Coronavirus COVID-19 and Community Pharmacy


UPDATE 19TH MARCH 2020 – 11:30

GPhC and PSNI Joint Statement on Regulatory approach in challenging circumstances – for instance, in the temporary absence of a pharmacy due to illness or the nedd to self-isolate – see:

https://www.pharmacyregulation.org/news/regulatory-approach-challenging-circumstances-gphc-and-psni-joint-statement

PSNC COVID-19 Update 19th March – includes information on PQS, pharmacy services and payments; other measures to help pharmacies; new services under discussion; PPE and medicines supply; rapid testing; nomination of pharmacy staff as “key workers”; RPS COVID-19 Hub Page.

https://mailchi.mp/psnc/covid-19-update-pqs-pharmacy-services-and-payments?e=014ac39e76

SSLPC/SSLMC Joint Statement – this is aimed mostly at addressing issues on repeat prescribing practices and everything associated with prescription processes at both practice and pharmacy level:

LPC- LMC Covid-19 letter v9.0

UPDATE 18TH MARCH 2020 – 13:00

Managing Substance Use clients
Your LPC has been trying to source definitive guidance on this, and has been sent the following information from Public Health England’s regional lead on Substance Use, Tony Mercer:

OFFICIAL
It is the responsibility of local treatment providers and pharmacies, in appropriate liaison with commissioners, to develop contingency plans to ensure that medicines are prescribed and dispensed safely and continuity is maintained, balancing the usual safety risks with those related to COVID-19. Treatment providers and the NHS and voluntary sector have developed, or are further developing, their contingency plans, and PHE has been supporting them to share information and learn from each other.

Specifically in relation to the frequency of supervised consumption, decisions will need to be made on a case by case basis by relevant clinicians, and broader contingency plans should also be in place, particularly as the situation escalates. These plans will need to be in line with legislative requirements around controlled drugs, and mechanisms such as reduced frequency of collection and the nomination of a relative or friend for collection are options. Services can also ensure scripts are signed well in advance in case the prescriber(s) becomes unavailable, and should consider prioritising arrangements for those with compromised physical health, particularly respiratory conditions. All decisions need to be taken on the balance of risk of overdose and diversion, and the containment of COVID-19.

The following extracts from the Clinical Guidelines on Drug Misuse and Dependence Update 2017 (https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management) are relevant:

  • ‘Levels of supervision should be based on an individual risk assessment for, and with, each patient.’ P101
  • ‘although, ultimately, the responsibility for the level of supervision for any prescription lies with the prescriber, decisions on when to relax or increase the requirement for supervised consumption should include consultation with the multidisciplinary team, the patient and liaison with the dispensing pharmacist.’ P101
  • ‘The risk assessment should include a review of compliance and individual circumstances, including whether the home environment is suitable for safe storage of medications.’ P101
  • ‘The level of supervision and the frequency of collection should be based on individual assessment of patient needs, including the risk assessment, and should be sufficiently flexible to respond to changing circumstances.’ P102
  • ‘While supervision of prescribed medication, even if directed on the prescription, is not a legal requirement, any deviation from the prescriber’s intended method of supply should be documented and the justification for this recorded.’ P 104

More broadly, extensive advice and guidance has already been produced by PHE, the NHS and others, some of which will be of direct relevance to people who misuse drugs and alcohol, and those in specialist treatment for drug or alcohol misuse and dependence. These populations may have particular vulnerabilities and needs that are considered within this guidance, alongside other populations.

The key resources include:

Tony Mercer
Programme Manager (Substance Use)

GPhC Statement
Further to this guidance, professional regulatory bodies (including GPhC) have issued the following as part of a fuller statement on regulation of health & care professionals during the COVID-19 pandemic:

“We recognise that in highly challenging circumstances, professionals may need to depart from established procedures in order to care for patients and people using health and social care services. Our regulatory standards are designed to be flexible and to provide a framework for decision-making in a wide range of situations. They support professionals by highlighting the key principles which should be followed, including the need to work cooperatively with colleagues to keep people safe, to practise in line with the best available evidence, to recognise and work within the limits of their competence, and to have appropriate indemnity arrangements relevant to their practice.”

