Letters
Emergency contraception
The Profession
Truss fitting
The Journal
The Society
MMR Vaccine
Dispensing
Fraud
Self-care
Exemption checking
Travel medicine
GlaxoSmithKline
Drug food interactions
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Emergency contraception
Entrusted responsibility
From Mr S. S. Kalsi, MRPharmS, and others
SIR,— Once again pharmacy has been targeted by the "investigative"
press and found to be wanting. However, we cannot hold the profession
totally to blame. The launch of Levonelle has been rushed through without
adequate preparation. The product was mentioned on the radio well before
Christmas as being available from January 1, 2001, even though distribution
was questionable and the product has only been officially launched on
January 30.
The Centre for Pharmacy Postgraduate Education courses to prepare pharmacists
to conduct sales with due care and attention are scheduled for mid February,
but the media have raised expectations of the public when there was hardly
any possibility of pharmacists meeting those expectations. Throw in a
scant few profiteers in the profession and we have the Daily Mail
and the Today programme fiascos.
The proper way to launch such a product would have been through a nationally
agreed, protocol-driven sale with records that would be subject to audit
and scrutiny, with built in anonymity and confidentiality for the patient.
The supply should be recorded with details of the patient’s age, the time
lapse since the unprotected intercourse and the area in terms of the first
half of the postcode being the only items on the record. Additionally,
this supply should be free of charge in keeping with the rest of the contraceptives
group. This would also be in keeping with (a) the current principles of
the National Health Service which are supported by the British Medical
Association and (b) the forthcoming pharmacist prescribing agenda. This
product would have been an ideal start for the scheme.
The availability of emergency hormonal contraception through pharmacies
has improved access at a time of great need. In our locality alone the
rate of teenage pregnancy and resulting abortions is considerably above
the national average. To those who say that the cost of a free supply
would be prohibitive, we would point out that the cost of a resultant
abortion to the NHS is much more. Figures of £800 per procedure
have been spoken of.
As a profession we have to take the responsibilities entrusted to us seriously
and should not just go for the fast buck. Otherwise we jeopardise our
future which so many have worked tremendously hard to prepare the ground
for.
S. S. Kalsi
Barking, Essex
R. M. Patel
London E7
P. K. Odedra
Barking, Essex
Shelf-life differences
From Mr A. Cooper, MRPharmS
SIR,— I write to point out to colleagues the short shelf-life of
the over-the-counter Levonelle compared with that of its POM counterpart.
For some reason Schering Health Care has given an expiry date of 10/02
for the OTC version, but a check on the POM version reveals an expiry
date of 10/04, despite the batch numbers being similar (94004A on the
POM product and 94005D on the OTC product).
I would be interested to hear from Schering Health Care, the product licence
holder for both products, why an OTC product should be expected to go
out of date two years before a POM version? Is this simply a ruse to get
a better turnover of the more profitable P version?
Alistair Cooper
Newton Abbot, Devon
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Dr GRAHAM BARKER (associate medical director, Schering Health Care Ltd)
replies:
The UK regulatory authority granted the initial licence for Levonelle in
late 1999 with a five-year shelf life. The European "mutual recognition"
regulatory procedure for Levonelle, carried out during the summer of 2000,
reviewed all aspects of the product and reached a consensus of European
opinion which modified a number of details in the summary of product characteristics
and other parameters. One of these was the shelf-life, where the decision
was made to set this at three years.
As a consequence, available stock of Levonelle may have different shelf-lives,
although they are exactly the same product. Ultimately all products (throughout
Europe) will have the same shelf life of three years. Some products at present
may have a shelf-life as short as 2002, owing to the possibility that they
have been in stock for several months prior to packaging. I trust that this
clarifies the situation. |
Reducing suffering
From Mrs J. R. Tadros, MRPharmS
SIR,— I have been reading with interest the comments made by fellow
pharmacists on the recent change of status of emergency hormonal contraception
from POM to P status. I do hope that Mr Tait and Mr Fallon (PJ,
January 20, p82),
who object on moral grounds, can say that they are and always have been
impeccable when it comes to contraception, and that they have never been
unfortunate enough to have been failed by a method of contraception which
they were using. Perhaps though, as men, they do not fully understand
the mental anguish often experienced by women who have found themselves
in just such a position. As a woman, I am delighted to be able to assist
in reducing such suffering.
