Pressures of work and home life mean blogs are becoming few and far between for me, but I was reminded to pen this brief one by a recent tweet.

Of late there’s been angst aimed at Keith Ridge over his perceived prejudice against community pharmacy. It’s important that we can and do share our opinions on all things that matter to us, but I’m still apprehensive about wading in on this because – frankly – I have little skin in that game these days, and certainly nowhere near the level of commitment of those most vociferous against him.

But in my mind there’s a point that needs airing – and one that isn’t the result of any conflict of interest (never met him, never worked for the department).
‘Austerity’ aside, the country as a whole is in depressing financial territory, which is likely to get worse as Brexit gets properly underway. Pressures on the treasury become pressures on all government departments, and we know the NHS is not immune to this – and so neither can its contractors, pharmacy included. The community pharmacy contract funding cuts are aren’t fair nor evidence based and I’m not ignoring the huge impact they will have on individuals and their families, but still they’re coming – and after post offices, libraries and schools taking the same we can hardly be surprised that pharmacies too are in line for a pounding.

And here’s the point: pharmacies ≠ pharmacists.

If bricks and mortar cannot or will not be funded by the treasury, then I expect our CPO to instead work hard behind the scenes to ensure that pharmacists themselves (and the value they provide patients and the healthcare system) continue to be funded and delivered in different ways in line with changes in the health system as a whole. A move into GP practices is a high profile example, but also consider the work being done in care homes, urgent and emergency care, community services and in years to come, genomic medicine and 3D-printed medicines.

The CPO is the of head of the pharmacy profession, not head of pharmacy sectors nor head of pharmacy infrastructure. We know the ‘sectors’ mentality has been bad for us in the past, and so to me it looks to me like our CPO is doing his job – ensuring the profession as a whole continues to be seen, heard and move with the times – and for that I feel I have to write in his defence.

The topic of this blog and the long absence since my last one (notwithstanding my still unresolved ranty-rant on customer experience) are much intertwined.  While Ford Prefect will have us believe that time is an illusion, it is still very much of the essence and of late I’ve found myself disillusioned with how little time I have. My difficulty is that I’m passionate about a lot of things and want to give them a part of myself by way of support; invariably this means my time, my energy and my resilience.

A quick stock-take of my commitments made for illuminating reading: I’m a husband, dad to two great kids, have two permanent jobs and own my own consultancy business. I’m a school governor, treasurer for a local branch of the RPS and I run the @WePharmacists Twitter account. I like to keep fit, see friends and have time be mindful. And ultimately I can only do so much before it impacts on the time I have to spend doing the things that matter most to me in life.

So while I’ve loved watching Little’un germinate a seed, plant it out and eat the resulting crop, the fact that she’s now more interested in Austin & Ally (don’t; just don’t) and Littlest is years away from understanding crop rotation and companion planting, I have handed back my allotment. I love the touch and smell of soil, wild flowers, the wildlife they attract and the technical challenge of growing but they demand time I no longer have – or at least want to give away.

My lesson has been that priorities change, life moves on and – despite allotments being harder to own than Sexy Fish key-rings – the only emotion I feel is relief at getting some balance back in my life.

I wonder now what I’ll give up the next time I take stock.

To: Charles Walton
Kybotech Limited
Dukeries Industrial Estate
Claylands Avenue
Worksop
S81 7DJ

Re: Garden Buildings Direct order

Dear Mr Walton,

I’ve two very happy children who love their new log cabin. We’ve also three friends with similar aged children who have expressed a strong interest in buying similar and my advice is always the same – do it, they’re great, just don’t ever buy it from Garden Buildings Direct…

