The Department of Health should commission services such as ‘test and treat’, and stop dismissing solid evidence that these services work, says Terry Maguire…

As we struggled to supply Pen V to anxious parents convinced their children were close to death because of a raised temperature and a mild cough, I wondered how we might get through this media-induced crisis and what lessons we might learn.

Strep A, the cause of impetigo, sore throat, scarlet fever and, very rarely, invasive gram A streptococcus (iGAS) which can be fatal, made an abnormal and unwelcome appearance in the weeks before Christmas. Locally, the BBC was especially sensational and sustained its reporting in the first week of December spurred on by the heart-breaking news that a five-year-old in Belfast had died – at that time one of 16 children across the UK to suffer a similar fate.

The public panicked and healthcare went into crisis mode. At this point reassurance was not going to cut it. Local community groups were calling for schools to be closed and the introduction of a Covid-like lockdown. Parents wanted antibiotics and doctors were told to change the prescribing habits of a decade and lower their prescribing threshold.

The result? Pharmacies dispensed a month’s supply of Pen V in a few days. The shelves were empty but the prescriptions just kept coming. Parents were angry and frustrated, and any suggestion that they go back to the GP, with whom they had spent many hours making the first contact, was met with contempt and disdain.

There were a number of options put forward to manage the situation, some practical, others not, but it always seems that measures to mitigate public panic are not considered – and if they are, they are implemented crudely or so late they cause more distress and turn the crisis towards disaster.

The media message needed to be better managed. The Public Health Agency took the lead and while its messaging was good it failed to say clearly that the vast majority of children with sniffles do not need antibiotics since, most likely, they have a seasonal virus. Pharmacists asked to comment on the story focused on the short supply of Pen V specifically and antibiotics generally and the rising cost for which we might not get paid. What a wasted opportunity!

I was asked to comment on a Strep A Test and Treat service provided by Northern Pharmacies across its six branches. The service, part of a service development project in 2019, was available very quickly as a commercial offering and advertised on social media. From the more than 30 tests completed only two were positive and the patients were provided with antibiotics via a PGD.

We had lobbied to have the service commissioned. The service is, I understand, available in Wales as part of Pharmacy First. The Welsh assessment reported in the Daily Telegraph showed that of 2,000 sore throats, 367 needed medical assessment (FeverScore or Centor) and 149 warranted a swab. Only 36 individuals were positive for Strep A and provided with antibiotics. That is 2 per cent of all those tested.

This service, had it been available in the first week of December, would have been invaluable. It would have massively reduced the inappropriate use of antibiotics, reassured parents and showed that pharmacists do more than gripe about reimbursement.

As the panic progressed Pen V was simply unavailable in any form despite repeated statements from the DoH that there were no shortages. When challenged with reality, the Department simply said it was in the wrong places. However, by 15 December, the DoH had published three Serious Shortage Protocols for Pen Vs and I was really excited, so I prepared to swap Pen V for amoxicillin until I noticed that the SSPs were only for Pen V switches to Pen V.

Over that weekend we turned away about 15 frustrated parents to find, on 19 December, that five more SSPs had been published, this time allowing substitutions. By this stage, however, we had a different problem. GPs were aware of the Pen V shortages and were working off an Interim Clinical Guidance from UK Health Security Agency issued on 9 December allowing other antibiotics to be prescribed.

By the time we got the additional SSPs on the 19^th most GPs were prescribing amoxicillin or clarithromycin which were also now out of stock but without SSPs.

This was a crisis that did not need to happen, and it certainly didn’t need to become a disaster. Strep A can be nasty, but it is a bug we know well and can largely manage. Many agencies need to consider their roles. BBC reporters need to be more responsible. The PHA needs to improve its messaging. The DoH needs to act more rapidly with SSPs we can use.

The Department also needs to stop saying it wants to make better use of community pharmacy and start doing something about it. Through Pharmacy First, it should commission effective services such as Strep A Test and Treat, and stop dismissing solid evidence that these services work.  

Terry Maguire is a leading community pharmacist in Northern Ireland.