Utilising community pharmacists to support people with cancer

Pharmacy has an important role to play in preventing cancer. Community pharmacists can provide smoking cessation and lifestyle interventions, as well as early diagnosis and self-management services for patients.

Published: 10 January 2020

This was published when the organisation was the Royal Pharmaceutical Society.

Sections on this page

Prevention
Early diagnosis
Supported self-management/living well with cancer
Palliative care
Initiatives that would support an increased role for community pharmacists in supporting people with cancer

Pharmacy has an important role to play in preventing some forms of cancer, and community pharmacists in particular can help patients through smoking cessation and lifestyle interventions, as well as providing early diagnosis and self-management services for patients.

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The NHS Long Term Plan¹ outlines a greater role for pharmacists in the direct provision of care and clinical services, highlighting a growing overlap between the role of pharmacists and those of doctors and nurses.

Specialised oncology pharmacists play an important role in hospitals and have moved away from the traditional operational role of production and manufacture of anticancer medicines. They work with the medical and nursing staff to maximise the benefits of drug therapy while trying to minimise toxicities and educate people with cancer about what to expect during treatment and the associated side effects. They also provide advice on how to manage complications of cancer treatment and can often prescribe the supportive medication required. Overall, the role of a specialised oncology pharmacist is integral in the management of the inpatient medication plan, right through to the medication plan that a patient will be discharged with.

In the community, people with cancer often need support with their medicines and this can be provided by community pharmacists². Community pharmacists already provide services such as the New Medicines Service and these have been adapted for use in patients with advanced cancer. Such services could be rolled out in the future. Community pharmacists add value by supporting people taking anticancer medicines and helping them to navigate the wider health and social care system and to manage and balance side effects with treatment. One opportunity for the 2020s could be to develop community pharmacies as not only healthy living pharmacies and self-care support centres, but also as early diagnosis hubs. Community pharmacists would receive education on the red-flag symptoms of certain types of cancer to enable them to refer people to specialist services so that cancers can be prevented or identified. There needs to be more acceptance of the role community pharmacists can play in supporting people with cancer from policymakers, commissioners and other healthcare professionals
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Pharmacy 2030: a professional vision

