The Pharmaceutical Journal Vol 266 No 7133 p146-149
February 3, 2001

Letters Emergency contraception Professional judgment Client’s interests Rubber-stamped? A question of price Morally wrong Oops! The Journal Appointment of editorial advisory board Banana skin PSNC What will CEO achieve? Practice research awards What about Scotland? Community pharmacy Treat us like grown-ups Private areas Life’s too short! Sandwich bar Contract limitation Time to get rid Drug administration An approving pharmacist is necessary Onlooker Sensitive issue

Emergency contraception: Professional judgment From Mr C. Morris, MRPharmS SIR,—I seemed to get lost half way through your editorial “In the spotlight” (PJ, January 27, p99). It starts off saying that, no matter what, we should not do anything to upset the Government. God help us if the Government should be against us! Then it starts saying, or so it seems to me, “Fight the Government. It should not define our professional attitudes.” Which is it? The answer may also answer my second point. Dr Balon seems quite irate at the 26 pharmacies who did not break the law to help the customer get over-the-counter Levonelle (PJ, January 27, p110). I question his statement that the pharmacists approached “did not do everything reasonably possible to assist”. If any of the 26 said, “None in stock! Goodbye!”, they were in the wrong. If they pointed out other avenues, then I believe they fulfilled their professional role. I work as a locum for a number of multiples which are not going to stock OTC emergency hormonal contraception yet. I am quite prepared to say, “I am sorry we have no stock. You would be best to go to . . .” I am wondering whether Dr Balon has a monopoly on ethics whereby he can tell everyone which professional judgment to come to? Oh, and can we take Dr Balon’s advice, supply a prescription only medicine without a prescription and assume Daily Mail reporters only work in London? Chris Morris Newquay, Cornwall Emergency contraception: Client’s interests From Mr I. G. Robinson, MRPharmS SIR,—On January 17, a young woman entered Dr Balon’s pharmacy asking about the “morning after pill” (PJ, January 27, p110). On January 20, the Daily Mail published an article regarding alleged unlawful or inappropriate supply of Levonelle. Two points spring to mind: First, having established that the customer had wasted valuable time visiting 26 pharmacies, which advised her that the over-the-counter pack was not available, Dr Balon might have asked if she worked for the Daily Mail! Second, perhaps after 65 hours, her best interests might have been served not in supplying emergency hormonal contraception but in advising her to visit her general practitioner or family planning clinic with a view to having an intrauterine device fitted, given the relatively high failure rate of EHC as the 72-hour limit is approached. Ian Robinson West Bridgford, Nottingham Emergency contraception: Rubber-stamped? From Mr A. O. Agbejule, MRPharmS SIR,—I disagree with some of the arguments in support of the deregulation of emergency hormonal contraception. I have read that repeat supply is not to be refused, as there is no evidence that repeat use will cause any more adverse effects. Does this mean that it could be used as regular contraceptive and, if not, how is the pharmacist to control the supply? Patients are registered with one GP practice. Hence it is possible for a general practitioner to keep track of a patient’s medication history and make an informed decision about providing EHC. How are pharmacists to prevent a situation where a patient (having known what questions are to be asked and arriving prepared with the correct answers) visits different pharmacies at different times to obtain EHC. I believe that our representatives should ask such questions before thrusting this task upon the profession and there probably should have been more consultation with the members before the Royal Pharmaceutical Society accepted this task on our behalf. Again all the publicity so far has involved prescription only packs of Levonelle-2. The pharmacy packs are not available yet, pharmacists are still being trained, yet the product has already been deregulated. It seems to me that the Society is not really in control of this deregulation and has merely rubber-stamped someone else’s agenda. This definitely does not augur well for the profession. Adewale Agbejule Saxmundham, Suffolk Emergency contraception: A question of price From Mr M. H. Franks, MRPharmS SIR,—The press has reported widely that pharmacists were to receive a “fee” of £10 per consultation for each sale of Levonelle. I have just received a price list showing the trade price is £11.06 + VAT = £13 per pack. With the sale price of £19.99 including VAT, ie, £17.01, the profit per sale is just £5.95, a vast difference to the £10 quote by the press. The price of the prescription only medicine pack is £5 and the true cost to the company is probably just £1 per pack, so the breakdown now becomes: Schering Health Care makes £10, pharmacists make £5.95 and the Government receives £2.98 in VAT. The Minister of Health should now take the following action: withdraw the POM pack to be replaced by the P pack at the same price - there is no justification for double stocking this product or for a 100 per cent increase in the price. The VAT could be reduced to 5 per cent (like sanitary towels) and the price to the public could then be reduced to £11.99. Without this action, the first question to ask a member of the public who asks for help would have to be “are you aware that the medication costs £20?”. M. Franks London N6 Emergency contraception: Morally wrong From Mr J. Ellis SIR,—I am currently undertaking my preregistration placement at a hospital in Manchester and am excited at the prospect of starting my career as a pharmacist, especially as we are witnessing a new era in pharmacy. There is one area that is causing me great concern, even uneasiness, namely, the supply of emergency hormonal contraception. I appreciate that pharmacists being able to prescribe in community pharmacy indicates a great step forward. However, I do question the choice of EHC as the working model of pharmacist prescribing for several reasons. First, I would like to ask the Royal Pharmaceutical Society and the Government whether the full issues surrounding the deregulation of EHC have been explored, and indeed whether they accept the possibility that EHC deregulation could bring about a surge in sexually transmitted infections and the further pressure that it may put on females (particularly the young and vulnerable) to engage in sex? Second, I would question the logic in deregulating EHC when the general public is almost certainly unaware of the way in which it acts (at least some of the time) to prevent the implantation of the already fertilised egg and thereby causing an early abortion of pregnancy. As a pharmacist I would not be happy to supply EHC to a woman, particularly since the mechanism of action of this medicine is not clearly stated. I believe that EHC is morally wrong and feel confident that many others feel the same way, too. James Ellis Pharmacy Department, Manchester Royal Infirmary Back to Top Emergency contraception: Oops! From Mr N. T. Fitt, MRPharmS SIR,—Question 4d on the sheet of multiple choice questions which accompanied the emergency hormonal contraception booklet issued with The Journal on January 20 states: “EHC is more effective if taken after 12 hours of unprotected intercourse than after 48 hours of unprotected intercourse.” After the initial hilarity had subsided, this statement provoked the following thoughts: Surely, after such exertions, CPR would have priority over EHC. Can younger members (sic) confirm a great increase in stamina since I were a lad (I registered in 1963)? When a request for EHC is made, have we to ascertain the length of unprotected intercourse? Is sildenafil even more effective than we have been led to believe or was the male partner suffering/enjoying a rare side effect of trazodone? Norman Fitt Manchester Back to Top