• We planned to construct the cabin in good time before our scheduled holiday in late August and our son’s christening in September and so ordered on 27^th
• You emailed the same day to tell me to say delivery would be within seven days as stated on your website (by 3^rd August).
• You emailed me again on 29^th July and 2^nd August to say my order was being processed and you would contact me again as soon as it was ready.
• On 7^th August I called you to find out where my order was but could not get through to anyone.
• A voicemail was left for me on 12^th August saying the delivery would be dispatched over two days because of its size and that it was planned for the end of the week (two weeks overdue).
• I tried calling a total of six times from my mobile while at work to explain no-one could accept the delivery on your chosen date; I was on hold for a total of 37 minutes across all calls but when I reached position one in the queue I was automatically cut off.
• I emailed you on 12^th August to reschedule for the 18^th and 19^th August as this was the first opportunity I had to reschedule my work and take the required time off as leave; you replied with an email to say my request was being booked.
• Delivery arrived in full mid-afternoon on 18^th August – I did not need to take two days off work but I did need to buy two large tarpaulings to keep the materials dry as the delivery delay meant we were in a patch of bad weather.
• I started work on the build on 19^th August and realised there were missing parts: I tried calling you and was on hold for 24 minutes before speaking to someone. I was told that all requests for missing parts had to be done by email because it was dealt with by a separate team. I explained the urgency of the build (holiday and christening) and asked for other options or someone else to talk to – I was denied this and told replacement delivery is a standard three to five days. I had to put the build on hold, including dismissing the help I had arranged.
• I emailed the address provided and explained the urgency; I also provided my home and mobile number so I could be contacted to discuss requirements. I emailed again on the 20^th in the morning, at lunchtime and again at 2pm as I had not received a reply. I requested that the parts – two small pieces of timber – were couriered to me for the following day and referred them back to the original email trail for details.
• I received a reply on 20^th August at 16:50 simply asking me to confirm the missing pieces (number and part number) – there was no evidence that my emails had been read or my needs understood. After confirming the information required I received another email saying the parts would be produced that day and with me in three to five days.
• I recovered a parts checklist from the supplied paperwork: it clearly shows no checks were made when parts were packed for delivery and not all parts were checked at manufacture or delivery to the loading bay. The ‘final part checking’ sign-off is also incomplete.
• I rescheduled our family holiday and my annual leave accordingly to ensure we were able to accept the pieces and continue the build before the pending christening. Build restarted to bring the cabin up to as high as possible without the missing pieces; help was arranged accordingly.
• On 25^th August I emailed again asking for an update on the missing pieces; I was emailed back saying this would be chased and the parts delivered “by a third-party courier”; we were unable to hold back our holiday any further and had to go on leave for a shorter duration with this situation unresolved.
• On 27^th August I emailed you again asking for an update – four weeks after the original order and eight days after informing you that you didn’t deliver all of my cabin. I received a reply saying the parts would be delivered on September 4^th.
• This was not particularly convenient to us so I tried to use the reschedule delivery link – this did not work so I emailed you back with a screenshot of the failed link, requesting delivery either on 28^th or 29^th August in line with your three to five-day promise and use of third-party courier. I said that if these dates could not be requested then we would have to stick with the 4^th as this was the least inconvenient date available.
• The following day saying the parts would be delivered on 1^st September, not a date requested and not in line with our requirements. To prevent any further delays my wife cancelled my daughter’s day trip so they could stay in and accept delivery (as I was back to work).
• At 9am on 31^st August I received an email saying the parts were being prepared for dispatch: this was followed by emails at 20:40 that evening stating it had been dispatched (presumably to the third party courier), then again 6am and 6.30am saying it was on it would be with me in around thirty minutes, traffic depending.
• At 7.11 you emailed me to say that delivery had ‘failed’ and you would contact me to reschedule a mutually convenient day. At 7.18 you emailed again to say it had automatically been rescheduled to the 4^th At 7.25 I received a text message from you saying delivery would be with me in thirty minutes.
• The parts arrived late afternoon, delivered by your staff and not a third-party courier as promised, on 4^th September; these were the wrong parts, but fortunately they were longer versions of what I needed so I accepted them and had to cut them down to size myself. The build restarted, again with additional help arranged at cost to us, and was finished only the night before my son’s christening which rather spoiled the build-up and celebration.

I’d like to think areas of improvement for your company are self-evident but I am happy to discuss this further if you wish, and provide you with the documented evidence to support all of the points above: I have reprinted this letter on-line at https://aptaim.net/2015/10/05/experience/  and will endeavour to embed the various emails, documents, phone records and photos over time for ease of access.

It is fair to say that our customer experience is the worst I have ever encountered, a feeling clearly replicated by those mentioning your company on Twitter, and it’s easy to see how their themes apply to my experience. For example, the huge discrepancy between the content of the emails I received on 1^st September, the text message and what actually happened that day along with something your driver said when delivering my missing parts on the 4th suggests you never had any intention of delivering that day and it was always going to be when most convenient to your delivery schedule, rather than convenient to your customer.

I would like to have the confidence to be able to once again use your company and recommend it to others, and so as accountable person for your company I am expecting the following in a written response from you as a result of this letter:

1. A full explanation of why things happened the way they did.
2. A statement of what compensation you believe I should receive and how this will be paid.
3. A description of the steps you will take to improve customer experience in the future.

Yours sincerely,

James Andrews

From:    Resolutions
To:        James Andrews
Date:    Tue, Oct 6, 2015 at 12:15 PM

Dear Mr. Andrews,

Thank you for your email. We appreciate customers who let us know when things aren’t right. Both positive and negative feedbacks are important to us. It will help us improve and work more on our customer service.

We are really sorry for all the hustles and inconvenience that happened regarding the delayed delivery of the replacement parts that you have requested.

Rest assured that this will be forwarded to our logistics team to make sure that this won’t happen again.

As much as we would like to, we are not allowed to provide any monetary compensation for what happened.

