Over 20 years ago, most dispensaries in pharmacies were hidden. Opening them up was a bold move. As a consequence dispensary shelves became tidy, books were put away, coffee cups and kettles went into tea rooms and smokers were banished. In my open plan pharmacy, patients asked to speak to me and rarely interrupted. I had a commanding view of the till and anyone who needed special attention. My checking skills were my forte, regardless of the distractions.
I believe Chijioke Agomo (PJ, 31 May 2008, p653) has been working in some poorly designed open plan dispensaries. When planned correctly they enhance the patient/pharmacist experience. I can assure him I do not have the X-ray eyes that he suggests pharmacists should have to achieve an error-free day, just experience.
Dave Fernley
Newark, Nottinghamshire
From Mr R. W. Selfe, MRPharmS
And what about this “complicated paperwork” when handing over responsible pharmacist duties two or three times a day? I hate to think how this would have operated during my time at the day and night service in Boots at Piccadilly Circus — even if we could always identify who actually was the “responsible pharmacist”.
Some admirable changes have taken place since my day, such as the addition of testing facilities for diabetes, but I do feel that the everyday ordinary requirements of our public get subordinated to the more involved legislation for those trying to attend to these needs.
R. W. Selfe
Benfleet, Essex
From Mr P. R. Dadswell, MRPharmS
This is not a big issue, maybe, but it does represent yet another nibble at our bottom line. Are my patients all to receive 56 of the same flavour fortified drink? Or shall I spend time that I am not getting paid for sorting out eight different flavours? Or is this another thing that we are getting paid for via the myriad of advanced services that are still to materialise.
How much can my poor medicines use reviews be expected to compensate for? Or was it just me who thought it was to cover category M price cuts?
Where will the next nibble come from, and who have we left in charge of negotiating to stop them?
Peter Dadswell
Cohens Chemist, Leeds
From Mr J. Coburn
However, if the prescription orders mixed, assorted or various flavours and several flavours of the same preparation are supplied, the contractor will receive professional fees equivalent to the number of different flavours dispensed and endorsed on the prescription form.
John Coburn
Information Officer
Pharmaceutical Services Negotiating Committee
From Mr D. McVeigh, MRPharmS
The Prescription Pricing Division (PPD) has introduced the Capacity Improvement Programme (CIP) and this is being rolled out. The CIP uses computer scanning technology to price the prescriptions, whereas before the CIP system, the PPD used people who assessed and interpreted prescriptions. Only if a pricing ambiguity arises during scanning does a human become involved to resolve the ambiguity.
I am sure the CIP has improved the PPD performance. However, the downside to the CIP system is that it does not allow for practices that have been traditionally accepted. For example, a prescription for: “Fortisip bottle strawberry 200ml x 28, please use as directed and supply assorted flavours”.
This happens as some prescribers’ systems do not have an assorted flavour choice, and are reluctant to write every flavour as a separate item. Before CIP we would have received payment for the number of flavours we endorsed against prescriptions written like this, but since CIP we will only receive payment for one flavour no matter what the endorsement since the computer prices according to information in the drug line, not the dosage line.
This has been confirmed on two separate occasions by the PPD. The solution is for “strawberry flavour” to be crossed out and replaced with “assorted”, and for the prescriber to initial the amendment, or for the prescriber to write “assorted flavours” in the drug line in the first place.
Community pharmacists and technicians need to be aware that the principle also applies in other ways, for example, generically written prescriptions where the prescriber calls for a brand to be supplied within or after the dosage line, as payment will only be made against a generic product.
Dale McVeigh
Scunthorpe
From Mrs J. Ward, MRPharmS
The Leeds Local Pharmaceutical Committee has received a number of calls from dissatisfied contractors who have identified discrepancies in their payments or have had prescriptions switched. As chief officer, I recently received a sample of checking statistics for eight bundles of prescriptions dispensed in October 2007, the first sets since the introduction of CIP here.
The eight bundles total 47,810 prescriptions and the total number of errors identified, such as price differences, fee or graduated fee errors was 2,681 — this is a 5.6 per cent error rate. In one set the total value was £45,000.06, the 245 errors resulted in an underpayment of £1,079.52 (2.4 per cent).
One of our contractors recently discovered an underpayment of £1,200 for an expensive item, which resulted in a further £1,200 in advanced payment, giving an overall loss on the month of £2,400. This has been corrected but it is a stark lesson of how vigilant everyone needs to be. My concern is how many errors, underpayments and overpayments may not have been identified in the prescriptions not subjected to a random check?
Looking back at the last eight checking reports under the old manual pricing system from November 2005 to September 2007 for prescriptions dispensed from October 2004 to April 2006, a total of 48,109 prescriptions had 407 errors (0.85 per cent).