The Journal: Appointment of editorial advisory board From Mr S. I. Dajani, MRPharmS SIR,—The paper outlined to the Royal Pharmaceutical Society’s Council, summarising the findings of the brainstorming meeting to discuss the future direction of The Pharmaceutical Journal (see PJ, October 14, 2000, p549) advised that an editorial panel should be set up and that the current job description of the editor would “probably” not need to change. So I was perturbed to read in the job advertisement (PJ, October 21, 2000, pA37) that the editor would “ideally be a pharmacist” and then to read in the job description that he or she “will work with an editorial advisory board appointed by Council”. This cannot be correct. This did not appear in any of the paperwork I received and the Council did not agree it. The Council did, however, agree with the advantages of such a board supporting the editor and my impression was that this would be set up under the auspices of the editor solely. Robert Blyth is right (PJ, January 20, p80) that there are some on the Council who would like to usurp the editor’s freedom, who have failed in their quest and who now are going through the back door to limit the editor’s freedom with an editorial panel appointed by the establishment. However, he is not quite right in his assumptions that the Council is failing in its duty to monitor decisions made on its behalf. Some of us on the Council are actively trying to do this but are denied answers to our questions and are instead being asked to refer our concerns to various new subcommittees. They go away, investigate and return to us without any facts - only a reassuring “yes that’s fine”. I personally never agreed to this system as it is not transparent enough, but the Council collectively has and so it is a decision I am forced to go along with. However, I have raised concerns about this with a motion recently. Mr Strachan (PJ, January 20, p80) is quite right that the best person for the job should be appointed, but the position of editor of The Pharmaceutical Journal is different because a non- pharmacist editor with little or no background experience in pharmacy would be heavily reliant on the establishment. Thus could the PJ quite easily become a censored publication, moving away from the interests and the views of the Society’s membership. I like to think that the PJ exists for all as The Journal is produced in the interests of the whole membership rather than the few with the power in the Society. Hence its policies and activities should be influenced by and be responsive to the members of the Society. In my view, a non-pharmacist editor would not be in a position to understand and gauge the importance of the membership’s concerns. The editorial advisory board being appointed by the Council is unacceptable. Whoever made this decision on the Council’s behalf should own up, but as with the purchasing of “the flat”, I am sure we will not find any corporate accountability. This raises the question: “Is the Council a lame duck?” Under the new ways of working, Council members know less and less about what goes on in the headquarters building and, as Mr Blyth so rightly points out, decisions have been taken on our behalf more than once - for example, the Council agreed to buy the flat only after it had been purchased! I am glad that the experienced, hardened, older and wiser statesmen and women - those whose track record is far more proven than mine - have also sounded concerns. I am reassured that I am not inappropriately outspoken or alone in my frustrations. Sultan Dajani Member of Council Royal Pharmaceutical Society The Journal: Banana skin From Mr G. S. Phillips, MRPharmS SIR,—I have to disagree with my old friend Ian Strachan (PJ, January 20, p80). A pharmacist for editor of The Pharmaceutical Journal is a must. Only a fellow member of the profession can think as we do and act in the best interest of the members of our honourable Royal Pharmaceutical Society. After all, it is our journal! We are only too aware of the threats, past and present, to the independence of the PJ. To allow The Journal to fall into the hands of a non-pharmacist, no doubt at the mercy of an editorial board not of the editor’s own choosing, would be unthinkable, untenable and totally unacceptable to the general body of the profession. I am confident that the Council will refrain from taking so unwise a step, and will not risk alienating the membership, particularly at a time when the Council is trying to rebuild its reputation for corporate governance and transparency. The appointment of a non-pharmacist as editor would be a banana skin too far. Graham Phillips St Albans, Hertfordshire Back to Top

