These commentaries by John Macgill represent his opinions only and not those of any Ettrickburn client.

Three Nations Three Practices

Community Pharmacy Eliminating Hepatitis C

Homeless People make Glasgow

Heart Failure – we can get treatment right for everyone

Bundles of Safety

Community Pharmacy’s Leader in Scotland

CPO: On the Road to Achieving Excellence

Pharmacy technicians may become prescribers

Profile: Dr Norman Lannigan OBE

Profile: Jonathan Burton MBE

Profile: Clare Morrison MBE

Deep Dive Pharmacy

Mind the Gap - Diagnostic Skills for Pharamacists

Bundles of Safety

Supporting Excellence - Alison Strath Interview

2018 Pharmacy Forum Agenda Launched

Which Referendum to Choose

Three Perspectives on Pharmacy and Mental Health

Pharmacy and the New GP Contract

Bordering on Problematic

Recognised by the Queen and her community

VACANCY Reporter/Researcher: Health and Care Policy in Scotland

Prescribing in Mental Illness – A Practice Pharmacist’s Perspective

What Matters to You? Communication in Pharmacy

Prescribing in Mental Illness – A Patient’s Perspective

Focusing the Vision: Dr Rose Marie Parr on the new strategy for Scottish pharmacy

All the things that could go wrong - looking ahead to the SNP conference

Ask Once, Get Help Fast? Pharmacy and Mental Health

Automation and Delegation in Pharmacy: Understanding the Moving Parts

Initiatives Highlight Potential of Community Pharmacy

Pharmacy First in Forth Valley One Year On

Trying to concentrate on the day job

Health and the Local Elections – a strange silence

The Pharmacist Will See You Now – The Growth of GP Pharmacy

Montgomery’s Review – Dr Brian Montgomery answers questions on access to new medicines in Scotland

An afternoon with SMC

Pharmacists at SMC

SMC – are drug firms voting with their feet?

Radical Surgery on the Horizon for Scotland’s NHS

The Future’s Bright – in General Practice

Community Pharmacy in a Changing Environment

Disclosing payments to doctors – has Sir Malcolm done the pharma industry a favour?

Health and Care in the First Minister’s Programme for Government

CMO: Scotland’s pharmacists “absolutely ideally placed” to practice Realistic Medicine

Profile: Maree Todd – MSP and Pharmacist

Scottish Parliament Health Committee Work Programme

Scotland’s new NHS – a Summer of Speculation

Scotland’s New Health Committee

Two million voices in Scotland – is integration the big opportunity to listen?

Medicines – levelling the playing field

Key appointment raises the bar for health & social care partnerships

What did our new MSPs do before?

SMC says no then NICE says yes – three times

SNP promises single formulary and a review of Scotland’s NHS

More Generous than the CDF – but less transparent

Comparison of Funds: New Medicines v Cancer Drugs

Bonfire of the Boards? SNP signals NHS Review

A tribute to five retiring MSPs

New Medicines Review - Health Committee sends findings to Government

Medicines New & Old in the Scottish Cancer Strategy

Great Ambitions, Slow Progress – New Models of Care in Scotland

Scottish Minsters Demand Up-Front Medicine Price Negotiation

Opportunity and Disappointment: MSPs Investigate New Medicines Access

Scottish NHS Strategy calls for 'Realistic Medicine'

The Scottish Model of Value for Medicines: Taking Everything into Consideration

When SMC Says No: An Access to Medicines Lottery

Reviewing the Review: Access to New Medicines in Scotland

A day of psephology and kidology

Insulting the Lifesavers

Worthy of Mention – Health and Science in the Honours List

News Silence from North of the Border

A Christmas PPRS Present from Pharma

Monday, March 18, 2019: Community Pharmacy Eliminating Hepatitis C

This article was written for PharmacyinPractice.scot

Elimination of Hepatitis C infection is one of the WHO’s Sustainable Development Goals. An eight week course of Direct-Acting Antiviral Drugs can cure what has previously been a debilitating and potentially fatal chronic disease.

 Community pharmacies in Dundee and Tayside have been at the forefront of a programme to identify and treat local people living with the virus. Providing leadership for the pharmacy programme is Andrew Radley, Consultant in Public Health Pharmacy with NHS Tayside. He has been telling Pharmacy in Practice that pharmacy teams are not just treating but also diagnosing the infection and assessing patients for treatment.