Click on the links provided to download a PDF copy of the full vision or the executive summary. Executive summary Introduction The vision: professional roles in pharmacy Achieving the vision: underpinning infrastructure Acknowledgments and strategic links Introduction Every health and care profession, every health service provider and every government has been influenced by the COVID-19 pandemic. It has caused everyone to reflect on whether the strategic directions set five or 10 years ago are still right for a post-pandemic future. Pharmacy is no different: it feels like the right time to set out a new professional vision, building on what has been developed previously to create something that describes the new future. Describing a vision for the future is challenging: some pharmacy teams are already pushing boundaries and delivering care that for others seems a distant dream. What this vision recognises is that everyone is on a journey, and it aims to support all of pharmacy to move forward to a new level of professional practice. It is an evolution from where we are now, not a revolution. The future of pharmacy By 2030, the traditional boundaries between pharmacy sectors will be broken down. Pharmacy teams will work together, both within pharmacy and with the wider multidisciplinary team, to deliver seamless care for patients. Pharmacy teams will take a person-centred approach and care will be provided holistically rather than by clinical condition. They will ensure high quality, safe, effective, cost-effective and sustainable prescribing in all settings. In addition, they will drive high standards of medicines governance, and ensure every aspect of prescribing and dispensing processes are effective and efficient. For pharmacists, this will mean being recognised as medicines experts who take leadership of prescribing in all care settings and who optimise therapeutic outcomes for individual patients. There will be a shift away from checking other professionals’ work towards pharmacists having a clinical, prescribing role to manage the care of individual patients. Pharmacy technicians will lead medicines management processes, both in technical roles focused on the safe and efficient supply of medicines, and in patient-facing roles to support patients’ use of medicines. The breaking down of boundaries between pharmacy sectors will be demonstrated through two key shifts. The first is that seamless patient care will be standard. As a patient moves between care settings, such as at hospital discharge, pharmacy teams will work together to ensure patients’ medicines-related care is supported and to avoid duplication of tasks in the patient’s journey. The second shift is that pharmacy will be more dynamic. Many pharmacy professionals are now actively seeking a portfolio career, working across different sectors. By 2030, a core generalist role for both pharmacists and pharmacy technicians will be developed to enable this flexible portfolio working. This change will be driven by digital and technology developments to enable whole-team working, and clear pathways of professional development which apply to all sectors of pharmacy. “Pharmacy will work together with patients and the multidisciplinary team, using their expertise to make the best use of medicines” The vision: professional roles in pharmacy Being the experts in medicines — "Ensuring the quality and safety of medicines use" The key role of pharmacy professionals, that distinguishes them from other health care professions, is expertise in medicines. This will remain at the centre of pharmacy in 2030, with pharmacy teams ensuring the quality and safety of medicines use through both patient-facing and technical expertise. In 2030, pharmacists will be the clinical lead for safe and effective prescribing within all care settings. Most pharmacists will work in patient-facing roles, consulting with patients: assessing, prescribing, monitoring and reviewing medicines for individual patients. They will be autonomous professionals working within multidisciplinary teams, prescribing in their own right, and managing caseloads of patients who take high risk medicines or who have complex therapeutic needs. These pharmacists will be known as “advanced generalist pharmacists” and will be able to move flexibly between care settings. Some pharmacists will choose to specialise in particular clinical or technical fields, and will become “advanced specialist pharmacists”. Some will develop further into consultant pharmacists who have an influence beyond the individual service to leading whole system improvements. In 2030, pharmacy technicians will lead and be experts in safe and secure purchasing, storage, dispensing and supply of medicines. This will include managing services and providing assurance on safe and effective processes. Pharmacy technicians working in patient-facing advanced level roles will consult with patients, undertake technical aspects of medicines reconciliation and medication review, triage patients, monitor and review blood results, provide patient education, administer medicines (if enabled by legislation/governance arrangements) and liaise with cross sector pharmacy teams. Optimising therapeutic outcomes — Prescribing, monitoring, reviewing, adjusting and stopping medicines n 2030, pharmacy teams will ensure every patient receives high quality prescribing of new medicines and timely, systematic medication reviews. All patients will receive the right care at the right time and the right place. Therapeutic outcomes will be optimised through prescribing, monitoring, reviewing, adjusting and stopping medicines. Pharmacy input will be targeted at: key stages in a patient’s journey such as at transitions between care settings, when patients are acutely unwell, patients who receive high risk medicines and complex therapies, and frail patients. This will improve medicines safety, help manage risk and reduce unnecessary polypharmacy. Optimising outcomes will include delivering greener, more environmentally sustainable services. Pharmacy teams will consider the environmental impact of medicines when prescribing and reviewing medicines, and take action to reduce medicines waste. Providing person-centred holistic care — Empowering patients to make shared decisions about their medicines The core role of pharmacy teams in 2030 will be to provide care for patients holistically, focused on the person rather than their clinical condition or medicines. They will enable person-centred care by having positive conversations with patients and their families/carers, and empowering patients to make shared decisions about their medicines and health. Prescribing decisions will be taken using a Realistic Medicine approach by asking patients “what matters to you”. Pharmacy teams will have regular conversations with patients about medicines. These conversations will be enhanced by pharmacy teams being trained in effective, inclusive communication to address inequalities caused by low health literacy. Pharmacy teams will have essential roles in preventing ill health by taking a holistic approach to care that goes beyond medicines. This will include the provision of health improvement services such as harm minimisation to reduce drug deaths, mental health support, brief interventions to reduce alcohol use, vaccination services and lifestyle advice including using a social/green prescription approach. Improving access to care — Achieving equity of access to pharmacy services Before 2030, all pharmacy teams will proactively offer services in a way that delivers equity of access. They will identify vulnerable patients who need specific support and adapt services for them. A service of particular importance