I wonder upon what evidence Mr Tait bases his comment that EHC encourages
sexual promiscuity? I wonder, too, if he has stopped to consider how many
marriages come under pressure and indeed fail after children come along,
and that some of those failed marriages may in fact have been saved by
the easier availability of EHC. Mr Fallon seems to be blissfully unaware
of the track record of safety which accompanies the use of progestogen-only
EHC, and of the potential for both physical and psychological suffering
which can accompany any pregnancy and birth.
As a professional, I welcome the opportunity to employ my knowledge, experience
and skills fully. I was impressed with the quality of the Centre for Pharmacy
Postgraduate Education training module distributed to all pharmacists,
and feel that I am now fully prepared to supply EHC in a safe, sensitive
and effective way. I am surprised that there are pharmacists who feel
otherwise, and I am saddened that some colleagues seem prepared to treat
Levonelle as just another sale. If, as a profession, we cannot rise to
the challenge of this new responsibility, then I fear for our future.
I would urge all pharmacists to work through the CPPE booklet and, at
the very least, find out where they can refer customers if they feel unable
or unwilling to supply EHC for whatever reason.
Janice Tadros
London NW2
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The Profession
Frustrating and demoralising
From
Mr M. W. S. Holden, MRPharmS
SIR,— On February 1, I watched in horror as the ITV programme Tonight
with Trevor Macdonald used undercover filming and a 15-year-old girl
to shoot massive holes in the profession’s attempt to supply emergency
hormonal contraception ethically.
The film showed cluttered and scruffy pharmacies in Liverpool and Manchester
where pharmacists totally bypassed all agreed protocols for the supply
of EHC.
The impression given to the public was of low professional standards,
poor communication skills and general incompetence. This rides on the
back of the Daily Mail research which showed the profession in
a similar light.
Surely the time has come for the Royal Pharmaceutical Society truly to
justify its role of self-regulation and deal with this issue of professional
standards across all aspects of premises, service and competence. For
those of us who constantly strive to maintain the highest of standards,
it is frustrating and demoralising to see that this self-regulation is
ineffective.
If something is not done quickly the profession will pay the penalty in
the short, medium and long term (if there is a long term).
Michael Holden
Fleet, Hampshire
Discredit
From Mr S. F. Howard, MRPharmS
SIR,— The television programme Tonight with Trevor Macdonald
set out to show how easy it was for a 15-year-old girl to obtain the "morning
after pill". While trying to do this, the programme came across a
pharmacist who, under the patient group direction scheme, supplied PC4
instead of Levonelle. This was quite reprehensible and brings discredit
to the profession as a whole.
As far as the sale to under-16-year-olds is concerned, the programme showed
two pharmacists selling emergency hormonal contraception to a 15-year-old,
both of whom asked if she was 16 and both of whom were lied to about her
age. The scheme does not require pharmacists to ask for proof of age,
nor should it, as this would inevitably cause delay in the taking of EHC
and probably fewer requests for the product.
This programme was a typical piece of journalism which lends itself to
the philosophy of "why let the truth get in the way of a good story?".
Unfortunately, the supply of Schering PC4, the real story, puts us all
in a bad light.
Stephen Howard
Sheffield
Gross insult
From Mrs G. E. Melling, MRPharmS
SIR,— I am in despair after watching the report on ITV on February
1, concerning the wrongful supply of emergency hormonal contraception.
When will these pharmacists realise what a disservice they do to their
profession and how badly they let down the vast majority of their colleagues?
The Royal Pharmaceutical Society should immediately suspend the registration
of any pharmacist either breaking the law (supplying Schering PC4) or
who supplies Levonelle with such a cursory "interview" ignoring
the health, current medication or personal situation of the client.
I would not be surprised if there are some pharmacists who never open
their Pharmaceutical Journal and so are unaware of the mandatory
requirements.
It is a gross insult to the members of the Society who keep up to date,
attend meetings and Centre for Pharmacy Postgraduate Education courses
and present to the public a caring and professional image, that such negligent
conduct is not dealt with rapidly and publicly.
