From Mr P. Melnick
SIR,—Ask any consultant rheumatologist how to treat osteoarthritis these days and he or she will almost universally suggest paracetamol 1g qds taken regularly, provided there are no contraindications. Non-steroidal anti-inflammatory drugs are reserved for acute exacerbations and occasional top-up analgesia when necessary. How many such prescriptions are seen in general practice for osteoarthritis patients? Why does it take so long for evidence-based medicine to permeate the ranks of general medical practitioners? Why, when faced with EBM, do so many GPs continue to prescribe in accordance with their old habits and prejudices?
These questions must have been taxing the Department of Health, because I believe that in his speech to the British Pharmaceutical Conference, Lord Hunt conceded that pharmacists are to be the catalysts for change in the National Health Service. Aspects of medicines management such as appropriate dosing and drug interactions will continue to take place within the pharmacy setting for now. But, more and more, a new role for pharmacists will be undertaken within GP surgeries — reactively at first, but proactively over time — as they increasingly influence the prescribing process. And surgeries will not be pharmacists' only workplace. Issues around hoarding of medicines, non-compliance and concordance will be most effectively tackled within the unhurried informality of a patient's home rather than anywhere else.
The potential benefits to patients and ultimately to the NHS are huge. But what else is in the Department's thinking? All the evidence of the past 13 years suggests that it sees pharmacists within a dispensary as an unnecessary expense. Yes, they perform a useful role, but for the most part they are overpaid for what they do and underutilised for what they should be doing.
The Minister has offered £30m to be paid over three years — a simple pump-priming exercise that equates to less than £1,000 per pharmacy per year. Peanuts. As a quick estimate, say a saving of £1 per month per patient is made by changing the medication of one million osteoarthritis sufferers to paracetamol. Add in a further saving because of the reduced need for H2-antagonists and fewer hospital visits, both of which can sometimes be required to treat or prevent the side effects of NSAIDs, and the Government's £30m is recouped within one or two years.
Lord Hunt has explicitly stated that pharmacies which provide the best service will gain at the expense of those which only provide a minimum service. There is no problem there. The contract has always rewarded the mediocre. If standards are to be raised then this statement is long overdue. But he also explicitly threatened that resources will be shifted away from the dispensing process to other areas. Once again pharmacy is to be expected to provide the capital and investment for the benefit of others. But how? Surely, this can only be achieved by reducing the cost of the current core service.
Perhaps that is why the Department of Health is so keen on electronic prescribing. Once that is established it will be followed by electronic scanners which will both read the prescription and the item dispensed against it. Pharmacists in GPs' surgeries will oversee prescriptions before transmission; non-pharmacists will dispense those prescriptions using electronics as the final check.
Food for thought indeed. No wonder Lord Hunt referred to the future as challenging.
Perry Melnick Ilford, Essex