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Efi Mantzourani,1,2,* Rhian Deslandes,1,* Karen Hodson,1,* Andrew Evans,3 Lydia Taylor,1 Cherie Lucas4 1Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, Wales, UK; 2Primary Care, Digital Health and Care Wales, NHS Wales, Cardiff, Wales, UK; 3Primary Care Services, Welsh Government, Cardiff, Wales, UK; 4Graduate School of Health (Pharmacy Discipline), University of Technology Sydney, Sydney, New South Wales, Australia*These authors contributed equally to this workCorrespondence: Efi Mantzourani, Redwood Building, Cardiff School of Pharmacy and Pharmaceutical Sciences, King Edward VII Avenue, Cardiff, Wales, CF10 3NB, UK, Tel +44 2920 870452, Email Mantzouranie1@cardiff.ac.ukBackground: A pilot Independent Prescribers’ Service (IPS) was introduced in 13 community pharmacies across Wales in June 2020. Independent Pharmacist Prescribers (IPPs) could prescribe in the areas of management of acute conditions, contraception, or opioid withdrawal, as agreed with local commissioners. Access to the patients’ medical records was provided via Choose Pharmacy, the national community pharmacy IT platform.Objective: To explore the experiences of IPPs delivering the service and commissioners responsible for financial resources regarding the IPS in Wales.Methods: A qualitative methodology was employed, with purposive sampling, semi-structured interviews, and inductive thematic analysis.Results: Five themes were constructed from 13 interviews (n=9 IPPs; n=4 commissioners): (i) patient experience and safety; (ii) professional enablement and rebalancing workload of GPs; (iii) role and limitations of remote consultations; (iv) funding and business model; (v) functionality on Choose Pharmacy to support patient care. The design of the service allowed pharmacists to determine how best to deliver the IPS, maximizing access for patients and promoting a sense of professional value amongst pharmacists.Conclusion: This study builds on the body of evidence on enhanced patient experience with prescribing services in the community, reinforcing that IPPs have a key role in rebalancing management of common conditions from GP surgeries to community pharmacies. Several considerations need to be addressed to ensure future success of the service implementation, delivery and enhanced sustainability, such as formal referral pathways and access to medical records. These can be used by other commissioning bodies in the UK and internationally to build a network of suitably supported IPPs, confident to appropriately deal with uncomplicated acute and chronic conditions; and liaise with primary and/or secondary care when referrals are needed.Keywords: non-medical prescribing, independent pharmacist prescribing, Choose Pharmacy, patient safety, patient experience

Introduction Antimicrobial resistance (AMR) is a global issue that needs addressing. While antibiotic stewardship has improved often by restricting antibiotic use, some antibiotics that are still sold legally over the counter (OTC), notably in sore throat medications. Recent findings suggest OTC antibiotics could trigger cross-resistance to antibiotics used in clinical treatments, whether systemic or topical. Here we investigated the impact of three antibiotics contained in OTC sore throat medicines on emerging AMR in vitro. Methods Bacterial pathogens were exposed to a bactericidal concentration of an aminoglycoside in the presence or absence of a during-use concentration of bacitracin, gramicidin or tyrothricin in a time–kill assay. Damage to the bacterial membrane was also investigated by measuring potassium leakage and membrane potential alteration post-OTC antibiotic exposure. Results Gramicidin (15 µg/mL) significantly decreased the bactericidal activity of amikacin, tobramycin or gentamicin in Acinetobacter baumannii. It also decreased gentamicin bactericidal activity in Enterobacter cloacae , Escherichia coli and Klebsiella pneumoniae , while tyrothricin decreased the aminoglycoside efficacy in E. cloacae and E. coli. Gramicidin significantly decreased bacterial membrane potential and caused significant potassium leakage. Conclusion Gramicidin and to some extent tyrothricin impacted aminoglycoside efficacy by affecting membrane potential, which is essential for aminoglycosides uptake. Thus, some OTC antibiotics can interfere with aminoglycoside activity, which could in turn affect treatment efficacy. Although the likelihood of OTC antibiotics and aminoglycosides being used at the same time might not be common, this research highlights one potential reason for OTC antibiotics' usage to result in treatment failure and their contribution to AMR development. [ABSTRACT FROM AUTHOR]

