The great patient medication returns debacle

Johnathan Laird Serial Nudger

 

The amount of money drained from the NHS via the oversupply of medication must be staggering and largely unmeasured.

 

I’m talking about the at times mountainous piles of returned medicines that get handed into community pharmacy for disposal.

 

The great patient medication returns debacle.

 

If you’ve ever worked in community pharmacy you’ll know the routine. The bin bags approaching up the middle aisle usually unfortunately from a bereaved close relative. In my experience, these great excesses of prescription drugs handed back to the community pharmacy usually come to light after the passing of a patient. The sadness of the moment is balanced by the mortification of the family members returning said medicines.

 

The empathetic shake of hands happens as you try your best not to raise an eyebrow at the three bin bags of returned medication about to be handed over.

 

Insulin, inhalers and dressings are expensive patients returns but the winner is usually the unused diabetic test strips and lots of them.

 

This problem needs to be tackled. It’s a classic lose-lose situation all around.

 

At the beginning of my career, I really did get irate when this happened. And on occasion, I will admit this probably clouded my mood so that I did not provide the highest level of patient-centred care. These situations would often involve offering condolences which in my more formative years was difficult through a mist of outrage. I’m not really proud of these occasions because family members deserve the care of their community pharmacist at that moment shortly after a bereavement.

 

I’ve often wondered what the public would think if the amount of money that the NHS wastes in this way. What is the average prescription item value these days? Something like £10-£12 per item? I honestly think the general public don’t have any idea about the scale of this problem. Perhaps putting the problem into context might help.

 

And on the flip side the problem really is conveniently difficult to measure because the system assumes that every patient will be adherent to their medication all of the time.

 

Well as pharmacists we know that even the most engaged patients will struggle to achieve 100% adherence.

 

The causes will be multifactorial but no doubt free access to medicines drives a certain amount of volume. Market forces are at play too. There is also the trend towards ‘managed repeat’ services but that’s whole other opinion article altogether. I think any conversation about waste must bring the desire for pharmacy contractors to sign up loyal repeat prescription patients. A patient on a managed repeat prescription service will I’m told generate higher annual dispensing sales compared to those patients not using such a service. I guess it’s easy for me to pontificate given that I don’t currently own a community pharmacy that still depends on prescription volume for profit.

 

One of the reasons I decided to write this article was the link from this topic I made with the charge that was initiated for plastic bags supplied from retailers in recent years.

 

I remember working in a community pharmacy in Scotland when the plastic bag charge was initiated. I found it absolutely hilarious the lengths some folk would go to to avoid the 5p investment in a bag to ensure their walk to the car was comfortable. Instead that first year there was some heroic resistance to splashing out on the bag charge. Things have moved on from then because any form of the plastic bag would surely be frowned upon now due to environmental considerations.

 

Now that’s all very interesting to you I’m sure but the bottom line about the plastic bag charge idea was that it actually worked. The number of bags used by the pharmacy absolutely plummeted. I’m guestimating here but I’d say in the six months after the charge came in the usage of plastic carriers bags in the pharmacy dropped by as much as 80%.

 

The difference before and after implementation of the charge was stark.

 

I think that was probably an example of nudge theory. I highly recommend the book, surprisingly called ‘Nudge’, where these ideas have been articulated.

 

The first chapter of that book involves a little story about a school headmaster. Basically this headmaster was tasked with improving the levels of healthy eating amongst the youngsters at lunchtime. The headmaster was given no extra budget and his brief required student choice to be respected. His solution was to rearrange the cafeteria. He put the fresh fruit, veg and healthy options at the front and the chips, burgers and other less healthy options behind the screen at the far end of the room.

 

Much like in the plastic bag example the plan worked and he began to ‘nudge’ the children towards making healthier options.

 

So what is the ‘nudge’ solution that could be applied to our patient medication return problem?

 

Well unlike our headmaster striving for healthier eating choices we can’t really make it more difficult for patients to access or re-order their medicines in the first place but perhaps we could disincentivise it. At the very least I’d like to support patient education to such an extent that the decision to order is at least considered. There has always been the argument that some kind of charge on prescriptions would be draconian and to be honest I agree.

 

But the lever in the plastic bag success story was a monetary one albeit a very low-level charge. Perhaps the solution could be something simple like making the price of the medicine really clear to our patients or enforcing a nominal 5-10 pence charge per item.

