evidence

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!

 

evidence

 

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.

table1

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.

figure1

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.

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seconds

PTMS2

It’s that difficult second album time for the peerless Mr Dispenser.

It’s been nearly a year since I was asked to review his first book and a lot has changed since then.  I’ve got older while it seems pre-reg’s have got younger, and the category M pot has become negatively correlated to pharmacy work-targets.  How could this book keep up with all this, did it need to, and most importantly would it make me laugh so hard that it hurt for a day afterwards?

You see, after the success of his first book it’s wouldn’t be enough for ‘Techs, Drugs and Birth Control’ to be a middle-of-the-road 3-star offering so when I first opened it I knew my review could go only one of two ways: ecstatic relief over an accomplished second release or crushing disappointment such that I’d be reaching for the Twitter block button.

But before I tell you what I think, I just need to put something out there. I’m genuinely worried about Mr Dispenser’s serious pen fixation. There. I said it. I’ll continue…

So did this book live up to my hopes and expectations?  Damn right it did, and once again I’m reminded what an honour it is to be working in the profession of pharmacy. As Mr Dispenser says himself, this is “‘OUR’ book” – members of the profession and our colleagues using social media to share the good times, lament the bad and celebrate the great.

For me that is this book’s greatest strength: I can go from wetting myself with laughter (Apprentice pharmacy clichés) to genuinely reflecting on previous experiences (Perils of the language barrier) and be left wondering how I can improve the experience of my patients now (except for those patients so well described in Deliveries).  But don’t worry – it’s mostly something to smile and laugh about: The show must go on is genius, but not as much as 9-5, and the Star Wars guide to pharmacy is brilliant with a generous helping of geek…and what makes all these so good is that despite being on Twitter most of my working day I had missed these conversations so it was all fresh.

A recent HSJ article described how a trust prepared medical students for on-call shifts using video-game simulations that had tasks appear with the same frequency and location as a real shift: if pharmacy wants something similar it can save itself a load of hassle and money by making this book (and its predecessor) recommended reading on the MPharm.  The Life of a Pharmacy Student by Sophie Khatib is enlightening, and whilst sections like Alternative OSCE and How to annoy your pharmacist are all written tongue in cheek there are some truths in there that will well prepare students for those realities not covered in the syllabus.  Helen Root’s Pharmacy guide to speed dating is great and there are some real pharmacy practice gems in there too, notably from Xrayser and Wee Neldo.  In addition it’s great to be able to get an insight into some of the higher machinations of pharmacy development thanks to John D’Arcy.

At this point I want to go on. I want to give you examples and snippets and quotes of all my favourite bits, but if I do, there won’t be much point in you buying this book because most of it would be replicated here. And you should buy it. Not only are 5% of proceeds once again going to the charity Pharmacist Support but it’s something that’s worth parting with your hard earned cash for.

Besides, it’s nearly Christmas (well, kind of…) and surely you know someone who would benefit from truly knowing about what you do as a pharmacist, or what they will be doing when they qualify?  And as it’s nearly Christmas I will leave you with just one of my favourite bits: read 12 days of pharmacy and I guarantee that for the rest of eternity, you’ll only ever sing “FIVE E – H – C’s” like this

So go on: treat yourself and get the book either for Kindle or paperback: you won’t be disappointed.

pity

images

A while ago I thought it’d be a great idea to spend a long weekend camping in the New Forest with my 3 year-old Little’un, and my manicure & hair-straightener loving wife.  That weekend has now arrived, and I’m wondering what the ‘great’ bits will be…

Unless I break early from cabin-fever I’ll be back at e-mails on Tuesday 6th August so please be patient; otherwise if you’ve got something urgent that can be answered by another pharmacist then please call Nikki on x.

Pity the fool…

dusted

dusted

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.

choice

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

blog photo use

 

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 21st 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.

noted

notes2

It’s noted that we are officially in a heatwave and that expert advice is for people to regularly drink cold drinks like water or fruit juice, and to avoid alcohol.

Whilst I will give this important advice all due regard, it’s the third weekend of July and as such I will be attending the Kent Beer Festival for the thirteenth consecutive year, regularly drinking luke warm beer and avoiding cold drinks like water or fruit juice.

I’m back and will be responding to e-mails – dehydration permitting – on Tuesday 23rd July.

Thanks,

J

afresh

start_anew-LRG

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?