000). Within this document, the government made its intention clear to make self-care an important part of NHS health care. It stated that the front line of health care was in the home. Since that time the government has published numerous papers detailing why and how maximizing self-care can be achieved.

NHS walk-in centres and telephone help lines

The UK government has been proactive in facilitating self-care, most obviously by the formation of NHS walk-in centres and the telephone help lines NHS Direct (England and Wales) and NHS 24 (Scotland). The aim of walk-in centres is to improve access to health care that supports other local NHS providers. The service is nurse led but some employ doctors to work at particular times. The first NHS walk-in centre opened in 2000 and there are now approximately 90 operating in England. The Department of Health states that over 5 million people have used a walk-in centre with the main users being young adults. NHS Direct is a 24-hour nurse-led service that receives over 500 000 calls per month. Although originally designed as a telephone help line service, NHS Direct now also offers an online service and direct interactive digital TV plus the publication of its self-help guide. In April 2013, NHS Direct was replaced by the NHS 111 service.

Deregulation of medicines

Less obvious, but arguably more important, has been the expansion of medicines available without prescription (Table 21.1). This has direct impact on community pharmacists and represents one of the major ways in which pharmacy can contribute to self-care. The switching of POMs to P status is now well established. Loperamide and ibuprofen were the first POMs to be switched in 1983. Between 1983 and 2012, over 80 POM to P and 50 P to GSL switches were made. Recent POM to P switches have seen new therapeutic classes deregulated (e.g. proton pump inhibitors, triptans, alpha-blockers) although the number of products switched has slowed. This is in contrast to P to GSL deregulation where the number of switches has steadily increased. This has led to the current situation where most medicines are now GSL and freely available from all retail outlets.

Knowledge

The cornerstone of making any diagnosis is having a sound knowledge of the presentation of conditions, which are likely to be seen in a community pharmacy. Exact prevalence data is lacking for community pharmacy consultations but it does not seem unreasonable that patterns of presentation in a community pharmacy are not too dissimilar from a GP practice. Based on this assumption, it is simple to identify those conditions that are most likely to be seen by a community pharmacist. This should be the starting point from which to build subject specific knowledge. For example if we take red eye, prevalence data from general medical practice would show that:

It would seem most prudent to have a thorough knowledge of the signs and symptoms of all types of conjunctivitis and sub-conjunctival haemorrhage as these will form the vast majority of red eye presentations seen by the community pharmacist. Of course this does not mean that other conditions that are seen less commonly by the pharmacist should be ignored. However, if basic information on common presentations is lacking then inappropriate referrals are more likely and signs or symptoms that might suggest more sinister pathology will be missed.

Gaining information

Observation, asking questions and physical examination should all be used, where appropriate, to elicit information from the patient. Most obvious is the need to ask questions (see below) to explore the presenting signs and symptoms. However, equally important is knowing who you are dealing with and the way in which they present in the pharmacy. Finally, in certain circumstances questioning and observation can be supplemented by performing a physical examination (see later).

Questioning

Pharmacists will rely heavily on asking questions to guide a differential diagnosis. Studies with doctors have shown that an accurate patient history (gained from asking questions alone) is a powerful diagnostic tool and will enable the practitioner to arrive at a right diagnosis in about 80% of cases. If a physical examination is conducted and/or diagnostic tests performed, then the probability of a correct diagnosis is increased by 10–15%.

The ability to ask appropriate questions to gain the necessary information is therefore critical. The choice of question asked is rooted in clinical reasoning (see below) but at a more basic level, the type of question and the way in which it is asked will dictate the level of response given.

Using observation and knowledge of epidemiology

Assessment of the patient begins the moment the patient enters the pharmacy. First impressions can provide ‘cues’ to their state of health. Most pharmacists will probably do this at a subconscious level but what is important is to bring this to the conscious level and build it into your consultations. Many visual cues will be apparent if they are actively looked for. It may give you an indication of severity, for example does the patient look well or poorly? Do they show any obvious signs of discomfort? This initial assessment will provide useful information which shapes your thinking and actions, and is the first step to reaching a differential diagnosis. It might transpire that they have a self-limiting condition such as viral cough that ordinarily you would not refer to the GP but because the person is elderly and has marked systemic upset, a referral is appropriate.

The key is to observe your patient. What is their physical appearance? Is the patient overweight or showing signs of being a smoker? Are there any signs of confusion, pain or systemic illness? Take time to assess what they look like, how they move and how they behave.

In tandem with observation, the pharmacist should draw on the epidemiology of conditions within a population. This will be very helpful in formulating early ideas about what the likely diagnosis will be.

Take headache as an example. The age and gender of the patient will affect diagnostic probability: migraine is three times more common in women than men, whereas cluster headache is eight times more common in men. Onset of migraine tends to occur in adolescents or young adults but is rare in people aged over 50 years old. Therefore, the age and sex of the patient asking for advice on headache symptoms will begin to shape your differential diagnosis even before you start to ask any questions. This principle can be applied to all consultations and can also be used while asking questions.

Take cough as an example. A question that pharmacists will ask is the symptom duration. Knowing how long the cough has lasted will again affect the most likely diagnosis. The longer the cough has been present, the more prevalent are conditions with sinister pathology. So for a patient with a cough of 3 days duration, the most likely cause will be a viral upper respiratory tract infection. At 3 weeks’ duration, the chances of it being a viral cause are lessened but other conditions such as acute bronchitis become more likely. At 3 months’ duration, then sinister causes of cough are much more likely, such as chronic bronchitis, TB and carcinoma.

The linking of epidemiological data of conditions to each patient consultation is an important aspect of clinical reasoning and should be an integral part of the process when making a differential diagnosis.