in improving access to care is the NHS Scotland Pharmacy First service: the public’s first port of call for common clinical conditions. By 2030, the vast majority of community pharmacists will be independent prescribers, enabling the Pharmacy First service to be further developed, and it will also be extended into populations who cannot currently access it. By 2030, pharmacy services will be planned alongside wider NHS clinical service provision to ensure equitable access to pharmacy services is achieved across the 7-day period. This does not mean that a full pharmacy service is needed in all settings 24/7 but that patients requiring immediate care, particularly in hospital and out of hours services, are not disadvantaged by the day of the week or time they access services. More generally, access will be improved by enabling services in the way patients want. Pharmacy teams will routinely offer patients a choice of remote consulting, asynchronous consultations and other digital services, as well as in-person care. Similarly, medicines supply will be offered by in-pharmacy collection, delivery services and remote collection, but in all cases, patients will have an opportunity to consult with a member of the pharmacy team, including a pharmacist, every time a medicine is supplied. Leading medicines' governance — Ensuring high-quality prescribing, supply and use of medicines through robust governance Pharmacy teams already play essential roles in medicines governance, focusing on ensuring the safe and effective use of medicines. The crucial difference between the future and today is that in 2030, this will be recognised by others as a leadership role. Currently pharmacy teams both define and implement medicines governance processes: in future, the wider health care team will be involved in implementing the processes. Pharmacy teams will ensure standardised robust work processes, and good governance around the supply of medicines and high-quality evidence-based prescribing. They will consistently implement lean processes to achieve accurate prescribing, dispensing and use of medicines. The supply of medicines will be modernised by 2030. Pharmacy technicians will be the professional leads for the assembly, distribution, and safe and effective supply of medicines. Pharmacists will continue to have an essential role in the medicines supply process through the clinical check. Every prescription for a medicine that is new or has been changed will be clinically checked by a pharmacist, and this will include a conversation with the patient. Accuracy checking will be automated through scanning technology to reduce workload and increase safety. Leading evidence-based practice — Involved in research and strategic leadership to shape service development The creation of a recognised evidence base to underpin the use of medicines and pharmacy practice will continue to be essential in 2030. By then, most pharmacists and pharmacy technicians will have developed research capability and will be involved in research, service development and quality improvement. Pharmacists working in academia and industry will play a leading role both in conducting research and in supporting the development of research skills in others. This evidence will be essential in enabling pharmacists to develop prescribing guidance. By 2030, such guidance will include consideration of the environmental impact of different medicines. Altogether this work will reduce harm, waste and variation. Pharmacists will also have an important role to play in strategic leadership to shape services and models of care in NHS boards and other organisations, wherever medicines are used. Achieving the vision: underpinning infrastructure Using data to deliver high-quality services — Data will underpin personalised care for patients and improved service planning By 2030, data will be used to enhance pharmacy services in a number of ways. Clinical data will be used to target and support decisions. Data will enable provision of personalised care and medicines for patients, including in pharmacogenomics. Decision support software, including artificial intelligence tools, will provide data that will be used to improve the quality and safety of care and prescribing. Data will also be used to make population-based decisions to plan services and prioritise pharmacy resources in response to local needs. In 2030, a national dataset will be available, which will demonstrate the effectiveness and quality of pharmacy services in all settings, enabling the impact of pharmacy services on improving population health to be determined. Clinical outcome measures will be developed, linking patient outcomes with prescribing and administration data. In addition, systems will be developed for obtaining feedback from patients and colleagues about pharmacy teams’ performance to drive continuous service improvement. Harness digital technology and innovation — A single shared electronic patient record will transform health and care services The biggest digital transformation of pharmacy and health care by 2030 will be the introduction of a single shared electronic patient record across all health and care services. This will be a universal patient record into which every professional both reads and writes information, using their existing clinical system as the entry point. Each professional group will have a different view, according to what is appropriate for their role. This record will release clinicians’ capacity, improve safety and enable the provision of better care for patients. Another significant digital development will be full electronic prescribing and transfer of prescriptions across all care settings, removing the need for paper prescriptions. Electronic systems will underpin the recording of administration of medicines in all relevant care settings, including hospitals, care homes, care at home services and prisons. Hospital Electronic Prescribing and Medicines Administration systems (HEPMA) will support triaging of patients to allow clinical pharmacists to target those high-risk patients who need pharmaceutical input as a priority. Technology will also be harnessed to develop patient-facing services including digital consultations and remote monitoring. Developing the workforce — Continual professional development will be embedded across the whole pharmacy workforce By 2030, career development pathways will be in place for all members of the pharmacy team to support professional development, enabling people to flourish and feel fulfilled in their roles. For pharmacists, professional development will be aligned to the RPS curricula for foundation, advanced and consultant practice. Some pharmacists will also choose to complete higher degrees. For pharmacy technicians, professional development will be shaped by a suite of frameworks similar to those for pharmacists. All patient-facing pharmacists will have advanced clinical assessment and consultation skills, and be independent prescribers. Across both pharmacy professions, there will be a cultural shift to a system that is committed to continual professional development. All pharmacy professionals will have a role in supporting the education and development of others. Protected learning time and peer support networks will enable professional development and underpin reflective practice. Leading and participating in research and quality improvement will be a normal professional activity. By 2030, the pharmacy workplace culture will be inclusive, celebrate diversity, create a sense of belonging and be supportive of team members’ wellbeing. Pharmacy professionals will have rest breaks during the working day, flexible working options including portfolio