Alesha Wale,1 Mark Ireland,2 Rowan Yemm,1 Sarah Hiom,3 Alison Jones,3 John Paul Spark,3 Mark Francis,4 Karen May,5 Louise Allen,5 Steve Ridd,6 Efi Mantzourani1,7 1School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, Wales, UK; 2Community Pharmacy Wales, Cardiff, Wales, UK; 3St. Mary’s Pharmaceutical Unit, Cardiff, Wales, UK; 4Swansea Bay University Health Board, Swansea, Wales, UK; 5Cardiff and Vale University Health Board, Swansea, Wales, UK; 6Mayberry Pharmacy, Cardiff, Wales, UK; 7NHS Wales Informatics Service, Cardiff, Wales, UKCorrespondence: Efi Mantzourani Email MantzouraniE1@cardiff.ac.ukObjective: Community pharmacy staff are responsible for obtaining and supplying unlicensed “special” medicines to patients in primary care. Less well-defined parameters for safe and effective use of unlicensed compared to licensed medicines, along with issues around maintaining consistency between care settings or among manufacturers, have been associated with increased risks. This study aimed to explore the views and experiences of community pharmacy staff on accessing and supplying unlicensed “special” medicines to patients in Wales and the perceived impact of challenges faced on patient care.Methods: A qualitative, phenomenological approach was employed, involving semi-structured interviews with pharmacists and pharmacy technicians working at one small chain of community pharmacies in Wales. The interview schedule focused on the personal experiences and perceptions of the participants on the processes involved in accessing and supplying unlicensed “special” medicines from a community pharmacy. Interviews were audio-recorded and transcribed verbatim.Results: A total of six participants completed the interview. Three main themes were constructed from inductive thematic analysis of the transcribed interviews: requirement for additional patient responsibilities; influences on the confidence felt by pharmacy staff when accessing and supplying unlicensed “special” medicines; and continuity of supply.Conclusion: This study gives a preliminary insight into the views and experiences of community pharmacy staff in Wales when accessing and supplying unlicensed “special” medicines. Further research is required to see if these views and experiences are representative of community pharmacy staff across the country.Keywords: unlicensed medicines, “special” medicines, specials, community pharmacy, transfer of care, medicines supply, transmural care, off-label, compounding

Efi Mantzourani,1,2 Ricky Hicks,1 Andrew Evans,3 Emma Williams,2 Cheryl Way,2 Rhian Deslandes1 1School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, Wales, UK; 2NHS Wales Informatics Service, Primary Care Services, Cardiff, Wales, UK; 3Welsh Government, Health and Social Services, Cardiff, Wales, UKCorrespondence: Efi MantzouraniNHS Wales Informatics Service, Cowbridge Road, Cardiff, UK and School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Redwood Building, King Edward VII Avenue, Cardiff CF10 3NB, UKTel +44 29 20 870 452Email MantzouraniE1@cardiff.ac.ukObjectives: To explore the views and opinions of community pharmacists regarding their initial experience of and levels of preparedness for the pathfinder sore throat test and treat (STTT) service in Wales.Methods: A phenomenological qualitative approach with constructivist paradigm was adopted as the first cycle of ongoing action research. Semi-structured interviews with community pharmacists who had completed at least three consultations within the first 3 weeks of the service were conducted, with informed consent and audio recorded. Interviews were transcribed ad verbatim and data were thematically analysed both inductively and deductively.Results: A total of seven interviews with pharmacists who had conducted more than three consultations identified three main themes: 1) perceived impact of the service on patient care, including the value of the structure and technology infrastructure, the role of STTT towards antimicrobial stewardship, and its potential role in rebalancing primary care resources so that workload is distributed appropriately among healthcare professionals; 2) factors that empower pharmacists to deliver the service, in particular quality and consistency of training, appropriate staffing resource and internally motivated willingness to engage; 3) interface with GP surgeries such as nature of existing relationships before implementing the service, role of GP staff and GP perceived value of STTT.Conclusion: The pathfinder STTT service has been well received by pharmacists who recognised the service’s role in providing patient education and contributing to principles of antimicrobial stewardship and described factors that would empower them to deliver the service confidently. Results have been fed back to the service implementation team to inform future developments.Keywords: sore throat test and treat, point-of-care testing, community pharmacy, antimicrobial stewardship, pharmacy services

Hamde Nazar,1 Gregory Maniatopoulos,2 Efi Mantzourani,3 Neil Watson41School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK; 2Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK; 3School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, Wales, UK; 4Pharmacy Services, Royal Victoria Infirmary NHS Hospital Trust, Newcastle upon Tyne, UK An emerging clinical role for community pharmacists is to become actively involved in the follow-up care of patients who are discharged back into the community (transfer of care services) by promoting better medication adherence and by contributing to the safe, effective, and efficient use of medication.1 Recent research highlights how this extended role of community pharmacists could help to reduce drug-related adverse events, unnecessary health provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the healthcare system.1,2

