A tweet earlier today got my blog reflex twitching over retail pharmacy, and the difficult balance it has providing quality patient care against  generating sufficient profit (or breaking even) in a pressured economy.  Added to this was the recent PJ article on the new RPS multi-compartment compliance aid guidance which in the opening column mentioned the business pressure that’s led to an increase in their use.

I’ve blogged before about such devices (and delusionally imagine the RPS read it before writing their guidance) and I’ve obviously no problems with business turning a profit, but I remain worried that the professionals working in this sector may be forced to lose its way over time; the PDA are usually ludicrously over-dramatic in their reporting, but the ‘perfect storm’ scenario isn’t an unreasonable extrapolation.

But as I went to blog proper about this I was reminded of something I wrote three years ago that was published in the PJ, and thought that I would instead post that.

I know it won’t be to everyone’s tastes, and I know a whole bunch of decent pharmacists on Twitter that this definitely does not apply to, but still felt it was worth being dusted off: we’ve moved on from some points, but some of it still chimes relevance with the current situation.

Who knows – maybe in another three years I’ll post it once again so we can see how much further we’ve all come. See you in 2016?

Perhaps “retail pharmacy” is a better descriptor than community pharmacy.  By James Andrews

Fri, 18/06/2010.  The Pharmaceutical Journal2010;284:604

I agree with the points of the Broad spectrum by Blenkinsopp and Bond entitled “Another reason for telling colleagues about pharmacy services that work” (PJ, 22 May 2010, p500), but there is one aspect of the BMJ article they refer to that remains unaddressed.

Richardson and Pollock concluded that recent change has “allowed the dominance of large corporate providers, which has implications for service provision that are not well understood in the UK, and which could undermine attempts at expanding pharmacists’ professional role”. I believe this is a key aspect of practice that deserves examination.

Perhaps community pharmacy may no longer be seen by others as a profession, and that the term itself may be misleading. What is not questioned though is the professionalism of the individuals working in this sector, of which I am one.

I see constant examples of pharmacists providing quality patient care in demanding and stressful working conditions, and the non-pharmacists I work with in primary care regard them as hard-working experts in their field. However, there remains the intimation that changes to practice are doing our professional image no good.

The many definitions of  “profession” tend to describe a group of qualified autonomous individuals, trusted to apply their responsibility and expertise to the benefit of others. However, in a dispensary operating for a large multiple, today’s focus appears to be on corporate financial benefit rather than the benefit of others.

Previously, I have described the pressure I was subjected to by an area manager into performing medicines use reviews outside corporate procedure and legislation (PJ, 27 March 2010, p315). This was a partial description written in conjunction with a grievance case I raised. In reality, the conversation was wider ranging and more personally focused than I reported.

Continuing PJ correspondence suggests this is not an exceptional circumstance, with the Pharmacists’ Defence Association reporting that pharmacists are under such pressure to deliver results they resort to fraudulent behaviour.

A brief review of my employer’s online pharmacist forum reveals descriptions of “bumping up” figures by claiming MUR intervention payments for confirming a patient’s international normalised ratio level before dispensing warfarin even when no intervention follows.

Other pharmacists on the forum describe having to allow disturbances while conducting MURs so they can check prescriptions or answer queries without fear of under-achieving company-dictated customer satisfaction and waiting time targets.

It is right to aspire to give patients a quality service and I have no discomfort with profitability within healthcare services, but there is only so far a professional should take this. None of these scenarios describes a profession and, when pharmacists feel they have no option but to forgo their autonomy and professionalism to chase targets contrary to their code of ethics, we must all ask why this is the case.

The responsible pharmacist legislation should empower us all to do something about the demise of our autonomy but, in practice, this does not appear to be happening.

We have taken on responsibility previously held only by well remunerated superintendent pharmacists, but have received no recognition of this from our employers, apart from the expectation we use the two-hour allowable absence for rest breaks, during which we must remain contactable to allow continued trading in defiance of safe practice and European legislation.

Challenges to this disregard are heavily resisted by employers so we are left in a position of ultimate responsibility with no employer acknowledgement within our terms and conditions.

The case of Elizabeth Lee (PJ, 11 April 2009, p401) highlights how corporate employers might use the responsible pharmacist Regulations to avoid culpability for an error regardless of the underlying situation of staffing level, pressure to achieve targets and rest breaks, over which the individual pharmacist involved has little or no control.

In practice, it now seems difficult for a community pharmacist working for a large multiple to practise in a way that allows the autonomy expected within a profession, and this situation is likely to become more difficult in companies that delegate accountability for pharmacy clinical governance to non-pharmacist managers as a result of restructure.

Based on the Royal Pharmaceutical Society description, this means that, for me, the safe and clinically effective running of the pharmacy will rest with a non-pharmacist store manager and non-pharmacist area manager, either of whom, as a non-pharmacist, may put targets and profit before safe practice.