PSNC: What will CEO achieve? From Mr M. G. J. Cooper, MRPharmS SIR,—Although I thought the purchase of an apartment for the President of the Royal Pharmaceutical Society for over £600,000 unnecessary, in 10 years’ time it will probably have appreciated to over £1m, whereas to pay over £100,000 a year for 10 years to the new chief executive officer of the Pharmaceutical Services Negotiating Committee will achieve what for all the pharmacy contractors contributing? M. G. J. Cooper Manningtree, Essex Back to Top

Practice research awards: What about Scotland? From Mr M. R. Hickey, MRPharmS SIR,—I read with interest in Notice-Board (PJ, January 20, p96) that applications are invited for the Galen award and the Sir High Linstead fellowship. The notice states that while “there are no restrictions on the topics for proposed investigation for either award, the Council of the Society has indicated that applications which reflect developments within the national pharmacy plan would be particularly welcomed”. Presumably the Council is particularly welcoming applications from within England and Wales, the only regions for which the “national plan” is relevant. This is yet another instance of our representatives acting as a glorified “parish” council and working for the benefit of those practising south of Hadrian’s Wall. Maurice Hickey Forres, Morayshire From Mr T. T. R. Johnson, MRPharmS SIR,—I am writing to protest about the attitude of the Council of the Society regarding the practice research awards announced in The Journal (PJ, January 20, p96). I always thought that we had a British Society, but as a retired Scottish pharmacist, it appears to me that I am disallowed from applying as the national pharmacy plan does not refer to Scotland. I am surprised that our Council, particularly with a President resident in Scotland, did not notice this obvious exclusion. Ross Johnson Elie, Fife Ms ZOE WHITTINGTON (practice research manager, Royal Pharmaceutical Society) states:

The Galen award and Sir Hugh Linstead fellowship are open to all members of the Society wherever they are based in Great Britain. In the absence of a specific programme for pharmacy in Scotland, there was little opportunity to reflect how the objectives of “Our national health - a plan for action, a plan for change” (the NHS plan for Scotland) would impact on the pharmacy profession in the notice (PJ, January 20, p96). However, given the breadth of the topic areas highlighted, it is unlikely that potential Scottish applicants will be disadvantaged. “Our national health - a plan for action, a plan for change” has many similarities with its English counterpart including pharmacy prescribing, improved access to health care and increased use of technology, eg, telemedicine. However, as there is no restriction on the areas for investigation, all proposals will be considered. We look forward to receiving applications from colleagues in Scotland in time for the closing date of June 29 and would welcome the opportunity to discuss the details of the awards if any further difficulties are envisaged.