 

I’m not sure what the answer is but what I am fairly sure of is that things can’t get much worse. Wouldn’t it be great if we could stumble upon a low cost ‘nudge’ type solution that tackles this issue once and for all?

 

This amount of waste has to stop so come on clever people answers on a postcard, please.

 

Johnathan Laird is a pharmacist who likes to think he is a serial nudger but probably often doesn’t realise he himself is being nudged.

 

 

 

Resilience initiatives deflect blame

 

Initiatives focusing on resilience as a solution to workplace stress suggest that the person experiencing the stress wouldn’t suffer so much if they were more resilient.

 

The blame for the stress, therefore, is placed on the individual for not being resilient enough. It’s not helpful at all to sufferers and in fact, may make them feel worse.

 

We need to tackle the root causes of workplace stress, but doing so is often against the interests of those responsible for the working environment. Some people or organisations keep the focus on resilience deliberately.

 

If any questions are asked of how they’re tackling workplace stress, a shiny document focusing on “resilience” deflects the blame back on to the sufferers, and away from their own responsibilities to address the root causes.

 

Where people and organisations spend enough time around others who take that approach, they can become infected with the same mentality.

 

They may become willfully blind to the root causes – essentially, captured by those with vested interests in keeping the focus on resilience. Or, they may simply not care what it does to the sufferer.

 

Bear in mind that the sufferers will include those with clinical mental health conditions. So when you think about it, taking an approach which places the blame upon them at a time they’re looking for help is pretty sick.

 

Point these issues out to the proponents of resilience, and they may insist that it’s a good thing – benign. But such insistence does nothing at all to change the impact on the sufferer.

 

I recently read the following:

 

“When things come into your head, take out a notebook and jot them down, then forget about them until it’s worry o’clock… At a specified time in the day, allow yourself time to worry; this should be no longer than an hour.”

 

Let’s just break that down.

 

Instead of asking why professionals are stressed in the first place, it’s asking them to *actually schedule in time to worry*. And to take time out of their probably-already-busy-day to do it.

 

Far from addressing the root causes of workplace stress – the workplace or environmental factors – this approach normalises stress and places responsibility for planning to be stressed on the sufferer.

 

It appears to be a new low.

 

The suggestion that all their worries can be contained into a 1-hour slot each day betrays an absolute lack of understanding of stress and mental health issues. Hopefully, nobody reading this would provide such advice to a depressed or anxious patient.

 

It’s not necessary to name the proponents of this stuff, but it needs calling out publicly because it risks damaging the cause they’re meant to represent.

 

Because here’s the irony: it hasn’t come from those with a vested interest in shifting the focus, but rather, some of the proponents of this actually have a responsibility for helping people to address workplace stress.

 

Which means that not only is the workplace broken for the sufferer, but the advice is broken too.

 

What hope have they got?

 

Before anyone suggests “have you emailed the proponent privately about it” – check yourself. It’s against the interests of an organisation to withdraw something like this and apologise for it when it’s pointed out.

 

Also, once they’ve published it, they’ve made it public themselves – so that’s where the debate needs to be, so that any sufferers thinking “what the actual…” know that they’re not alone in finding it ridiculous.

 

This is an opinion piece by Greg Lawton who is a pharmacist.

 

Patient stories are not yours to share

 

I’ll level with you. I get really nervous when healthcare professionals, not just pharmacists, start describing encounters online they have had with patients in practice.

Maybe I’m too cautious but I feel that patient confidentiality is something that we need to protect with rigour and vigour. I reckon the protection of patient confidentiality is one of the most precious aspects of being a pharmacist.

The inception of the internet and the proliferation of the use of social media by pharmacists and other healthcare professionals has presented some challenges in this area.

There is no doubt that there are considerable benefits to sharing stories about encounters pharmacists have with patients. The internet and the many social media platforms that have come and gone in recent years have allowed us all, myself included, to network with and learn from fellow health professionals. I have met and learned from so many fellow pharmacy professionals over the years but sharing patient stories is the next level beyond simple networking.

If we consider the sharing of patient stories I think there is a myriad of ethical considerations.

For example, if you are reading an account by a fellow pharmacist how do you gauge the quality of the information? I have seen many examples of either extremely naive questions or downright factually incorrect information being shared.

I think if you are a pharmacist or pharmacy technician and you choose to cross that rubicon and describe encounters you have experienced in your own practice you need to remember that these stories are not yours to share. This information belongs to the patient and therefore consent should be gained before putting any details online on any platform.