It is difficult to reconcile this move with the ethos of the responsible pharmacist legislation, adding justification to the European Court of Justice warning that “operation of a pharmacy by a non-pharmacist may represent a risk to public health” (PJ, 23 May 2009, p604).

The job of supporting pharmacists with professional issues now falls to the new professional body. For a body committed to responding actively to our needs, its silence on the pages of the PJ regarding pressures and stress over MUR targets is disappointing but not surprising given that it is likely to have a sizeable proportion of its future funding from joining fees paid by large multiples.

The suggestion of Richardson and Pollock that commercial interests may undermine the professional role of pharmacists seems timely, and the historical lack of drive to gather and publicise evidence to the contrary highlighted by Blenkinsopp and Bond has left community pharmacy in a difficult and indefensible position.

At this fresh time in the political world, a strong pharmacy voice could make a massive difference to the professional standing of all pharmacy sectors by highlighting their ability to deliver quality patient care individually and as an integrated whole, but current isolation and a lack of cohesion will remain if the needs of patients and pharmacists are overlooked by our leaders for corporate benefit.

The new health secretary’s announcement that changes to the NHS must be evidence based and supported by GP commissioners may make integration of community pharmacy services into real patient care pathways more difficult, with a danger that our only function becomes medicines supply.

The description of the prescription factories of the high street and large out-of-town pharmacies miles from the nearest house as “community” pharmacies appears a misnomer at a time when the NHS is rightly moving more services closer to patients. In practice, “community” services are delivered by multidisciplinary teams providing care directly to patients within an integrated care pathway.

These pathways should formally include community pharmacy, but do not. Next time you are at work, consult your manager or corporate documentation to see who they think benefits from your application of expertise. If the answer is customers rather than patients, then perhaps “retail pharmacy” is the better descriptor.

Ladies and gentlemen!  It’s a genuine pleasure to be hosting a blog from the brilliant & knowledgeable @cathrynjbrown…. 

Safe supply of pharmacy medicines

My thoughts on this have changed, it took a while, but I have been convinced that a total prohibition on open display is not the way to ensure safe supply of pharmacy medicines in the 21^st century.

A few things; this removal of the proscription on having pharmacy medicines on open display is part of a whole new suite of standards for pharmacy premises. They are a move away from strict rules which can act as a brake to innovation. The evidence on medicines on open supply is slight, but a total prohibition is not going to help the collection of such evidence. Some people are concerned about the nature of these standards, which are broad, but as professionals we should be able to work within grey areas.

The standard itself, and indeed the whole of principle 4, highlight the importance of treating medicines as special and not just ordinary items of commerce.  And none of these standards remove the necessity for pharmacy medicines to be sold or supplied under the supervision of a pharmacist.

4.3 Medicines and medical devices are:

• obtained from a reputable source
• safe and fit for purpose
• stored securely
• safeguarded from unauthorised access
• supplied to the patient safely
• disposed of safely and securely

We are in an internet age, for good or ill, and as such patients and customers have access to massive amounts of information about medicines and medical conditions compared with the past. They also have easy access to pharmacy medicines there; both from regulated and unregulated websites (don’t get me started…). Why then, once they come into a pharmacy do we treat them as children and not allow them to touch the box until we’ve decided it’s right for them? When I’ve spoken with members of the public about this, they are evenly split; with younger people wanting to make their own choices, versus older people who want to rely more on the judgement of a professional.

Some pharmacists are concerned about open display of drugs of abuse, I am concerned too, but hope that we can rely on the judgement of pharmacy superintendents, who are our fellow professionals, to store and display these safely such that members of the public won’t be harmed. I think that early adopters of any change will be closely monitored, both by the GPhC and by the pharmacy media to see that no harm comes to any patients who are able to choose their own medicines.

People are concerned about the quality of interaction between a patient who might have made a choice to buy something, and the pharmacist or staff member at the till. I know that the Which? report didn’t give us a shining review, but I believe we can train our staff such that they are able to help patients get the right treatment or referral. We also need to trust our staff to be able to do the right thing by our patients, and if we don’t feel able to do that, are we letting both our colleagues and patients down? If the presence of a physical barrier between a patient and a medicine is the only thing keeping them safe, I think we have more things to worry about than just where items are displayed.

This is most likely to work safely and effectively in pharmacies where the only tills are in the pharmacy area, or where every member of the team is trained as a medicines counter assistant or to a higher level. As such supermarkets are unlikely to be early adopters of this, pharmacy is only a small part of their business and the capital investment required is likely to put them off. Also, only small areas of supermarkets are registered, and the confusion around which tills can be used would not lead to good customer experiences. The same would apply in a lot of larger pharmacy premises, unless the areas are very proactively staffed.

