Health and social care staff working in the community: a briefing for pharmacists Vs.3

East & outh East England pecialist Pharmacy ervices East of England, London, outh Central & outh East Coast Medicines Use and afety Health and social care staff working in the community: a briefing for pharmacists Vs.3 There are many different professionals working in the community and this paper aims to give an overview. It is in three parts: Nursing staff Allied Health Professionals ocial ervices staff. Part 1 Nurses General background All nurses, midwives and specialist community public health nurses who practise in the UK must be on the Nursing and Midwifery Council (NMC) register. The register shows their Register Entry which indicates what type of nurse they are. There is also a section for Recorded Qualifications which will show if they are a nurse prescriber and what type and other qualifications such as a pecialist practitioner qualification in Community (District) nursing. Nurses working in the community Nurses working in the community aim to enable clients to take part in their own health care by providing nursing care and health information. Three of the main groups in terms of numbers are community adult nurses (sometimes called district nurses), practice nurses and specialist community public health nurses (sometimes called health visitors). There are also other specialist nurses working in the community. They will have had specialist training and may or may not have a recognised community nursing qualification as well. Examples of specialist nurses include stoma, continence, diabetic, paediatric nurses, palliative care, contraception and sexual health. Nurse prescribing District nurses and health visitors were the first groups of nurses to undergo training as independent nurse prescribers, but can only prescribe from the limited nurse formulary. This is listed in the back of the BNF and comprises mainly dressings and appliances. These are now known as Community Practitioner Nurse Prescribers. In April 2002, independent nurse prescribing was extended to a wider formulary, aimed at treatment of minor ailments, minor injuries, health promotion and palliative care. From 2003, supplementary prescribing was introduced, where nurses undertook prescribing in line with a Clinical Management Plan. From 2006 independent nurse prescribing was extended to the complete BNF with the exception of most Controlled Drugs although this has been changed in April 2012 to include all Controlled Drugs. Nurses are expected to work within their own competency. Advanced Nurse Practitioners (ANPs) The RCN recommends that nurses aspiring to become ANPs should ideally undertake an RCN accredited advanced nursing practice programme. It is important to note that they do not have automatic prescribing rights, unless they have completed, in addition, the nurse prescribing course. Community adult nurses Community nurses look after housebound clients where they live in the community. They are usually employed by an NH organisation and linked to a GP practice, or health centre, and are managed by a team leader or locality manager. Community nursing focuses on healthcare although they can assess for social need their prime role is to deliver healthcare interventions. Referral is usually made by other healthcare professionals, for example GPs, from hospitals after discharge, from intermediate care teams, from social services or even from the client themselves. Community nurses provide an important link between hospital and the community. East & outh East England pecialist Pharmacy ervices

Medicines Use and afety All community nurses will have completed the three year degree level course to become a registered nurse. Following work based experience community nurses can take a postgraduate course (either at degree or masters level) to become a specialist practitioner in community nursing. This will equip them to lead and manage teams of nurses working in a range of community settings. The use of 'skill mix' means that a community nursing team will usually have only one community nursing sister, who leads the team; working with her will be registered nurses and healthcare assistants. In addition to providing professional nursing care, community nurses bring information and practical assistance to the patient's family, and help raise awareness of health issues. They also offer empathy and support, very often caring for the same patient for many years, and they aim to help patients take care of themselves as much as possible, to preserve their independence and dignity. An average daily list might total about a dozen visits, the majority being to the elderly. Within that list the procedures to be performed could range from general care, e.g., the care of wounds or chronic conditions such as ulcers and pressure sores, to peritoneal dialysis and the administration of cytotoxic drugs. Other routine duties could include: instilling eye/ear drops administering insulin injections or drawing up for client to self administer administering various intramuscular or intravenous injections providing palliative care e.g. drug administration via a syringe driver health teaching and health promotion referring patients to other agencies supporting relatives and carers Increasingly the NH is seeking to provide care closer to home. Community nurses and their colleagues in intermediate care teams are pivotal in this shift in provision. Increasingly community nurses are become more skilled so that they are able to offer services such as intravenous therapy. Intermediate care teams often offer increased support at times of critical health care need to achieve the following: prevent an unplanned admission to hospital support a timely and early supported discharge from hospital avoid admission into long term health care reduce dependency on long-term care packages to improve independence and minimise intervention in daily life. Community Matrons manage patients with long term conditions. As well as providing nursing care, community matrons act as case manager a single point of contact for care, support or advice, typically for a caseload of around 50 very high intensity users. ometimes community nurses need pharmacy advice regarding such questions as the stability of insulin and other products. With the increasing use of the community setting for acute care, it is likely that community nurses will be requiring more support concerning different medications, e.g. the use of intravenous and cytotoxic drugs in the home. Also the increasing sophistication and complexity of wound care products is likely to lead to community nurses looking to pharmacists for more information. Community nurses may be Community Practitioner Nurse Prescribers or they may have undertaken the course to be an Independent Prescriber so will interact with pharmacists when their prescribing data is monitored. Community nurses will also work under PGDs e.g. for the provision of the influenza vaccination programme. Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 2