SUPPLIES OF PERSONAL PROTECTIVE EQUIPMENT
Personal Protective Equipment (PPE) should have been delivered to community pharmacy contractors by now – this comprises 50 masks, 200 aprons and 100 pairs of gloves. These are are being delivered to community pharmacies by DPD, if you received yours by 18 March, please call the National Supply Disruption line on 0800 915 9964 or email supplydisruptionservice@nhsbsa.nhs.uk
The PPE is only for use in the pharmacy as advised in the NHSE&I SOP – PPE only needs to be used if you are entering a room in an emergency, where an infected/possibly infected patient is isolated and when decontaminating a room where such a patient has been present (in this case the PPE is to protect the worker from the cleaning products being used).
As a consequence of this, the need for community pharmacies to have to use PPE, at this time, is low; the guidance on PPE use will be kept under review as the pandemic progresses.
Wherever possible, a patient presenting in the pharmacy with possible COVID-19 infection should be immediately told to return home and then access NHS 111 online or call NHS 111 (calling being a secondary option to online access) in order that the pharmacy does not have the increased risk of dealing with an isolated patient in the consultation room and the subsequent need for decontamination.

Ibuprofen and COVID-19:
A number of stories have been spreading via social media, suggesting a link between increased death rates and consumption of ibuprofen. These appear to be of questionable origin, but the theory is based on the potential for the side-effects of ibuprofen and NSAIDs on the GI system and kidneys to impact on the outcome within patients suffering with COVID-19. Therefore the NHS has stated on its COVID-19 page:

“There is currently no strong evidence that ibuprofen can make coronavirus (COVID-19) worse.

But until we have more information, take paracetamol to treat the symptoms of coronavirus, unless your doctor has told you paracetamol is not suitable for you.

If you are already taking ibuprofen or another non-steroidal anti-inflammatory (NSAID) on the advice of a doctor, do not stop taking it without checking first.”

The NHS also says that people who are already taking ibuprofen on the advice of a doctor, should not stop taking it without checking first.

ACE Inhibitors
There is also some concern about reports suggesting that patients taking ACE inhibitors are also more at risk of coronavirus; again, this is based on observations and not research, and other patient factors appear not to have been taken into consideration in these observations. The advice is the same, patients who are taking ACE inhibitors and displaying symptoms of coronavirus should not stop taking their medication without checking with their GP fist.

Sexual Health:
Please note that Open Clinic have suspended their “walk in & wait” services until further notice. Therefore these slots are now “appointment only” – if you are referring a client as a result of a pharmacy consultation, please get them to call one of the following numbers:
South Staffs 0300 124 5022 or S-o-T/North Staffs 0300 7900 165
Data Security and Protection Toolkit – deadline extension:
Providers of NHS services within England, including community pharmacy contractors, are required to give information governance assurances to the NHS each year via the online self-assessment: the Data Security and Protection Toolkit (previously called the ‘IG toolkit’). The deadline for completing the mandatory questions was 31st March 2020, however as a result of the impact of COVID-19 this has now been extended to 30th September 2020.

