Free medication deliveries were used to grow market share

 

In response to the following article:

 

“PSNC advise against delivering services for free”

 

Dear PIP editor,

 

I do not think patients should have the right to receive free deliveries of medication all of the time. I do feel that the NHS should pay for medication deliveries from a community pharmacy.

 

I also think it is fair to charge for medication deliveries.

 

The reason community pharmacies have traditionally offered services like medication delivery services for free is purely and simply to achieve market share and customer loyalty. These were the key drivers for the majority of community pharmacies.

 

There are instances where the pharmacy addressed the genuine needs of patients in ensuring they received critical medications, but the population have now become accustomed to services in other retail experiences being provided to their doorstep.

 

I’m afraid though that I cannot describe a fair charging structure for delivering medicines in community pharmacy. Regardless of how we ‘slice and dice’ the rule for free delivery of medication, there will be winners and losers.

 

The profile of our population is so diverse that it is almost impossible to make a hard and fast rule to encompass all and prevent hardship to those who genuinely couldn’t afford to pay for delivery. Perhaps there should be a baseline charge or fee from the government to cover that fee if there are circumstances that an individual cannot afford the costs.

 

I have experienced the scenario where a local large chain pharmacy stopped all deliveries and the provision of MDS (unless a charge was made). This caused an influx of patients wanting to avail themselves of our delviery service and MDS provision. We had to rationalise the service, point out that it was intended for housebound people and people with disability to access their medications.

 

We disappointed some people, and some suddenly realised that ‘delivery wasn’t the norm’.

 

Yours etc.

 

Darren Powell

 

Community pharmacist

 

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Pharmacists should follow Canada and be able to change prescriptions

 

In response to the following article:

 

“Pharmacists should be allowed to make prescription changes”

 

Dear PIP editor,

 

Given a predetermined set of parameters, there are no more risks than there are with pharmacists filling a doctors prescription. After all, we do know a lot more about medication than physicians do, just as they know a lot more about diagnosing conditions than we know. These are two very distinct and separate professions that can work synergistically when working collaboratively.

 

The benefits are almost unlimited.

 

Easier access to medications, particularly for refills, dramatically decreased costs for unnecessary physician visits that allow physicians to spend more time with patients rather than having to see ‘x’ amount of people in a day just to pay the bills. That said I do not know how physician remuneration works in the UK. I know in Canada and the USA, most physicians are on a fee for service and essentially need to see 40-50+ patients a day to pay the bills.

 

I truly suggest that the UK look at the Pharmacist Prescriptive Authority in the different provinces in Canada. We can renew, change, adapt, alter dosage form, and substitute medications as well as prescribe for minor ailments such as cold sores, fungal infections, erectile dysfunction, conjunctivitis, atopic dermatitis, bug bites, Gastro-esophageal reflux disease, and many many other conditions. Of course, if we see something that requires a physician consult, we immediately refer. This ability helps the system in many ways, but it is particularly beneficial to patients.

 

There could be a number of reasons why these changes have not happened in the UK so far. At first, about 15-20 years ago, there was an issue with physician ‘territory protection’. Then, as newer, more progressive physicians saw the benefit in having pharmacists work with them, the only obstacle was the will of the stakeholders.

 

I’m not saying it’s perfect here now because many of the products we can ‘prescribe’ are forced on us and for the most part. In many cases, I would prefer to use a different product than one that is on the list of products that we are permitted to prescribe for certain conditions.

 

That being said, it’s been quite a journey to get this far and it is continually evolving and expanding the scope of practice for pharmacists within the health care system with pharmacists being recognised as a very important piece to healthcare teams.

 

Yours etc.

 

Glenn Murray

 

Community pharmacist from Canada.

 

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Pharmacists are disillusioned, disenfranchised and marginalised

 

Dear PIP editor,

 

Like many of my clinical pharmacist colleagues, my concerns about hospital pharmacists being forced to wear uniforms are extensive. There is nothing to suggest that the current duties of hospital clinical pharmacists in the UK give rise to increased risk of healthcare-associated infections.

 

I want to share my view on what pharmacist should or should not wear but first some context.

 

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or simply ‘COVID-19’) pandemic has drastically affected pharmacists physical, mental and social wellbeing.

 

Both pharmacists’ professional and personal identities have particularly been impacted by forced moves to non-familiar clinical areas, additional hours, full seven-day service rotas, rapidly evolving change in Public Health and NHS guidelines policy, facemasks, visors unisex uniforms/scrubs, medicine shortages, staying on top of evidence-based treatments, cancelled holidays, and personal life restrictions etc.

 

The thing that keeps many of us going, is the faith that medical intervention, in the form of a vaccine and/or prophylactic drugs, looks promising to come in the second quarter of 2021.

 

Hospital pharmacists are a very diverse professional group including specialists in aseptic preparation, medicines information, governance, formulary, clinical pharmacist’s, radio-pharmacy, production, practitioners, management.

 

The largest group being the clinical pharmacists.

 

The rationale to wear uniforms is to reduce touch contact contamination and subsequent transmissions. Staff who are required to wear a uniform are those in close physical contact with patients on a prolonged basis.