Gillian Melling
Preston, Lancashire
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Truss fitting
A pharmacy is the place
From Mr E. E. F. Giles, MRPharmS
SIR,— Clearly, by his own admission and description, Mr Stroh’s
pharmacy is not a suitable place for the supply and fitting of trusses
(PJ, January 27, p114).
Some of us, however, have over the years seen this service to be a satisfying
part of the job and, although it is not financially rewarding, bringing
rapid relief to an uncomfortable patient brings its own reward.
Truss fitting is not an obligatory element of the National Health Service
contract and most choose not to do it; indeed, at one time I believe that
I was the only pharmacist in Worcester offering this service. This extended
to being called to the Worcester Royal Infirmary on one occasion to an
inpatient who needed refitting when there was no one on the hospital staff
at that time who felt able to do it.
Patients requiring a truss can be measured without them removing much
clothing and in a standing position. However, fitting should be done lying
down and so a simple couch in a private room is a minimum. Since this
is not always possible to provide adequately, I have often measured patients,
both male and female, young and old, and then made an appointment to visit
them in the privacy of their home for the fitting, ensuring a chaperon
is present where appropriate.
A general medical practitioner has no expertise in measuring and fitting
trusses and one is lucky to get more than a simple note on a prescription
form saying "please fit a truss to this patient". The fitter
will decide on type, size and position, and the pricing bureau has rarely
returned a prescription which we have had to complete.
May I reassure Mr Stroh that community pharmacies are suitable establishments
for the measuring, fitting and supply of trusses, but those who feel unable
for any reason need not do it.
Eric Giles
Pershore, Worcestershire
Good nature
Mr D. J. Richardson, MRPharmS
SIR,— Mr Stroh is quite right: a community pharmacy is not the
place for truss measuring and fitting (PJ, January 27, p114).
A patient who is new to trusses needs two or three home visits for a pharmacist
to do the job properly, and with dignity. The system relies heavily on
the good nature of the pharmacist — "I’ll pop in and fit it
for you on my way home" — after a nine-hour day in the dispensary
and for a derisory £1.97 fee. It is high time that we were recognised
and rewarded for our true value.
Another point — would any pharmacist really want to risk having the
local general practitioner measure someone for a truss?
D. J. Richardson
Sheffield
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The Journal
Not in crisis
From Dr P. J. Brown, MRPharmS
SIR,— I have followed with interest the correspondence in your
columns about the replacement of the previous editor of The Journal.
Writing as a publisher of over 30 news publications and magazines for
the international health care industry, I would say that the whole matter
has been blown out of all proportion when considering the problem that
needs to be addressed.
As I understand it, the previous editor left under unhappy circumstances.
Out of this simple beginning, we have seen all manner of argument advanced
about his replacement — should he or she be a pharmacist or not,
and is there now a need for an editorial board to give guidance on editorial
matters?
I would say that the reasons which resulted in the departure of the previous
editor need to be put into perspective. I would point out that there is
no evidence of gross interference by the Council or permanent staff of
the Royal Pharmaceutical Society in the day-to-day editorial activities
of The Journal.
So the whole matter boils down to the question of just who should be appointed
to the post of editor of The Journal. This is not the complex issue
that it has been made out to be. Again, with my publisher’s hat on, I
would say that the first thing to do is to see whether a suitable successor
can be found from the existing editorial staff. This is what I have done
over the years, and by and large it has worked out very well. The advantage
of this approach is that there is continuity in all aspects of the work.
It is very seldom that there are many candidates for positions such as
the editor of The Pharmaceutical Journal. This is because such
publications demand specialist knowledge and experience. If one is going
to look outside the organisation, one should know precisely whom to approach.
If there is no such person, then nothing good will come from advertising
and head-hunting. Certainly, advertising and head-hunting will bring a
number of interesting candidates to light, but they will all have drawbacks
because they lack some or all of the essential qualifications — professional
journalistic skills, knowledge of the subject matter, and knowing how
to work in the particular editorial environment.
From what I see and read, it is clear that the present acting editor is
doing a good job. He knows what he is doing and how to do it, so why look
elsewhere for an editor? The task of the editor of The Journal
is to maintain the quality and readability of the publication, which is
happening. The PJ is not a publication in crisis and, therefore,
there is no real need to make changes to its contents or presentation.