Efthymia Mantzourani,1 Cheryl M Way,2 Karen L Hodson1 1College of Biomedical and Life Sciences, Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, 2NHS Wales Informatics Service, Cardiff, Wales, UK Objective: The aim of this study was to explore the views of community pharmacists participating in the pilot of a secure online platform in Wales, the Choose Pharmacy application (CPA), with particular interest in the electronic Discharge Advice Letters (e-DALs) and online Discharge Medicines Review (DMR) form.Materials and methods: A qualitative approach with semi-structured interviews was adopted. A gatekeeper from National Health Service Wales Informatics Service identified 35 pharmacies, of the 43 pharmacies where the CPA had been implemented, that had completed at least one DMR, and these were therefore invited to an interview.Results: A total of 17 pharmacists were interviewed. Overall, the results were positive and CPA and e-DAL were perceived to facilitate continuity of care between care settings. The design and usability were perceived as good as pharmacists could navigate the CPA without problems; many felt this was due to the level of training they had received. Many pharmacists were happy for other services to be included on the platform due to its ease of use and automatic reimbursement. Several pharmacists felt that communication between primary and secondary care can be further improved as the uptake of e-DAL increases.Conclusion: CPA was found to streamline the completion of online DMR improving continuity of care between primary and secondary sectors, which in turn should improve patient safety on discharge from hospital. Keywords: continuity of care, electronic Discharge Advice Letter, Discharge Medicines Review

Home telecare services based on broadband communication were established in five locations in Europe. Two different types of telecare unit were developed: one based on a PC or set-top box containing a videoconferencing codec and another on off-the-shelf videoconferencing units. The participants in the project were 13 medical staff, 135 patients and 88 people informally caring for the patients. Questionnaires were used to evaluate user satisfaction with eight telecare services. Almost all participants rated the usability of the system as good or excellent. A total of 105 telecare sessions were scored by the medical staff. Overall, the quality of audio and video communication was judged satisfactory. For the patients and carers, the perceived quality of communication was also satisfactory and did not vary significantly between sites. The medical staff were reasonably satisfied with how the service supported them in their work. Except for the item about being able to support patients in a critical situation, medical staff agreed that an improved quality of health services was offered through telecare. All participants agreed that personal information was treated confidentially and that there was little risk in using the telecare services. The medical staff trusted the assessments they could make remotely while using the telecare system. Although the findings cannot be generalized due to the small number of telecare sessions and the relatively short duration of the experiment, the results encourage further research. [ABSTRACT FROM AUTHOR]