There is a precedent in medicine for sharing interesting, unique or clinically significant cases. These are known as case reports. I have selected an example of such a case report here. The most important two words in this case report are ‘patient consent’.

Without going through the process of gaining patient consent to share the details of a case you leave the risk of breaching patient confidentiality.

And there is some evidence that this can happen unintentionally or accidentally.

An American study involving the analysis of 271 physicians and nurses found that of blogs that described interactions with individual patients 16.6% included sufficient information for patients to identify their doctors or themselves. Another study described how medical students behaved unprofessionally online. This behaviour included using derogatory terms to describe patients and also involved some breaches in confidentiality.

And this leads me to another point. The tone and intent of the online post have a bearing here. If for example, the pharmacist posts a genuinely useful and unique case, makes some effort to deidentify the patient and fellow pharmacists read the post and reflect on it then again there is an argument for risking not asking for consent.

However, in reality, posting about patients has taken a more sinister turn. And it feels like the mob has mobilised in these cases. I’m talking about the moan.

“x patient came in and was complete B****. Even though I delivered great service they still weren’t happy. And why are they in such a bad mood all the time. For God’s sake cheer up.”

Whilst this quote is completely fictitious it is very typical of those being posted in closed groups on various platforms. In fact, I would say this is quite tame compared to some I have seen recently. The motive behind writing this type of post can only be self-gratification or self-betterment in my view. There is a trend online nowadays towards extremes. Anything less will get no attention and the narcissistic need of the author will likely therefore never be satisfied.

The sinister aspect of this behaviour is the act of the vocal minority acting to normalise such behaviour. After posting a risque story many group members will pile in to support thus further embedding the echo chamber environment norms.

And the naivety is at times quite breathtaking. For example, in the fictitious quote above there is a potential cry for help coming from a patient who is very possibly suffering from mental health issues. It amazes me how many amongst us feel that patients should rock up to the pharmacy or to our clinics in a tip-top mood to engage with us exactly as we wish. People come to see us as pharmacists mostly because they are ill so they should be forgiven for having off days and more than that we should be trying to understand their health-seeking behaviour on each visit.

I’m sorry but no matter how bad a day you are having or how difficult your working environment is as a registered pharmacy professional you have a duty to stand down before going to such extremes.

As pharmacists, we are entering a brave new world of much more dynamic risk. A swashbuckling prescriber centred approach to practise within which we are supposed to be confident to justify our actions in court. But my issue with the risk in the area of sharing cases online is that we may accidentally divulge information without even intending to.

So assuming consent is not gained, which as mentioned I think it very rarely is, then as pharmacists why take the risk of compromising the most precious responsibility bestowed upon us?

I will concede that there is a debate to be had about whether it is ever acceptable to hide the identity of a patient and then discuss their cases online. Personally I think any risk, no matter how small when it comes to the issue of trust, is too much and as described above it is has been found to be quite easy to accidentally give enough details to identify patient or practitioner.

I’ve thought for some time that this behaviour goes on perhaps because a vocal minority of so-called ‘key opinion leaders’ in pharmacy behave in a reckless overconfident way. Unfortunately, their actions give the green light to other potentially less informed colleagues. That said being vocal certainly does not bring with it credibility. A lot of the recklessness in this area I believe is driven by a need for attention. The pressing desire and time-pressured need for adulation in the moment hence the time-consuming process of gaining patient consent is not of interest. By the time consent is acquired the social media moment will have passed.

Finally, I think there is something more fundamental to consider here about whether as health professionals we are really seeking to do good and avoid evil. Do we really always have the patient at the centre of our decision-making process? Some may say that posting a deidentified patient case is a justified risk for the greater good. There are many examples elsewhere in medicine where a positive act can be justified by a negative. One example of many could include the dying patient in severe pain. To relieve the pain the physician must give an opiate dose so high that it causes respiratory depression.

The intent to do good may well be pure but how can it ever be justified to take that risk of a confidentiality breach for the sake of shared learning? My final assertion is that intentions can never be 100% pure if the simple act of gaining patient consent is negated before posting.

And whilst this most complex of ethical areas may well continue to change over time the simple way round any doubt is to simply gain consent form the patient to tell their story.

Because it’s their story to tell not yours.

Johnathan Laird is a pharmacist who tells stories but only those that he is allowed to tell.