Right now, The Journal needs to stay on track and not undergo radical
changes — for what purpose?
My advice is to put this whole matter to bed as quickly and efficiently
as possible. Appoint the present acting editor to the position of editor
and put to an end what has become something of a nonsense.
Philip J. Brown
Kingston-upon-Thames, Surrey
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The Society
Thrown to the wolves
From Mr A. G. M. Madge, FRPharmS
SIR,— May I support Ian Caldwell’s erudite and factual letter,
which raises fundamental points regarding the future of our Royal Pharmaceutical
Society, and also Brian Spencer’s letter regarding the "slaughtering"
of the Agricultural and Veterinary Pharmacist so assiduously nurtured
by Steven Kayne (PJ, January 27, p112).
As a former chairman of both the Agricultural and Veterinary Pharmacists
and the Industrial Pharmacists groups, I deplore the axing of their newsletters.
It seems a complete reversal of policy, which was to encourage active
participation of all sections of pharmacy. They helped to build a basis
of mutual interest in the promulgation of the profession.
Is it the Society’s policy to throw all minor groups to the wolves and
curtail interest in pharmacy by official and Government bodies? Much spadework
has been done. It must be borne in mind that there are bodies that are
jealous of the position pharmacists hold and that are only too willing
to use it to their advantage. Perhaps there should be a rethink on such
actions and a decision made to encourage rather than destroy.
Mervyn Madge
Plymouth, Devon
Regret
From Mrs M. G. B. Ryan, MRPharmS
SIR,— I read with great regret the final edition of the Agricultural
and Veterinary Pharmacist. In its short life of eight editions, this
journal has proved to be a useful way of keeping up to date with agricultural
and veterinary pharmacy news and evidence-based information.
It is appreciated that the journal only caters for a minority group of
pharmacists but is still an important branch of pharmacy. Like many others,
I have an interest in this branch of pharmacy and work in a rural area
where, although not directly involved, I receive inquiries regarding issues
of agricultural and veterinary pharmacy, particularly zoonoses.
It is also particularly regrettable that the agricultural and veterinary
pharmacy diploma has been suspended at the same time. I hope that this
will only be for a short time and look forward to seeing the reappearance
of both in the near future to ensure knowledge in this branch of pharmacy
is maintained.
Margaret Ryan
Prescribing Adviser, Lomond & Argyll Primary Care NHS Trust
What does it do for industry?
From Mr M. C. Olver, MRPharmS
SIR,— Having read that the Royal Pharmaceutical Society is unable
to fund the Industrial Pharmacist, I am considering what business
justification there is for me to ask my employer to continue to pay my
retention fee. Perhaps a member of the Council would consider helping
me in understanding exactly what the Society now does for one of the few
remaining profitable industries in the United Kingdom.
Malcolm Olver
Hatfield, Hertfordshire
Lack of commitment towards science
From Mr A. Jayan, MRPharmS
SIR,— Based on experience as a PhD student about to enter the pharmaceutical industry,
it is my opinion that the discontinuation of the Industrial Pharmacist
is symptomatic of a lack of commitment of the Royal Pharmaceutical Society
towards pharmaceutical science and its promotion as a career pathway open
to pharmacy students. The latter is of particular concern, as a situation
where there is a diminution of quality and quantity of pharmaceutical
scientists moving into both academia and industry has been quite widely
foreseen.
Maybe individuals with influence need to look towards the formation of
an independent body analogous to that of the American Association of Pharmaceutical
Scientists (AAPS), possibly through lobbying of the Association of British
Pharmaceutical Industry. Only then can we have a structure in Britain
that is fully dedicated to the promotion and networking of high quality pharmaceutical
science.
I would like to focus on an additional, but not wholly unrelated point. While
commenting on the discontinuation of the Industrial Pharmacist
and the Agricultural and Veterinary Pharmacist, many colleagues
have pointed to a lack of consultation and accountability of the Society.
All pharmacists, whichever area they work in, should be considered "stakeholders".
The Society must not let itself be perceived as a black box. It must be
more proactive in providing transparency in operations and decision-making
rather than leaving the onus on its members to seek information. Particularly, there
must be an obligation to provide all members with an annual report that
not only sets out achievements and strategies, but also includes detailed
financial spending and status, with a fully independent audit. After all,
it is only right that the Society opens itself to the same level of auditing
that it rightfully enforces on its members and affiliated establishments.