Back to Top

Community pharmacy: Treat us like grown-ups From Mr A. J. Rogers, MRPharmS SIR,—Lord Hunt, speaking to Redbridge and Waltham Forest local pharmaceutical committee, talks about “unlocking the potential of community pharmacy” and “being imaginative” (PJ, January 27, p100). It does not take too much imagination to realise that returning every prescription for Glucotrend or Ventolin Easibreathe to the prescriber for amendment is a waste of our time and theirs. And surely most of us imagine that we are wasting our time snipping a bit here, and adding a bit there, when we could be treated like grown-ups, and allowed to supply the quantity of medicine to the nearest patient pack. The Health and Social Care Bill has been laid before Parliament. The Royal Pharmaceutical Society and the Pharmaceutical Services Negotiating Committee retain Members of Parliament as advisers - we even have a sitting pharmacist MP - so it should be possible to get an amendment tabled to permit these changes in practice. If Lord Hunt is genuine in his belief that we are responsible adults, I am sure he will agree to give the move Government backing. If not, then every pharmacist in the country should write to their MP, urging them to support the amendment. With an election looming, they will not want a protracted debate, so we stand a good chance of pushing it through. Who is going to pick up the telephone first? Alan Rogers Ewell, Surrey Community pharmacy: Private areas From Mr A. E. Humfress, MRPharmS SIR,—Mr Stroh’s letter (PJ, January 27, p114) concluded that a community pharmacy is not a suitable place for fitting a truss, and a few weeks ago I recall a letter in which the correspondent concluded that a community pharmacy was similarly inappropriate for giving advice on emergency contraception. In both cases the reason given was that most pharmacies do not provide anywhere that allows for privacy. This problem is raised from time to time, but surely when there is overwhelming support for an extended professional role for pharmacists in medicines management and advice, it is becoming urgent. If one goes to see a doctor, practice nurse, dentist, optician, physiotherapist, osteopath, psychotherapist, solicitor, or even the financial adviser in our local branch of the building society, one is seen in a private office or treatment room. Pharmacists are unique in expecting their clients to discuss their most intimate affairs within the hearing of their staff and members of the public. The sources for medicines advice are increasing all the time, for instance with improvements to medical practices, NHS Direct centres, NHS walk-in centres, and internet services. If pharmacists cannot provide a suitable service, other professionals will be willing to do so, and the public will vote with their feet for the service which they feel most comfortable with. I realise the provision in every pharmacy of a totally private consulting area or room will be difficult, expensive, and impossible for some. However, am I alone in fearing that if this does not happen, either pharmacists are going to have to leave their pharmacies and move to where there are suitable NHS facilities, or abandon the idea of a major new role? A. E. Humfress London NW3 Community pharmacy: Life’s too short! From Mr M. D. Mochan, MRPharmS SIR,—Much has been written about the relatively low pay, and undesirable working conditions that pharmacists must endure. Reproduced below are two paragraphs taken from my recent letter of resignation: “Working 10 and a half hours per day with little or no chance to take a break, and being responsible for the dispensing of in excess of 300 (on occasion in excess of 500) prescriptions per day, is in my considered opinion a guaranteed recipe for disaster. “It would be professionally irresponsible of me to continue under these conditions.” I am going to take some time out to decide whether I want to remain in a profession whose members are expected to jeopardise their own physical and mental health, and consequently put at risk the health of those they are obligated to protect. No amount of monetary remuneration is worth it, and life is too short. Murray D. Mochan Great Yarmouth, Norfolk Community pharmacy: Sandwich bar From Mr F. B. Hewitt, MRPharmS SIR,—I have seen the light! I now know the road that pharmacy must travel in order to succeed in the 21st century. “Next time you fly from Newcastle airport, why not take advantage of Boots and try out the range of sandwiches” - (Horizons, Newcastle Airport Magazine). F .B. Hewitt Newcastle upon Tyne Back to Top