 

 

 

Some pharmacists should receive penalty points

 

I’ve got a confession to make.

 

I’ve got penalty points on my driving license.

 

I was ‘caught’ on a speed camera south of Aberdeen slightly over the speed limit in a 50mph zone. The letter that came through the post one rainy Tuesday morning was a complete shock to me. I was completely mortified and quite stressed because obviously I was really concerned about what this might mean for my registration as a pharmacist. I quickly remembered that it would have no impact because the GPhC do not require you to declare traffic offences of this nature.

 

It felt like a close shave.

 

I took my money to the police station and paid my fine. The points are set to come off my license this summer. Hitherto I had never broken the law so whilst some reading this may feel this is a minor offence in my naive state and given that I am a pharmacist and all-round honest chap it certainly didn’t feel minor at the time.

 

And it has really made me think about driving. A wrap over the knuckles with enough consequence to make me really stop and think about how good a driver I was after all these years. Bad habits had perhaps crept in. On reflection, I maybe was becoming a bit relaxed on the road.

 

Does this incident mean I’m unfit to be a driver?

 

No

 

Should I be banned from driving?

 

Almost certainly not.

 

Did it give me a jolt and make me focus on improving my driving?

 

Yes, of course.

 

So why do I make this earth-shattering confession that no-one else will likely care about?

 

Well, as I consider recent events in pharmacy circles it got me thinking. Two things come to mind.

 

There was a rather rude outburst on Twitter recently involving some aggressive expletives by a ‘leader’ in the profession.

 

Now folk that know me will agree that I’m very relaxed about most things but we must draw the line somewhere. I really thought this was completely unacceptable and in fact, in previous employment situations, I have been involved in disciplinaries with staff resulting in significant sanction for much less.

 

Is the behaviour exacerbated if the person in question is in a leadership position?

 

I think it is. Being in a position of power and/or influence is a privilege, not a right. Let me be clear. It’s a disgrace to our profession to do such a thing in a public forum. I was embarrassed as I’m sure many others were too.

 

But how on earth does the GPhC regulate activity like this and should it?

 

I have to admit this is a really tricky task in this fast-paced digital world of passive-aggressive online behaviour and hastily deleted social media posts. The disinhibition associated with operating on social media is clearly too much for some. It continues to fascinate me how the most placid people offline become complete keyboard warriors on social media. Combine this with the binary, combative nature of many social media platforms and the intoxication of a group of like-minded followers cheering you on and you can quickly find yourself in tricky situations.

 

Which brings me to the second issue I have been pondering.

 

It will be no surprise to many to read the recent news that the GPhC had fallen short on some of the PSA standards. In case you missed the story the standards not met by the GPhC are as follows:

 

Standard 5

The fitness to practise process is transparent, fair, proportionate and focused on public protection.

 

Standard 6

Fitness to practise cases are dealt with as quickly as possible, taking into account the complexity and type of case and the conduct of both sides. Delays do not result in harm or potential harm to patients and service users. Where necessary, the regulator protects the public by means of interim orders.

 

Standard 7

All parties to a fitness to practise case are kept updated on the progress of their case and supported to participate effectively in the process.

 

Standard 8

All fitness to practise decisions made at the initial and final stages of the process are well reasoned, consistent, protect the public and maintain confidence in the profession.

 

For any registered pharmacist these findings should absolutely send a shiver down your spine. If you, unfortunately, become involved in a fitness to practise case you have every right to expect it to be dealt with in a fair and timely fashion. The median time for a fitness to practise concern to proceed from receipt by the GPhC to a final hearing is now 93.7 weeks – nearly two years. The impact on a registrant’s mental health during this period has been shown to be significant.

 

Whilst none of the cases examined were deemed to have had an incorrect outcome it surely stands to reason that if the process has been found to be poor along the way then the likelihood of registrants to have faith in the process may well be diminished. This may result in further disengagement from the organisation altogether.

 

If you talk to pharmacists who have been through the fitness to practice process these findings will come as no surprise. I was contacted by someone going through the fitness to practise process last year and that person described the process as “traumatic”.

 

I have spoken to others who have described exactly what the audit found. Poor communication, significant delays and basically from a registrant perspective a horrible experience.

 

So how do these two events weave together?