A few final thoughts; yes, patients feel like it’s theirs once it’s in their hand, but we have to take it off them to scan it through the till anyway. If they refuse to give it to us, and plan on leaving the shop with it, that’s shoplifting and there are rules against that sort of thing. Yes, some patients can be aggressive, but we don’t have to serve everybody, if you are unhappy with a patient’s behaviour, ask them to leave, or call the police. Yes, patients lie, but they always have and will. Possibly beginning to treat them like adults when they are managing their own symptoms might start to reduce this.

I have worked in pharmacies where this could work and pharmacies where it definitely wouldn’t. My hope is that this leads to better interactions between patients and pharmacy staff, and hopefully more visibility of pharmacists.

Two tweets have finally spurred me into writing a blog; every week I think about a subject I want to talk about, and every week something gets in my way of doing it (usually work/beer).  The tweets in question came first from @TheMMP1, the second from @EPSPharmacist (both of whom I found to be thoroughly nice blokes at the RPS & GPhC’s Which? event): the first got me thinking about the future of retail then the second had me daydreaming whilst parked up on the M3 that if I were the one true God of Pharmacy and felt it was time to start it all afresh – which I get the impression it probably is – what would I want it to look like at the finish…

And aptaim smelled the sweet savour; and aptaim said in His heart: ‘I will not again curse the ground any more for pharmacy’s sake; for the imagination of pharmacy’s heart is evil from its youth; neither will I again smite any more every thing living, as I have done. While pharmacy remaineth, prescriptions and dispensing, and counselling and services, and medicines and appliances, and 100-hour premises shall not cease…

On the first day I will create a retail pharmacy from which patients will mostly get public health advice and a fully running minor ailment scheme from.  They’ll also get regular ongoing management of long term conditions heavily based around adherence to therapy, including support with newly prescribed medicines either from GP or hospital, made easier with access to the patient’s SCR.  Funding will be about half from joint health and social care budgets directed by the health and wellbeing boards, the rest from prescription volume. The pharmacists won’t be prescribers, but the medicines on sale will all be strictly evidence based and either GSL or a new pharmacist-only category of medicines that require an initial consultation and regular checks for ongoing supply: think oral contraceptives.

On the second day I will create GP practices that’ll have pharmacists and technicians in the background managing the governance, safety and clinical effectiveness of the prescribing.  Advising, supporting the prescribers, both doctor and nurse, and giving specific training as needed.  They’d mostly be employees of the CCG, paid for from running costs not budget top-slices, and they’d be deployed to practices as determined by risk and need.  That said, some practice will think to employ their own from LES monies to get the service they want.

On the third day, hospitals will be built where patients will see specialist clinical pharmacists, all prescribers, able to support their medicines taking from admission to discharge.  They’d be specifically responsible for ensuring accurate medicines information is passed on to the patient’s GP practice, and the retail pharmacy nominated by the patient for their EPS.  They’ll work alongside clinical leads, ensuring evidence based practice is applied in a way that suits the patient so that they can self-administer at all times possible on the wards, and be able to take their medicines without problem when they get home.  If they think there will be a problem, they’ll know who to call in the community to make sure the patient is well looked after post-discharge.

On the fourth day, I will command that community service providers will all have their own pharmacists and technicians, working between the primary and secondary care interfaces to ensure safe and appropriate use of medicines.  They will provide direct patient care on discharge, ensuring medicines are reconciled and appropriate, and manage issues directly with their GP practice, hospital and retail colleagues as necessary. Some may be prescribers, but it’s unlikely – and only where there’s a clear need, such as in mental health trusts or services.  They will also be responsible for the ongoing safe and secure use of medicines in those services without direct pharmacist contact – urgent treatment centres, and children’s or community nursing for example.

And on the fifth day I will see to it that supporting all of these areas will be academic pharmacists, continuing to ensure a sound evidence base to future developments, and support the decommissioning of services that are not delivering the expected patient outcomes.

Leaving two days, which isn’t too bad I think.  So what have I forgotten?

CSUs (for as long as they survive)? Sure we’ll find one pharmacist, maybe with a technician, here working on behalf of multiple CCGs spanning various geographies to ensure consistent commissioning of specialist medicines and management of new medicines as needed.

Area teams? Here I’m less convinced, certainly from a ‘pharmacy’ perspective, but this is more because of the shifting remits and structures. I was initially demanding that the structures have a pharmacist, but now I’m not convinced: what can they deliver that those listed above couldn’t?

Social care? There’s a definite need, but the sector is so closely matched to community services they’d be daft not to host a joint post where geography allows.

You may have also noticed I’ve not once used the word optimisation. That’s because all of these scenarios should deliver this without us needing to use the term: if it’s not delivering good patient outcomes from medicines then it needs to be decommissioned, period.  I’m fed up of getting hung up on terminology.

