1. Role Preparation for Health Information Advisors Handling Medicines Calls Day 1 Name Centre Medicines Information Service

2. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Learning Outcomes 1.Have an overview of NHS Direct policies for medicines calls and roles of staff. 2.Have a baseline knowledge about medicines. 3.Have an overview of Community Pharmacy services and emergency supply of medicines. 4.Be able to handle medicines calls safely and effectively.

3. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Learning Outcomes 4.Be able to handle medicines calls safely and effectively. Know what background information is needed to clarify the question and minimise the risks when advising the caller. Be able to navigate the key medicines information sources and be aware of their merits and disadvantages. Be able to interpret information about medicines and turn it into appropriate advice. Know when and how to refer medicines calls to UKMI. Be able to use the NHS Direct Medicines Algorithm.

4. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Outline of training Day 1 NHSD policies for medicines calls and roles of staff Baseline knowledge about medicines Navigating key medicines information sources Practice medicines calls Overview of community pharmacy Day 2 Adverse effects Drug interactions Medicines in pregnancy Medicines when breastfeeding Medicines Algorithm Areas of risks when handling medicines calls

5. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Morning Timetable 9.30Introduction NHS Direct Policy for medicines calls Workshop 1: Ethical dilemmas Baseline knowledge for medicines calls 10.30Tea break Workshop 2: Navigating the eBNF, BNFC eMC, netdoctor & NHSD Medicines FAQs 12.45Lunch

6. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Afternoon Timetable 1.30Overview of handling medicines calls Workshop 3: Practice medicines calls 3.30Tea Break Community Pharmacy 4.00Close

7. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Why are Medicines Information Skills needed? Therapeutic and information explosion 6% calls for information/advice on medicines. 40% answers included advice about medicines.

8. Role Preparation For NHS Direct HIAs: Handling Medicines Calls NHSD Policy for Medicines Calls The policy covers Definition of a medicine call. Principles for handling medicines calls. Guidance for specific types of medicines calls. Approved information sources. Record keeping and documentation. Standards and quality assurance. Training and development.

9. Role Preparation For NHS Direct HIAs: Handling Medicines Calls What is a Medicines Call? Questions about Prescribed medicines. Medicines bought from a pharmacy or shop. But also Herbal medicines. Homeopathic medicines. Food supplements and vitamins. Recreational drugs and drugs of misuse e.g. cannabis, Ecstacy, steroids in sport.

10. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Principles for medicines calls Everyone is entitled to be involved in decisions about whether a medicine is right for them and to choose a different option if they prefer. Everyone will be able to get the medicines information they want and need, from whatever source they choose. Doctors, nurses pharmacists and other healthcare professionals will be supported to help patients/carers be involved in decisions about medicines and the effective use of their medicines.

11. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Guidance for specific types of medicines call Therapeutic choice Avoid naming a specific medicine if referring to another HCP. Identification Identification of a “tablet” can not be done over the phone. Refer to pharmacist. Repeat medication Make sure there has been no sudden increase in use due to worsening symptoms. Third-party & intermediary Be careful not to break patient confidentiality.

12. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Information sources Consult the eBNF for all medicines calls. Use only if an NHS Direct approved information source. NAs - may use just one information source if confident this is the best source. HIAs - confirm in a second information source unless using a designated sole source e.g. NHSD Medicines Q&A.

13. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Roles of NHS Direct staff when handling medicines calls Health AdvisorsP4 “Quick Calls”: information on access Locations & opening hours of pharmacies, family planning clinics, walk-in centres. Where can I get EHC. How do I get a repeat prescription. How do I get a new oxygen cylinder. Interim information on Low Toxicity ingestions Interim care instructions for dental pain Health Information Advisors P4 Calls: Information about medicines No new or worsening symptoms. Nurse AdvisorsP1-4 Calls: Advice or information about medicines Symptoms. No new or worsening symptoms. Dental Nurse Advisors Information about medicines for dental conditions

14. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Streaming of P4 medicines calls P4QC Quick calls about access to medicines. e.g. “Is there a pharmacy close to me that is open?” M1 Assess within 20 mins Caller upset or very anxious. Not usually for complaints or angry callers. e.g. Caller crying. M2 Assess within 1 hr Urgent medicines call - answer needed before the next dose. Goes to the First Advice Queue after HI service closes at 8pm. e.g. “Can I take paracetamol with amoxicillin?” M3 Assess within 4 hr All remaining medicines calls. After HI closed, remains in HI Queue until the next day. Advise caller that HI is closed so will be answered next day. e.g. “What vaccinations do I need for a trip to Africa in a few months time?”

15. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Workshop 1: Ethical Dilemmas A man asks how long cocaine stays in the body. He used some cocaine at the weekend but is due to have a drug test tomorrow. What advice would you give? A woman says she has found some medicines in her son’s room. She reads the labels - lamivudine, zidovudine & lopinavir / ritonavir. Can you tell her what they are for? Would your answer be different if the call was from his wife?

16. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Morning Timetable 10.30Introduction NHS Direct Policy for medicines calls Workshop 1: Ethical dilemmas Baseline knowledge for medicines calls 11.30Tea break Workshop 2: Navigating the eBNF, BNFC eMC, netdoctor & NHSD Medicines FAQs 1.00Lunch

17. Role Preparation For NHS Direct HIAs: Handling Medicines Calls What’s in a medicine? Active ingredient Excipients e.g. bulking agents, tablet coatings, colours, flavours, stabilisers, pH adjusters. Form e.g. tablet, capsule, suppository, injection, cream, patch, eye drops

18. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Naming medicines GenericBrand AmoxicillinAmoxil ® SalbutamolVentolin ® FluoxetineProzac ® OmeprazoleLosec ® MefloquineLariam ®

19. Role Preparation For NHS Direct HIAs: Handling Medicines Calls “Co-” medicines Co-amilofruseAmiloride & furosemideDiuretic Co-careldopaCarbidopa & levodopaFor Parkinson’s Disease Co-amoxiclavAmoxicillin & clavulanic acid Antibiotic Co-dydramolDihydrocodeine & paracetamol Painkiller

20. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Brand names Many preparations have the same brand attached to slightly different products Paracetamol, Pseudoephedrine & Diphenhydramine Guaifenesin Levomenthol Diphenhydramine Levomenthol Dextromethorphan

21. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Marketing Authorisation “Product Licence” Granted by MHRA if Safety, Quality, Efficacy shown. Key aspects in Summary of Product Characteristics (SPC) found in the electronic Medicines Compendium (eMC) ww.medicines.org.ukww.medicines.org.uk Prescribing outside the SPC (licence) is the responsibility of the doctor. Medicines & Healthcare Products Regulatory Authority www.mhra.gov.uk

22. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Unlicensed medicines Off Label UK product licence but being used for an indication / at a dose / by a route not in the licence. No Licence No UK product licence. Patient must give informed consent e.g. Methotrexate for asthma and lupus Patient must give informed consent e.g. Thalidomide, most herbal products

23. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Legal classification of medicines General Sales List GSL May be sold in general shops e.g. Paracetamol (packs of 16) Pharmacy Only P May be sold in a pharmacy but not a general shop e.g. Ranitidine Prescription Only POM May only be supplied on prescription e.g. Amoxicillin Prescription Only Controlled Drug POM CD May only be supplied on prescription, harmful / prone to misuse e.g. Morphine

24. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Reclassification of medicines POM  P Simvastatin Omeprazole Sumatriptan Chloramphenicol eye drops P  GSL Paracetamol suspension Ibuprofen syrup Aciclovir cream Clotrimazole pessaries Cetirizine liquid Chlorpheniramine tablets New focus to encourage wider availability of medicines as soon as adequate evidence of safety

25. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Misuse of Drugs Act Prohibits production, supply or possession of certain substances. Class Ae.g. heroin, LSD, ecstasy, morphine, remifentanil. Class Be.g. amphetamines, barbiturates, codeine. Class Ce.g. anabolic steroids, cannabis, growth hormone.

26. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Black Triangle medicines Newly licensed. Monitored intensively by Committee for Safety of Medicines (CSM) which reports to MHRA. Black triangle status usually reviewed after 2 years.

27. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Medicines that may not be prescribed within NHS Sometimes known as the Black List. Pricing Prescription Authority (PPA) will not reimburse dispensing cost to pharmacist. NHS

28. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Medicines that may be prescribed in certain circumstances Sometimes called the Selected List. Cost of dispensing reimbursed only if GP has endorsed the script “SLS ”. SLS e.g. Viagra for erectile dysfunction

29. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Tea Break

30. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Morning Timetable 10.30Introduction NHS Direct Policy for medicines calls Workshop 1: Ethical dilemmas Baseline knowledge for medicines calls 11.30Tea break Workshop 2: Navigating the eBNF, BNFC eMC, netdoctor & NHSD Medicines FAQs 1.00Lunch

31. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Workshop 2: Navigating eBNF, eMC, netdoctor & NHSD Q&As www.medicines.org.uk www.netdoctor.co.uk nww.nhsdirect.nhs.uk www.medicinescomplete.com

32. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Merits / Disadvantages MeritsDisadvantages eBNF BNFC Gold standard Some opinion Care when searching Jargon eMC Easy to search Comprehensive info Technical Unlicensed / off label Not all medicines netdoctor Easy to search Layman’s terms Use, side effects, drug interactions Pregnancy Breastfeeding NHSD Meds Q&A Saves time Difficult to find info Limited number Need prompt updating

33. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Lunch Break

34. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Afternoon Timetable 1.30An overview of the process for handling medicines calls Workshop 3: Practice medicines calls 3.30Tea Break Community Pharmacy 4.00Close

35. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Handling a Medicines Call Clarify the question Plan search strategy & research problem Evaluate the information Tailor the answer/advice Refer to MI Call record

36. Role Preparation For NHS Direct HIAs: Handling Medicines Calls The Iceberg Theory This is what the caller may ask This is the rest of the story!! ?

37. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Essential questions to ask Allergies? Conditions or diseases? Medicines? Name, dose, frequency of all medicines? What prescribed for? OTC, complementary, oral contraceptive pill? Pregnant? No. of weeks, going well, medicine taken already? Breastfeeding? Baby’s age, term/pre-term, well/unwell, medicine taken already? Confirm no new or worsening symptoms

38. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Key information sources eBNF / BNFC Electronic Medicines Compendium (eMC) Netdoctor NHSD Medicines Q&As Medicines Chest Online

39. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Standard Search Strategies Pointers to the best sources available to answer particular types of medicines call. Not a definitive list of sources and should check other sources as appropriate. No need to check every source in the search strategy for every call. Encourage best practice and sharing of expertise

40. Role Preparation For NHS Direct HIAs: Handling Medicines Calls What should be documented? Website e.g. eBNF, eMC, netdoctor All places looked including those where no information was found. Web page link / brief detail of the information found. Brief detail of what was said to caller. Is warfarin safe in 1st trimester of pregnancy? eBNF: Link. eMC: No monograph. netdoctor: Link. Toxbase: Link. Advised caller that warfarin is known to cause foetal malformations if taken during pregnancy. Speak to GP by end of the day.

41. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Referral to UKMI Complex medicines call. 3 or more prescription medicines. Medicines in pregnancy & breastfeeding unless there is a NHSD Medicines Q&A. No information can be found. The information found is unclear or conflicting. Not within your competency.

42. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Role of UK Medicines Information Service (UKMI) Speed Dial 004 Mon- Fri 9am - 8.00pm Sat & Sun 9am - 3pm except Bank Holidays

43. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Workshop 3: Medicines Calls

44. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Afternoon Timetable 1.30An overview of the process for handling medicines calls Workshop 3: Practice medicines calls 3.30Tea Break Community Pharmacy 4.00Close

45. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Community Pharmacy Services Specialist in medicines and no appointment necessary. 6 million people visit a pharmacy every day. NHS could save £380 million/year if 1 in 4 people consulted their pharmacist about minor ailments instead of their GP. Extended hours – 100 hour pharmacies.

46. Role Preparation For NHS Direct HIAs: Handling Medicines Calls What services do community pharmacies offer? Standard services Advising on medicines Dispensing & repeat prescriptions Selling OTC medicines Patient records Sale or supply of EHC Emergency supply of medicines Health promotion campaigns Disposal of medicines Specialist services Medicines use review Smoking cessation Needle exchange schemes Nursing Care Home support Supervised administration of medicines Anticoagulant clinics

47. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Staff in a community pharmacy Counter assistants Trained to sell and advise on medicines when supervised by a pharmacist. NVQ training, follow protocols. Dispensing technicians Trained to dispense prescriptions, checked by pharmacist. NVQ / BTEC training. PharmacistResponsible for all sales and supply of medicines. Degree & pre- registration year/exam. Pharmacist must be present for sale/supply of medicines

48. Role Preparation For NHS Direct HIAs: Handling Medicines Calls NHS prescription charges £7.10 for each item Irrespective of cost to NHS of medicine. Irrespective of the quantity prescribed. Various charges for combination products. Pre-payment certificates forms available from the pharmacy or via PPA website.

49. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Prescription charge exemptions Under 16 years. 16, 17 or 18 yr in full time education. 60 or over. Maternity Exemption certificate. Medical Exemption certificate. War Pension exemption certificate. Prescription Prepayment certificate. On a NHS Charge certificate (HC2). Free of charge oral contraceptives. Income Support or Income Based Jobseekers Allowance. NHS Tax Credit exemption certificate. Partner gets Pension Credit Guarantee.

50. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Emergency supply of medicines by a pharmacist Pharmacist must interview the person Immediate need and impractical to obtain prescription Previously prescribed for the person Dose appropriate for the person Supply up to 5 days except Insulin, ointment, cream, drops, inhaler – smallest pack Oral contraceptive - a full cycle Antibiotic - a full course of treatment Can not supply a Controlled Drug Except phenobarbitone for epilepsy Charge to patient

51. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Emergency supply of medicines by a pharmacist Advice to the caller Person requiring the medicine must go to the pharmacy. Go to your usual pharmacy if possible. Take evidence of the medicine (e.g. repeat prescription slip, empty box/bottle). Take personal identification. There will be a charge. Pharmacist makes a professional judgement and may refuse a supply.

52. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Emergency Hormonal Contraception (EHC) Sell EHC Cost to patient. Subject to national restrictions e.g. patient age. Supply EHC by local arrangement Free to patient. Local funding and guidelines (PGDs). May include under 16 years. Subject to pharmacist training.

53. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Learning Outcomes 1.Have an overview of NHS Direct policies and roles of staff for Medicines Calls. 2.Have a baseline knowledge about medicines. 3.Have an overview of Community Pharmacy services and emergency supply of medicines. 4.Be able to handle medicines calls safely and effectively.

54. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Learning Outcomes 4.Be able to handle medicines calls safely and effectively. Know what background information is needed to clarify the question and minimise the risks when advising the caller. Be able to navigate the key medicines information sources and be aware of their merits and disadvantages. Be able to interpret information about medicines and turn it into appropriate advice. Know when and how to refer medicines calls to UKMI. Be able to use the NHS Direct Medicines Algorithm to support handling of medicines calls.