I want to tell you about Mrs S. She’s a patient who has a significant drug burden and as time has progressed has found it harder to manage her regime. We’ve reviewed and rationalised, and what’s left is as simple a therapy as is possible without jeopardising her care. She’s cool with it all and wants to adhere but can’t as she finds it tricky to consistently remember exactly which medicine is taken when. Reminder charts have been useful but as another bit of paper, they’ve succumbed to the inherent risk of becoming inaccurate, lost or incomprehensible without anyone noticing until too late.

Unsurprisingly at this point the idea of a NOMAD was raised by a colleague. For those of you not in the pharmacy-know, NOMAD is one version of what are collectively termed “Multi-compartment Compliance Aids” or MCAs – these are those trays that people have their medicines popped into by a pharmacist, friend or relative such that each day of the week has morning, afternoon, tea-time and night-time medicines neatly separated. 

For Mrs S, it seemed like a good idea: none of her medicines were excluded from being in a MCA and she clearly needed something more to support her.  A call was put into her usual pharmacy to discuss, but was met by an almost instant refusal.  There was no capacity to do any more I was told. It was unsafe to accept another patient onto the system was the explanation. There was nothing more that could be done for Mrs S was the closing statement.

It’s not that often that I get so pissed off with my pharmacist colleagues that I bad-mouth them to my GPs, but I’ll admit to losing it over this phone call.  It’s not that I don’t understand the risks of these devices – as a locum, nothing in the world worries me more than arriving to find a note telling me there’s eight MCA to complete that day – but I’m angry that a patient who would likely benefit from one is being denied it because the system is already at capacity.  Is this position unfair of me? I think not for the following reasons:

1. Making ‘reasonable adjustments’ to dispensed medicines is a requirement of the Equality Act (EA) (previously Disability Discrimination Act) and is an essential part of the retail pharmacy contract.  To this end, all pharmacies get a monthly payment from the NHS to help them provide such adjustments (up to 6.6p for each item they dispense regardless whether the item requires ‘reasonable adjustment’).  Of course an argument exists whether a MCA is ‘reasonable’ in this case, but this wasn’t part of the pharmacy’s reasoning or conversation.  At the least the pharmacist was under obligation to assess the patient themselves or discuss alternate solutions with me.
2. Now more than ever pharmacy should be demonstrating its worth as the best support option for patients unable to take their prescribed medicines. You can term it the shiny new ‘medicines optimisation’ or call it good old-fashioned good pharmaceutical care, but if it’s not being done for those most at need why will I turn to the sector for help in the future? Why wouldn’t I just commission a more responsive nurse-led service?
3. The large multiples – mostly Boots – have pushed these devices as a free service for years, as a way of getting what they term ‘lock in’; that is, once a patient is hooked on a MCA they won’t take their medicines in any other way and therefore will be locked in to taking their prescriptions to Boots until the day they pass on.
4. I know that this store in particular, because of point 3) above, provides MCA to a chap on just two medicines (one once daily, one twice daily) who whilst seeming useless at taking these two drugs is quite able to run his own, successful, painting & decorating company: hardly a suitable candidate under EA?

I’ll admit early that I’m not the biggest fan of these devices, and after years providing a domiciliary medication review service you can count the number of MCA’s I’ve initiated on the fingers of one head.  But my experience suggests that the people that benefit are those like Mrs S – unintentionally non-adherent to their medicines, orientated in time and space, able to manipulate the packaging and capable of remembering that they need to take their medicines and whether they’ve already done so. Yet I’m now in a position whereby a suitable candidate is geared up for it but is being denied because the system is full of patients who either aren’t benefiting from them, who get them simply out of their own laziness, or because the pharmacy had a target to reach and have ‘sold’ them to unnecessarily straightforward patients.

I know there’s no formal funding for this service, I’ve previously spoken to the LPC at length about 7-day prescriptions and remuneration (the argument doesn’t wash for me– see point 3) and so I appreciate pharmacies are caught between a rock and a hard place. But ultimately Mrs S needs help and can’t get it from her usual pharmacy because they’ve put targets before service and maxed themselves out.

So my next steps? Easy – Mrs S has switched pharmacies to one that has capacity and will be locked in to another pharmacy for the foreseeable future. She’s doing well, reports no problems and despite a few teething problems getting prescriptions ready and redirected, it looks like it was the right solution for her.  It still leaves the issue with the near-by maxed-out pharmacy, and with an ever increasing population of complex elderly patients in the community, I can see them losing out time and again. 

