Date of prep: December 2020
Prescribing information and
adverse events reporting
For healthcare professionals only
I’ll level with you. I think the widespread use of volunteers to deliver medicines to the most vulnerable in our society poses a significant and potentially unnecessary risk on a number of fronts.
You don’t need to think too deeply about this issue to come up with a dozen reasons to explain why this idea introduces risk into the systems of a given community pharmacy.
But given that we find ourselves in an unprecedented pandemic situation I have to ask the following question:
As pharmacists, are we being too risk-averse?
Is the current outrage about the volunteer-led medicine delivery services justified or is our profession once again missing a golden opportunity to step forward and do the right thing for our patients?
Pharmacists are experts in snatching defeat from the jaws of victory and missing opportunities to demonstrate our true worth because of the constant need to self-mutilate our own professional standing.
I spoke to Mike Hewitson after the announcement about the English essential and advanced volunteer-led delivery services were announced.
“After four weeks of waiting for details of this service to arrive, pharmacy teams can be forgiven for feeling let down. This service loads all of the responsibility and risk on to them and does nothing but add to their workload. There remain major issues around the safety and appropriateness of the volunteer scheme and no clarity about the mechanisms to resolve problems with this service. The fact that pharmacies are being used as a last resort to deliver medicines is a slap in the face for the care and diligence that they have demonstrated throughout this crisis. NHS England should once again be ashamed of themselves.”
As someone with considerable experience over the years in dispensing and prescribing roles in pharmacy, I get it. I really do.
It needs to be said that in my view community pharmacy contractors in England, and therefore by proxy community pharmacy employees and locums, have been treated very badly in recent weeks, months and years. For me the problem is clear and whilst it is a debate for another day I think there simply are far too many cooks spoiling the broth in English community pharmacy circles. NHS England therefore, have free reign to tactically push hard during contractual negotiations and ease their way towards the online pharmacy market to save a shortsighted quick buck.
Let’s do that debate another day. Back to deliveries during this pandemic.
It occurs to me that maybe our reticence to throw ourselves into opportunities like the volunteer medicine delivery services stems from the systemic de-professionalisation of the role of a pharmacist in this country in the last few decades.
Do we need someone to hold our professional hand and allow us to paint by numbers?
If so prove me wrong.
So to deliver or not to deliver?
Well, the truth of this little saga is that in the grand scheme of things given our current pandemic situation it probably doesn’t matter that much. There are bigger fish to fry quite frankly. That said I think it is an interesting insight into our professional identity and how we react in such circumstances.
Let’s work the detail.
My first observation around the pandemic medicines delivery arrangements was the difference between Scotland and England. England proceeded with a grand announcement from the centre, harshly delivered on the evening of Good Friday, which created uncertainty behind the scenes and, I’m sure reinforced, the inherent mistrust that thrives between NHS England and the community pharmacy contractor network.
In Scotland, the approach could not have been more different.
The bargepole was rapidly deployed and a holding pattern was assumed by Community Pharmacy Scotland. They appeared to push back initially on the idea of using volunteers to run the delivery service through the community pharmacy network. During this lag time, a new solution emerged. The Health Boards would take responsibility for the service. If I’m not mistaken NHS Fife was the first Health Board to get going.
Interestingly when the service specification and proposed standard operating procedure emerged in Scotland the word ‘delivery’ appeared to have been replaced with ‘collection’.
Communication is everything. This was a clever move.
Another key difference was the tone from the centre. Alarmingly the service in England which is set to use volunteers to deliver medicines after these shielded patients have been identified by the community pharmacy has been categorised as an ‘essential service’.
Too much tell = rebel.
The tone of such communication matters. It feels like it thinly veils a deep-seated snobbery likely built on the view of arbitrary hierarchy within our profession that have been constructed to protect certain corners of power.
The essential service in England does have modest payments associated with it however the consensus is that this will be no-where near enough investment to prevent this service being run at a loss especially when start-up costs are included.
The advanced service in England commands a modest payment of £5 per delivery.