Medicines Use and afety pecialist Community Public Health Nurses This qualification now includes health visiting and school nursing. Health Visitors Health visitors are a key part of the healthcare team. Their aim is to improve the health of families and children in the crucial first few years of life. Working in the community, they prevent illness and promote health and wellbeing. Health visitors must first qualify and register as a nurse or midwife. They then take an approved programme in specialist community public health nursing/health visiting (CPHN/HV). Programmes are at degree level and are normally a minimum of one year full time or the part time equivalent. It is possible to undertake a '2+1' programmes, where a graduate with a health-related degree can complete their pre-registration nurse training in two (rather than three) years, then follow this with the 1 year full-time CPHN/HV programme. Health visitors are pivotal in leading and delivering child and family health services (pregnancy through to 5 years) by supporting and educating families. They provide: parenting support and advice on family health and minor illnesses new birth visits which include advice on feeding, weaning and dental health physical and developmental checks providing families with specific support on subjects such as post natal depression ongoing contact with families during the first year, between one to three years and three to five years. Health visitors provide ongoing additional services for vulnerable children and families. They are skilled at identifying families with high risk and low protective factors, referring them to suitable support services. This may include: referring families to specialists, such as speech and language therapists arranging access to support groups organising practical support - for example working with a nursery nurse on the importance of play. Health visitors play a vital role in contributing to multidisciplinary services in safeguarding and protecting children. Health visitors are trained to recognise the risk factors, triggers of concern, and signs of abuse and neglect in children, as well as what must be done to protect them. chool nurses chool nurses are mainly engaged in health promotion work with children. They often cover a number of schools including those providing education to children with special needs. Children may be referred to them by teachers, parents, social services departments, voluntary organisations and other health care colleagues. It is possible to enter school nursing straight from initial registration. They may then go on to work towards the pecialist Practitioner - chool Nursing/pecialist Community Public Health Nurse qualification. This is at either degree or masters level and offered by a number of HEIs. chool nurses provide a variety of services including: Promoting healthy lifestyle and healthy schools Working with vulnerable children and adolescents Public Health including immunisation Child and Adolescent Mental Health Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 3