So why the blog? Because I want pharmacists to think about their MCA service.  If you recognise your store in this scenario perhaps it’s time to re-assess your MCA patients:  do they really need it or are they’re a case in point of targets before care?

This is an impromptu blog: I’ve been meaning to do a few recently but haven’t managed it, but I wanted to share these thoughts before they drift away.  They’re not directly pharmacy related but have some lessons for us nonetheless.

We moved house a year ago to Yateley which although has a population leaning towards the older side, has some awesome schools for Little’un.  After moving we went round the seven other properties in our close and introduced ourselves, but aimed to get everyone round to us for a BBQ once we’d settled. The weather never let us, so we said that New Year drinks would be good, but then chicken pox got in the way. So today we finally had the neighbours round for drinks and nibbles; eight people (youngest >60) from five of the seven households showed up and a couple of things really struck me that I want to share.

• They didn’t eat much, despite the huge spread, but after 45 minutes I had to pop to the shop to buy much more wine
• The oldest frail guy, who lives alone, was the wittiest
• The dour Scottish chap who talks little outside had the best stories
• Three households had at least one person who was effectively houseboud through illness or age, and their lives run on the help from unpaid carers (mostly family)
• When one chap starts drawing his pension next year he automatically loses the carers allowance he currently recieves: he reckons they’ll be financially worse off from this despite nothing in their life actually changing apart from the date on the calendar

But the most stricking thing? Social isolation is a killer for these people.  Few of them go out much, and when they do it’s not far and locally there’s no longer much for them to access despite the population demographic.  What really hammered this home was that two of the households had not even spoken to each other properly in the seven years they’d lived on the same 200 metre strip of road.

So what’s this got to do with pharmacy? Well it wasn’t easy hiding my profession and so I’m now versed on all their ailments and therapies, and this is key: they all get their medicines delivered from the local pharmacy and none of them have spoken to a pharmacist since this service was started. 

It’s known that these patients may have higher needs and there’s already ideas around how pharmacists can support their care; what I’d ask is that if you’re a pharmacist who provides a medicines delivery service to housebound patients, please reflect on how long it’s been since you last saw these people or even simply spoke to them (and remember from above that they are people, not just ‘patients’); maybe it’s time to pick up the phone?

Pharmacy in the UK, along with much else, is in a period of serious change, to some extent serious jeopardy and of course serious seriousness, and so it was with immense relief that I read Mr Dispenser’s first – and with luck, not last – entertaining book “Pills, Thrills and Methadone Spills”.   An eclectic compilation of blogs, stories and witticisms, it jogged me to remember that no matter how serious things are in the world of pharmacy, it’s a world that will always be able to put a smile on your face.

Personally I wouldn’t know where to start in writing a book, but if a serious drinking session disrupted my thought processes such that I made an attempt, I can’t imagine how I’d make pharmacy  the theme.   As such I had little idea of what to expect; in the back of my mind I did have memories of the excellent read by Drug Monkey ready to compare it to, but I need not have worried. 

I’ve followed Mr Dispenser on twitter pretty much since I joined it eighteen months ago and thought I’d have seen most of the book’s content through this, but thankfully I was wrong.  A wonderfully informal and original piece of work, if somewhat a little unstructured in parts,  I read it in one go, not out of a need to tick another job off the list, but because even at 1am when the Mrs was seriously pissed off I still had the bedside light on, it was compellingly difficult to stop.   Immensely reflective of my past experiences and gloriously enlightening on the experiences of others, funny in most places and sincere in parts, it’s a genuinely worthwhile read.  

The New Year will invariably make people reflect on their previous twelve months, and as usual, hearing “If I only knew then, what I know now” won’t be uncommon.  Similarly if I’d only read this book before I qualified I’d have been so much better prepared for the wonderful world of pharmacy.  I would have never ruined my favourite cream and pink striped tie had I been pre-warned that checking the lid is secure before shaking was the most critical part of antibiotic reconstitution.  If I’d only read the patient attempts to pronounce medicine names I wouldn’t have had my own infamous “ferocious sulphate” incident.   And although I read @weeneldo’s account of his pre-reg and wept with laughter, I do wonder that had I read it before qualification whether I’d have switched to another course… 

But that’s not to say this book is only suitable for students – far from it.  I almost wept with relief after reading the ‘Locums Deserve Respect’ section: here was someone who understood my woes, my fears, my wishes.  And the wise words within Candy Sartan’s genius “Badges” should now be the theme-tune for all pharmacists, though I do worry which of her ‘male pharmacist’ breeds I fit in.  On the serious(-ish) side there’s also the excellent contribution from @OptForOptimism – even after a decade of being a pharmacist it was good to be reminded how we, and our services, may look to patients .