careers, access to wellbeing services and a proper work-life balance. Workforce planning will be carried out across Scotland to ensure that the right skill mix and staffing levels are present in every pharmacy team. This will optimise the roles of pharmacy team members, maximise the time for clinical care, motivate staff and deliver optimal care for patients. Delivering seamless care — All pharmacy professionals will work together across transitions of care By 2030, all pharmacy professionals from all sectors will work together to deliver seamless transitions of care for patients as they move around the health service. Pharmacists will stop being described by their location but by their skills. Care will be planned around patients, for example transforming the supply of medicines on discharge from hospital so they are supplied by the patient’s community pharmacy instead of waiting in hospital. Seamless care extends beyond pharmacy to the wider multidisciplinary health and social care team. Pharmacy will be embedded in multidisciplinary teams and will have well-established referral pathways in and out of pharmacy services. Pharmacy will also play a central role in the new National Care Service to ensure the safe and appropriate use of medicines in care services. Acknowledgments and strategic links Achieving the vision: Key enablers Create a single shared patient record into which every professional both reads and writes information, using their existing clinical system as the entry point Make electronic prescribing, transfer of prescriptions & medicines administration systems available in all settings Improve skill mix within pharmacy teams, combined with effective workforce planning to ensure safe, effective and appropriate pharmacy staffing Support all patient-facing pharmacists to train as independent prescribers NHS Scotland to align the pharmacist post-registration development pathway to the RPS curricula for post-foundation, advanced and consultant practice; and equivalent professional development and credentialing pathways developed for pharmacy technicians Introduce protected learning time for all pharmacy teams to enable professional development and research activities Provide equipment to enable patient-facing digital services and training to maximise its use Establish a national data set to demonstrate the effectiveness and quality of pharmacy services Embed the use of data, such as pharmacogenomics, to help guide treatment decisions and deliver personalised medicine Further embed pharmacy into the wider health and social care multidisciplinary team and develop clear referral pathways in and out of pharmacy services. Acknowledgements We are hugely grateful to all the pharmacists and pharmacy technicians across Scotland who contributed to this vision by participating in focus groups, and sharing their views through surveys, emails, phone calls and meetings. We are also grateful to the pharmacy and non-pharmacy stakeholders who met with us through the consultation period and commented on numerous drafts. This vision was shaped by every single person who was involved: it could not have been created without them, and this final version belongs to them all. Strategic links To make this vision relevant to the strategic direction of travel in Scotland, documents produced by Scottish Government, NHS Scotland and other stakeholders were referenced. The section below highlights some key quotes from some of these documents: Achieving excellence in pharmaceutical care “The evolving focus of pharmacy practice to ensure that people have an understanding of what to expect from their medication requires an acknowledgement that people and their carers rightly wish to be active partners in treatment options." “Pharmacy resource can be targeted through a triage model, focusing on high risk and complex cases.” “Hospital discharge can be a difficult time to support people with adherence to new medication regimens. There is a role for pharmacists and pharmacy technicians in supporting this transition by taking on a greater part in managing care prior to and during discharge.” Scottish Government. 'Achieving excellence in pharmaceutical care: a strategy for Scotland'. August 2017. Scotland’s national clinical strategy “The contribution of pharmacists can be considerably enhanced, with their expertise in ensuring that people with complex medication regimes have their care optimised, and the potential for side effects or harmful interactions reduced." Health care teams should “provide care that is person centred rather than condition focused.” NHS services must “collect and use more information on outcomes, especially those that matter most to patients, rather than clinical data such as biochemical or other surrogate markers”. “While medicines can bring great benefit, they can also cause significant harm. Older people tend to experience worse side effects or consequences of treatment. That is why we should strive to actively manage risk associated with polypharmacy by regularly reviewing and rationalising our patient’s medications.” “Serious harm can result if we don’t listen to the people we care for, and if they are not given the information and support they need to make informed decisions about their care.” “NHS Scotland is a significant contributor to the climate emergency. It emits a large amount of greenhouse gasses, consumes huge amounts of resources and produces copious amounts of waste. We have a moral obligation to help tackle the greatest threat to human health by reducing our impact on the environment. Responsibility rests with us all.” Scottish Government. 'Recover, restore, renew — Chief Medical Officer for Scotland Annual Report 2020-2021'. March 2021 The ALLIANCE’s report on health and wellbeing priorities for the future Care should be “flexible, person-centred which recognises the holistic nature of individuals” and that “being involved in the decision-making process and treated as an expert in their own life circumstances and care” is of the utmost importance to people. “For many people the innovative and accelerated implementation of virtual services improved access, made it quicker and supported more choices for the individual. People have welcomed the use of this technology, and its wider implementation and use should continue.” ALLIANCE. 'Health, wellbeing and the COVID-19 pandemic: Scottish experiences and priorities for the future'. February 2021. The NHS Scotland recovery plan 2021-26 “We will design services so that we minimise unnecessary travel and increase the focus on ‘net-zero’ approaches.” “We will continue to support the move to more health care being provided in the community and closer to home.” We will design a new sustainable system, focused on reducing inequality and improving health and wellbeing outcomes, and sustainable communities." “We will develop and introduce a new pharmacy woman’s health and wellbeing service through our public health services.” “We will also establish a community pharmacy hospital discharge and medicines reconciliation service to help speed up the process for people being discharged from hospital.” “We are investing in developing new digital solutions such as ePrescribing and eDispensing to make the prescribing process paperless.” Scottish Government. 'NHS recovery plan 2021-26'. August 2021 Scottish polypharmacy guidance “With up to 11% of unplanned hospital admissions being attributable to harm from medicines and over 70% of these being due to elderly patients on multiple medicines, there are significant opportunities to reduce this burden by timely and effective interventions.” Scottish Government. 'Polypharmacy guidance — realistic prescribing', Third edition, 2018.