If there are some parts of your order that needs replacing, just let us know and we will deal with it as a priority.

We can assure you that all these negative feedbacks will be prioritized and carefully investigated and considered for us to provide a better customer service.

Kindly let us know if how would you like us to proceed regarding this matter and as soon as we receive your response, we will deal with it as a priority.

Once again, we are really sorry for what happened It was not our intention to cause you any trouble, please accept our sincerest apology.

Kind Regards

From:    James Andrews
To:         Resolutions
Date:     Thur, Oct 8, 2015 at 09:28 AM

Thanks for your speedy response however it is wholly inadequate as it fails to answer my points and takes no account of the additional costs, lost annual leave, stress or shortened holiday that your company’s failure to deliver as promised has caused. As requested, I would like you to proceed by answering the following queries, the latter three which remain unanswered from my complaint letter:

1) Why wasn’t my complaint letter read by, and responded to, by Mr Walton the addressee?
2) Please describe the limitation or restriction in place that does not allow you to provide monetary compensation.
3) Can you provide me a full explanation of why things happened the way they did.
4) Can I have a statement of what compensation you believe I should receive and how this will be paid.
5) Describe the steps you will take to improve customer experience in the future.

Regards

From: Christopher
To:       James Andrews
Date:    Thu, Oct 8, 2015 at 2:59 PM

Dear James,

My name is Chris and I am the Chief Operating Officer at Kybotech.

I wanted to contact you personally to apologise for the issues with your order process.  I can totally appreciate your frustration throughout the process.

I really appreciate your offer to let us restore your faith in buying from us in the future.  I would like to offer you 20% off your next order as a gesture towards this.  Clearly the only way for us to restore your faith is to give you a World Class Service on your next purchase and I would very much welcome the opportunity to do this.

Best wishes
Chris

From: James Andrews
To:       Christopher
Date:     Mon, Oct 12, 2015 at 9:39 AM

Dear Chris,

Many thanks for taking up my complaint personally as I see this as encouraging progress.

As I am still without answers to any of my questions and your company’s Twitter feed continues to identify newly dissatisfied customers, I feel I must decline your offer: there is no evidence that I would receive the type of service you aspire to. However if your 20% offer was in the form of a refund of what I’ve paid to you then this would be acceptable – it wouldn’t cover my excess outlay or reimburse my family’s lost holiday but would be enough for us to draw a line under this complaint and move on.

I look forward to your considered response.
Thanks again and best wishes,
J

From: Christopher
To:       James Andrews
Date:   Mon, Oct 12, 2015 at 10:11 AM

Hi James

Thanks for your email.

Sorry you are declining the offer.

If you do change your mind at any point, please do let me know.

Apologies again for the problems you had.

Best Wishes
Chris

From: James Andrews
To:       Christopher
Date:   Mon, Oct 12, 2015 at 10:25 AM

Right – so that’s it from your company then? I shouldn’t expect any more dialogue or correspondence over my complaint?

From: Christopher
To:       James Andrews
Date:     Mon, Oct 12, 2015 at 10:50 AM

Hi James,

We clearly fell short of your expectations on your order.  I am very sorry about this.  Our processes have been reviewed and updated as a result and our staff have been re-trained where required.

I would love to prove to you that the vast majority of our customers get a fantastic experience when buying from us, hence the substantial discount available to you for placing another order.

On the rare occasion that we  do get it wrong, either myself or one of my senior team will personally call the customer and discuss what we got wrong and what we have done to improve as a result.  I and my team have offered to call you but you have insisted for a written reply, which is then being published on your blog.

My offer of a call remains, I can assure you we have worked hard to resolve the issues and move forward.  If you give us another chance and place a new order we will be able to demonstrate this to you

Best Wishes,
Chris

From: James Andrews
To:       Christopher
Date:   Thu, Oct 15, 2015 at 2:07 PM

Thanks Chris,

I must first point out that I have not refused a telephone conversation: my request for a written response was made as a direct influence of the wording on your complaint procedures page [http://www.gardenbuildingsdirect.co.uk/help/complaintsprocedure]. As it stands I’m not averse to a chat, though at this stage I wonder what detail you would give me that has not yet been covered in our correspondence; a pertinent standard used within healthcare is that something hasn’t happened unless it’s written down, and in the continued absence of answers to all my outstanding questions I can only assume nothing has been changed or implemented.

This goes some way to explaining my use, like the vast majority of people, of a blog – this is a factual record of events providing transparency and openness, and I see it as in no way different to your own use of social media. However if you have concerns about this or feel it is a barrier to coming to a resolution then please say so – I haven’t had an opportunity to update this with our recent exchanges yet and will now hold off until I hear back from you.