Arvind Jayan
School of Pharmaceutical Sciences, University of Nottingham
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MMR vaccine
Can Crohn’s disease be a coincidence?
From Mrs A. F. MacDonald, MRPharmS
SIR,— The Department of Health does not have accurate figures of
the actual incidence of Crohn’s disease in children. Crohn’s disease is
not an infectious disease and as such, I believe I am correct in saying,
it is not a notifiable disease. I have a letter dated October, 1996, from
the communicable disease and immunisation branch of the Department of
Health stating that no cases of Crohn’s disease were reported after the
1994 MMR vaccination campaign.
I beg to differ! I had healthy 12-year-old identical twin daughters, growing
normally, with excellent health and great energy and zest for life until
they received the MR (measles and rubella) vaccine in November, 1994.
One twin stopped growing and began to lose weight within six months of
the vaccine. Within 12 months she was malnourished, suffering severe abdominal
pain, oesophagitis, mouth ulcers, and chronic constipation. She was finally
diagnosed in February, 1996, as suffering from Crohn’s disease after a
colon- oscopy showed her bowels to be "cobblestoned" with ulcers,
and gut biopsies confirmed these results. She has been a semi-invalid
over the past six years, fed through a gastrostomy tube, suffering constant
abdominal pain, nausea and arthralgia.
As a result, now at the age of 18 years, she has missed out on her education
and teenage years, and faces an uncertain future both with regard to her
continuing poor health, and any future career.
Her twin has also been diagnosed with Crohn’s disease, and over the past
few years has suffered symptoms similar to those of her sister. (She received
exactly the same batch of vaccine as her twin.)
A friend of my daughters, the same age as them, living in the Midlands,
has also been diagnosed with Crohn’s disease. She also had the vaccination
in 1994 and suffered a slow deterioration of health over the following
years. Can this be a coincidence?
A register to record cases of inflammatory bowel disease in children is
now being set up by paediatric gastroenterologists, concerned over the
increasing number of children being diagnosed with Crohn’s disease and
inflammatory bowel conditions.
My daughters had the single measles vaccine prior to school with no ill
effect. Was this third "top up" vaccination with MR in 1994,
promoted by the Department of Health at the time, necessary ? Why has
no one from the Department of Health investigated the adverse drug reaction
report form sent in by our general practitioner. Is it easier to deny
the problem exists rather than face the fact that there might be a very
serious problem facing our children?
Few GPs send in ADR reports on drug reactions and, if they do not believe
that the vaccine caused the problem, they may choose not to do so. Hence
under-reporting is a major issue.
I would not wish to see any other child suffer this horrendous illness
if it can be avoided.
Anne MacDonald
Skipton, North Yorkshire
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Dispensing
Party to fraud?
From Mr S. Green, MRPharmS
SIR,— Most pharmacists should now be aware that it is illegal for
nurses and practices to order stock items, for example, dressings, on
FP10 prescriptions. Stock ordered on FP10 prescriptions is the property
of the patient and should not be reused by a nurse or practice.
I would be grateful if the Royal Pharmaceutical Society could issue guidance
on the position of contractors who continue to dispense prescriptions
when they know items are for stock and not the patient named.
My concern is that contractors may be deemed to be party to defrauding
the National Health Service should an investigation take place.
Shaun Green
Exeter, Devon
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Mr STEVEN LUTENER (head of pharmacy law, Royal Pharmaceutical Society)
replies:
Mr Green is correct that pharmacists who dispense prescriptions which they
know are to be used for the purpose of replenishing stocks could find themselves
implicated in investigations.
For every prescription dispensed, the pharmacist decides whether he needs
to speak to the patient, and any routine collection of dispensed medicines
by others, especially if this involves the staff of the doctor’s practice,
will raise questions about how the patient is to be counselled, and how
the delivery of the medicine to the patient is to take place. Suggestions
by those staff that the pharmacy need not label the medicines would heighten
concerns.
It is, though, important to note that many patients receive their medicines
from pharmacies, via a district nurse, and there is no suggestion that this
is improper. |
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Fraud
Coloured forms the answer
From Mr G. C. Trask, MRPharmS
SIR,— The proposals of the Prescription Pricing Authority to carry
out under-cover checks at pharmacies are unreal (PJ, September
23, 2000, p435).