Protected learning time (PLT)

The Royal College of Pharmacy believes that all pharmacists should be able to undertake educational and research activities during protected time within their working hours.

Growth in the area of pharmacogenomics also presents an opportunity for pharmacists to lead in testing patients for genetic risk factors for cancer to support preventative measures, and in tailoring drug therapies to optimise efficacy³. The introduction of technologies such as AI-backed risk assessment and diagnostic programmes, or blood sample-based cancer testing will offer pharmacies new opportunities to contribute to health improvement.

Prevention

Between 30-50% of all cancers are preventable⁴. The two highest causes of preventable cancers are smoking and obesity. Community pharmacists and their teams are well-placed to address these issues and have an active role in providing preventative lifestyle advice. Community pharmacies also provide a network of accessible health advice and patient education. This could be the key to patients being more aware of a symptom that could indicate early onset.

Smoking cessation services: Services offered through community pharmacies have provided evidence that people using this service are more likely to quit. The pilot suggested in the Community Pharmacy Contractual Framework⁵, which refers those beginning a programme of smoking cessation in secondary care for completion through community pharmacy, could be a good example of this.

Public health campaigns: community pharmacies provide six national public health campaigns each year as part of the Community Pharmacy Contractual Framework. One or more of these campaigns could be focused on raising awareness on the symptoms and red flags of certain types of cancer which would ensure a wider reach into communities. In the past, these have included campaigns to raise awareness of early symptoms or risk factors for cancer, for example ‘Be Clear on Cancer’⁶, and ‘Stoptober’.

Lifestyle interventions: community pharmacists could undertake a basic health assessment and provide information and support for people to make healthy lifestyle changes as well as recognise early signs and symptoms of cancer. Early acceptability and feasibility results from a study in which community pharmacists were trained to deliver a health assessment of men with prostate cancer⁷; with information/support provided to improve lifestyle over a 12-week period showed that this was feasible and acceptable.

The Greater Manchester Cancer Vanguard, in partnership with the University of Manchester and Lloyds Pharmacy, used community pharmacies to support people to complete a Risk Estimation for Additional Cancer Testing (REACT) model. This model weighs up an individual’s current risk of having cancer based on their self-reported symptoms. It has been widely used in GP practices, but experts wanted to test it in the community. Trained pharmacists helped participants to complete a series of questions during a face-to-face consultation within the pharmacy. Participants were given an estimate of their risk of having cancer and individuals with high risk scores were referred to a GP for further investigations to help improve early diagnosis of the disease. The findings from this pilot prove that community pharmacists can play an important role in helping patients to understand their risk of having cancer. Participants of the REACT questionnaire said that they valued the guidance and support of a trained healthcare professional. The inviting, community feel was also an important factor in helping patients to feel comfortable talking about the condition. An initial learning is that language and communication is important when talking to people about cancer. Community pharmacy can play a vital role in helping people to think more about their risk of getting cancer and then to get tested more regularly.