Unfortunately the idea I would give you more of my money after being subject to your catalogue of errors and terrible customer service is farcical. I’m now of the opinion that a partial refund is my only option and I await either a discussion on implementing this or your explicit refusal to provide one.

Thanks,
J

From: James Andrews
To:       Christopher
Date:   Thu, Oct 22, 2015 at 9:22 AM

Hi Chris,

In the absences of your usual swift response I thought I should drop you a quick line over my outstanding email. I’m aiming to update my blog over the weekend so a reply would be appreciated.

Thanks,
J

From: James Andrews
To:       Christopher; Resolutions
Date:   Sun, Nov 15, 2015 at 11:42 AM

I appreciate this is a bit tardy but I’ve been away on leave and with work, and was similarly giving you the benefit of the doubt over the recent half-term holidays.

I was contacted by Matt from your local Trading Standards about two weeks ago; he said he’s dealt with your company before, had discussed my case with you and I should’ve heard from you the following day or so. This is obviously not the case so my outstanding request of October 15^th remains please – a partial refund or your explicit refusal to provide one.

Ta,
J

From:  Christopher
To:       James Andrews
Date:   Sun, Nov 15, 2015 at 12:03 PM

Hello James

I am sorry my responses haven’t been good enough for you.

There is nothing more I can add to my previous emails which in summary was a substantial discount on any future orders.

Like most businesses we pay Trading Standards an annual fee to provide us with advice and counselling on various issues. You may or may not be aware that this is how Trading Standards are now funded, by businesses paying for advice time with their local office.

If you have made a Trading Standards complaint, Matt or his manager, Sarah, will be in touch with us to discuss it and find a resolve.

Once again my apologies
Best wishes
Chris

From:  James Andrews
To:       Christopher
Date:   Sun, Nov 15, 2015 at 12:15 PM

Thanks for an unexpected response on a Sunday, but I’m disappointed this is your final position.

When in the grips of the healthcare system it’s great to be treated by someone personable: the difference it makes to the success of the consultation and the chance of building a good relationship can’t be underestimated. As such I quite enjoyed my cardiology appointment just before Christmas although the consultation itself is not what I remember most.

The consulting room was next to a physiotherapy unit, buried in the middle of a rheumatology outpatient department, without a reception or formal signage and identifiable only by a handwritten  doctor’s name taped to one door in the middle of a line of four.  I couldn’t tell what the eleven other people sitting in the narrow corridor were queuing for so as my appointment time drew nearer I asked those nearest the door if they were waiting for cardiology.  After seeing a suited chap come out of the room and wander about a bit before going back in, I thought it best to pop my head round the door and introduce myself. A warm welcome, a quick scrabble in my notes after his healthcare assistant fetched them and we were good to go.

The consultation was at a good pace, contained clear descriptions and plenty of chances to ask questions although having the healthcare assistant come back into the room to have an ECG form re-done for a patient who claims she was never given one but “well I know I gave it to her so she must of lost it” when I’m topless was a little disappointing: no embarrassment on my part (at least now my chest hair has grown back) but for other patients this may have been less amusing.

Fifteen minutes later we’re all done and summarising the treatment options, one of which will be agreed  after I return to outpatients for a repeat ECG. A thank-you, a handshake and I’m back into the strip-lit corridor and after two attempts I find the right way out and head back to work.

I’ve mentioned before that until you’re a real patient it’s not possible to walk the pathway: you know and assume too much on the things that matter to patients and I suspect it’s the same at this hospital. I’m sure staff know that the location of this clinic could be improved if not just the signage, but maybe it’s assumed there’s no space elsewhere or there’s no funding available. I hope the healthcare assistant knows about privacy and dignity but assumed that as I was younger I either wouldn’t mind or wouldn’t taking off my clothes.

Who knows. What I do know is that what I remember most is the overall front-of-house experience, and how little things could have made a big difference – not just to me but to all the other patients waiting. How many of us can confidently say we ask the questions that challenge the status-quo in an attempt to improve the patient experience – and how many of us will agree to do that just once this month to see what happens?

It’s been two weeks since my A&E shenanigans which means by now I should’ve heard from the cardiology clinic about a rapid access appointment – but I haven’t. I’m discharged from acute care, not in specialist follow-up and not yet back to primary care for GP responsibility – I’m in a healthcare vacuum.  Not only that, but the beta-blockers prescribed in A&E would have run out by now if I was taking them (that’s right, the pharmacist who bangs on about the importance of medicines adherence is not adherent to his medicines…blog obviously to follow on that).

So given I’ve not had any further episodes and I’m back to running 5 miles most days is this a problem? Individually maybe not, but from a systems point of view it is. We know pathways can be porous and leaky but it’s in our interests to have them plugged: if I was an average AF punter with a CHA₂DS₂VASc score above zero what would I do next? Try and book a GP appointment, pay A&E another visit or do nothing and play my chances of having a stroke?

