A scheme urging people with sore throats to see a pharmacist rather than a GP is based on slim evidence
England’s health authorities are now telling patients with sore throats to visit their local pharmacist for an on-the-spot group A streptococcus test.
It’s part of a new screening program English National Health Service officials say will combat antibiotic resistance, save the system £34 million a year, and take some of the strain off the nation’s overworked GPs.
The program scales up a walk-in service developed by Britain’s largest pharmacy chain, Boots UK. The “sore throat test and treat” service was trialled on 367 patients across 35 pharmacies in London and Leicestershire in 2014 and 2015.
It’s one of eight schemes picked up this year by the NHS Innovation Accelerator, an annual competition that gives winners a bursary of up to £30,000 and access to key players in the English health system, and aims to speed up the roll-out of new medical technologies and techniques.
This year’s other winners includes an online hospital booking service and a scheme that embeds specially trained police officers in community mental-health programs.
“With rising demand and escalating costs, innovation is not an option but a necessity if we are to build a sustainable NHS,” NHS England’s national medical director, Sir Bruce Keogh, said in a statement.
While the plan has not encountered a backlash from English GPs, it has split experts. It’s clever and innovative, say some. Others warn it’s based on slim evidence, and will erode the NHS principle that care is “free at the point of use”.
Boots currently charges patients £7.50 per consultation, and a further £10 for antibiotics if needed, and there is no indication the NHS is prepared to pick up the tab for those medications.
HOW IT WORKS
The mechanics of the scheme are laid out in a Journal of Antimicrobial Therapy paper authored by two Boots employees and two academics. The company funded their research.
A patient presents at the pharmacy with a sore throat, and the consultation begins with a Centor clinical score, which assigns one point each for fever, tonsillar exudates, tender anterior cervical adenopathy and absence of cough. A patient with both fever and absence of cough is referred to the pharmacist, who examines their tonsils and palpates for cervical adenopathy.
If there is either tenderness or tonsillar exudates, the patient undergoes a throat swab administered by the pharmacist (who has completed a “training package”), which is tested for strep A using the OSOM® Strep A Test.
Test developer Sekisui Diagnostics says it has a 96% sensitivity and a 98% specificity. The result is ready in five minutes.
Those who test positive are offered penicillin V at a dose of 500mg tablets every six hours for 10 days, with clarithromycin substituted (250mg twice a day for five days) in case of allergy. Patients with “atypical symptoms” are referred to their GP.
According to a 2014 study in the Journal of Antimicrobial Chemotherapy, 62% of UK GP consultations for sore throat result in a prescription for antibiotics. The Boots pilot appears to have reduced antibiotic prescriptions to fewer than 10% of those who sought treatment.
It’s an achievement not lost on Australian infectious diseases specialist Dr Bernard Hudson, who has spent much of his career fighting the development of antibiotic resistance. He told The Medical Republic the model made sense.
Dr Hudson agreed that without NHS funding it appeared to shift costs on to patients, which could harm its effectiveness. But the net gain in fighting a major cause of antibiotic resistance was worthwhile.
Dr Hudson was agnostic about who should administer the rapid strep test, which he said was relatively easy to use and had good sensitivity and specificity.
“There’s no reason pharmacists shouldn’t offer it as a way of sifting out patients who don’t need antibiotics,” he said.
But training was vital to ensure results didn’t spoil, as was quality control and good recordkeeping. Dr Hudson pointed to the success of point-of-care testing in revolutionising the treatment of malaria in the tropics, where it has prevented antimalarials being prescribed indiscriminately for fever.
He joined Dr Adam Roberts, a University College London microbiologist interviewed by the BBC, who said the plan was innovative and resulted in a “massive reduction” in the number of individuals given an antibiotic prescription.
The pilot trial had serious limitations, however. It was only performed during winter months and women outnumbered men almost two-to-one. Just 30% of participants were aged over 44.
Also, the researchers calculated how many GP visits were saved with a questionnaire that was answered by less than two-thirds of those who accessed the service. In other words, those who did not get antibiotics were less likely to answer.
Also, there was no control group and there was no patient follow-up.
None of that stopped the authors from concluding their program could reduce GP consultations by 800,000 each year. And it didn’t stop Boots UK employee Malcolm Harrison, named as the creator of “sore throat test and treat”, from recording a promotional video saying it could save the NHS budget £34 million a year, a number heralded in the NHS press release.
Mr Harrison referred The Medical Republic back to the Boots paper, which concluded (based on the survey) two-thirds of sore throat patients who would have seen their GP did not have strep A, and hence that they didn’t need to see a GP. The paper projects this onto a figure of 1.2 million patients in England who visit a GP with a sore throat each year.
Never mind that the 1.2 million figure is gleaned from a 2009 report commissioned by the UK’s over-the-counter-medicines lobby group, PAGB, to spruik analgesics and throat sprays.
One UK health official told The Medical Republic the NHS was making a “huge assumption” about how many patients were saved a GP appointment. The official worried that due to the generally self-limiting nature of strep throat, and the removal of the barrier of GP waiting times, the real impact of the program was hard to predict.
The authors of the Boots study recommended a full health economic analysis, and randomised controlled trials to determine whether using point-of-care testing before prescribing antimicrobials was clinically effective and cost effective, but none of this is yet to occur.
Dr Hudson is pragmatic, however. “Boots will be making money, and the government won’t care less because it’s something that they won’t have to pay for,” he said.
“But anything that selects out people who don’t need antibiotics is a good idea.”
NHS England did not respond to enquiries.