So in these austere times do I recommend that you spend your hard-earned pounds on this book? Yes I do, regardless of whether you’re in pharmacy, planning to join it, come in to contact with it regularly, or have no idea what it actually entails.  You’ll love the ‘Pharmacy Films’, laugh at our Gangster similarities, be amazed at the lengths we go to when supporting and helping our patients, and come away with the feeling that whilst we sometimes get  unfair flack when trying to keep people well with their medicines, we’re also always able to see the funny side of it all.

The e-book is available for download from Amazon and I’m happy to report that 5% of sales will be donated to Pharmacists Support a charity that offers a helping hand to pharmacy colleagues who find themselves in difficult circumstances.  There really is no excuse not to buy a copy.

The end is nigh (of 2012) so I thought I’d get in early with some pharmacy predictions for 2013, and given how much uncertainty the NHS will be in from April I’m expecting to be as good as the Mayans in getting this right. 

Starting from April the biggest changes will obviously affect our colleagues currently in primary care: the lucky ones will end up being part of a Commissioning Support Unit (CSU), the really lucky ones will be in a Clinical Commissioning Group (CCG). Many won’t be lucky and there’s a real risk that some great talent that may be lost from pharmacy altogether: at a certain level in PCT-land you’re not clinical enough to keep your banding in a hospital, and you’re earning too much to go straight into retail.  Pharma is one option, but they’re not a safe bet if your mortgage depends on it.

For the lucky ones their work will be dependent on how focussed and forward thinking their CCGs are: there are some real opportunities to make a difference to patients and their medicines, but I fear that most of their work in 2013 will be nickel & diming.

Sticking with the NHS, let’s consider our hospital colleagues. Again money dominates: acute trust funding, FT or not, is going to get a kicking especially when CCGs try to squeeze tariffs or pull activity via referral reduction or re-commissioning work into the community. In this instance, retention will be about specialisation – focus on a speciality disease area, be super clinical on it and prove you make a difference; my money’ll be on cardiovascular and endocrine.  Other opportunities will exist though for those in trusts who hold vertically integrated community services….

Community services pharmacy is, I think, where the exciting stuff will start to happen: whether CFT, FT or independently based these services are being seen as the answer (wrongly) to the NHS’s ‘troubles’ and will need to really innovate to deliver outcomes on restricted budgets.  Where better to show the value of pharmacists? If Medicines Optimisation has a natural home then this will be it.  Hand in hand with this are our colleagues in mental health services: the new Health Secretary’s focus on dementia will play well here as funding will follow – again another good place for medicines optimisation to thrive.

Retail pharmacy: my roots and love in all of pharmacy.  I think 2013 will be a holding year for retail with little changing, but I suspect that it’ll be the calm before the storm of self-selection and remote supervision in 2014.  The difficulty will come from a lack of proven outcomes for what is done already, a squeezed budget from central NHS coffers and a lack of a cohesive plan for more commissioned clinical services.  An influx of pharmacists from PCT-land may also add pressure to the workforce, and staff may find (as locums are now) that remuneration and T&Cs are adversely affected.  And if that’s not bad enough you’ll all still be selling homeopathy.

Academia: I have no idea! You’ll have to speak to Messer’s Bush and Cox (no seriously, they’re called that, and they aren’t a late-night Channel 5 comedy duo: go follow @josephbush and @drarcox  to find out)

Industry – err. Dunno?!

Overall? 

There will be opportunities to do some innovative things in 2012 but it’ll be small-scale, patchy and uncoordinated; if experienced pharmacists have the balls then they’ll start up their own provider company (no CQC registration needed remember) and approach CCGs with ideas on what they can do to makes medicines count for patients.

In retail, the opportunities will be outside the NHS and with Local Authorities, using their key geographical positions, extended opening hours and enviable reach and footfall to place themselves at the forefront of what’s left of public health. But if anything, pharmacists are the most business-minded of healthcare professionals and in this current climate that is a huge strength.

But then again the best laid plans of mice and men and all that…

Roll on the New Year…

This month I joined a secret pharmacy club.  A pharmacy club is so secret I can’t tell you its name let alone its rules.

During my initiation conversation the topic got onto the concept of branding and the benefits it brings. I’m not talking red-hot bits of metal, but the shiny boxes and snappy logos that pharmacists are well versed in: explaining to patients that ibuprofen in a 16p pack is the same quality as the stuff in a £3 box of Nurofen and all that, though if people say they’re happy with the cheaper one it appears that when you’re not looking they’re snapping up the expensive stuff.