Medicines Use and afety Working with schools who educate children with chronic complex health needs ex education within schools chool Nurses are involved in the immunisation of children during their school years. Contact with pharmacists involves requests for information about maintaining the cold chain, working under PGDs and vaccine specific queries. Contraceptive and exual Health Nurses Contraceptive and exual Health nurses see women for a number of reasons ranging from contraception (both pre- and post-coital), screening for sexually transmitted infections, pregnancy testing and advice, smear tests and infertility to sexually related anxieties, premenstrual syndrome and menopausal symptoms. As well as a supply service, they offer counselling and practical advice. They will see women with or without their partners. They also see men alone to supply condoms, to offer pre-vasectomy counselling and to discuss sex-related problems. They usually work in a contraceptive and sexual health clinic run by an NH trust. Contraceptive and sexual health nurses will have completed the three year degree level course to become a registered nurse. They will then undertake a degree level postgraduate qualification in contraceptive and sexual health, which includes clinical placements and a competency framework. ome nurses will go on to receive further training so that they can carry out clinical duties such as inserting intrauterine devices and contraceptive implants. The majority of contraceptive and sexual health clinic work is concerned with contraception and a pregnancy advisory service. The contraceptive and sexual health nurse offers appropriate contraceptive advice and supplies, health education including preconceptual care, and counselling regarding unwanted pregnancy. Contraceptives are supplied free of charge (including condoms). Most contraceptive and sexual health nurses in NH clinics will be issuing contraception under PGDs. An increasing number of contraceptive and sexual health nurses are independent prescribers. Much of the nurses' work is concerned with careful explanation and teaching of the different contraceptive methods. Contraceptive and sexual health clinics also aim to offer the opportunity to air any sexually-related problems that clients might be reluctant to discuss with their GP. Clinics may work on an appointments system but also offer a young people's walk-in service, and they will generally see anyone, regardless of where they live or work. Practice Nurses Practice nurses are centred on a GP practice and work exclusively with that practice's patient list. They are usually employed by the practice. The number of practice nurses employed in any surgery reflects the GPs' choice regarding the services to be provided by the practice and the division of labour between the different health care professionals. Practice nurses will be registered nurses but in addition they may hold advanced qualifications such as Advanced Nurse Practitioner. Increasingly practice nurses are training to be Independent Prescribers. Practice nurses provide a nursing service generally within the general practice surgery although a few visit patients in their homes under the direction of the general practitioner. Practice nurses are providing increasing support to general practitioners in their fulfilment of their contracts through immunisation, health promotion, screening and managing patients with long term conditions such as diabetes and asthma. Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 4

Medicines Use and afety Contact with pharmacists often involves requests for information about immunisation and vaccination issues such as maintaining the cold chain or working under PGDs. Practice nurses are often Independent Prescribers so there may be contact with pharmacists when their prescribing data is reviewed. Other community nurses There are many other specialist nurses working in the community and their qualifications and training will be dependent on their role. These specialist nurses are often at the forefront of their speciality and may well be independent nurse prescribers a few of these are listed below: breast care nurse community paediatric nurses continence nurses geriatric liaison nurses HIV/AID nurses palliative care nurses respiratory support nurses stoma care nurses Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 5

Medicines Use and afety Part 2 Allied Health Professionals Podiatrists/chiropodists Chiropodists (now often called podiatrists) diagnose and treat abnormalities of the lower limb. They give professional advice on the prevention of foot problems and on proper care of the foot. Patients will be of all ages from infants to the elderly. In the NH staff see many patients at high risk of amputation for example those who suffer from diabetes. Podiatrists in the NH hold a Bc (Hons) degree in podiatry which is approved by the HPC. Combining study with clinical placements, the degree programme takes three or four years to complete full time. Registration Registration with the HPC is a requirement for NH employment. The titles of podiatrist and chiropodist are now protected, but there may be some practitioners who are working with non NH organisations that are not eligible to register with the HPC and may use the title Foot Health Practitioner. It is, therefore, important to ascertain status on the HPC register especially when working with non-nh organisations. Professional Body Their Professional Body is The ociety of Chiropodists and Podiatrists http://www.feetforlife.org/ Additional Qualifications ome Podiatrists will have additional qualifications; these include a licence to administer local anaesthetics, a POM qualification and supplementary prescribing. ome may also be qualified as Consultant Podiatric urgeons and undertake foot surgery. Remember that this qualification does not give them automatic prescribing rights. Podiatrists treat people of all ages and from all walks of life. ome examples are: Assess and treat foot care ailments, ranging from problems such as verrucas to deformity Analyse a person s gait and correct the anatomical relationship between the different segments of the foot. Orthotics are often prescribed to achieve this Monitor and manage foot problems and deformities caused by diseases such as rheumatoid arthritis Advise and treat patients at high risk of foot problems and amputation such as people who suffer from diabetes Nail surgery using local anaesthetics Podiatric surgery (following further training) i.e. joint surgery on foot, which can be performed on a day care basis, thus reducing orthopaedic waiting lists. In the community, most podiatrists in NH organisations have referral criteria and will see only highrisk category patients. NH practitioners in the community usually obtain their supplies from the designated pharmacy supplier of the NH trust which may be an NH trust pharmacy or another supplier. Podiatrists must be annotated on the HPC register that they hold a Local Anaesthetic Licence before they can administer local anaesthetics. They may also hold a POM qualification (again annotated on the HPC register) which allows them to sell or supply a number of POMs including analgesics and antibiotics. However, this process cannot happen on FP10s as the Regulations do not allow it. Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 6