UPDATE 17TH MARCH 2020 – 18:00

A contractor in the Midlands has expressed concern about pharmacy staff being at risk of exposure to COVID-19, whereas GP practices have been closing off the surgeries to all but essential cases, and then only after telephone triage. 
NHS England & NHS Improvement (NHSE&I) locally along with LPCs  in Staffordshire and Shropshire have agreed the following approach to restricting access to community pharmacy premises in order to protect staff:
  • All contractors will have Business Continuity plans which should by now have been reviewed and updated in the light of COVID-19. 
  • Business Continuity plans should be implemented locally as and when the Responsible Pharmacist and/or Superintendent Pharmacist see fit.
  • NHSE&I, LPCs and contractors are all concerned with the safety of patients and staff – and as every pharmacy premises is different, there is no single approach that can be recommended to ensure that pharmaceutical services continue to be made available whilst ensuring the safety of all concerned.
  • Whilst the provision of pharmaceutical services is essential for the health and wellbeing of patients and local population, there will inevitably be circumstances in which this may have to be achieved by restricting access into the pharmacy premises to patients and public.
  • In extremis this may mean operating the pharmacy behind a closed door – whilst continuing to provide Essential services, or working on a basis of only allowing a limited number of patients/customers into the premises at a time. 
Please ensure at all times that you keep NHSE&I and your LPC abreast of such developments, and for contractors that are part of small or large multiples please refer to your line management for advice. 
Finally, just a further reminder that contractors having to close unexpectedly MUST inform NHS England and NHS Improvement as soon as possible, using the designated form​  by email to england.rugeleyprimarycare@nhs.net in addition to alerting GP practices and other community pharmacy contractors – as well as your LPC.

UPDATE 12TH MARCH 2020 – 15:15

Reports from LPCs across the country are suggesting a number of patients with potential COVID-19 symptoms/history being referred into community pharmacy under CPCS by NHS111; whilst PSNC are seeking to ensure that if such referrals are made they should initially be undertaken by telephone conversation, should contractors in the mean time get any concerning or questionable referrals, they should submit an incident report via PharmOutcomes, which will ensure the NHSE&I regional team and NHS 111 see the report and investigate it. If it is of significant concern and they have time, they could also follow up with a call to the NHS 111 health professions line.

Further to our recent news item on COVID-19, please find summary of currently available information and advice available to community pharmacy contractors – please ensure that you check back regularly for updates, which will be included at the top of the page; plus we advise regular access your shared NHS.net mailboxes for relevant updates from other sources eg NHS England. Here’s a video which explains more about COVID-19:

PSNC’s Covid-19 page is located here: https://psnc.org.uk/the-healthcare-landscape/covid19/

The latest PSNC bulletin on COVID-19 can be found at: https://mailchi.mp/psnc/covid-19-update-11th-march?e=014ac39e76

The NPA also has a dedicated Coronavirus page: https://www.npa.co.uk/coronavirus-updates/

Advice to all Pharmacy Teams:

