Letter from the Editor

The Journal
Physician-assisted suicide
Emergency contraception
Contract limitation
Thalidomide
Medicines management
Community pharmacy
Pricing
MMR vaccine
Aseptic manipulation
Probiotics
Hospital pharmacy
Murphy's Law

The Journal

Substance and quality

From Mr W. N. P. Chapman, FRPharmS, and Mrs J. F. Chapman, MRPharmS

The letter from Philip Brown is timely (PJ, February 10, p186). It reminds us of the value of experience, probity and a genuine feeling for the profession by a pharmacist.

The common sense that is shown is welcomed by us. Furthermore, it is apparent that recently The Pharmaceutical Journal has been more substantial and of greater quality than ever. The abandonment of a team that is performing is very serious and there should be clear and obvious reasons for doing so.

When the product is good, why change it?

W. N. P. Chapman
J. F. Chapman
Consett, Co Durham

It ain't broke so don't fix it

From Professor J. H. Perrin, MRPharmS

So The Pharmaceutical Journal has a non-pharmacist as editor. Pharmacist publisher Philip Brown (PJ, February 10, p186) has given simple and intelligent reasons for the post of editor to be filled by a current member of staff. His opinion was sought and subsequently rejected by self-proclaimed wiser administrators and Royal Pharmaceutical Society Council members.

What is wrong with the PJ at the moment? It seems most members feel that very little is wrong.

As a person with two passports resident overseas, I should say how proud we should all be of the PJ, particularly and especially because it has allowed free and open discussion unlike some other professional pharmacy journals I used to read. It is obvious that The Journal prepares itself from week to week because of the fine experienced staff, most of whom are pharmacists. Other publishers will be wanting to hire them, maybe even Philip Brown, and, of course, they are pharmacists.

What if those who are occasional contributors and are so necessary for the diversity of The Journal decide not to contribute? I cannot imagine that most of these authors write for financial reward. I have done it to take advantage of the free speech allowed by the previous editor Douglas Simpson.

Will this freedom be allowed in future?

The profits from The Journal are substantial. My friend, Phil Brown, has said all that is necessary, namely: it ain't broke so don't fix it.

John Perrin
Gainesville, Florida, United States

Views ignored

From Mr G. S. Phillips, MRPharmS

The letter from Philip Brown (PJ, February 10, p186) bears close examination. Mr Brown, himself a pharmacist, is also a successful medical publisher. He states that, in his considerable experience, the most successful way to replace an editor is to promote from within. He also says that the existing editorial staff, who have carried the PJ since the departure of the last editor, Douglas Simpson, are doing a good job, and that there are will be few other appropriate candidates for the post because it demands specialist knowledge and experience. I could not agree more. The existing editorial team are doing an excellent job, and I would like to commend them for it. The argument is surely incontrovertible. It is clear that the overwhelming majority of the membership wish to continue the fine tradition of pharmacist-editor. This opinion has been publicly supported by a previous editor (Mr Blyth), and now by an experienced publisher in the field (Mr Brown).

The Royal Pharmaceutical Society's Council has made its decision and appointed a non-pharmacist editor. As it has decided to ignore the voices of experience and the views of members, then one has to question for how much longer it will retain our confidence.

Graham Phillips
St Albans, Hertfordshire

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Physician-assisted suicide

Serious debate

From Dr B. O. Hughes, MRPharmS

I cannot see that Pamela Lyons's discourse (PJ, January 13, p53) on Greek contributes helpfully to the very serious debate on physician-assisted suicide. Neither do I think that to label Stephen Smith as "enjoying some irrational beliefs", because he quotes from Genesis, a particularly tolerant view of fellow beings. To argue that euthanasia does not actually mean what we commonly assume it to mean, simply because the meaning has deviated from its Greek root, does not allow for language to be living. The Concise Oxford Dictionary (1990) defines euthanasia as "the bringing about of a gentle and easy death in the case of incurable and painful disease".

There are two strands to the argument on euthanasia: (1) the need for pain relief from an incurable and painful disease and (2) the desire to determine for oneself a timely death, when one's life is no longer deemed useful or sustainable in one's own eyes.

In the first instance, the pharmacist clearly has a major role to ensure that his or her professional advice to medical and nursing colleagues enables the most effective relief from pain that is possible. To this end over the past quarter century, the hospital pharmacist in particular, together with the Macmillan nurse, has pioneered the expansion of good "continuing care" into the general community as well as in the hospice. The pharmacist also has the task of reassuring the public that in most cases (95 per cent is usually quoted) good management should bring satisfactory relief.

In the second instance, this is a more open public rather than professional debate. Here, views on faith, God and on such ethical issues as responsibility to others, be they family or the wider community, have an important place. I recall vividly the effect on the carers, let alone the family, of one person who took her life at a stage when good pain control and general symptomatic relief had been effected to enable a good degree of independence. As so aptly put by John Donne, "No man is an island."

Bryn Hughes
New Malden, Surrey

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Emergency contraception

Education and assessment

From Mr H. P. Radnan, MRPharmS

I have been a pharmacist for more than three decades, during which time the profession has arrived at many "crossroads". In each case, after all the hyperbole has died down, the import and impact, for the most part, has changed very little of the traditional practice of community pharmacy.

We are once again at a crossroads, but this one is major one. We have been given the opportunity to discard the image in which the profession is largely perceived by many other primary health care professions — an image however ill-conceived, in which professionalism plays second fiddle to profit. The profession is on the brink of a revolution in that the Government and other professions are at last prepared to recognise our knowledge and skills and to allow us to put these into practice in a way about which my generation could only dream.