Scotland is in an excellent position to be one of the first countries in the world to eliminate Hepatitis C. In Tayside, we have been working for a number of years to cure people carrying the virus, the majority of whom are injecting drugs. This group generally stay away from hospitals, but regularly attend community pharmacies, which are local to where they live. Pharmacy colleagues have built up good long-term relationships with the group and are likely to be trusted sufficiently for them to accept the offer of a test.

To show first that somebody has been exposed to the Hepatitis C virus, all you require is to get one good-sized drop of blood from a finger prick and dab it onto a piece of blotting paper, which is posted off to a local lab. The laboratory then assay the dried blood spot to look for the presence of Hepatitis C antibodies.

About a quarter of people will clear the virus spontaneously but the remaining three quarters will have an ongoing infection though, often, they’ll have no symptoms, or they’ll have had a short acute phase without realising. You can have Hepatitis C for years and have non-specific vague feelings of being unwell – you feel weak, fatigued and perhaps depressed. Eventually you may become cirrhotic, and develop jaundice and other signs of liver disease.

When the initial dried blood spot test shows exposure to the virus, we arrange for a phlebotomist or a peripatetic nurse to meet the person in the pharmacy to take some blood samples which are then sent off for assessment. These include a polymerase chain reaction (PCR) test for viral RNA to confirm the presence of circulating virus and liver function tests.

Back in the day when I was a young pharmacist working on hospital wards, we used assess kidney function using a Cockcroft-Gault equation! In a similar way, pharmacists in Tayside have been using the Fib-4 test to assess whether the patient has cirrhosis. The community pharmacist can use an app to do the Fib-4 calculation, and there is a website they can use to check for potential drug interactions with the direct acting antiviral drugs before starting the treatment. If the patient’s laboratory tests are within normal ranges, the pharmacist can use the PGD or a prescribing pharmacist will write the prescription and the patient can start treatment, according to our local protocol.

Overall in Tayside, we think that we have diagnosed about 80% of those with Hepatitis C and we have probably treated about 70% of those we have diagnosed. Some of the Tayside community pharmacies have done particularly well and have treated all of the people with infection from the entire cohort of people attending their pharmacy. Progress in Tayside compares well with most other places in Scotland.

The programme in Tayside has, I think, succeeded in doing something really quite special with community pharmacy colleagues. We have linked them with the hospital team and delivered effective care to a vulnerable group.

My contribution has been to build the evidence base for pharmaceutical care, showing that the outputs and patient outcomes that can be achieved by using pharmacy services improve the health of their local populations. Working with Dundee University, we have carried out a whole series of studies to understand the perspectives of the patient group and experiences of pharmacy staff so we could tweak the intervention and make it as good as possible. We used a method called a ‘discrete choice experiment’, a health economics approach to assess the value people placed on different choices for a service; and most recently, we've completed a cluster randomised trial with colleagues in Grampian and Glasgow, which should be the definitive study to quantify the clinical effectiveness of using pharmacy to clear Hepatitis C from this population.

It is important that the profession grasps the potential to grow practice and how much patients value hands-on services. Our studies have shown that assessing and identifying patients for the right treatment, counselling them and prescribing drugs – were all things that were accomplished excellently by the pharmacists who took part in this work. Right across our programme of work, the patient feedback has been about how much they valued having a longitudinal, positive relationship with a pharmacist.

Throughout my career I have always been proud to be a member of the pharmacy profession and valued the significant contribution we make to patient care. Right from the start I have tried to innovate and extend the boundaries of what can be delivered through pharmacy and, at this stage in my career, I am particularly pleased with what we’ve been able to achieve for people with Hepatitis C.

But, with a new programme getting underway to deliver care to breast cancer patients from community pharmacies, I am not quite finished yet!

Andrew Radley will be leading a session on ‘Dot C -Community Pharmacy Hep C treatment’ at the Celtic Conference for Pharmacy in Scotland, Wales and Northern Ireland, being held in Edinburgh on Tuesday 26 March.  Registration is free for healthcare professionals at www.pharman.co.uk/celtic-conference