The recent reports accept that issues have been identified that cause error in payment for some prescription items and we are told that work is well advanced in correcting the errors and the NHS Business Services Authority PPD has had discussions with the Pharmaceutical Services Negotiating Committee to review the problems. The LPC appreciates this situation is not of the PSNC’s making, however, I am deeply concerned for contractors, especially in the present climate. It begs the question, is this an improvement programme?
Janet Ward
Chief Officer
Leeds Local Pharmaceutical Committee
From Mr R. J. S. Hazelhurst, FRPharmS
Comparing check results under the Capacity Improvement Programme (CIP) with those from legacy pricing shows the number of errors have risen by a factor of at least seven. The best score previously compared with the worst shows around 50 times the number of errors. The amounts of underpayments are up about 10-fold and the largest single errors are significantly higher.
Whatever the factor of increase, an error rate of 7 per cent is unacceptable. What would the health of the nation look like if pharmacists had a 7 per cent error rate in dispensing?
None of the above implies any criticism of the Pharmaceutical Services Negotiating Committee. Indeed, without the NPRC’s work, these error rates may pass unchallenged. But the latest edition of Community Pharmacy News includes an update on the CIP that does not inspire confidence. The NHS Business Services Authority Prescription Pricing Division is quoted as claiming that accuracy levels are within its targets and this is backed up by a table of overall results from May 2007, six months earlier than the errors described, during which time we might have expected there to have been some improvement.
The community pharmacy service is made up of separate contracts and what interests each pharmacy is the pricing accuracy of their own prescription bundles. The suggestion that the system is accurate overall must carry the implication that three other contractors have been overpaid by £1,341, £3,011 and £3,505 to balance out the above underpayments.
For the multiples, the swings and roundabouts principle means that their underpayments will probably be balanced by their overpayments. But it is of no consolation to a single-handed contractor to be told that his £3,500 underpayment was “balanced out” by a matching overpayment to someone else.
The PSNC news article begs another question about defaults. There are several references to the fact that the CIP system no longer has default values. Almost every computer process that we ever use has default values, so why not the CIP? Surely the introduction of a supposedly reliable automated process should have made it easier to use defaults, therefore, reducing the workload for contractors. Instead, contractors appear to be penalised if they rely, whether deliberately or accidentally, on defaults.
The CIP may have improved capacity but it seems it has not improved accuracy and the cost is being borne by some of the contractors on an entirely random and constantly varying basis.
Dick Hazlehurst
Secretary
Bradford Local Pharmaceutical Committee
From Mr P. Fieldhouse
The improved processing system which the PPD of the NHS Business Services Authority has introduced uses scanning and intelligent character recognition (ICR) software to read prescribing information from prescription forms. Where additional information is required the system sends details about products to a member of staff for further assessment and data capture. Dale McVeigh (PJ, 26 July 2008, p98) referred to Fortisip assorted flavour being misprocessed by computers. Products like Fortisip that have more than one flavour are not normally recognised by ICR software even if a flavour is specified as part of the name, and will therefore need to go to an operator for checking.
The PPD has robust quality assurances processes and delivers a high level of accuracy for reimbursement and remuneration of pharmacy contractors. We work openly with the Pharmaceutical Services Negotiating Committee which scrutinises our systems and processes to ensure accuracy of payments.
We are running a series of open days for contractors to visit the PPD and see Capacity Improvement Programme in operation. The next events are 23 September, 21 October and 25 November. Readers can telephone 0845 610 1171 to find out more or to book a place.
Paul Fieldhouse
Head of Pharmaceutical, Policy and Services
Prescription Processing Division
NHS Business Services Authority
Our job is not to reduce anyone’s workload
From Mr P. J. Harrison, MRPharmS
At a recent university reunion, I reflected on how pharmacy was when I graduated. I commented that in our training, the closest we came to anything living was a piece of rabbit gut and we never had any contact with other healthcare professionals. Diplomatically, I suggested that things must be different today.
I have been critical of the Royal Pharmaceutical Society so it was with some hesitation that I opened a recent e-mail that encouraged me to “get involved”. After the obligatory mea culpa, I see that there is a desire to change the role of the profession that will enable a reduction in GPs’ workload.
This comment demonstrates to me the total misunderstanding about the pharmacist’s role that permeates the professional body and academic institutions. A pharmacist’s role is to help manage the health of the nation or, less pretentiously, of those with whom he or she has contact. I emphasise the word “health” because it goes beyond the management of disease. A pharmacist is, therefore, an integral and complementary member of the team, who is not there to reduce anyone’s workload.
