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?
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?
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.
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.
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 Joshua
Associate Director of Pharmacy
NHS Direct
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. Sweetman
Editor
Martindale: The Complete Drug Reference
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.
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?
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”.
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
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.