Background: To date, no research has compared longer-term outcomes (antibiotic provision; re-consultations; hospital admissions for quinsy; cost-effectiveness) following presentation with acute sore throat at general practice (GP) versus newer, pharmacy-led services., Methods: A retrospective, longitudinal cohort study of sore throat consultations between 1 November 2018 and 28 February 2020 either with the Wales pharmacy-led sore throat test and treat (STTT) service or with a healthcare professional at GP. Individual-level pharmacy consultation data from the national Choose Pharmacy IT application were securely uploaded to the Secure Anonymised Information Linkage Databank and linked to routinely collected, anonymized, population-scale, individual-level, anonymized health and administrative data., Results: Of 72 736 index consultations, 6495 (8.9%) were with STTT and 66 241 (91.1%) with GP. Antibiotic provision at the index consultation was 1382 (21%) with STTT and 25 506 (39%) with GP [adjusted odds ratio (AOR), 0.30; 95% CI, 0.27 to 0.32]. Antibiotic provision within 28 days of index occurred in 1820 (28%) STTT and 26 369 (40%) GP consultations (AOR, 0.44; 95% CI, 0.41 to 0.47). GP re-consultation rate within 28 days of index date was 21% (n = 1389) with STTT compared with 7.4% (n = 4916) with GP (AOR, 3.8; 95% CI, 3.5 to 4.1). Coding limitations may lead to overestimates of GP re-consultations rates in the STTT group. Hospital admissions for quinsy were rare in both STTT (n = 20, 0.31%) and GP (n = 274, 0.41%) (AOR, 0.68; 95% CI, 0.43 to 1.1). STTT was less costly than consultation with GP., Conclusions: The pharmacy-led STTT service is safe, cost-effective, and contributes to antimicrobial stewardship., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Background: The use of unlicensed medicines has been associated with safety concerns, availability and accessibility issues, and lack of integrated care across care settings., Objective: To understand the interaction between the views and experiences of those who prescribe, those who supply and those who receive unlicensed "special" medicines, so that factors affecting the patient journey and successful treatment can be identified and used to inform areas for change., Methods: A qualitative, phenomenological approach was adopted, with semi-structured interviews with prescribers, community pharmacy staff and patients. A combination of stratified, purposive, snowball and convenience sampling was used to identify participants. Interviews were analysed using reflexive thematic analysis and the findings were integrated using an adapted model of the Pillar Integration Process., Results: Three pillars were constructed after synthesising results from interviews with patients (n=4), prescribers (n=5) and pharmacy staff (n=6): the awareness of licensing status; perceptions of patient care and acceptability of unlicensed medicine use; and challenges associated with the accessibility of unlicensed medicines. The varying levels of awareness when unlicensed medicines are prescribed and the varying perceptions of responsibility and acceptability of the use of unlicensed medicines help to explain the challenges faced by participants across the patient journey, Challenges identified included understanding what unlicensed medicines are, awareness of the licensing status when unlicensed medicines are prescribed, managing care across care settings to ensure the patient is effectively treated and ensuring continuity of care for patients in the community., Conclusion: The results highlight a clear need for more integrated care and support for prescribers to reduce the chances of delays between care settings, and more patient-centred care to ensure that any delays when accessing medicines do not lead to treatment disruption for the patient. The new national guidelines informed by findings of this study can support policy-makers across the globe., Competing Interests: The authors declare no conflicts of interest., (© 2024 Wale and Mantzourani.)

Background: Community pharmacies in Wales delivered an NHS-funded sore throat test and treat (STTT) service during the period of increased invasive Group A Streptococcus (iGAS) incidents in winter 2022-23. Service users were screened using FeverPAIN/CENTOR scores, offered GAS rapid antigen detection tests (RADT) if appropriate, and antibiotics if indicated., Objectives: To evaluate the service's response to a substantial rise in sore throat presentations during a period of heightened public anxiety., Methods: Cross-sectional study with anonymized individual-level data from electronic pharmacy records of all eligible STTT service users, between January 2022 and March 2023., Results: Antibiotics were supplied to 24% (95% CI: 23-24) of people who used the STTT service and 31% (95% CI: 31-32) of those who met the threshold for an RADT. Of 27 441 STTT consultations, 9308 (33.9%) occurred during December 2022. In the week commencing 2 December 2022, following the announcements of increased iGAS incidents, we observed a statistically significant increase of 1700 consultations (95% CI: 924-2476) and a statistically significant decrease in supply rate of 13.9 antibiotics per 100 RADT (95% CI: -18.40 to -9.40). Antibiotic supply rates increased thereafter to those observed before the announcements of iGAS incidents. Referral rates to other primary care or emergency settings remained below 10% throughout the study period., Conclusions: Our findings suggest that, despite a dramatic increase in sore throat consultation rates in response to media reports, the pre-specified pathway followed by pharmacists ensured appropriate use of antibiotics, and absorbed a substantial workload that would otherwise end up in other healthcare settings., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Background: Sore throat is a common problem and a common reason for the overuse of antibiotics. A web-based tool that helps people assess their sore throat, through the use of clinical prediction rules, taking throat swabs or saliva samples, and taking throat photographs, has the potential to improve self-management and help identify those who are the most and least likely to benefit from antibiotics., Objective: We aimed to develop a web-based tool to help patients and parents or carers self-assess sore throat symptoms and take throat photographs, swabs, and saliva samples for diagnostic testing. We then explored the acceptability and feasibility of using the tool in adults and children with sore throats., Methods: We used the Person-Based Approach to develop a web-based tool and then recruited adults and children with sore throats who participated in this study by attending general practices or through social media advertising. Participants self-assessed the presence of FeverPAIN and Centor score criteria and attempted to photograph their throat and take throat swabs and saliva tests. Study processes were observed via video call, and participants were interviewed about their views on using the web-based tool. Self-assessed throat inflammation and pus were compared to clinician evaluation of patients' throat photographs., Results: A total of 45 participants (33 adults and 12 children) were recruited. Of these, 35 (78%) and 32 (71%) participants completed all scoring elements for FeverPAIN and Centor scores, respectively, and most (30/45, 67%) of them reported finding self-assessment relatively easy. No valid response was provided for swollen lymph nodes, throat inflammation, and pus on the throat by 11 (24%), 9 (20%), and 13 (29%) participants respectively. A total of 18 (40%) participants provided a throat photograph of adequate quality for clinical assessment. Patient assessment of inflammation had a sensitivity of 100% (3/3) and specificity of 47% (7/15) compared with the clinician-assessed photographs. For pus on the throat, the sensitivity was 100% (3/3) and the specificity was 71% (10/14). A total of 89% (40/45), 93% (42/45), 89% (40/45), and 80% (30/45) of participants provided analyzable bacterial swabs, viral swabs, saliva sponges, and saliva drool samples, respectively. Participants were generally happy and confident in providing samples, with saliva samples rated as slightly more acceptable than swab samples., Conclusions: Most adult and parent participants were able to use a web-based intervention to assess the clinical features of throat infections and generate scores using clinical prediction rules. However, some had difficulties assessing clinical signs, such as lymph nodes, throat pus, and inflammation, and scores were assessed as sensitive but not specific. Many participants had problems taking photographs of adequate quality, but most were able to take throat swabs and saliva samples., (©Mark Lown, Kirsten A Smith, Ingrid Muller, Catherine Woods, Emma Maund, Kirsty Rogers, Taeko Becque, Gail Hayward, Michael Moore, Paul Little, Margaret Glogowska, Alastair Hay, Beth Stuart, Efi Mantzourani, Christopher R Wilcox, Natalie Thompson, Nick A Francis. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 08.12.2023.)