It is the responsibility of the Society to define this role practically and psychologically, and to ensure that preregistration training reflects this. Also, it is the responsibility of universities to include this in curricula by combining some courses with those of physicians and nurses, so that each professional has an understanding of the other’s role. It would be unthinkable in any other context for members of a team not to meet until they were working together.
Philip HarrisonMontreal, Canada
Disappointing quality of advice given by some pharmacists
From Mrs G. E. Foreshew, MRPharmS
The current advice to members of the public is to “ask your pharmacist” to obtain advice on minor ailments.
My recent experience of the advice received, when two separate pharmacies were consulted, left me with the view that useful advice was the last thing that was on offer. As a 16-week pregnant hospital pharmacist, I had the occasion to seek advice on the most suitable product for the relief of excessive trapped wind.
At the first pharmacy I visited, I self-selected a box of simeticone tablets, which stated on the box “may be used safely in pregnancy since simeticone is not absorbed by the body”. To confirm that I had selected the most suitable product, I checked with the counter assistant because over-the-counter medicine knowledge is not my forte.
Having explained she needed to check with the pharmacist, she came back saying she could not sell me anything, the pharmacist said I must see my doctor. I pointed out that the box said it was safe but was told I could not buy it and again referred to my GP. At no point did the pharmacist come to see me.
Taken aback by the advice given, I visited a second pharmacy and checked the same product with the pharmacist. The advice I received this time left me even more disappointed. The advice was: “you are pregnant, you should not be taking any medicines in the first 12 weeks at all.” I explained that I was 16-weeks pregnant and was told “I should still avoid all drugs”.
There was no discussion about which medicines were thought to be safe in pregnancy or giving me the information to help me make a well-informed decision. If this is the level of advice pharmacists are offering patients then they may as well stop piloting schemes for pharmacies to expand the medicines they can supply and advice they can offer, and refer all patients to their GP for a prescription.
Steve Churton, President of the Royal Pharmaceutical Society, recently told delegates at the British Pharmaceutical Conference that consultations for minor ailments could be handled by pharmacists, therefore, releasing doctors’ time. It appears to me from the consultations above that some pharmacists may be some way off that.
Gail ForeshewNottingham
Medicine pack sizes change
From Mr D. H. Patel, MRPharmS
What is wrong with the pharmaceutical companies in this country? They still cannot agree on a simple issue as to how many days there are in a month (ie, 28, 30 or 31 days).
Everyone was happy with the pack size of 28 tablets of Plavix. The pack size has now been changed to 30.
Novartis has announced it is changing the pack size of Voltarol Rapid from 28 to 30 tablets. Who will benefit from this change? Not patients, because many prescriptions are written in multiples of 28.
D. H. PatelSt Albans, Hertfordshire
We need to have the right
We need to have the right to alter any prescription quantity to reflect the nearest convenient pack size without referral to the prescriber. (with a few obvious exceptions eg drugs of abuse). The PSNC should make this a top priority.
Some specialist prescriptions can be unclear
From Mr S. Bajaria, MRPharmS
Many community pharmacists will have noticed that there is no end to the weird and wonderful ways some specialists and consultants write prescriptions, sometimes resembling a J. K. Rowling novel rather than a specific order for a medicine.
The problem is that, quite often, the product intended is unclear or, more importantly, the legality of the prescription may be questioned, especially in relation to Controlled Drugs.
As a result, the pharmacist trying to resolve the problem sometimes ends up in confrontational situations with the patient or the specialist when he or she is told that the prescription cannot be dispensed until specific alterations are made.
I believe these scenarios are common and wondered whether any attempts have been made by hospital, mental health or primary care trusts to address this?
Sunil Bajaria
Bromley, Kent
Building health centres without proper public consultation
From Mr J. R. Ahmed, MRPharmS
Recently, a “secret” public meeting was held where a select number of local residents were invited by Birmingham East and North (BEN) Primary Care Trust to debate a new local improvement finance trust multi-practice health centre 200 metres from my pharmacy.
Pharmacists in the area, including myself, were not invited. The meeting was held to give lip service to public consultation because the plans for this health centre had already been drawn up and were to be submitted within two weeks. The plans include a 100-hour pharmacy in an area that is already served by 13 local pharmacies, including two that operate as 100-hour pharmacies.
Previous conversations with those at BEN PCT have resulted in them saying how they were deeply concerned about the disruption to the stable pharmacy sector caused by 100-hour pharmacies that 20 years of contract limitation had produced.
There is legislation going through Parliament to limit any new pharmacies to a fixed distance from existing contractors. I can only assume that those at BEN PCT has undertaken this decision with the view to secure a 100-hour pharmacy in this development before the legislation comes in because they would not get permission if this legislation were passed.
Or maybe, as a PCT, they do not need permission and can please themselves?