The work from this vanguard is now feeding into a larger study on cancer prevention and early detection⁸.

Early diagnosis

Community pharmacies provide a convenient and accessible place for people to present with symptoms that they may be concerned about. This could be a pivotal point at which people could be appropriately referred into either general practice or maybe in the future, directly into secondary care for further clinical assessment and diagnosis.

Community pharmacists and their teams could provide screening services to enable early cancer diagnosis⁹. Enabling community pharmacy to be an active part of the referral pathway would benefit patients through reduced waiting times for diagnosis, which in turn leads to early treatment and improved health outcomes¹⁰.

A study of 33 pharmacies in Northern England found that 642 patients presented at community pharmacies with red-flag cancer symptoms – Badenhurst J, Husband A, Ling J, Lindsey L and Todd A – Do patients with cancer alarm symptoms present at the community pharmacy? – International Journal of Pharmacy Practice, volume 22, supplement 2, page 32.

Community pharmacists need to be encouraged and supported to implement National Institute for Health and Care Excellence (NICE) guidance on suspected cancer recognition and referral¹¹.

The draft primary care network (PCN) service specification for early cancer diagnosis¹² recognises the role of primary care and the need for locally agreed standardised systems and processes for identifying people with suspected cancer, referral management and safety netting. Community pharmacists should be included in the delivery of this service.

Below are examples of what community pharmacists could offer to support the early detection of cancer.

Human papillomavirus (HPV) vaccination service: individuals who miss out on receiving the vaccine through schools, could be offered the choice of vaccination at a community pharmacy. This would also increase accessibility and patient choice particularly in the evenings and weekends. This service is currently offered through some community pharmacies to people who can pay. A nationally commissioned roll out of this service through the NHS would prevent some instances of cancer from occurring and increase uptake across a diverse section of the population. The community pharmacist can also play an important role in encouraging, educating and dispelling anti-vaccination misinformation around HPV vaccinations.

Mole screening service: pharmacists can help to assess moles and pigmented lesions that a patient may be worried about and can help identify any that might be suspicious and refer the patient directly to secondary care. Skin cancer screening services are beginning to be commissioned in some localities such as Cornwall. If this service were nationally commissioned, it could help to support early identification of skin cancers and reduce the volume of patients visiting their GP for a referral. A mole screening service, provided by community pharmacies in Norway from 2010 to 2014, performed 25,836 mole scans which were interpreted by trained specialists. Of these, 83.6% had normal scans, 1% had melanoma, and 15.4% had another skin condition. In 2014 the service identified 4.1% of melanoma cases registered in the Cancer Registry of Norway. Nearly all (99%) felt the pharmacy was a suitable venue, and 95% would recommend the service to others. In total, 99% of respondents scored their overall satisfaction as “good” or higher.¹³

Bowel cancer screening service: there is a national screening programme available which deals directly with people. Community pharmacies can encourage people to access the national service if they have signs and symptoms that provide cause for concern. Cumbria’s local pharmaceutical committee is using healthy living pharmacies to raise awareness of lung and bowel cancer and encouraging bowel screening uptake¹⁴.

Chest x-ray referral service: people who present at the pharmacy with certain symptoms could be assessed and offered referral directly for a chest x-ray without needing to be referred to their GP practice. This service is already commissioned in several areas across England such as Doncaster¹⁵.

Increasing cancer screening: people can be screened for early signs of cancer, but these NHS screening services are often not taken up, particularly in certain areas and populations. A study in Yorkshire used community pharmacy teams to encourage women from ethnic minorities to improve their uptake of cancer screening services using lifestyle advice on diet, fitness and general health awareness¹⁶.

Pharmacists have already proven themselves capable of direct referral; a 12-week South West London pilot found that 55 to 60 direct referrals to secondary care or suspected lung cancer by community pharmacists were appropriate – xviii Punwani R, Nimako K, Brzezicki T, Loke TK, Draper A, Hill A, Ozdilli J, Keddie Z, Tamby Rajah D, O’Brien M – Community Pharmacy Referrals Project: Increasing awareness and early diagnosis of respiratory disease via a direct pathway to secondary care -National Cancer Research Institute Cancer Conference 2014, Abstract B122, 2-5 November 2014.