This conversation got me thinking why is branding so influential, and importantly, what is the brand power of ‘pharmacists’?

If we take the advertising wizard David Ogilvy‘s definition of a brand, it’s

The intangible sum of a product’s attributes: its name, packaging, and price, its history, its reputation, and the way it’s advertised.

So if we put aside physical attributes – name, packaging and price – and bluntly try to apply the rest of this definition to a profession, what do you get?  Ask this about doctors and the public ‘brand’ them as the most skilled and focused of professionals and consistently rate them highly on trust.

In healthcare, trustworthiness is arguably the most important perception we can ask for, however whether this continues to apply to doctors after 2013 when they become the front of NHS cuts and service closures is not certain.  Throw into the mix their industrial action over their pensions and an ineffective mixed stance on the NHS Act, then unfairly or not could this see the start of full-scale public distrust of doctors and destruction of their ‘brand’?

Personally I doubt it, but some reputational damage is probably unavoidable and so it begs the question who will become the new most trusted profession in healthcare – and can pharmacists step in here?

It’s hardly surprising that our largest retail pharmacy chain currently uses trust as its strap-line, but is this the pharmacist’s ‘brand’ or just corporate marketing?  A true brand requires many things, but firstly it requires a unified approach to how it’s presented.   Research suggests that pharmacists perceived as an ‘expert’ have improved patient satisfaction and loyalty, but it appears we have a long way to go before we’re fully there and can push things forward.  I’ve blogged before that pharmacy needs to be more unified than it currently is, and I wonder whether this fragmentation is a reason for the current mixed perception of pharmacists. 

So do we need to reconsider how we advertise our ‘brand’?  Or should we instead ask whether our profession exhibits ‘expertise’ to our varied consumers each day?

In fact should we start with each pharmacist asking that same question of themselves?  

*First posted as a guest blog via the excellent @MrDispenser*

I’m taking advantage of being a guest blogger to do something that doesn’t always come naturally, and that’s to admit that I’m wrong. Actually more than that, I’m confessing that I’ve been exactly wrong for more than the last year.

A couple of weeks back I was at an intimate strokey-beard meeting on commissioning with various representatives from the DH, NHS Commissioning Board and such, and it was there I realised just how wrong I’ve been.  The meeting was tabled as a discussion on the place in the new NHS of Local Professional Networks – designed in principle to be pools of subject experts that could be pulled upon by the NHS CB for input into the commissioning process – but it transpired that for various reasons they no longer exist in the new NHS framework:  a three-in-the-morning decision if ever there was one.  This, and the recent news that pharmacy commissioning representation in the Local Area Teams of the same Board is absent, made me realise my folly.

Because right now, who will commissioners go to for pharmaceutical advice?  More importantly, who will champion the role of pharmacists so that commissioners even know that they are a viable option?  Some may seek support from their emerging CSU, others will house some expertise in their CCG. But how many of them fully understand the breadth of pharmacist’s potential and the services that can be offered by pharmacists, and more so in the easily accessible sites that are retail pharmacies? 

Perhaps some of you will suggest our governing body the GPhC. Well personally I’m not so sure, after they responded to my P-medicine self-selection query.  So what about Pharmacy Voice? The PSNC perhaps? The AIMp? The legendary Chemist and Druggist Senate? The NPA then? The CCA? The PDA? The UKPCA? No? OK, surely the PCPA? The GHP?  The PPRT?

And herein lays my concern: there are too many organisations that ‘represent’ parts of pharmacy, and too few that represent ‘pharmacists’.

In 2010 I decided that the Royal Pharmaceutical Society wasn’t worth my money, mainly after hearing a local (then) RPSGB branch member say that the cleaving of professional and regulatory functions wouldn’t actually change anything other than their logo.  But now in late 2012 I know that was the wrong decision based on someone else’s flawed attitude.

From my experience so far the RPS has changed. It is not always the speediest or responsive of organisations (their statement on 3-for-2 offers was praise-worthy, but I think we’re still waiting to hear their position on salbutamol by PGD?) and their coverage doesn’t extend fully to all sectors including my own speciality in community services, but that’s down to individual members, and the pharmacy ‘representatives’ above, to influence.  But what they do deliver on is media engagement, and this is important for three reasons.

I thought that my first blog-proper would be a pending guest post for the excellent Mr Dispenser, but an e-mail today from the General Pharmaceutical committee (GPhC) has forced my hand.