In another area, a 100-hour pharmacy was built into a new PCT owned and run health centre and a major multiple secured the site by paying expensive rent and an upfront deposit. This was way beyond any amount offered or could be afforded by the local pharmacies.
BEN PCT has stated that, in this case, the pharmacy contract will be given to the highest bidder and I do not need to think too hard as to which companies might get the contract. No one else can afford the rent and the closure of local pharmacies will be awaited in eager anticipation by the highest bidder.
Forget about the many years of service that current existing pharmacists, including myself, in the area have given. Forget about the way we have embraced the new contract and new services that have resulted in better healthcare to local patients. Forget about the hard work and dedication we have given to BEN PCT by way of our contractual obligations.
It is now stabbing us in the back and this is an appalling indictment on BEN PCT. Local people have not been consulted properly and it is not up for discussion: the health centre will be built regardless.
The National Pharmacy Association invited me to a meeting at the Pharmacy Show this month (October 2008) to debate “prescriptions or extended services, what are we going to offer?”.
My remuneration comes from prescription fees and practice payments, with a minimum number of monthly prescriptions required to secure this payment.
I am already close to the lower limit due to the 100-hour pharmacies already opened. What chance have I got when this new 100-hour pharmacy is built? BEN PCT has consistently cried “not enough money” when it has been asked about extra and vital services this area needs so I am in a precarious position. I cannot increase my income from new services because they are not being introduced or restricted to a few pharmacies.
When will the NHS live up to its name and produce services that all PCTs have to implement for their patients, whom they are contractually obligated to look after?
Jawaid Ahmed
Birmingham
Birmingham East and North Primary Care Trust, responds
From Jonathan Tringham, director of resources, Birmingham East and North Primary Care Trust
Birmingham East and North Primary Care Trust recently conducted an extensive 12-week public consultation into the development of three new GP practices and a GP-led health centre. As part of this consultation, which was held during the summer, 10 public meetings were held and publicised widely in the communities where the new services will be located.
In addition, existing groups and community associations were invited to request a presentation on the developments and an opportunity to put forward their views.
The PCT was invited by a residents’ association to present on the proposals at one of its meetings because one of the new GP practices is in its local area. The PCT has existing plans to build an additional health and well-being centre in this area and it is proposed that the new GP practice will operate from this centre alongside a range of other services, including a new pharmacy, enabling patients to access a range of services from a single location.
Hundreds of responses to the consultation were received, verbally, on paper and electronically, from a wide range of patients, stakeholders and staff. The results of the consultation have been independently analysed and are being fed into specifications for the new services.
BEN PCT takes seriously its responsibility to the health and well-being of the diverse communities it serves. Access is a key issue patients have raised with us again and again, and these new proposals aim to tackle this issue, providing extended opening hours, additional capacity and new services.
Some PCTs prevent provision of services
From Mr N. S. Bashford, MRPharmS
Having undertaken the AAH Pharmaceuticals and Novartis pharmacy influenza programme to provide influenza vaccinations privately, I saw it as a good opportunity to test out our new contract opportunities by submitting an application to the local primary care trust to provide the service for NHS patients.
This would have required an NHS patient group direction to be set up to allow a pharmacist to administer the vaccine to patients under the NHS. Every step of the way, I had to pursue the PCT for correspondence, from confirmation of my application to all outcomes and responses.
My proposal was for a cost-saving pilot scheme with patient benefits. The response I finally received was that it was not a priority. If ever there were a commissioning service that the public would benefit from, this is it.
I fail to see how it is not a priority for the PCT when we are actually in the influenza season. It was the ideal opportunity for our local PCT to be seen as being proactive for commissioning services to community pharmacy, as detailed in the pharmacy in England White Paper.
What else can a pharmacy contractor do to be able to provide these “high quality services” that the Department of Health says it will reward pharmacies for if the commissioning bodies keep rejecting valid applications where contractors have invested their time, money and resources to be in the position to offer quality NHS services.
The current system for administration of the influenza vaccination is certainly not convenient for patients and 80 per cent of our private vaccine administrations so far have actually been NHS patients who chose to pay rather than have to travel, wait or miss the odd day that the surgery operates the service.
Pharmacy representatives are fooling themselves when they relay to us that PCTs are commissioning enhanced services for us, such as emergency hormonal contraception and supervised methadone. We had these before.
As it is, we make about £20 per year from these two enhanced services. The GPs keep all the smoking cessation clients and will not refer even with long waiting lists and limiting appointments to one morning or afternoon per week.
We are reminded how much a medicines use review is worth as though it is a source of new income but the reality is it was our money in the first place.
Pharmacy wants to provide these high quality services for the DoH but at the grassroots level some PCTs inhibit any ambitions.