  • Read the standard operating procedure and briefing note issued by NHS England and NHS Improvement on COVID-19 for the primary care sector — this includes advice to patients and the public and advice for primary care providers such as GP practices and community pharmacies
  • Read the COVID-19: guidance for health professionals
  • Stay up to date on the latest information about COVID-19; refer to Coronavirus latest information and  advice of the GOV.UK website and Coronavirus disease outbreak section of the World Health Organisation (WHO)
  • It is extremely important to now check this guidance DAILY.
  • Check the latest GOV.UK guidance COVID-19: Specified countries and areas with implications for returning travellers or visitors arriving in the UK
  • Be aware of the features and symptoms – see https://www.nhs.uk/conditions/coronavirus-covid-19/
  • Advise patients to follow general prevention measures to prevent the transmission of respiratory viruses
  • Refer to the Foreign and Commonwealth Office section on the GOV.UK website for the latest travel advice
  • Advise Isolated people to avoid having visitors in their home but it is acceptable for friends, family or delivery drivers to drop off food and medicine.
  • Supply chain issues and period of treatment on prescriptions –PSNC’s Dispensing and Supply Team are monitoring the supply of medicines and are keeping in close contact with partners in the supply chain and DHSC. Following some of you flagging local moves by general practices to extend the period of treatment, NHSE&I and DHSC agreed to issue guidance to practices that this should not happen.
  • Please be reminded to use the PSNC reporting tool HERE  for any stock/supply issues you encounter.
  • Prescriptions: Practices should not change their repeat prescription durations or support patients trying to stockpile: these actions may put a strain on the supply chain and exacerbate any potential shortages. Practices should consider putting all suitable patients on electronic repeat dispensing as soon as possible. The whole repeatable prescription can be valid for a year but each repeat should be for no longer than the patient has now. We are working on local guidance on eRD prescribing, which will be posted as soon as agreed. If you find this guidance is not being followed, please immediately raise this with the LPC by using our Contact Us form.
  • Please note the point about practices increasing use of eRD as soon as possible, as this provides an important mitigation should a practice have to temporarily close and not be able to issue repeat prescriptions to its patients.Please keep an eye on the LPC Website News for updates to information and advice – and regularly check your shared NHS.net mailbox.
  • Posters – please be reminded of the importance of prominently displaying the COVID-19 posters at all entrances to your pharmacy. Those posters and the general guidance posters (washing hands and other hygiene measures) can be accessed HERE
  • Business Continuity Planning: As well as looking at your business continuity plan start to think about services and whether your plan covers them. The NPA has produced a template COVID-19 Business Continuity plan (accessed by members only); there are also standard templates on the PSNC website, and be reminded to inform NHSE and any service providers of any changes in provision. Your plans should also include reducing hours, reducing services offered and forced closures etc..
  • Unexpected Pharmacy Closures – in the event that you are unable to open your pharmacy when contracted to do so, please ensure that you follow the points below:
    • Provide information to patients, practices and other local healthcare professionals on the closure, how long it is expected to last and how they may be able to access pharmaceutical services from other providers (having checked that alternative providers are trading). It would be helpful to include information at the pharmacy, also on any pharmacy website or social media page, and on telephone voicemail messages. Don’t forget to update NHS111 Provider and the DoS.
    • Notify NHS England Shropshire and Staffordshire team – firstly by email to ENGLAND.RugeleyPrimaryCare@nhs.net, and within 24 hours using the form below

    Pharmacy Forced Closure

    • Temporarily update your NHS Choices page where possible to ensure that the current information is accurate.
  • Please consider completing a Business priority grid / action plan (examples HERE – courtesy of Coventry LPC). For example, Drug User Services are going to be looking alternative mechanisms of ensuring supply to patients which may include relatives collecting supply or extended time between collections, changing pharmacies at short notice etc.
  • Further COVID-19 planning – PSNC will be undertaking further discussions with DHSC and NHSE&I to plan for the later phases of the outbreak and to seek to agree CPCF arrangements that cover circumstances such as pharmacies having to temporarily close due to COVID-19, the temporary re-deployment of pharmacy staff to other community pharmacies or healthcare settings and community pharmacy support which can be provided to patients who have to self-isolate due to possible infection or pre-existing conditions which put them at particular risk from infection with COVID-19.
  • CPCS – it may be worth suggesting CPCS consultations are held over the phone rather than the patient coming into the pharmacy in certain cases.
  • You may also want to start looking at the HR implications of having any staff members contract the virus, e.g Statutory Sick Pay etc.

Methods to prevent the transmission of COVID-19

  • Frequently clean your hands by washing your hands with soap and water for at least 20 seconds (see the video below) or by using an alcohol-based hand sanitiser that contains at least 60% alcohol if soap and water are not available
  • Avoid touching your eyes, nose and mouth with unwashed hands
  • When coughing and sneezing, use a tissue or if caught without cover your mouth and nose with a flexed elbow (when the tissue is used, discard it immediately into a closed bin and clean your hands as above)
  • Avoid close contact with anyone that is coughing, sneezing and has a fever, and maintain at least 2 metre distance
  • Clean and disinfect frequently touched objects and surfaces
  • If you have fever, cough and difficulty breathing, share information about any recent travels with NHS111/NHS Direct Wales/ NHS 24 111 (people in Northern Ireland should contact their GP)
  • If you have mild respiratory symptoms and no specific travel history, carefully follow the precautions listed above and ensure that you stay at home until you recover
  • Avoid eating animal products that are not thoroughly cooked
  • Avoid direct contact with live animals or surfaces in contact with animals when visiting live markets situated in areas where cases of the novel coronavirus have been confirmed