Contract limitation: Time to get rid From Mr D. F. Miller, MRPharmS SIR,—The definition of “adequate” is the ability to fulfil a need without being outstanding. It could also be the definition of our National Health Service. It is the standard which health authorities accept when they appraise the level of service of pharmacies. It is no wonder, therefore, that governments hold our profession in such low esteem and why we find it so difficult to obtain a proper remuneration package. It is also the standard which the pharmacy establishment seems willing to accept. If pharmacy had insisted on standards of excellence and had provided a rational distribution of pharmacies (as was once envisaged) to supply that service then perhaps we could have acquired some of the money the Government has wasted on “walk-in medical centres” and “NHS Direct”. Both of those have failed and would have been operated far more succesfully by locally established professionals. Unfortunately for pharmacy, the multiples are being allowed to take over and are exerting more and more influence. The bigger they become, the bigger their discounts, the larger their share of the NHS cake and, therefore, the greater their profits, much of which now goes abroad. It is no wonder that any pharmacist aspiring to own his or her own pharmacy finds it almost impossible to do so. With “contract limitation” it has become impossible to open a new pharmacy and financially impracticable to purchase an existing one. The result is fewer individually owned pharmacies, more locums and a further lowering of standards. We as a profession have been previously castigated by consumer organisations for our level of service and have now been let down by several of our fellow professionals who, as reported in a recent national daily report, failed to follow the correct protocol over the supply of the “morning after pill”. Despite this there are opportunities for pharmacy. With the lifting of many prescribing restrictions which are envisaged over the next few years we can elevate our profession to its proper level. First we must remove an iniquitous barrier by getting rid of contract limitation, thereby breaking the present monopoly and allowing pharmacy to move forward. Some will argue that the supermarket chains will exploit the removal of contract limitation and open huge numbers of pharmacies in their stores to the detriment of existing ones. This is only one side of the coin. In opening more pharmacies they would elevate the profile of pharmacy. This would offer more opportunities to pharmacists. Salaries would increase because of supply and demand. Both the NHS and the general public would benefit from having greater access to more and more professionals, and it would give pharmacy a more powerful voice when negotiating for Government money. Finally, I still believe that independent pharmacists could flourish in this environment by offering the services people want and we as a profession should be willing to provide. David Miller Congleton, Cheshire Back to Top

Drug administration: An approving pharmacist is necessary From Mr W. G. Peberdy, FRPharmS SIR,—The current case in Nottingham of a patient who has been injected intrathecally with vincristine (and which, sadly, seems likely to become a fatality) must inevitably lead to an inquiry to avoid this situation in the future. It appears to be an ideal case for pharmaceutical intervention in regard to the safe handling of potent drugs. If a pharmacist has “sufficient skill and knowledge” to dispense drugs for patients, is it too much to expect that he or she would be an ideal person to ensure that drugs like vincristine were correctly administered to the patient? My suggestion - and it could be varied in detail as necessary - is that wherever a drug from a specified list is to be administered parenterally by a doctor below the level of senior registrar, it should be in the presence of an approving pharmacist. Before the drug is administered (perhaps before it is even supplied) an entry should be made in the patient’s notes showing the total dose of the drug, its physical form, strength and volume, and the proposed route of administration and the entry signed and dated by the approving pharmacist who would then remain until the administration was complete. To have a second opinion of these details would seem a minimum precaution. In the current case it would seem that two doctors were involved but even this was insufficient to prevent a catastrophe. Who is better qualified to fill this second role than the pharmacist with his different and essentially cautious approach, and in a field in which he is pre-eminent? Initially the above procedure could be by an internal protocol established by a hospital’s controlling body, the list of eligible drugs being produced by the pharmacy department and similarly approved. One would hope that it would acquire national recognition and legislative support. W. G. Peberdy Scarborough, North Yorkshire See p137.—EDITOR. Back to Top

Onlooker: Sensitive issue From Mr B. B. Speight, MRPharmS SIR,—“Onlooker” has really touched on a sensitive issue when he asks the question “what about human responsibilities?” (PJ, December 2, 2000, p804) and, in my opinion, explodes the whole myth that education equals good morals - a supposition long held by the erudite elite. It certainly is satisfying to be blessed with a good brain and an above normal IQ but that does not guarantee that the knowledge will be used with good intent and effect. In fact, recent history is full of clever crooks who have used their abilities to exploit others. Barry Speight Botha’s Hill, South Africa Back to Top