Medicines Use and afety A summary of these exemptions is given at: http://www.mhra.gov.uk/howweregulate/medicines/availabilityprescribingsellingandsupplyingofmedic ines/exemptionsfrommedicinesactrestrictions/chiropodists/index.htm Podiatrists can administer drugs under PGDs, and can train to be supplementary prescribers. It has been agreed that they will soon be able to train to be Independent Prescribers. These activities will involve working with pharmacists. Physiotherapists Physiotherapy is a healthcare profession which sees human movement as central to the health and well-being of individuals. Physiotherapists identify and maximise movement potential through health promotion, preventive healthcare, treatment and rehabilitation. The core skills used by physiotherapists include manual therapy, therapeutic exercise and the application of electro-physical modalities. Physiotherapists also have an appreciation of psychological, cultural and social factors which influence their clients. All current physiotherapy courses are at degree level, and the three year course leads to a Bc in physiotherapy. Graduates of these courses are then eligible to apply for membership of the Chartered ociety of Physiotherapists (MCP) and to register with the HPC. ome existing physiotherapists have the diploma qualification, which has now been superseded. Registration Registration with the HPC is a requirement. Professional Body Their Professional Body is The Chartered ociety of Physiotherapy (CP) http://www.csp.org.uk/ Physiotherapists work in all areas of the NH. Physiotherapy is a treatment of pain, injury and disease that works by enhancing the body's own healing mechanisms. It employs techniques of mobilisation, manipulation and exercise in order to maximise functional ability and improve posture. In most cases it is painless, and drugs are rarely used. Physiotherapists aim to teach people to help themselves to better health, and take into account people's lifestyle, work and leisure needs during the process. They also give advice aimed at reducing further injury. The range of problems they treat includes: disabling conditions such as cerebral palsy, cystic fibrosis and Parkinson's disease rehabilitation after serious accidents sports injuries, damaged ligaments, pulled muscles arthritis, back and neck problems, slipped discs stroke rehabilitation chest conditions, particularly in the elderly or in children. Physiotherapists can administer drugs under PGDs, and can train to be supplementary prescribers. It has been agreed that they will soon be able to train to be Independent Prescribers. pecialist Musculoskeletal Physiotherapists can be trained to administer intra-articular injections of local anaesthetics and/or steroids. These are usually given under PGD. Physiotherapists cannot delegate their authority to work under a PGD so cannot supervise those Physiotherapists undertaking injection therapy training. The authority to administer in these cases must be given by a registered prescriber. Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 7