They put the pharmacist in an irresolvable position.
If prescription forms were printed in different colours on white paper,
eg, red for exempt and green for non-exempt, pharmacists would not have
responsibility. Exempt patients could give evidence to doctors’ staff
and by pension books, birth certificates, etc, the category could be noted
on the patient’s medical card — thus the doctor would use the appropriate
coloured form.
The present forms could be used for emergency prescriptions, eg, holiday
workers not known by doctor. The correct completion of forms could then
be verified by National Health Service records — thus the patient
would be responsible for correct endorsement. Different coloured forms
would also have resolved the problem of the "expensive mistake"
highlighted by Mr Urwin (PJ, December 16, 2000, p895).
G. C. Trask
Alicante, Spain
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Self-care
Enhanced role
From Mrs A. Britton, MRPharmS
SIR,— As project operations manager, may I take this opportunity
to respond to Mr Rew’s letter regarding the self-care project taking place
within the Tyne and Wear health action zone (PJ, January 13, p55).
I acknowledge the point raised by Mr Rew with regard to the current resource
issues associated with the pharmacy profession. The project has been developed
with pharmacists rather than imposed on pharmacists, the local pharmaceutical
committees being fully involved with the development of the project and
represented on the project steering committee. I hope the following information
will provide a clearer understanding of the project taking place.
The overarching aim of this project is to reduce the inequalities in access
to health care services and to improve the services available to patients.
Although The Pharmaceutical Journal chose to use "Pharmacists
to reduce GP workload" (PJ, December 9, 2000, p845)
as the headline for its article relating to the project, this is not the
project’s primary aim. Indeed, it will not be a secondary outcome, as
any GP consultation not used by a patient accessing the pharmacist will
be available for a patient actually in need of a GP consultation.
The project, although conceived in association with the Proprietary Association
of Great Britain before publication of either "The plan for the new
NHS" or "Pharmacy in the future", seeks to empower patients
to self-care for minor, self-limiting conditions. Patients presenting
at the surgery with upper respiratory tract infections or gastrointestinal
symptoms are offered a patient information leaflet and the opportunity
to consult a local pharmacist. If the patient chooses to see their GP,
the GP can issue a leaflet, rather than a prescription, as the end-point
of the consultation.
The patient information leaflets provide information about the symptoms
the patient is experiencing and self-care advice. For those patients exempt
from the prescription charge, there are two tokens incorporated into the
leaflet which can be exchanged in the pharmacy against the cost of over-the-counter
medicines recommended by the pharmacist. The pharmacist completes a "prescription"
for those medicines, which he or she supplies to charge-exempt patients.
This is then submitted to me for reimbursement of medicine costs. Those
patients who pay the prescription charge are not excluded from the project
but are not able to redeem the tokens within the patient information leaflet.
They are expected to purchase the medicines recommended by the pharmacist.
I hope the very brief description given above of the project serves to
show that this project will help to enhance the role and profile of the
pharmacist within self-care. Pharmacists provide this help and advice
to patients every day of the week but a significant proportion of the
population are currently excluded from this service because of the cost
of medicines.
I am happy to provide more detailed information regarding the project,
on request.
Ann Britton
Community Pharmacy Facilitator
Newcastle and North Tyneside Health Authority
Benfield Road
Newcastle upon Tyne NE6 4PF (
Tel 0191 219 6075;
e-mail Ann.Britton@nant-ha.northy.nhs.uk
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Exemption checking
"I told you so!"
From Mr S. A. Wheatley, MRPharmS
SIR,— It is with more than a little interest that I read that four
motions on the subject of prescription charge exemption checks are to
be presented at the local pharmaceutical committees’ conference on March
12 (PJ, January 27, p100).
Some of the practical difficulties arising out of this procedure were
well rehearsed in my letter which you kindly published on April 25, 1998
(p595). In that letter I concluded: "To add a requirement to check
some form of documentary evidence of exemption is a burden too far and
must be resisted at all costs." I went on to urge the Pharmaceutical
Services Negotiating Committee urgently to review its stance on the matter.