Syd Bashford
Delivery Chemist
Scarborough
Information about pharmacy services out of hours
From Mrs A. E. Joshua, MRPharmS
I read with interest the Article about access to medicines out of hours (OOH) and the feedback from service users about the information available regarding pharmacies open during the OOH period. It may help pharmacists to understand how NHS Direct collates information about its services in order to support them better in informing their customers.
NHS Direct receives regular updates from primary care trusts about contractual information related to the provision of NHS services in its locality. Pharmacy services are one of those services included in this dataset. Data are entered into our health directory and it is these data that are also entered into the web-based “find a service” directory of information provided by NHS Choices.
GPs are currently able to update their own entries into NHS Choices information about services. As things stand, pharmacies are not able to update its information direct but it is important that in future pharmacies are able to do that.
The provision of OOH services and additional pharmacy services is often not reflected in the data set that is collated by PCTs and, therefore, NHS Direct regularly contacts individual pharmacies to make sure that the information is collated, in particular to support OOH provision.
In the new year, NHS Direct is planning to undertake an audit of the pharmacy services information that is available through NHS Choices and the information held within the NHS Direct health directory to ensure that the best information can be made available to the public about pharmacy services. It is hoped that through this process pharmacists can help to make the best information about their services available.
Pharmacists should be encouraged that, by including the NHS Direct telephone number 0845 4647 on their pharmacy practice leaflets, patients contacting us will be provided with the most up-to-date information about local pharmacy services.
Anne JoshuaAssociate Director of Pharmacy NHS Direct
Pharmacists must have adequate information resources
From Mr S. C. Sweetman, FRPharmS
The importance of the forthcoming change in UK law to permit dispensing of European Economic Area and Swiss prescriptions was reflected in the fact that it was covered on no fewer than five pages in the PJ (PJ, 25 October 2008, p432a, p433a, p442a, p446a and p459a).Having read these articles, it should be obvious to anyone attempting to dispense such a prescription that access to an international reference work on medicines is essential for identification and to ensure that the patient receives the correct medicine.
Many of the local generic names used in various European countries are already included in Martindale publications and are constantly added to. Likewise, coverage of European proprietary preparations in Martindale is extensive and access to this information could prevent inadvertent dispensing errors.
Guidance issued by the Royal Pharmaceutical Society states that “if a doctor or dentist from the EEA or Switzerland has written a prescription for a specific brand, pharmacists may only give that brand”. However, one should never make assumptions about equivalency of proprietary preparations. Faced with a prescription for Acepril issued in Switzerland, a quick consultation in Martindale would inform you that if you dispensed Acepril, containing captopril, the patient would be receiving the wrong medicine.
Although dispensing of European prescriptions is a welcome step forward that removes one of the obstacles that have prevented pharmacists helping non-UK residents obtain their medicines while in the UK, pharmacists must, as at any other time, make sure that they make informed decisions and have the necessary information resources to enable them to do so.
Sean C. SweetmanEditor Martindale: The Complete Drug Reference
Review current SOPs
From Mr M. Leech, MRPharmS
It was with dismay that I read yet another article in the press criticising the advice offered to patients from community pharmacies.
Apparently, Which? and the Daily Mail are on a witch-hunt and the studies lack credibility because there are only a few pharmacies involved.
Although I recognise these studies have their shortcomings, coupled with the fact that we, as pharmacists, cannot be the only profession offering poor advice in some situations, but surely alarm bells must be ringing.
As a profession, we pride ourselves on the fact that we are the most accessible healthcare provider but to maintain this prestige we must take heed of what we are being told time and time again.
We are at a most critical juncture in our profession with the recommendations suggested in the pharmacy in England White Paper: the creation of a new professional body and the advent of more challenging clinical roles. How, though, can we demonstrate we can deliver new clinical services to an excellent standard if we are continually criticised about the advice patients receive when purchasing over-the-counter medicines or seeking advice about minor ailments?
Being the most accessible profession will almost certainly mean pharmacists are subject to the most scrutiny but we must get our house in order. I am not suggesting a full scale review of current training courses, or that pharmacists must be involved in every OTC sale, but simply that it might be an opportune moment to review current standard operating procedures. Indeed, this review could be timely if pharmacists wish to become involved in minor ailment schemes, forming part of an enhanced service commissioned by a local primary care trust or part of a national scheme.
What is clear is that, in many of the cases highlighted by Which? and the Daily Mail, had the pharmacists or assistants asked the basic questions covered in their training or the frequently used mnemonics, these poor examples may have been avoided.
Michael LeechBrighton
Fuel surcharges
From Mrs L. M. Lake, RegPharmTech
While driving past a service station today, a question suddenly popped into my head. With the continuing decrease in fuel charges, with petrol now at less than £1 per litre, are wholesalers going to take the added monthly fuel surcharge bill away from our bill?