Community pharmacist Michael Ball expressed his concern about the fee structure:
“I’m not sure about the funding structure proposed, although I can’t think of a fair way to share it out, right now. This model puts a lot more work on pharmacy and I suspect the payments won’t go anywhere near to cover the salary cost of sorting it all out. The essential service needs coordination skills and for the advanced service, the logistics of deliveries takes time. It will be a big learning curve for those who have never delivered.”
Now, details aside I am genuinely torn between my pharmacist instinct to veer towards a procrastinating perfectionist mindset but at the same time, I understand that the unprecedented situation does require unprecedented solutions.
So does the use of volunteers to deliver medicines in this way create an unacceptable level of risk?
These patients are the most vulnerable in our society. There is generally very little wiggle room in terms of making any sort of medication error with this group. The chances of causing harm will be significantly higher than younger or less vulnerable people. That’s my first concern.
I have always been nervous about allowing people I don’t trust to work in the pharmacy that I am in charge of. Medicines and the supply thereof is a serious business despite what some in certain quarters will have you believe. When working as a pharmacist, I need to trust the people around me and I need to know at what level of competence they are currently at. This takes time and considerable effort to ease them into how things work. Volunteers could come from any background and are therefore a completely unknown quantity. That’s my second concern.
Many of the shielded patients will have their medicines dispensed into multidose compliance aids. Giving one of these to the wrong person can be fatal. There have been a number of high profile cases recently involving these compliance aids being given to the wrong patient ultimately ending in death. That’s my third concern.
Finally, I find the lack of any sort of national IT support is quite surprising. It would be really quite straight forward to deploy one of the many delivery audit trail type platforms to encourage a robust process to track deliveries and create an audit. I’m sure there are many logistics companies out there who would secretly be delighted with the marketing opportunity to save the day here.
Perhaps a decision was made to keep things in-house. Government and by proxy NHS command and control. That’s yet another topic I’ll return to in the analysis of this pandemic response.
To be honest, I could go on. But there’s little point.
All that will do is likely further convince you that I’m a pharmacist that craves perfectionism every time and that is honestly not me.
I do struggle with unnecessary risk though.
When assessing any risk of running these volunteer-led delivery services across the UK we will all have to consider the severity of the potential outcome versus the likelihood of it happening.
Although I am generalising here my view is that the likelihood of something going wrong in any given community pharmacy population is ‘likely’ and that such an event could well be ‘serious’.
It’s all well and good that the GPhC has made seemingly comforting statements about cases being considered sympathetically given the circumstances but to be honest I wouldn’t fancy betting my registration on this sympathy lasting.
This article has meandered so apologies for that. And there is no definitive right or wrong answer.
There is just risk.
Likelihood of something happening versus the severity of the impact of the event.
Whether you can tolerate that risk is up to you as a pharmacist to decide. How you choose to mitigate it is also up to you.
Only you can decide what to do and how to move forward.
I remember writing my first prescription for an undifferentiated diagnosis and albeit under the supervision of a GP colleague I signed the script. Ramipril 1.25mg caps once daily for 7 days then review. I remember it like yesterday. I was at the edge of my tolerance of ambiguity at that time but that person needed that medicine at that time and I did the right thing. My patient didn’t care that I didn’t sleep that night or that I was doing mental gymnastics whilst speaking to him.
But he did remember that I did the right thing.
On occasion, the timing of a conversation in your professional life enables multiple jigsaw pieces to fall into place. My conversation recently with Professor Zubin Austin was one such occasion. He really is quite an inspiration and reset my thinking around how I view myself as a pharmacist. His research has shown that as pharmacists, we have common traits.
We are risk-averse.
We put off making decisions until we can confirm a perfect answer.
We often self-sabotage.
We live in an era in our profession there is an abundance of organisations clamouring to support and guide us as professionals. They try to sell the comforting enveloping cloak of certainty. As any pharmacist who has dispensed or prescribed an item will tell you, this support is all well and good until you get out into practice.
At the coal face you can, of course, phone a friend, you can bounce ideas off your team and you can read around a problem but at the end of the day, the ball eventually falls into your court. Only you can decide to step forward and play or step aside and hide.
Deep breath. Weight it up. Decide. Commit. Go for it.
Your shielded patients need you to do the right thing.
Pharmacy in Practice is a UK pharmacy publication with its roots in Scotland.