Late diagnosis due to late presentation commonly results from lack of disease awareness or in many cases mental paralysis and emotional upheaval of feared diagnosis. Community pharmacy offers a ready-made support and patient advocacy network alongside its signposting role.

A recent study called ‘Not Normal For You’ revolves around encouraging self-referral of people following a conversation about a suspected cancer red-flag symptom. It has taken place in ten pharmacies over six months. Initial results show that the pharmacy staff responded well to training and felt confident to deliver the service and empower people to see their GP. The pharmacist/pharmacy staff relationship with people shone through in the feedback. Referrals were appropriate and averaged one per pharmacy per month to two months.

Supported self-management/living well with cancer

Medicines optimisation: oral anticancer agents give many people with cancer freedom from numerous hospital visits, allowing them to obtain their medicines from their local community pharmacy. People taking these oral medicines still require support, as many of these agents can be toxic. Community pharmacists can also support those people who have been deemed to be terminal and need support managing their symptoms, such as pain¹⁷.

Community pharmacies are ideally placed within the community to help these people and can:

Explain any concerning signs and symptoms, particularly symptoms of infection;
Explain how the medicine should be taken and how it works;
Provide reassurance as many people are apprehensive of these medicines;
Counsel people on safe handling and storage of anticancer medicines;
Review side effects that might occur and help people manage these alongside their symptoms.

Community pharmacists should be supported by specialist pharmacists within their local hospitals. Formal referral systems would help community pharmacists to identify the people that need support in this area¹⁸. Community pharmacists should also have good relationships with their local PCN pharmacists and be able to identify and refer people for structured medication reviews.

Pharmacy organisations have developed guidance and service specifications for community pharmacists who may dispense and supply oral chemotherapy and systemic anticancer medicines in primary care¹⁹.

As pharmacogenomics develops, community pharmacists are likely to have a role in undertaking medicine-related interviews to ascertain if people are on the best medicines for them as individuals, using their genomic data.

Collection and/or administration of treatment: the LloydsPharmacy Healthcare Centre based in Scunthorpe began by providing a breast cancer treatment service through a partnership with Northern Lincolnshire and Goole NHS Foundation Trust. The service, which is co-located in a community pharmacy, involves nurse-administered subcutaneous injections. This service grew to become a healthcare centre, a four-chair infusion centre, which administers IV immunotherapy, S/C haematology and oncology treatments, releasing up to 400 hours of chair time in the hospital. The service now has over nine molecules being administered in the healthcare centre by working in partnership with the trust. The use of the community pharmacy location enables people with cancer to receive their care closer to their homes without the stress of car parking and long wait times. It also means that people can access advice and support from the pharmacy team, as well as any over-the-counter products they might need.

Enhanced information services: since 2011 Boots has been working with Macmillan to train up Boots Macmillan Information Pharmacists (BMIP). These pharmacists are specially trained to understand more about cancer diagnosis, treatment, medicines and how cancer affects people. Having BMIPs available in community pharmacists has enabled the pharmacy to deliver significant improvements in the support available to people living with cancer across the UK. BMIPs all complete an online training course to ensure they are confident with what their role entails, learning the signs and symptoms of cancer, diagnosis and tests that customers might experience, different types of treatment and how they can affect people. They also learn how to have a supportive conversation and listen effectively, how to signpost people to Macmillan and other organisations to address needs that they cannot meet themselves, and how to support customers to live life as fully as they can after a cancer diagnosis. During 2018 the BMIPS held 92,000 conversations²⁰, whether that be a one-off conversation or by providing ongoing support.

Pain experienced by many people with advanced cancer is often not well-controlled and community pharmacists are potentially well-placed to provide care and support. A nationwide study of bereaved carers in 2015 found that pain was least-controlled when people with cancer died in community settings, with only 18% of carers describing pain as completely controlled, compared with 38% for people dying in hospital and 63% for those who died in hospices²¹. Pain can be caused by the cancer itself or the treatment the person experiences and this does not always end when treatment ends. The majority of cancer pain can be controlled with a combination of medicines, although there is also some evidence for physical exercise and complementary therapies such as music to help with pain levels²². Community pharmacists are the most frequently accessed healthcare professional for people with cancer and are in every high street and are often open extended hours²³. Pharmacists can provide advice for people with cancer when managing their pain so they can get the best use of the medicines they have and provide signposting to other healthcare professionals when necessary. Community pharmacist medicines optimisation interventions have been found to show promise for improving cancer pain and in a recent study were found to be acceptable for patients and feasible to provide²⁴,¹⁷.