Lynda LakeCannock, Staffordshire
See Fuel surcharge
Ah, ha, ha, ha … stayin’ alive!
From Mr R. F. Poole, MRPharmS
A recent report that paramedics listening to the Bee Gee’s track “Stayin’ alive” were able to perform cardiopulmonary resuscitation (CPR) at the recommended rate of 100 compressions per minute more effectively had me thinking. This could be the perfect slogan for pharmacy in the future.
Along with our dispensing function, we are increasingly becoming lifestyle gurus. We encourage healthy diets, smoking cessation, the sensible use of alcohol, weight control and, of course, physical exercise. “Stayin’ alive” could be written over the door of every pharmacy.
Many pharmacy staff learn first aid techniques, including CPR. Now we have the opportunity to combine two useful and life-enhancing activities. We can exercise and practise the rhythm of our CPR at the same time. But do please take care.
Rather than resuscitating that white suit, I would suggest a new use for a more traditional garb. Clear a little floor space in the consulting room and borrow a CPR dummy. On with the old white coat and away we go. One, two, three … “Ah, ha, ha, ha, stayin’ alive, stayin’ alive”.
At least it would be an improvement on those dreadful Christmas background tracks and “mood music”.
Roger Poole
Ludlow, Shropshire
Lack of sufficient breaks
From Mr A. J. Jukes, MRPharmS
I was concerned when I recently saw a colleague working in a large multiple community pharmacy about six hours into his shift.
On entering the pharmacy area, there was a large queue forming and the assistant was totally overwhelmed by the demands of customers.
I entered the dispensary and saw a cup of stone-cold coffee, complete with a circular Frisbee on top of it and a curly, congealed sandwich that looked like it had been on a railway carriage display stand for three days unrefrigerated. My colleague confirmed that these were intended to be consumed as lunch during his “break”.
A break is when you have mental and physical removal from the work area and this is becoming increasingly rare in community pharmacy.
The two staff, my colleague and the assistant, were both stressed and, in my opinion, this constitutes a risk to patients through dispensing errors. I understand work is under way on addressing such issues but it has been under way since I did a similar type of shift two years ago.
Can someone update the progress on such issues of work break provision and outline exactly when companies will have to own the responsibility of environmental conditions that constitute a risk to patients?
And when will we, as a profession, not have to endure unacceptable conditions, including being denied of a proper break?
Andrew Jukes
Brighton
Insufficient breaks contribute to dispensing errors
From Mrs C. W. Hunter, MRPharmS
In his recent letter (PJ, 15 November 2008, p560), Andrew Jukes expresses several concerns relating to the apparent lack of adequate provision of rest breaks in some community pharmacy settings. His definition of a break as being “when you have mental or physical removal from the work area” is apposite to the scenario described in his letter.
As noted by Mr Jukes, stress can have an adverse impact on all those experiencing it and also has the potential to create risky situations that could impact adversely on patient safety.
I am a member of the Addiction Services Critical Incidents group and am responsible for investigating dispensing-related errors. In my experience, excessive workloads and long working hours with insufficient breaks are often contributory factors in many incidents.
A Law and Ethics Bulletin that was published early last year (PJ, 20 January 2007, p90), together with paragraphs 7.5 and 7.6 of the Code of Ethics for Pharmacists and Pharmacy Technicians and paragraph 4.5 of its professional standards and guidance documents may provide the ammunition that Mr Jukes and his colleagues require to counter pressures to work in potentially risky conditions.
The advice about rest breaks that is provided in all three documents is underscored by the Working Time Regulations of 1998, which state that if an employee is required to work for more than six hours at a time, he or she is entitled to a rest break of 20 minutes and that the break should be taken during the six-hour period rather than at the beginning or the end.
Carole Hunter
Denny, Stirlingshire
In-hours access as important as out-of-hours access
From Miss J. A. C. Jenkins, MRPharmS
I read with interest the out-of-hours (OOH) access to medicines Article (PJ, 25 October 2008, p447a), particularly the reference to the case of the palliative care resident in a care home who experienced a number of problems when trying to access palliative care drugs in the OOH period.
In 2004, I came to the post of palliative care pharmacist for the Pan-Birmingham Network, with one of my roles being to establish systems such that palliative and end-of-life patients and their carers could access essential symptom-control drugs 24 hours a day.
The first thing I did was to conduct a number of informal interviews with nurses working OOH to discover the issues they experienced day-to-day in accessing drugs. One theme repeatedly to come out of these interviews was that many problems in accessing drugs in the OOH period could be tracked back and the episode would have started many hours previously in the in-hours (IH) period.