Medicines Use and afety Occupational therapists Occupational therapy is the assessment and treatment of physical and psychiatric conditions using specific, purposeful activity to prevent disability and promote independent function in all aspects of daily life. Occupational therapists work in hospital and various community settings. They may visit clients and their carers at home to monitor their progress. When a course of therapy is completed, the therapist will analyse how effective it has been. normally consists of a three year course leading to a Bc in occupational therapy. If someone is already an occupational therapy support worker or a technical instructor, they might be able to study part-time, in which case the course would take four years. There are also graduate entry schemes to a two year accelerated course which also lead to a formal qualification. Registration Occupational therapists are registered with the HPC. Professional Body The British Association of Occupational Therapists is the professional body for all occupational therapy staff in the United Kingdom Occupational therapy has a unique philosophy that acknowledges the link between what people do and their health and wellbeing. To the profession occupation means all the activities a person undertakes, enjoys and values. Occupation includes all daily activities such as making a hot drink, using public transport and socialising. Occupational therapists use a range of strategies and specialist equipment to enable people to reach their goals to enable their independence. This could range from helping someone regain the confidence to shop or cook unassisted for his or her family or return to work after a physical or mental illness. The scope of occupational therapy ranges from infancy to old age. Occupational therapists aim to get people functioning given any social, mental or physical challenges which they face. Occupational therapists can work in a variety of fields including social care, mental health, rehabilitation and children s services. Work settings include people s homes, work environments, prisons and hospitals. Occupational therapists work in partnership with people to create practical solutions to the problems that affect their independence. Although the work of occupational therapists does not directly concern the use of medication, contact with pharmacists could arise in the following ways: Aids to daily living; occupational therapists will have extensive experience of adaptations and aids, and those pharmacists who provide this specific service may need to liaise with them on a local basis concerning availability and suitability of items for individual clients. Compliance aids; occupational therapists can usefully contribute to the selection of a memory aid for an individual, particularly regarding the physical dexterity required to use it. ome occupational therapists may want information about side-effects of medication, for them to inform their clients. Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 8

Medicines Use and afety Dietitians Dietetics is the interpretation and communication of the science of nutrition to enable people to make informed and practical choices about food and lifestyle, in both health and disease. Dieticians undertake the practical application of nutrition with both individuals and population groups to promote the well being of individuals and communities to prevent nutrition related problems. They are also involved in the diagnoses and dietary treatment of disease. A qualified dietitian will have studied a three or four year degree in dietetics that is recognised by the Health Professions Council (HPC). Alternatively they may hold a relevant science degree and then have completed a postgraduate diploma or Mc which takes two years. Registration Registration with the HPC is a requirement for NH employment. Nutritionists do not need to be registered with the HPC so would not be able to work under a PGD. Professional Body The British Dietetic Association the professional association and trade union for dietitians. Dietitians work with people who have special dietary needs, inform the general public about nutrition, give unbiased advice, evaluate and improve treatments and educate clients, doctors, nurses, health professionals and community groups. Dietitians can work in a variety of areas; many of these are in the NH within hospitals or in the community. Both hospital and community dietitians educate people who need special diets as part of their medical treatment. Dietitians have special skills in translating scientific and medical decisions related to food and health to inform the general public. They also play an important role in health promotion. Dietitians may interact with pharmacists in a number of areas but predominately in the area of developing clinically and cost-effective prescribing of oral nutritional supplement (ON) products and gluten-free products. They may also work together on guidance for administering drugs via enteral feeding tubes. Dietitians can also supply and administer drugs under PGD. peech and language therapists The role of a speech and language therapist (LT) is to assess and treat speech, language and communication problems in people of all ages to enable them to communicate to the best of their ability. They may also work with people who have eating and swallowing problems. Qualification is through a three or four year undergraduate course approved by the Royal College of peech & Language Therapists (RCLT). Post graduate courses, over 2 years, are also available on a limited basis. Registration Registration with the HPC is a requirement of employment. Professional Body The Royal College of peech & Language Therapists is the professional body Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 9

Medicines Use and afety Additional Qualifications Newly qualified practitioners undergo supervision during their first year, within a clinical setting. Once successfully completed they are the accepted as autonomous clinicians and given full RCLT membership. peech and language therapists assist children and adults who have the following types of problems: difficulty producing and using speech difficulty understanding language difficulty using language difficulty with feeding, chewing or swallowing a stammer a voice problem peech and language therapy does not routinely involve the use of medication, so contact with pharmacists is limited. However, support may be required when needing to know about possible adverse effects of medication that could affect salivation, swallowing or the control of muscles affecting speech or voice control. The use of thickening agents to aid swallowing may be one area where peech and language therapists may seek the advice of a pharmacist. In addition peech and language therapists may also ask pharmacist for advice on different formulations when patients are unable to swallow. Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 10