 

Pharmacists have never historically worn uniforms in the hospital or had a true need too. All pharmacists are taught at university what professional attire looks like, smart but modest, and nothing below the elbow. At this point considering the WHO 5 points of hygiene is useful in assessing risk.

 

Considering the wider pharmacy team, each member of the ward pharmacy team plays a significant, yet varying role in providing patient care. These different roles carry different levels of risk.

 

The only members of the pharmacy team that routinely enter the immediate patient area are the pharmacy assistants and technicians when assessing patients’ own medicines.

 

Modern clinical pharmacists do not routinely undertake these activities, thus are not at the same high risk as other pharmacy team members. In the absence of a fully resourced ward medicines management pharmacy team, it is not safe or physically possible for a pharmacist to run these services on their own, thus there is never a need to take that risk.

 

In addition to standard NHS infection control training precautions, pharmacists have background knowledge of aseptic and sterile production thus are well informed and practised in how to limit microorganism spread. Many of us also have specialities working with immunocompromised patients or those with infectious diseases or both.

 

The use of PPE, shielding, and precautions isn’t new to us. It is just more extensive during the current pandemic.

 

In the past pharmacists wore laboratory white coats, and these were either laundered by the hospital, or by the individual pharmacist. The issues with white coats were primarily two-fold:

 

  • By their nature, they had long sleeves, thus not ideal in the eyes of infection control.
  • Hospital budgets looked to reduce clothing and laundry costs.

 

The reasonable risk management approach was and still is to drop the white coats, and tie long sleeves, and continue with the other parts of professional dress.

 

During the pandemic, many pharmacists have either agreed to wear a pharmacy technician uniform and cover the embroidery, or wear scrubs. That was hard as the professional dress is part of the pharmacist identity for patients, other professionals and pharmacists alike. Many pharmacists, including myself, agreed to wear uniforms as a temporary measure during the pandemic out of a mixed fear from:

 

  • Managers anxiety.
  • General personal and public anxiety about COVID19.

 

These fears could be internalised and rationalised as there was an expectation of a return to normal, and restoration of pharmacist’s identity, in 12 to 18 months from the pandemic outbreak onset.

 

I can also say from personal experience that the response from professional colleagues towards pharmacists’ wearing a uniform has not been a positive one. Our teams experience is that clinical pharmacists have been taken less seriously since we started to wear ‘tabard uniforms’.

 

The centre for disease control state that the risk of catching COVID-19 from a dry surface is extremely low. This is not proven and is theoretical. It is very frustrating as there has been very little coherent approach to PPE in NHS Scotland, with many of the recommendations changing week to week being based on opinion and resource availability rather than science.

 

Some of the comments I’ve heard from senior and director level staff justifying a new uniform policy are bizarre.

 

“When I started, I was told that woman should wear a skirt instead of trousers.”

 

My reply:

 

Paraphrase ‘my grandmother went to school in a horse & cart so you must too’. Much has changed since the 1980s. It is 2020, and it is appalling for anyone to dictate to anyone else what to wear based on gender. It is equally appalling and harmful to once identity, emotional and psychological health to force people into unisex clothing.

 

“Pharmacy technicians and nurses have to wear uniforms.”

 

My reply:

 

They take a risk, with unsafe equipment, let’s make ourselves feel better by making pharmacists take an unnecessary risk. The solution is to give people uniforms that are fit for purpose if required.  The vast majority of hospital pharmacists do not require a uniform.

 

I could go on…

There is also a general concern that the role of the pharmacist has been devalued with reduced opportunities over the last 30 years. Examples include the following:

 

  • The 1990s – Exodus of pharmacists form the pharmaceutical industry in the 1990s driven by consecutive governments polices, and greed of commodity dealers. The rise of the pharmacy multiples.  This has led to generally fewer career options of pharmacists.
  • The 2000s – Multiple SOPs opening in the UK leading to an oversupply of graduates, leading to supply outstripping demand.
  • The 2010s – GPhC no longer regulate qualified persons, gradual fleecing of science from the pharmacist syllabus
  • The 2020s:
    • Dispensing errors still criminalised for hospital pharmacists.
    • Pharmacist apprenticeships (this is turning back the clock over 50 years).
    • Pharmacy Technicians to administer PGDs.
    • Removal of supervision.
    • Lack of posts for progression beyond band 7.
    • Lack of equality of banding between clinical and non-clinical hospital pharmacist roles.
    • Devaluing of prescribing, as entry grade pharmacists are planned to qualify as prescribers from year 1, without the remuneration to match.

 

My point here is the pharmacist workforce at large are disillusioned, disenfranchised, marginalised, and have reduced opportunity for career choice and progression.

 

There is the hypocrisy of our ‘leaders’ in Scotland, many of whom haven’t practised in a clinical setting for decades, and will not ever wear a uniform, earning at least double what your average clinical pharmacist does, to use public funds to take non-evidence-based decisions about clinical pharmacists’ identity without full consultation and consent from our community.

 

As you know, hospital pharmacists are classified as clinical scientists. We are not nurses or allied healthcare professionals. Thus, clinical pharmacist practise requires a professional expression to span both the art of healthcare and the science base behind the exterior.