Many interviewees stated that they would often spend a large amount of time looking for drugs in the IH period when the patient’s symptoms were often minor but needed addressing. Due to difficulties in locating palliative care drugs, the hours passed, IH became OOH and the patient’s symptoms escalated. They would now be dealing with an OOH emergency because an IH problem had not been resolved.
It was due to these interviews that, across the Pan-Birmingham Network, we not only set up systems within the OOH period, using the OOH providers and acute trusts, but also an IH scheme. The scheme was launched on 1 January 2005 and we now have 73 pharmacies that hold palliative care drugs across six primary care trusts, covering a population of approximately 1.8 million residents.
Primary care dispensing data for palliative and end-of-life drugs has been collected for all PCTs, OOH providers and acute trusts since 2004. In 2005, the year the schemes were established, less than 0.2 per cent of all palliative prescriptions were dispensed when all community pharmacies were shut.
Since then, the percentage dispensed in the OOH period has declined further, with dramatic increases in numbers dispensed by community pharmacies.
Around the clock access to palliative and end-of-life drugs is highlighted in the National Institute of Clinical Excellence guidelines for “Supportive and palliative care for adults with cancer” and the recent Department of Health “End of life strategy”.
Many establishments implementing the guidelines interpret this as ensuring access in the OOH period. The Article in The Journal and the Birmingham data suggest that ensuring access in the IH period is equally, if not more important, than that in the OOH period to ensure full access.
Abi Jenkins
Pan-Birmingham Palliative Care Network
The meaning of “see your doctor”
From Mr J. D. Henderson, MRPharmS
A few weeks ago, Gail Foreshew (PJ, 27 September 2008, p360), a pregnant woman, complained of the advice she received at two pharmacies for “trapped wind”. At the first pharmacy, she was told to see her doctor.
“See your doctor” means: “My workload is such that I do not have time to consider your problem. Go away. Your doctor is well educated, rested, relaxed and well paid for this, with access to organisations that support him or her. I am on my own. I have no support. I am driven crazy with actual work and the nonsense procedures. My horizons are possible litigation and the pharmacist-bashing of the Royal Pharmaceutical Society.”
So “See your doctor” is the voice of the experienced pharmacist. Just three words and not easy for the prospective patient to argue with. Minimum time used.
At the second pharmacy, Mrs Foreshew was told to avoid drugs during pregnancy. True, of course, but unworkable because people believe they need to swallow something. In this case, “best to avoid drugs during pregnancy” means the same as “see your doctor” but I guess this was a young pharmacist. The same need to get rid of a problem quickly but not as effective. I can imagine a pressured young pharmacist dredging through his or her education for something that would give a get-out.
As Mrs Foreshew pointed out, she had been encouraged to ask her pharmacist. The difference in her actual experience and her expectations was due to the difference between those who do the job and those who do not do the job.
Those who do not do the job recognise their own expertise and publish their ideas. I do not know how this comes about.
John Henderson
Consett, County Durham
Expectations fall short in the real world
From Mr M. I. I. Bobat, MRPharmS
After reading John Henderson’s letter (PJ, 15 November 2008, p562), I believe there must be many independent pharmacy owners who could also relate to similar pressures of work.
We all know that over the past 20 years or so there has been a gradual increase in workload, ranging from operating a profitable business (to pay for all the overheads and award oneself a decent salary) to running an efficient and professional pharmacy so that patients get the best possible service.
We live in a world where expectations are high. Consider Gail Foreshew (PJ, 27 September 2008, p360), who was encouraged to ask a pharmacist for advice. Her actual experience fell short because she lives in the real world. There is a huge gap between real, everyday people and the ideal that only exists in the media.
Having information readily accessible does not guarantee correct understanding and evaluation of the subject. In years to come, as information technology spirals out of control, the gap between expectation and reality will widen.
For the independent pharmacy owner, the answer lies in prioritising one’s service. They should not take on any new service that cannot be incorporated easily into the business. They should not be tempted by extra remuneration. They should keep their outgoings modest so they do not need to earn more and more to maintain a particular lifestyle.
Quality time spent outside the profession is just as important, if not more, to recharge the battery.
M. I. I. Bobat
Southsea, Hampshire
Myth-busting powers of this Government have fallen on deaf ears
From Mr H. S. Badwal, MRPharmS
I seem to have been the victim of a seasonal upturn in the prescribing of penicillins for “flu”.
Is it not ironic that this surge of antibiotic prescribing accompanied the Department of Health’s recent push on the promotion of prudent use of antibiotics (PJ, 15 November 2008, p564)?
Is this a defiant campaign from the prescribing community or have the myth-busting powers of this Government fallen on deaf ears?