Medicines Use and afety Part 3 ocial ervices Domiciliary Care Local authorities have a duty to assess a person who may be in need of community care services. They may need services because of serious illness, physical disability, learning disability, mental health problems or frailty because of old age. Following this assessment a care package may be set up. The most common type of care an individual will receive will be domiciliary care in their own home. Domiciliary care workers are either directly employed by social services, or more likely, work for a private or voluntary agency that has a contract with a social services department. They give domestic assistance and personal care to people living in their own homes, following assessment of need. The traditional view of domiciliary carers performing mainly domestic tasks such as shopping and cleaning has changed significantly over the past few years. There has been a marked shift towards domiciliary carers providing more personal care (bathing, dressing, feeding, giving medication) and less domestic support. In some areas, domestic help is provided separately by a different workforce. There are several reasons for this shift: earlier discharge from hospital increasing frailty of clients who are living longer increased numbers of people with disabilities living in the community. Domiciliary care workers come from a variety of backgrounds but their caring skills may be considered more important in recruitment than qualifications. Most training is, therefore, provided inservice, but it varies significantly across the UK in quantity and content. It should be noted that domiciliary care services must be registered with the Care Quality Commission and need to comply with The Essential tandards of Quality and afety including Outcome 9. The largest group of a domiciliary carer s clients is elderly or disabled people, but some other groups are growing in significance. They include: people with mental health problems people who have AID people who have drug or alcohol problems Levels of support Domiciliary carers may have differing levels of involvement with medicines support for their clients. The level of support will depend on whether they provide assistance with medication or if they are directly involved in the administration of medication. Level 1 upport General support or assistance with medication Domiciliary care staff assisting with medication must receive suitable training and should only give assistance with medication under instruction from their manager and in accordance with the service user s care plan. Level 1 support is given when the service user takes responsibility for their own medication, i.e. the service user indicates to the care worker what actions they are to take on each occasion. The support given under Level 1 may include: requesting repeat prescriptions from the GP collecting medicines from the community pharmacy Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 11

Medicines Use and afety disposing of unwanted medicines safely by returning the supply to the community pharmacy (when requested to do so by the service user). manipulation of a container, for example opening a bottle or popping tablets or capsules out of a blister pack at the request of the service user and when the care worker has not been required to select the medication Level 2 upport Administering medication Administration of medication may include some or all of the following: selecting and preparing medicines for immediate administration (including medicines in monitored dosage cassettes and liquid medicines) applying creams and ointments inserting drops to ear, nose or eye assisting with the administration of inhaled medicines The care agency must ensure that the care worker has received appropriate training and is competent to carry out the tasks. Level 3 upport Administering medication by specific technique Following an assessment by a health care professional, a domiciliary care worker may be asked to administer medication by a specific technique. If the task is to be delegated to the domiciliary care worker, the health care professional must provide the necessary training and documented evidence that the care corker is competent. Care workers can refuse to assist with the administration of medication by specific techniques if they do not feel competent to do so. Any domiciliary care workers who are expected by their employers to administer medicines should follow locally agreed guidelines for this task, and any specific training on medicines should be based on these guidelines. It may often happen that for housebound clients, the domiciliary care worker will be the main link with the pharmacist, when they collect medicines. The pharmacist will be able to discuss the client's needs, e.g., suitable dose forms, medication aids, containers and labelling. The domiciliary care worker may also need advice on how to monitor clients following changes in medication, and likely side effects, and they may need to know how to remind GPs if medication is not regularly reviewed. If they are administering medicines, administration techniques and record keeping will need to be discussed. For complex problems, the pharmacist may be able to offer a domiciliary visit. The pharmacist should bear in mind that quite often both a home carer and a community nurse are visiting the same client, and liaison with both may be necessary. Guide to roles of health and social care staff in the community: v3 June 2012 (TR) 12