 

The previous Chief Pharmaceutical Officer for Scotland, Professor Bill Scott, was extremely wise in realising that a unisex uniform, pulled over one’s head, is not befitting to the science or art of the pharmacist profession.

 

Put simply it is a waste of public funds.

 

Yours etc.

 

A clinical pharmacist

 

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Community pharmacy isn’t set up to deliver interventions at scale

 

In response to the following article:

 

“Pharmacy should be at the centre of new obesity strategy”

 

Dear PIP Editor,

 

This is, at first glance, an example of the Royal Pharmaceutical Society (RPS) and Claire Anderson making a very good point albeit in isolation. 

 

Why should pharmacies, with their accessibility and high footfall not be best placed to be the ‘go-to’ healthcare professional for a policy drive like this?

 

And the argument is valid, but unfortunately, it is a misplaced one due to false pretence. Despite huge strides made over the last six to seven years, in particular, the community pharmacy platform in England is just not set up to deliver these interventions robustly at scale.

 

Why?

 

Our NHS network connectivity goes through the patient medication record supplier aggregator so cannot resolve access to local internal .nhs sub-domains, where all the sharing of resources happens.

 

Never mind being on the same playing field, we’re not in the same park…

 

And that’s just one minor part of it. When you think of the whole system of prescribing cost centres, read coded data extracts, and write access to records. I could go on…

 

We’re playing French Cricket with a tennis ball, whilst everyone else is at Old Trafford with a Duke Ball.

 

All of which means the RPS and Claire Anderson are not wrong in arguing for pharmacy, but we need the underpinning enablers first. So the next time government wants to role out a massive public health intervention make sure the infrastructure is there to make it easy and attractive for community pharmacy to deliver it.

 

Yours etc.

 

Steve Mosley

 

Pharmacist

 

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Excessive accumulation of medication at home is common

 

In response to the following article:

 

“Tramadol overdose death raises questions over repeat prescriptions.”

 

Dear PIP Editor,

 

I feel that patients being put at risk due to how repeat prescription services are being managed. I think the excessive accumulation of prescription medication is a common occurrence and I have seen this in practice.

 

On occasion, I had excess returned medication when we used to order peoples’ repeat prescriptions. This happened despite asking then every time what medicines they needed next time. We also would follow that up with:

 

“Are you sure you need x, y, z next time?”

 

For random creams, paracetamol other when required items we would also ask this question. Lots of people just want everything because they feel entitled or just too lazy to really check what they need.

 

I think the current supervision of the repeat supply of prescription medicines is not acceptable.

 

There is no easy answer to making sure this type of incident never happens again. I favour pharmacies not ordering prescriptions on behalf of patients. The area where I work now does not allow pharmacies to order on behalf of patients any more. This move has reduced the workload for us. I am sceptical whether it will help with the volume of prescriptions being ordered but at least the pharmacies will stop getting blamed for excesses.

 

As mentioned, we don’t order on behalf of patients anymore however, when we did we used to double-check ‘when required’ items. In most cases, patients filled in the repeat slip themselves. We just conveyed the information by hand or electronically to the GP and in all cases, the item is marked at the GP practice as being ‘due’.

 

I am concerned that patients are ordering and therefore creating the excesses because they cannot see the state of their medicine stash at home. There is often no way for the patient to know they don’t need it when they are saying they do during the conversation with the pharmacist.

 

Yours etc,

 

Anon.

 

The author of this letter is a community pharmacist who wishes to remain anonymous.

 

 

We don’t ask patients about their medicines as often as we should

 

In response to the following article:

 

“Tramadol overdose death raises questions over repeat prescriptions.”

 

Dear PIP Editor,

 

I believe patients being put at risk due to how repeat prescription services are being managed. I agree with the experienced specialist mental health nurse in this case when she said that excessive accumulation of prescription medication is a common occurrence.

 

I have seen this in practice. This ranges from patients ordering their own repeats and also batch prescriptions. With batches, we ask the patient each time if each prescription item is needed at each supply. If the patient is unsure, I ask them to call us and we make a note on their batch auditable paperwork.

When patients order their own medicines, we probably don’t ask as often as we should. I would say we don’t check every time if the prescription they are receiving is the one they are expecting.

 

There is an assumption that if a patient has control over their prescription then they must need it and it is correct.

 

I don’t think there is an easy solution to this.

 

A point to note is that a patient’s regular pharmacist cannot go into a patient’s home to talk to them about their meds. I think this would help with those patients that we do not see on a regular basis.

If stockpiling is an issue then other healthcare professionals need to contact the pharmacist as their duty of care. They need to check if they are taking their medicines, check compliance, check health outcomes and also check who is ordering the repeat medicines.

 

This is where batches come in.

 

We don’t manage prescriptions for our patients. This would be up to the patient or the carers or the carers to prompt the pt to re-order.

 

PRN medicines should also never be placed on repeat. For example, I think painkillers should never be on repeat slips.

 

I believe to prevent such case as this happening again there should be no ordering of prescriptions without the prior informed consent of the patient. This may mean having to contact them month after month!

 

Yours etc.

 

Anon.