Or would I pop to the pharmacy to talk to the person who dispensed my beta-blockers and (hopefully) talked me through them and what to expect? If I did, and that pharmacist was you, what would you do to help me?

Feel free to leave your answer as a comment below…

Photo: The Lonely Vacuum Of Space (JD Hancock) / CC BY 3.0

Blimey. Two blogs in a week? I must be ill…

A couple of tweets today got me thinking again about the recent decision not to cap pharmacy student numbers.  As you all know the joint consultation last year by HEFCE and HEE showed most of the 180 or so respondents wanted some kind of limit on student numbers and only a minority opposed the cap, but minister for universities, science and cities Greg Clark MP chose instead to let the market dictate in line with the wider government policy to remove student number controls wherever possible, responding there’s “no need to consider further options for a pharmacy number control”.

So why waste all that resource and effort on three years of consultation and reporting? Formally it’s because a cap didn’t fit with the government’s “objectives for pharmacy” although I’ve yet to see any objectives written down, SMART or otherwise (and if the reserved offerings in NHS England’s Five Year Forward View are an indication of what’s in store then we’re in trouble).  In reality then what makes pharmacy so different to other capped professions like medicine and dentistry? My money is, of course, on money.

I’m a constant annoyance to many in referring to our largest sector as ‘retail’ but I know deep-down you all know it’s true. Between them the four largest chains employ about 100,000 people in the UK with supermarkets adding about 1000 pharmacies to that figure; with about 27,000 pharmacists working in retail this is not an insignificant proportion of high-cost staff at a time when returns from dispensing are flat and income from additional services inconsistent.  Since the demise of the glorious X-files I’m not one for conspiracy theories, but I recall the outcome of the PDA’s application for a declaration of incompatibility against Boots, which at the last minute surprisingly swung Boots’ way following ‘the governments direct representations at the hearing’. I’ll leave it to you to decide if there are any parallels here.

So what next? Start telling under-grads not to expect to become a pharmacist? Pin our trust in the new five-year integrated course? Hope that the NHS will find the money to redeploy pharmacists into new and relatively unproven roles? Or tell them their best bet is to join academia in advance of the explosion of new schools of pharmacy?

It’s time to put our thinking caps on.

My first ever comedy gig experience was going to watch Rob Newman with a good college mate when I was in my late teens. I remember three things from that night: me and my mate drinking whiskey with him (albeit briefly) in the bar afterwards, getting him to sign a poster we hurriedly ripped from the wall (that I can no longer find) and the joke about shoes that’s in the first thirty seconds of this clip.

Last Thursday was very much a ‘these are my shoes’ day for me – that the shoes on my feet were mine was pretty much the only thing I was sure about.

I was in a meeting where the conversation had drifted to the sex industry career opportunities available to a colleague (not an agenda item): a hard unexpected snork from me and I quickly felt wrong – thumping chest, light-headedness and the need for fresh air. There was no change after a minute or two so I made an excuse and went to the gents where a quick pulse check suggested I was probably in AF. I tried the Valsalva manoeuvre but just felt woozy so tottered back to the meeting to quietly continue hoping that it’d stop. After about twenty minutes the meeting ended and I thought it was probably a good time to ask a colleague to walk me across the road to the St Peter’s Hospital A&E department on whose grounds we were (luckily) meeting in.

The initial care I got from staff was ace, and apart from ECG pads that stick without me needing to have my chest shaved, I couldn’t want more. But this long-overdue blog isn’t about standards of care or a particular hospital, but shoes.

I’ve always believed I was good at seeing things from the patient’s perspective, objectively being able to review a service or pathway. What I realised on Thursday as I sat Dr Dan style in front of the nurse’s station is that you can’t walk a pathway as a patient until you’re really in patient’s shoes. The emotion, the pressure, the bewilderment all took me by surprise and hugely influenced what was important – human contact, a drink, knowing whether I could go to the toilet and being able to contact the Mrs (thank-you St Peter’s for the free wi-fi).

But silver linings and all that – here’s my chance to walk the cardiology pathway in patient’s shoes, my own shoes, as a mid-thirties healthcare professional turned patient.

I’ll keep you posted on what I find!

Pharmacists. We’re the experts in medicines, right? But what does that mean in practice, and how does our conduct in the community (retail…) sector fit with the rest of the healthcare team and the direction in which it travels?

This is something spoken about on Twitter before, and a topic I’ve often pondered as both a locum and customer at community pharmacy.  To help frame this some more, it’s my absolute pleasure to be able to post an article by a crackin’-good pharmacist which was recently published in Medical Writing.  For you referencing geeks out there, it’s: Johnson, H. Selling Evidence over the counter: Do community pharmacists engage with evidence-based medicine? Medical Writing 2013; 22(4): 275-278.