Increasingly, patients are becoming more involved in the decision-making process when medicines are prescribed. Is it that difficult to tell patients that their perceived knowledge of the benefit of a broad-spectrum antibiotic against the common cold virus is wrong?
Surely it is in the interest of those concerned to save these medicines for when they are needed to limit resistance.
Hardeep Badwal
Derby
Antiobiotics mixture packaging
From Mr P. D. Burgess, MRPharmS
Is it possible that, by voicing my current frustration with the situation concerning some antibiotic mixtures through The Journal, something might change?
I am sure I am not the only pharmacist who wonders how manufacturers are allowed to market their products without asking pharmacists for their comments beforehand.
Does anyone else wonder about the practicality of the latest Sandoz clarithromycin mixture? It requests the dispenser or pharmacist add two-thirds of water and make it up to the line marked on the bottle. Instead of the usual few seconds to make up a mixture, I found myself messing about for nearly a minute.
Despite thorough examination of the packaging, I could see no mention of the amount of water in millilitres to add, so I added a small amount of water until I saw the powder floating slightly above the line. Initial panic but, thankfully, a good shake left the volume below the line again.
Personally, I do not think that this type of packaging is progress.
Paul Burgess,
Kingston Upon Thames, Surrey
Sandoz Limited UK responds
From Nik Ball, Head of quality and pharmacovigilance, Sandoz Limited UK
We are naturally concerned that a product bearing the name of Sandoz should give cause for concern. The quality of the products that we distribute is of paramount importance to us in maintaining the reputation of our company name. When we talk about quality, we also mean ease of use and contribution to optimising patient compliance.
The original approved labelling of the bottle indicated a fill line on the bottle up to which the reconstituted suspension should be filled, with instructions on how to do this on both the carton and the label.
We have already taken the necessary steps in order to improve the clarity and completeness of the reconstitution instructions. Following the approval from the Medicines and Healthcare products Regulatory Agency, the total volume of water required for reconstitution is now clearly stated on the outer carton and bottle label. This revised artwork is used in current production. We would hope that these measures will resolve this issue.
Expanding the clinical role of pharmacists never fully materiali
From Mr N. Ali, MRPharmS
In its launch, the minor ailment scheme (MAS) was heralded as a format for expanding the clinical role of pharmacists. Sadly, this has never fully materialised.
Further to the News item “NHS Scotland praises the minor ailment scheme in its annual report” (PJ, 6 December 2008, p652), the reality is that the MAS has simply expanded the supply role of pharmacists. More “baked beans” out the door, but this time, with the paperwork associated with it in registering the patient and generating a prescription and label.
The MAS has diverted sales of over-the-counter medicines away from the supermarket shelves and other general retailers to the counters of pharmacy stores throughout Scotland.
There is now a deluge of requests for medicines through prescriptions from patients. Pharmacists and their staff are overwhelmed. The process requires little clinical skill, but it involves lots of data collection, and form and label printing. This is significantly more labour intensive than scanning the barcode on a medicinal product when making a sale.
However, it is not all bad news. Pharmacy contractors are reaping the financial rewards since they have increased their market share of the supply of medicines.
Nadim Ali
Glasgow
Providing health advice
From Mr R. I. Dunkley, MRPharmS
As pharmacists who should actively promote healthy lifestyles, we are often called on to provide “health checks” to members of the public. We provide “checks” on cholesterol, blood sugar, height, weight, body mass index, waist measurement and blood pressure (BP).
BP measurement is, perhaps, one of the more important health checks that pharmacists may offer. If we discover a patient has extremely raised BP, what do we do? We refer the patient immediately to his or her doctor, possibly as a high risk case of possible stroke or other end organ damage.
But has any pharmacist considered the effect that we, as pharmacists, may have on the person who having his or her BP checked?
A recent paper1 in the Archives of Internal Medicine shows that the “white coat” (eg, pharmacists) phenomenon can result in patients having raised BP that is out of context to what their everyday BP is.
BP should not be measured as a “one off” measurement, but rather over several days by the patient in his or her home environment. This will provide a more accurate measurement.
In conclusion, the authors of this paper state that data from several studies show that who measured the BP and how it was measured (ie, by a person or an automated device) may have a substantial effect on the measurement. Therefore, we should, in light of this paper, look at the health advice we are providing our patients.
Finally, the British Heart Foundation has an excellent booklet on blood pressure and its measurement that can be downloaded from its website
Bob Dunkley
Leeds
Reference
1. Ogedegbe G, Pickering TG, Clemow L, Chaplin W, Spruill TM, Albanese GM et al. The misdiagnosis of hypertension: the role of patient anxiety. Archives of Internal Medicine 2008;168:2459–65.