With the hindsight of experience, it is now obvious that this checking
procedure does detract from the value that could be derived from the contact made
during the "professional moment" at the patient/pharmacist interface.
Exempt and non-exempt patients alike can become confused, resentful, even
distressed by the immediate requirement to complete the declaration properly.
In the brave new world of Pharmacy in the Future, how can we hope to contribute
to the proper management of medicines if our patients are preoccupied
with and irritated by this mandatory and time consuming bureaucracy and are
thus non-receptive to our advice and guidance?
It is difficult to switch out of the "I told you so" mode.
I entreat the delegates attending the conference of local pharmaceutical
committees to support particularly the motion put forward by St Helens
and Knowsley LPC, that the Department should be told that the profession
is no longer willing to take responsibility for the checks.
Stan Wheatley
Blandford Forum, Dorset
Tuppence worth
From Mr A. J. T. Low, MRPharmS
SIR,— I am glad that the local pharmaceutical committees’ conference
is to debate point of dispensing exemption checks (PJ, January
27, p100). I am also intrigued
by what Dr Cross wrote in his letter: that dentists were paid 10p for
every National Health Service exemption check (PJ, January 27,
p114). In response
to Dr Cross’s letter, Mr Axon, the general secretary of the Pharmaceutical
Services Negotiating Committee, stated that comparing dentists’ checks
with pharmacists’ checks was not comparing like with like.
I do not know how complicated it is for a dental surgery to check exemption
status but I should not imagine it takes anything more difficult than
a pharmacy’s "Do you normally pay for your prescriptions?" or
some such sort of question. Perhaps the staff might say: "Do you
normally pay for your dental treatment? If not, could you say why?"
I do not see why dentists should be paid four times more for this than
pharmacists. Perhaps they negotiated a better deal.
Mr Axon said that the remuneration for checking prescriptions was lower
because there were more prescriptions than dental appointments for the
average patient. So? Surely payment should be made on a like-for-like
basis, because the effort involved in the check is the same. In fact,
it is often on the second or subsequent occasion of a patient presenting
a prescription that the real difficulty begins. The patient simply says,
"I’m exempt — it should be on your record". Well it takes
a certain amount of staff interaction and a look at the patient medication
record on the computer to make sure this is the case. All this for 2.3p
— they certainly get their tuppence worth. In fact, the whole procedure
makes one feel like a tax collector, not someone who is there to improve
the patient’s health.
As for the role of the Directorate of Counter Fraud Services and how effective
it is, I am not convinced. Pharmacy staff often have strong suspicions
of people who fraudulently claim exemption and score an emphatic cross
"evidence not seen" in the roundel on the back of the form.
This goes on every time the patient collects a medicine but I doubt whether
it leads to any further investigation and certainly no reward. The NHS
could not afford it.
Andrew Low
South Harrow, Middlesex
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Travel medicine
Useful website
From Mr D. F. Brint, MRPharmS
SIR,— The best website for travel health advice and officially
required inoculations is beyond doubt that of the United States government’s
Centers for Disease Control and Prevention on www.cdc.gov.
All you could want to know about the health hazards of travel outside
the US is there, and free for the taking.
The use of the fax-back service described by Mr Allen (PJ, January
20, p81) requires
access to a telephone and a fax machine and incurs a potentially high
telephone payments. Internet access is cheaper and,with luck, faster.
Incidentally, why do I have to pay to use the online British National
Formulary but I am able to use the equally useful Merck Manual free of
charge?
Dennis Brint
Clevedon, Somerset
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GlaxoSmithKline
Medicines in Ghana
From Mr S. Whitaker, MRPharmS
SIR,— Glaxosmithkline’s website (www.glaxosmithkline.com)
proclaims on its front page that "Glaxosmithkline — one of the
world’s leading research-based pharmaceutical and health care companies
— is committed to improving the quality of human life by enabling
people to do more, feel better and live longer".
I wonder how the company reconciles this statement with the fact that,
according to an article in the Wall Street Journal of December
1, 2000, it is purposefully blocking the importation of affordable generic
HIV drugs into Ghana, a country ridden with AIDS but too poor to be able
to afford Glaxo’s patented formulas.