Some of you may have seen my Twitter rant when I first heard that self-selection of Pharmacy-only medicines was to be allowed as part of the GPhC’s overhaul of the standards for registered pharmacies.  After reading the detail of their consultation response report, I couldn’t understand why the decision was made, so I asked them for clarification via an e-mail.

Today’s response e-mail from them contained a word document embedded with seventeen PDFs most of which I’ve uploaded for your reading pleasure (all well worth a read: there are some gems in there).

Firstly, a sincere doff of the hat to the GPhC for responding swiftly and in full: this level of transparency is both welcome and refreshing following RPSGB days. 

However, I’m still left unconvinced by the decision on self-selection and fail to see what the benefits to patients will be, and what the evidence or risk/benefit balance is to support the move.

The bottom-line is that the GPhC wants to be a light touch regulator, allowing pharmacies to manage themselves within a framework of professional standards that focuses on patient safety and outcomes, so they can focus their regulatory efforts on risky practices or services.  So, given there isn’t a law actually prohibiting self-selection of P-medicines, the view is that maintaining the existing RPSGB prohibition would be an inconsistent hands-on regulatory approach.  With my community services hat on I can see this is exceptionally CQC-esq: I can only hope they’ve learnt lessons from such existing regulators especially as they recognise this approach runs the risk of losing confidence (ref 650), a theme that has already been raised on this particular issue.

So can I see it from their perspective? Well, yes I can: they want to be hands-off, the law doesn’t prohibit self-selection, so they won’t get involved in restricting it.  It also appears some justification is to match internet pharmacies, where the argument is that consumers are free to browse P-medicines online so why not in store? To me this is a fragile comparison, and given previous problems exposed with this sector I don’t think it’s the best benchmark, and against the context of their approach and the detail of the standards, I don’t think it quite fits and may cause unintended conflict.

The GPhC go on to make continued references to their move away from a prescriptive rules based approach, to an outcome-focused set of standards which sit under four principles and include examples of how pharmacies can evidence compliance.  These standards are mandatory, and the pharmacy owner or superintendent “must satisfy inspectors how they have met the outcomes.”

Self-selection sits predominantly under Principle 4, Standard 4.4 which can be paraphrased as ‘the health, safety and wellbeing of patients and the public are safeguarded as medicines are stored securely and are safeguarded from unauthorised access’ .  The GPhC suggest that owners and superintendents can evidence this by “[considering] where medicines are displayed, including whether medicines should be available for self selection or not”.

At this point I have two worries. Firstly, copying CQC methodology, ‘considering’ self-selection is not a patient-safety focussed outcome, it’s a ticked-box action, and if it’s the standard that is meant to also be an outcome, then this will be hard to demonstrate. Secondly, superintendent implementation of self-selection may not be compatible with one of the GPhC’s other aims of encouraging “pharmacists to use their professional judgement” let alone principle two of the GPhC’s standards of conduct, ethics and performance.  Professionally I feel it is inappropriate to allow self-selection of codeine based products, but if my superintendent has implemented self-selection what are my options as responsible pharmacist?  Throw in 3-for-2 promotions and the GPhC’s assertion that medicines are ‘not normal items of commerce’ doesn’t stand up to scrutiny.

The GPhC then go on to list the five ‘for’ arguments, again which seem fragile:

1. “Should be safe to rely on the professional judgement of pharmacists who decide what medicines should be on display”.
   We know this decision can only be made by owners or superintendents so that a tiny proportion of registered pharmacists will be dictating how otehr retail pharmacists will practice.
2. “Cost and time benefit”
   To whom? What is the benefit? What evidence is there to support this?
3. “Reflects that one size doesn’t fit all”
   Huh?!
4. “Supports informed decision making”
   Picking something up off a shelf and having someone run through WHAMM questions is not ‘informed decision making’: talking to someone about options based on the symptoms you present is. 
5. “Encourages collaboration and dialogue”
   Well doesn’t all of pharmacy, including the current arrangements prohibiting self-selection? If not, we’re probably already screwed as a profession. 

But in the end does it matter? I dare say probably not.

The position of the GPhC will not change and given that only 298 pharmacists responded to this consultation apathy to change remains abound in the majority of the profession.

I still believe this move is not in the best interests of patients or the professionals working in retail pharmacy, and safeguards should be introduced to allow the responsible pharmacist to remove self-selection items if they think it is professionally right to do so.  I’m sure we can all envisage how wrong this could go, so if given the opportunity I will be responding to any future consultation on the necessary GPhC draft compliance guidance: I hope other pharmacists will consider the options and comment below – and then go on to respond to any consultation.