 

Well, I think the GPhC, like other large organisations, struggle to understand what is happening at the myriad of coal faces in our profession. Incidentally, I feel that the area of pharmacist independent prescribing could be argued to be very loosely regulated at the moment. Let’s be honest, how on earth does the current revalidation process give any indication whatsoever that a registrant is a safe prescriber?

 

This lack of faith manifests itself I feel in a fear of the regulator. It erodes registrant faith in the organisation and that is not helpful for all parties concerned.

 

We have found from our published professional dilemmas that the vast majority of unprofessional behaviour will not be reported to the GPhC and if the findings of the audit are to be believed the cases that are reported are often dealt with in a very convoluted problematic way from a registrant perspective.

 

Blue sky thinking…

 

Surely the regulator could come up with the equivalent of a speed camera? Some unprofessional activity will automatically meet a threshold of unacceptability for all to see.

 

And maybe a fine?

 

It is absurd that everyone can see that certain behaviour is inappropriate and brings our profession into disrepute but nothing happens. Who would want to report someone and therefore put themselves through the regulatory mill even for the greater good?

 

So the truth is everyone stays quiet and nothing changes.

 

Some points on the pharmacist’s GPhC license? Repeat the offence and perhaps the formal fitness to practise process could kick in?

 

The trouble is, as evidenced through (the highly unscientific just for fun) results of our dilemmas is that the threshold for referring to the GPhC is really very high. In our dilemma about a group of pharmacists on a wild night out, 21% of respondents would not refer the pharmacist in question to the GPhC for openly using cocaine at a party.

 

I am absolutely not in favour of more regulation but I am in favour of effective regulation.

 

Registrants deserve a regulator that is firing on all cylinders and completely engaged with the profession. Unfortunately, evidence in the market and evidence revealed from the PSA investigation suggests there is still some way to go before we reach this point.

 

Johnathan Laird is a pharmacist who is now a much more careful driver than he was before.

 

Dr Edward Snelson on examining childrens’ throats during the pandemic

 

As increasing evidence comes out of the countries hit worst by the COVID-19 pandemic, there is growing concern about the number of healthcare workers being affected. A large number of COVID-19 positive tests in Italy (currently about 10%) have been healthcare workers.

 

It is important to emphasise that these statistics will inevitably have at least some bias. Healthcare workers are much more likely to be tested for COVID-19.

 

It is a concerning figure nevertheless and it is well known that healthcare environments are inherently risky when it comes to acquiring an infection.

 

There are three main ways to avoid getting an infection as a healthcare worker. The first is to avoid patient contact where possible. The second is to use appropriate personal protective equipment as per guidance. The third is to minimise the risk of the clinical encounter.

 

Over the past few weeks, there has been a growing discussion amongst frontline clinicians about a radical cultural change in clinical practice.

 

We have been asking the following question:

 

Should I stop examining children’s throats?

 

Like any such suggestion, the first time the question was asked out loud was probably in a one-to-one conversation in a closed room after checking that the General Medical Council hadn’t bugged the place. Then, as the question was asked more and more, it became quickly apparent that there was a large proportion of frontline clinicians who felt that this was a sensible move in the current situation.

 

On 25th March 2020, the RCPCH published guidance stating that in the current situation “the oropharynx of children should only be examined if essential.”

 

Never before in my career have I seen such a change in practice go from whispers between colleagues to official college guidance in such a short period of time. Well done RCPCH! For the first time since the introduction of FAOMed, you’re ahead of us!

 

While this move is entirely intended to reduce the risk of clinical contact during the COVID-19 pandemic, clinicians will at the very least have questions. When something is part of our routine and then taken away from us it will cause anxieties. As acute clinicians, our intuitive thinking relies on a reasonably consistent approach and in most paediatric encounters, we are used to looking in the throat.

 

So the question is, is it OK to stop doing that routinely?

 

Here are a few common questions in response to this radical change.

 

What if I need to know what the focus of infection is?

 

Good question.

 

This has always been a hugely subjective issue. Even before this pandemic, the majority of clinicians and organisations have been trying to encourage self-care for uncomplicated febrile illness in children. If a clinical confirmation of infection focus was essential, health care organisations would be getting the message out.

 

“Never give your child fever medicines without seeing a doctor to check what the problem is.”

 

That’s not a thing.

 

A snotty febrile child has an upper respiratory tract infection (URTI). URTI does not exclude other infections nor does it exclude sepsis so the redness of the throat should not reassure us if we think a child has another probable diagnosis such as UTI, LRTI or sepsis.