Simon Whitaker
Cardiff
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Ms VICKI EHRICH (Glaxosmithkline Corporate Communications and Community
Affairs) replies:
Thank you for giving us the opportunity to explain the situation, which
has unfortunately been misreported in the media.
Ghana has no public funding for AIDS medicines and thus, only a few people
in the private sector are able to access these medicines. As far as we can
establish, there is no plan for Ghana to supply antiretroviral medicines
in the immediate future. Cipla attempted to sell and then donate a lamivudine/zidovudine
combination in the private sector in Ghana, which was not registered with
the Food and Drug Board, which body then ordered the local distributor to
withdraw the product.
Our letter to Cipla was intended to alert it to the existence of our patents
on lamivudine and zidovudine in Ghana. It was stated that no immediate action
would be taken. Thus no action has been taken by GSK against Cipla in relation
to patent infringement in Ghana.
The letter was sent to Cipla in good faith under the belief that our patents
extend to Ghana.
Patent documents issued by the ARIPO (African Regional Industrial Property
Organisation) indicate that they extend to Ghana (one of their contracting
states). Renewal fees for these patents in respect of Ghana have been paid
and accepted by the ARIPO.
GSK is committed to maximising access to its range of medicines in the developing
world.
I n May, 2000, we announced our participation in the Accelerating Access
Initiative, co-ordinated by UNAIDS. This initiative is intended, through
partnerships, to increase access to AIDS medicines in the developing world.
Preferential pricing offered on the GSK range of AIDS medicines puts them
on a par with generic prices. The Ghanaian government has been advised by
GSK of this initiative but the country has not yet indicated its interest
in participating.
The focus on the patent status detracts from the real issues surrounding
access to medicines in Ghana. GSK is able and ready to offer its range of
AIDS medicines in Ghana and other developing countries at a price on a par
with generic medicines.
The pharmaceutical companies alone cannot guarantee that medicines would
be affordable to the world’s poorest people, especially in the case of combination
treatments required for HIV/ AIDS. It is widely accepted that the lack of
funding for AIDS medicines, whatever their price, is a major stumbling block
in the developing world.
Experience shows that, to make expanded access successful, partnerships
in terms of the participation of national governments, donor funders, UN
agencies, non-governmental organisations, local communities, the industry
and other stakeholders is essential. |
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Drug food interactions
Lack of communication
From Mr E. Muammar, MRPharmS
SIR,— Two years ago, a patient’s wife asked me to explain the interaction
of her husband’s medicine, Tritace, with other drugs. As I read out the
list, she did not understand what was meant by "medicines containing
potassium". I explained to her that these may contain potassium instead
of sodium, and I gave her the examples of sea-salt and Lo Salt which should
be avoided in case the patient is treated with Tritace or similar drugs.
At this point she protested bitterly saying, "Why has nobody told
me? I have been using Lo Salt in cooking all his food."
Since such salt supplements interact with all ACE inhibitors and angiotensin-II
receptor antagonists, I decided to investigate patients’ awareness of
this interaction. I also investigated patients’ awareness of the interaction
of calcium-channel blockers (class I and most of class II) with grapefruit
juice.
In respect of grapefruit, there was negligible awareness, but little problem
as most patients responded that they did not drink or like grapefruit
juice. One woman had developed swollen ankles, which were resolved as
a result of hospital advice to wean off the juice. Hospitals tend to issue
such warnings when the patients are started on a drug.
The potassium salt alternatives should be dealt with more seriously, because
patients consider them "healthy" but do not realise the risk
of taking them with the drugs mentioned above. Many say they are not aware
of the interaction; others say they do not take salt at all, and a few
said they used sea salt alone for cooking.
Here, there appears to be a problem with communication. Patients may read
the patient information leaflet, perhaps understand it and possibly discard
it. The carers may not see the leaflets and are responsible for feeding
the patient. It is more likely that they will see the patient pack than
the leaflet. It would, therefore, be better if the warnings appeared as
a plain message on the pack.
I discussed the consequences of overlooking these warnings with information
pharmacists from two local hospitals. They believed that ignoring such
interactions might seriously affect the cardiovascular and renal systems.
May I suggest that the Royal Pharmaceutical Society proposes a solution
to this problem.
Elias Muammar
Chandlers Ford, Hampshire
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The
Pharmaceutical Journal Vol 266 No 7134 p184-189