Read it, consider it and let me know what you think with a comment or tweet as ever please.  But most of all – enjoy!

From the author:

“A while ago, I was asked to write an article by Adam Jacobs (@dianthusmed), who was guest editing an issue of Medical Writing. The theme for the issue was Good Pharma.

I had intended to write something about how different the sort of evidence base community pharmacists have access to differs to the sorts of evidence (or lack of) that accompanies complementary and alternative medicine. But, during my literature searches for the article, I was taken in a very different direction. I started wondering about how and why community pharmacists engage with evidence-based medicine (EBM). I often think that, in discussions about it, the practicalities of life as a busy front-line pharmacist can be forgotten. I wanted to see what the evidence had to say on the matter, and this is the resulting article.”

Selling evidence over the counter: Do community pharmacists engage with evidence-based medicine?

Traditionally, products sold over the counter (OTC) in a pharmacy may have been guided more by commercial gain than rational, evidence-based medicine (EBM). Even those products that are licensed may not have a robust evidence base for their effectiveness. Irrational combination products, cough medicines, and unproven complementary medicines line the shelves of most stores, leading some prominent promoters of good science to recently criticise pharmacy as a ‘quack trade’.¹

As the role of the pharmacist evolves, it is becoming more and more imperative for the profession to distance itself from quackery and embrace EBM. This is particularly important in the face of deregulation of prescription-only medicines, the potential for self-selection of pharmacy medicines by patients, and a general public that is increasingly willing to take responsibility for its own healthcare.²

The cornerstone of EBM is the ability to locate, appraise, understand, and communicate clinical evidence. Pharmacists often act as the front-line interface between the patient and the healthcare service and as such require the skills to translate complex statistical health information into language which patients are likely to understand and engage with.³

Opportunities for EBM in the community pharmacy

An effective OTC encounter in a pharmacy is a stepwise, logical process of elimination, using good questioning and knowledge to narrow the available products suitable for an individual patient. The first step involves the use of careful, structured questions, usually following a mnemonic (see Table 1), to establish the symptoms and check the diagnosis. Symptoms which require referral are identified and patients directed to appropriate services where required. Once the diagnosis is identified, the range of OTC products available to treat it will be borne in mind by the pharmacist. Knowledge gained from questioning about the patient’s medical history and drug history is used to eliminate any products which are inappropriate for the individual patient due to cautions, contra-indications, or drug interactions. The pharmacist may then recommend a product based on a number of factors. Counselling points on how to use the product effectively and safely should then be conveyed to the patient.

As some of the most easily accessible health care professionals, community pharmacists often deal with patients presenting with health- and medicines-related questions, which may be prompted by sensationalist media reporting or information gathered from friends, family, or the Internet. There are therefore clear opportunities within daily community pharmacy to utilise clinical trial evidence in accordance with the principles of EBM.

The evidence for a lack of evidence

A survey conducted in 2005 amongst pharmacists from all sectors in Illinois by Burkiewicz and Zgarrick found that 90% of 323 pharmacists held positive attitudes towards EBM.⁴ In a more recent survey of community pharmacists in Northern Ireland conducted by Hanna and Hughes, 88.3% of 205 community pharmacists stated that they were familiar with the concept of evidence-based practice.² This is indicative of a profession that understands the underlying concepts of EBM.

In spite of these studies, there is an overall lack of robust evidence community pharmacists’ attitudes and uptake of EBM, and the currently published evidence is limited by small sample sizes and methodological flaws. However, the qualitative studies which do exist offer an interesting insight into the considerations when selecting an OTC preparation.

Hanna and Hughes conducted a series of surveys into pharmacists’ attitudes to OTC sales.² They found that the over-arching concern when selecting a product was patient safety, with 91.8% of pharmacists agreeing or strongly agreeing that safety was their main concern. Effectiveness of the product was of secondary interest. Pharmacists cited patient and colleague feedback, along with personal or family use, as the most common methods to determine a product’s effectiveness, with clinical trial data appearing to be a less important consideration. This would seem to be at odds with the principles of EBM, and suggests that while pharmacists are broadly in favour of EBM, their ability to use it in their everyday job is limited. Over 60% of respondents agreed that evidence-based practice is more difficult for community pharmacists compared to other healthcare professionals.²

In May 2013, the consumer magazine Which? performed an undercover investigation of the quality of advice given in a sample of 122 community pharmacies in the UK. The report found that unsatisfactory advice was given by pharmacy staff in 43% of visits.⁵ While this report has been widely criticised due to its small sample size,⁶ it may be indicative of a wider problem which may be improved by increased uptake of EBM. Which? also investigated the evidence for claims made for a variety of healthcare products, and has published a list of ten popular and widely available pharmacy products for which no good evidence of benefit exists. This includes well known brands such as Benylin and Covonia cough medicines, Bach’s Rescue Remedy, Bio-Oil, and Boots Cold and Flu Tablets.⁷

Reasons for the lack of EBM uptake

In the 2005 study by Burkiewicz and Zgarrick,⁴ 45% of all pharmacists cited lack of time as the main factor limiting their ability to practice EBM. In a community pharmacy setting, the proportion is likely to be even greater, given the fast-paced, unpredictable nature of the retail environment.⁴ Constant interruptions and juggling many tasks whilst maintaining an open, appointment-free approach to healthcare can lead to a lack of time available for the pharmacist to read and interpret clinical data.