 

The important question has always been, “does this child have signs of serious bacterial infection or sepsis?”

 

If the answer is no then the throat exam won’t really change things (see below).  If the answer is yes, you’re looking for a source and it probably isn’t in the throat.

 

 

When might I need to examine the throat?

 

The necessity for this is probably going to be mainly to look for evidence of a significant pathology such as peri-tonsillar abscess.  I would suggest that such a possibility can be all but excluded clinically if a child is well analgesed and is able to eat or drink.
If you do feel that examining the throat is important to do, you must wear eye protection.

 

Don’t I need to determine if the child has tonsillitis?

 

Tonsillitis in children can always be treated symptomatically. The NICE guidance for treating sore throats attempts to direct the clinician toward cases where a symptom benefit from antibiotics is more likely but does not mandate the use of antibiotic in any uncomplicated URTI or tonsillitis. The reason there is no mandate is that there is no evidence that in this era in the UK, antibiotics prevent the rare complications of URTI/tonsillitis.

 

Regardless of clinical findings, the symptom benefit from antibiotics is poor. The lack of evidence for the significant benefit has led the Children’s Hospital Melbourne to recommend no prescription of antibiotics in any case apart from high-risk children or signs of complicated URTI.

 

So if the child is low risk (99.9% of children) and has no signs of complications from the infection, the visualisation of the tonsils is non-essential.

 

Should I, therefore, prescribe antibiotics empirically?

 

In the interests of openness and honesty, I need to say first that the RCPCH does advocate this. There is a reminder that under the age of three years old, FeverPAIN should not be used. Over the age of three, it is proposed that in the current climate we prescribe antibiotics as follows.

 

“If using the feverpain scoring system to decide if antibiotics are indicated (validated in children 3 years and older), we suggest that a pragmatic approach is adopted, and automatically starting with a score of 2 in lieu of an examination seems reasonable. 

 

Children with a total feverpain score or 4 or 5 should be prescribed antibiotics (we suggest children with a score of 3 or less receive safety netting advice alone)”

 

I’m going to stick my neck out and suggest that this approach is wrong, for the following reasons:

 

  1. First and foremost, it contradicts the public health approach to containing the COVID-19 pandemic. People are being told that if they have a fever without signs of something that looks like a serious illness (difficulty breathing, poorly responsive etc.) they should stay at home, self-medicate and not seek a face to face clinical contact. This is for their benefit, to protect the health service and to reduce the spread of COVID-19. Lowering a threshold for prescribing antibiotics for sore throat at this time goes against that move.
  2. Secondly, the RCPCH has misquoted the NICE guidance. In their speediness to protect clinicians from unnecessary risk, they have missed a word. Just the one but it the word from the guidance that frequently goes unnoticed. That word is consider’. It doesn’t say give’ antibiotics for a FeverPAIN score above 4. It says consider. I consider that question every time and in most cases the answer is “The likelihood of benefit from antibiotics does not justify the risks.”  

 

I feel (personal opinion) that since there is no mandate to treat low-risk children who have no signs of complications of their URTI or tonsillitis, we should default to not prescribing antibiotics in these cases. To lower our threshold for prescribing instead of raising it at this time of such a high-risk clinical environment feels wrong. It seems contrary to the need to protect children and their carers from the risks of a visit to a GP or hospital and it feels contrary to the drive to reduce the number of people bringing COVID-19 with them to those places.

 

Again, huge respect to the RCPCH for cutting through the red tape and rapidly producing guidance to protect healthcare workers.  Whenever something is done in that sort of timeframe, it is likely that detail gets missed.  That’s where we come in.  We notice the typos and consider the implications.  We ask questions that deserve answers after the fact in lieu of the consultation period that couldn’t happen due to the timescale needed.

 

Edward Snelson
@sailordoctor

 

You can view Edward’s excellent blog by clicking here.

 

 

Volunteers, medicine deliveries and what if it all goes wrong?

 

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.

 

  • Are the volunteers competent and how is this checked?
  • Can the volunteer be trusted?
  • What about patient confidentiality?
  • Who carries the can if an error is made?
  • What happens when the volunteers stop volunteering?
  • Will the monies being made available in England be enough to cover the costs?
  • Can community pharmacy teams cope with this increased workload?
  • Why has no centralised logistics technology solution been provided to support this project?

 

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?

 

Too harsh?

 

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.