And aptaim said, “Let there be pharmacy,” and there was pharmacy. And aptaim saw that the pharmacy was good.

Of course, it’ll be when I hand it over to you mere mortals that it’ll fall apart again, won’t it?

Over the last two days I’ve had Rick Astley going round and round in my head (you’re welcome), but also going round and round on my timeline has been a discussion on whether ‘medicines optimisation’ is ‘medicines management’ after a haircut, shave and with a nicer tie on.  140 characters hasn’t been enough to effectively explain why I don’t think that’s the case, so this blog is my attempt to say why I think medicines optimisation is not just a rebranding exercise.

I was struggling where to start this blog until this Thursday, when I had a practice visit by the currently PCT, but soon-to-be-CSU, pharmacist. I’ve got plenty of time for this pharmacist, certainly compared to their colleagues, and it’s always nice to have a chat and catch up.  Towards the end of our meeting they came to the last item on what turned out to be their ‘must discuss’ list from the boss, which was a copy of a recalled prescription from NHSBSA. The item was a ‘specials’ cream prescribed to Mr R: a mash-up of Betnovate, coal tar and salicylic acid, used in this case for psoriasis, a 200g pot of which was costing me a grand total of £447.

Now whether you live and breathe healthcare or not, you can’t have failed to notice that the NHS is a little stretched for resource, and let’s face it, a cream coming in at nearly 3.5 times the price of silver seems somewhat extravagant. But to me, it’s right here that the difference between medicines management and optimisation is clear, and through the power of alternate history I will try to explain all…

It is the time of Medicines Management: the pressure to cut costs from the drugs budget under the banner of QIPP is unrelenting even though as a CCG we’re already £400,000 under-spent despite two rounds of ‘efficiency savings’ being removed from the budget.  The PCT pharmacist asks what can be done about the cream: it’s clear that it’s not deemed acceptable and that suitable cheaper alternatives must be sought.  Betnovate on its own, with separate Cocois is suggested and the new GMC guideline on prescribing unlicensed medicines is wheeled out to drive the point home.  This is relayed to the prescriber who feels he has no option but to ‘trial’ the new regime with the patient. The PCT pharmacist returns to base safe in the knowledge that the special has been managed out of the system and the cost contained…

But consider also…

It is the time of Medicines Optimisation: the pressure to cut costs from the drugs budget under the banner of QIPP is unrelenting even though as a CCG we’re already £400,000 under-spent despite two rounds of ‘efficiency savings’ being removed from the budget.  The PCT pharmacist asks what can be done about the cream: it’s clear that it’s not deemed acceptable and that suitable cheaper alternatives must be sought.  We pull up Mr R’s medical record and look to see what’s going on.  The cream was initiated in 2011 by the dermatologist at the local acute after a series of attempts using other preparations, guided by NICE, failed to control the plaques on this 71 year old’s trunk and lower limbs. His next step will be oral methotrexate but in numerous clinic letters the consultant says the patient is adamant he’s not started this medication, and goes on to note that since initiation of the special cream his plaques have subsided to two small patches the size of a 50 pence piece so we can probably avoid the cytotoxics. Whilst Mr R uses an emollient each day, he has reduced his application of the specials cream so that 200g lasts about three months.  His personal circumstances are also reviewed, including his reducing mobility and dexterity.  Realising that for Mr R, what matters is keeping his plaques under control as easily as possible so that he isn’t forced onto methotrexate, the decision is taken that despite the high cost and unlicensed status, the specials cream is the right medicine for him and so far is proven to deliver the outcome we all want.  A note is added to his record that it will be prudent to discuss the risks associated with long term steroid application and consider a switch in the choice of emollient, and the PCT pharmacist agrees to relay back to the CSU that this patient’s therapy has been optimised to achieve an appropriate outcome.

What I didn’t speculate on in my alternate history is what would’ve happened to Mr R had the change in his therapy been forced under medicines management. Would he have adhered to the new medicine regime, would his plaques return and would he feel pressured into starting methotrexate?  I don’t know and that’s why I didn’t speculate, but it’s not hard to imagine that some of that would apply.

So is medicines optimisation the shiny new version of medicines management? No, I really don’t think so, though I admit that’s not always been the case.  It is different in my mind, but perhaps that’s the problem – every other bugger’s going to have a different opinion because although the term has been formally around since 2010 no-one official has come up with a decent, acceptable definition. How can anyone get behind something that’s taken two years to define? How can a profession coherently apply themselves to something that’s seemingly insubstantial?

For me that’s the prime issue in all of this – let’s stop going round and round on whether it’s different or not, but let’s, all of us, make sure it is different.

And for the record, one of those alternate histories is a true reflection of last Thursday. I’ll leave you to decide which you think it is…