Community pharmacies can be under-resourced to effectively practice EBM, while trusted medical information resources such as Micromedex and Medicines Complete may be too expensive for the average community pharmacy to feasibly access, and can be difficult to navigate in the community pharmacy environment. With the delivery of advanced clinical services such as Medicines Use Reviews – an initiative to improve medicines adherence in the UK by providing support to patients with long-term conditions who are taking multiple medicines⁸ – along with an ever-increasing dispensing workload, the pressures on a community pharmacist’s time are vast and many.⁹

The availability of new OTC products and the deregulation of prescription-only medicines can lead to an overwhelming amount of extra training and research for a community pharmacist, on top of their usual daily workload. At present, OTC training tends to take the form of industry-sponsored training packs aimed at enabling community pharmacy staff to sell new products. In my experience, these training packs tend not to address any shortcomings in clinical evidence or proof of benefit, but instead focus more on practical selling points. Whilst they may be adequate to allow pharmacy staff to safely sell a product OTC, they do not always include enough information to allow a pharmacist to make an unbiased, evidence-based assessment of a new product. Moreover, in Hanna and Hughes’ study, only 38% of community pharmacists agreed that they knew how to perform a literature review and critically appraise research papers.² This highlights a gap in the knowledge of community pharmacists and an important training need. Whilst critical appraisal is covered in pharmacy degree courses and pre-registration training, it may not be used often enough in everyday practice to allow community pharmacists to maintain and hone their skills sufficiently.

Patients appear more likely to rely on personal experience or anecdotal evidence than robust clinical trial evidence when choosing an OTC product, and seem on the whole ambivalent about the need for evidence of effectiveness.¹⁰ This, coupled with advertising and the policy in the retail environment that the ‘customer is always right’, means that patients may be unresponsive to messages about lack of evidence from the pharmacist. In an Australian qualitative study, pharmacists reported that advertisements for OTC medicines opposed their professional advice, leading to a sense of disempowerment.¹¹ In the face of consistent rejection of scientific, evidence-based advice, it may be understandable that many pharmacists give up attempting to convey such information.

Solutions

Somewhat alarmingly, Hanna and Hughes² found that only 23.9% of community pharmacists in their survey were familiar with the work of the Cochrane Collaboration, one of the world’s foremost independent organisations for the dissemination of information about the effects of healthcare interventions. Improving community pharmacists’ awareness of (and access to) reliable sources of medicines information is crucial to improving uptake of EBM in the sector. Pharmacists may not have the time or skills to interpret clinical trial data themselves, so need to have access to robust, concise resources from organisations skilled in the interpretation of evidence. Primary care guidelines such as the Clinical Knowledge Summaries provided by NICE (the National Institute for Health and Care Excellence) in the UK and the guidelines provided by Patient.co.uk can be helpful resources for dealing with minor ailments, but there is a lack of high-quality, independent guidelines for OTC medicines.

Greater collaboration between the pharmaceutical industry and accredited pharmacy training providers may be one solution. An independent review process similar to peer review, but tailored to OTC needs, could be implemented to ensure that any potential biases in industry-sponsored training packs for community pharmacy are reduced. The standardisation of such packs, and inclusion of information on clinical data and its limitations, may improve the ability of pharmacists to make evidence-based decisions.

Greater awareness and utilisation of medicines information services (see Figure 1) amongst community pharmacists may be helpful, as these provide a rapid and efficient evidence-based enquiry answering service, allowing community pharmacists to use their time to deliver other services. Staff in medicines information centres are specially trained in the retrieval, interpretation, and appraisal of evidence and can act as a go-between to interpret clinical trial data and apply it to a clinical situation.

There is a clear need for independent training on critical thinking and appraisal skills that is tailored specifically towards community pharmacists. The ability to disseminate complex safety and effectiveness data to patients is a valuable skill that the pharmacy profession could focus on. Questions remain about how best to close the gap between patients’ reliance on advertising and anecdotes and more reliable clinical trial evidence, and any future research in this area will be extremely valuable.