Support for carers and families: cancer doesn’t only affect the individual but also those who support and care for them. Community pharmacists and their staff often know the families within the communities where they work and can offer them support and advice to help them in their caring role.

Support for people who have survived cancer: currently there is not a lot of information that supports the role of community pharmacists in this area. However, a study looking at identifying the scope for developing a community pharmacist-led intervention to provide support and improve health outcomes for breast cancer survivors has just been published²⁵. This study identifies considerable scope for community pharmacists to take on a larger role in breast cancer survivorship services, highlighting several potential features of future interventions. Increased awareness of survivor care needs amongst community pharmacists is needed to encourage proactive conversations, networking activities and further training.

Palliative care

In many areas, community pharmacists maintain a supply of pre-approved drugs, with the potential for extended access including evenings and weekends as part of a palliative care service. If implemented nationally, this service could allow patients to have more choice about where they die, currently many people die in hospital and one of the many complex reasons is due to the lack of access to these medicines in the community. Pharmacists can support the person and their family at this difficult time and reduce spend on avoidable hospital admissions. This service may require collaboration between community pharmacy and the voluntary sector. A national palliative care service has been mentioned as part of the new Community Pharmacy Contractual Framework, but details are not yet available.

A model for pharmaceutical palliative care in rural Scotland which is experience-based and funded by Macmillan Cancer Support has shown positive results²⁶. Scotland has also established a Community Pharmacy Palliative Care Network which provides value to aspects of the medical supply chain; access to training; opportunity to discuss good clinical practice; connection to specialists and multidisciplinary teams. The service demonstrates that relationship building between district nurses and community pharmacists is needed for better understanding of patient needs and timely medicine supply²⁷.

The Royal Pharmaceutical Society’s policy on palliative and end-of-life care provides more detail and recommendations which enable pharmacists to improve care at the end of people’s lives²⁸.

Initiatives that would support an increased role for community pharmacists in supporting people with cancer:

Working with patient groups such as Macmillan. Patient education may help to raise awareness of the role of community pharmacy practitioners (CPPs) in supporting people with cancer. Patients and carers in this evaluation often were unaware of the support network until they came across it accidently, therefore if CPPs knew about the support network available to people they could signpost them to these services. The number of participants who had visited a community pharmacy with a cancer query could increase through greater understanding of the CPP role. As 77% of participants already visit a community pharmacy regularly, patients may benefit from encouragement to discuss their cancer queries with community pharmacists. CPPs could do more to promote their professional image and services²⁹.

Community pharmacists can also have a role in supporting people through prehabilitation. This has been shown to be essential to cancer care and should be delivered in a community setting by multidisciplinary teams that include pharmacists³¹.

Digital advances: there have been many digital advances over the last few years, including the use of NHSmail within community pharmacies. This enables community pharmacists to be able to receive discharge information when people are discharged from hospital as well as other communications from across the system. As community pharmacy systems become more integrated with the wider NHS, the value of the community pharmacist and the interventions they make will be more visible.

Acceptance of the role that community pharmacists can play. There are currently several barriers in place that inhibit the progression of community pharmacies to provide better clinical care within a community setting. These include community pharmacies not being recognised as clinical settings as well as community pharmacists not being seen as clinicians who can contribute to clinical care as outlined in this paper. These need to be addressed in order to provide accessible, convenient and more support for people living with cancer.

Education and training: pharmacy training for early diagnosis of cancer – Accelerate, Coordinate, Evaluate (ACE) Programme; an early diagnosis of cancer initiative supported by NHS England, Cancer Research UK, and Macmillan Cancer Support (2017)¹⁴ is available. Community pharmacists need to be supported to undertake appropriate training so they can better support people with cancer. All previous experimental studies where pharmacists provided educational interventions for people with advanced cancer pain involved an element of additional training for the pharmacists²⁴. Inclusion of such training in the pharmacy undergraduate syllabus would improve the palliative care knowledge of the future generation of pharmacists, enabling more pharmacists to be able to confidently provide advice and services for this patient group.

The British Oncology Pharmacist Association (BOPA) has also produced an online community pharmacy training programme and guidance for supporting patients receiving oral anticancer therapy³⁰.

References

RCPharm policies A-Z