Background: The Discharge Medicines Review (DMR) is a community pharmacy service in Wales that aims to reduce medicines-related harm after care transitions, including hospital discharge. To undertake a DMR, the Community Pharmacist must receive a patient's discharge medicines information, either electronically, by fax or presented by the patient. Although the DMR has evidenced benefits for improving patient safety, its evaluation showed inconsistent uptake, which Community Pharmacists partially attributed to hospitals not providing the necessary information., Objective: Aiming to develop recommendations to improve hospital engagement to DMR referrals, this study explores hospital pharmacy professionals' views of the service., Methods: Qualitative focus groups, using hermeneutic phenomenology, were conducted in 16 hospitals across Wales, using a quota sampling method to include 61 Pharmacists and 31 Pharmacy Technicians. To understand the suboptimal engagement to DMR referrals, framework analysis was undertaken using the Consolidated Framework for Implementation Research (CFIR)., Results: The data were mapped onto all five CFIR domains, each containing barriers and facilitators to engagement with DMR referrals and suggestions for improvement. Only one hospital had successfully implemented DMR referrals, with many participants lacking any knowledge of the service or how to refer to it. Specific barriers included a clear absence of processes to implement referrals and engage hospital pharmacy professionals. A considerable barrier was many participants' perceptions that Community Pharmacist roles were less clinically orientated and patient-centred than their own, viewing them almost as a different profession. Participants believed that local champions for DMR referrals could promote engagement and integrate them into the workflow of hospital pharmacy professionals. Further recommendations to improve engagement was staff training for DMRs and regular feedback of its value., Conclusion: Policymakers may use the findings and recommendations from this study to promote hospital pharmacy staff engagement to similar community pharmacy services like the Discharge Medicines Service in England., Competing Interests: Declaration of competing interest None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Community pharmacies have long been advocated as an accessible source of advice on health improvement in communities. This cross-sectional study explored the association between provision of pharmacy public health services and factors that might influence the extent to which pharmacies contribute to tackling inequalities., Methods: Publically available data were used to explore the association between pharmacy public health service provision and pharmacy characteristics (socioeconomic deprivation, urbanity, opening hours and workload). Regression models were fitted to the number of service consultations. The association between the number of services provided and the mean number of consultations across each service was investigated using regression models., Results: Pharmacies showed a propensity for being situated in areas of higher socioeconomic deprivation. There was no association between socioeconomic deprivation and number of service consultations a pharmacy provided. Clustering of pharmacies in less affluent areas led to over half of all public health service consultations being in the two most deprived quintiles., Conclusions: Providing healthcare services from pharmacies in more deprived areas does not mean the public use them or that pharmacies will prioritize their delivery. The higher prevalence of pharmacies in disadvantaged communities is an important factor in ensuring pharmacy services support reducing inequalities., (© The Author(s) 2022. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)