Selling honestly: a personal perspective

I worked as a community pharmacist for many years, and can identify with the use of patient feedback and personal use as the main means of informing OTC product selection. Bombardment with information about new products, along with the highly pressured and stressful job of managing a pharmacy day to day, can be so overwhelming that it can be virtually impossible to keep up with emerging evidence. It becomes easier to rely on more immediate, passive methods of differentiating between products than evidence appraisal.

After moving into a job in the medicines information field, I have improved my skills in finding, appraising, and communicating complex trial information. When undertaking locum shifts in community pharmacy, I have found that this in turn improves and informs my ability to advise OTC. Having more confidence to seek out and question evidence, as well as encouraging critical thinking and evidence communication, allows me to improve an engaged patient’s ability to make an informed choice. I have found patients to be variably receptive to this, with reactions ranging from gratitude, satisfaction, and engagement, through to impatience and, rarely, anger. For the most part, I have found that being honest about the lack of evidence for OTC products increases trust, as patients can see that I am not there primarily for commercial gain, but instead to provide them with good-quality health and medicines advice.

Conclusion

Community pharmacy has an inherent conflict of interest, given its situation as both a retail outlet and a professional healthcare service. Commercial interests may have traditionally outweighed the need for high-quality, evidence-based OTC advice, but a sea change is required to ensure the profession remains a respected part of the wider healthcare community. Other aspects of the healthcare system (and pharmacy) are adopting and implementing EBM, and there is an increased focus on the importance of clinical trial data in the health and popular media following the AllTrials petition (an initiative led by Ben Goldacre, and various other groups, which is calling for all past and present clinical trials to be registered and their results reported). This in turn is exposing the gap between reliable, robust evidence of benefit and how OTC products are currently being sold. Improving understanding of the importance of clinical trial data amongst community pharmacists will be a key step in converting pharmacy from a quack profession into what could more comfortably be considered ‘good pharma’.

References

1. @lecanardnoir 2013. ‘@bengoldacre the unspoken problem is that by any reasonable criteria, pharmacy is a quack trade. It pains me to say.’ Twitter; 2013 May 24 [cited 2013 Aug 19]. Available from: https://twitter.com/lecanardnoir/status/337872315666808832.

2. Hanna L, Hughes C. Pharmacists’ attitudes towards an evidence-based approach for over-the-counter medication. Int J Clin Pharm. 2012;34(1):63-71.

3. Davidson J, Valuck R, Moore G. Evidence-Based Medicine in the Pharmacy. Patient Safety and Quality Healthcare; 2006 [cited 2013 Aug 19]. Available from: http://www.psqh.com/marapr06/ebm.html

4. Burkiewicz J. Evidence-based practice by pharmacists: Utilization and barriers. Ann Pharmacother. 2005;39(7):1214-1219.

5. Can you trust your local pharmacy’s advice? London: Which.co.uk; 2013 May 20 [cited 2013 Aug 19]. Available from: http://www.which.co.uk/news/2013/05/can-you-trust-your-local-pharmacys-advice-319886/.

6. Gregory J. The Which? Scenarios: What would you have done? Chemist and Druggist; 2013 [cited 2013 Aug 19]. Available from: http://www.chemistanddruggist.co.uk/feature-content/-/article_display_list/15729377/the-which-scenarios-what-would-you-have-done.

7. 10 health products you don’t need. London: Which.co.uk; 2012 [cited 2013 Aug 19]. Available from: http://www.which.co.uk/home-and-garden/bathroom-and-personal-care/guides/10-health-products-you-dont-need/.

8. NHS Community Pharmacy Services – a summary. London: Pharmaceutical Services Negotiating Committee; 2013 Jul [Cited on 19/08/2013]. Available from: http://psnc.org.uk/wp-content/uploads/2013/08/CPCF-summary-July-2013.pdf.

9. Gregory J. Dispensing workload in England rockets 62 per cent over decade. Chemist and Druggist; 2013 [cited 2013 Aug 19] Available from: http://www.chemistanddruggist.co.uk/news-content/-/article_display_list/16053812/dispensing-workload-in-england-rockets-62-per-cent-over-decade.

10. Hanna L, Hughes C. Public’s views on making decisions about over-the-counter medication and their attitudes towards evidence of effectiveness: a cross-sectional questionnaire study. Patient Educ Couns. 2011;83(3):345-351.

11. Chaar B, Kwong K. Direct-to-consumer advertising: Australian pharmacists’ experiences with non-prescription medicines. Int J Pharm Pract. 2010;18(1):43-50.

12. ResourcePharm. Pharmacy Mnemonics: WWHAM, ASMETHOD, ENCORE, and SIT DOWN SIR. 4Pharm Ltd. [cited 2013 Aug 19]. Available from: http://www.resourcepharm.com/pre-reg-pharmacist/pharmacy-mnemonics.html.