Pharmacy development groups are implementing changes throughout the country. Pharmacists working under pharmacy group directions are at the cutting edge of professional development in permitting the pharmacists to prescribe and dispense prescription only medicines under agreed protocols.

Unfortunately, we have among us a handful of rogue pharmacists who are prepared to drag the profession into disrepute so long as they make a profitable sale. The television programme Tonight with Trevor McDonald is not the only occasion when rogue pharmacists have been spotlighted.

There is another category of pharmacist who is basically not a rogue but cannot be bothered to make the effort to acquire and implement the necessary knowledge to meet the new challenges. The programme depicted pharmacists selling emergency hormonal contraception who either had no idea what to ask the client or, if they did know, could not be bothered to follow the guidelines.

My suggestion, for the sake of the credibility of the profession, is that no pharmacist should be permitted to sell EHC until he has become accredited, by completing the Centre for Pharmacy Postgraduate Education course followed by satisfactory assessment.

H. P. Radnans
Salford, Lancashire

Ask for date of birth

From Mr C. J. Heathcote, MRPharmS

When clients ask for emergency hormonal contraception, I would suggest that one way in which pharmacists might be able to sort out the under 16s from the over 16s is by asking them not for their age but for their date of birth. It would be more difficult for them to invent an over-16 birth date on the spur of the moment without some hesitation or confusion if, in fact, they were under 16. As we have been forced into this unenviable position it might help us make the best of a bad job.

C. J. Heathcote
Hayling Island, Hampshire

No justice to the profession

From Mr M. A. Aziz, MRPharmS

The article regarding supply of emergency hormonal contraception, which appeared in the Daily Mail on Saturday, January 20, did no justice to pharmacy as a profession.

I was one of the London pharmacists who referred the 15-year-old young woman to the local family planning clinic. However, I was astonished by the article headlined "What you will read will shock you".

The message of the article was that pharmacists are not correctly regulating sales of EHC, which could promote abuse. The article placed a negative view of pharmacists in the public domain.

I spent a quarter of an hour reassuring this young woman while finding the nearest family planning clinic which was open and convenient for her to get to. However this was not mentioned.

Next time a young girl comes into our pharmacies for EHC will the decision to supply be based on our professional judgment or will it be influenced by thoughts of the media testing our professionalism? The latter scenario might result in a desperate, genuine patient — the type of patient this drug was deregulated for in the first place — being denied the product.

I cannot help but wonder whether, if no supply had been made by any pharmacies, there would have been an article commending pharmacists rather than condemning them. I guess not, as this would not sell newspapers, would it!

Asif Aziz
Ilford, Essex

Peanuts instead of proper remuneration

From Mr B. I. Stroh, MRPharmS

The supply of Levonelle emergency hormonal contraception in community pharmacy has not been properly thought out at all.

I suggest:

1. The consultation and the supply of Levonelle should be totally free to the patient
2. A form in triplicate should be signed by both the pharmacist and the patient at the time of supply
3. One form should be retained by the pharmacist, one by the patient and one submitted to the Prescription Pricing Authority
4. The PPA should then reimburse the pharmacy the full cost of the Levonelle plus a consultation fee of a minimum of £30

The present deal whereby the pharmacist is making a "giant" profit of £6 (PJ, February 3, p146) is a disgrace and an insult to the profession.

Pharmacists in the "New Age" who are willing to take on new responsibilities and tasks for peanuts instead of proper professional remuneration will have only themselves to blame when they end up in the monkey house.

Brian Stroh
London NW11

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Contract limitation

The demise of independent pharmacy

From Mr D. P. D. Nickels, MRPharmS

I would like to add my support to David Miller's letter (PJ, February 3, p149) regarding contract limitation. The conception of contract limitation was a knee-jerk reaction to so called "leap frogging". It was thought to be the saviour of community pharmacy from multiples which could afford to buy their way into doctors surgeries or to open a pharmacy as close as possible to the source of prescriptions.

I believe that the reverse is happening. Major multiples can still get hold of the contracts they require by being able to afford the legal costs of going to the high court or by buying a contract just to relocate it. The difficulty, for the independent and smaller groups, of getting a contract nowadays has caused a huge premium in the price for pharmacies.

With National Health Service revenues decreasing every year it has become impossible for newly qualified pharmacists to purchase a medium to large pharmacy. No bank is going to listen to a 25- to 30-year-old pharmacist with little or no collateral and whose income from NHS dispensing is dropping about a sensible business plan. That, again, leaves the larger multiples to cherry pick the best pharmacies.

The real danger is that pharmacy will become a profession of locums and store managers run by large corporate companies which are only accountable to their shareholders. How long before these stores, thinking that pharmacists are expensive, lobby Members of Parliament and the Department of Health, for qualified dispensing staff to be able to carry out our role?

I have mentioned the concept of removal of contracts to other pharmacists and their general reply is "how would you like Boots/Moss, etc, to open next door to you?". This situation, obviously, would not be ideal, but this is the free society we live in. In no other business could you stop another business from opening. In most other sectors of business the Government has promoted competition. There is no doubt that competition raises standards. It would mean that pharmacists and their staff would have to concentrate on offering services that the public desire and do so in a professional manner. In general it is independent community pharmacies that can identify and respond to the needs of the local population more specifically and more quickly that the multiple outlets.

I think that the notion of contract limitation, although created in good faith, in the long term will see the demise of independent community pharmacy.

Dave Nickels
Newquay, Cornwall

We can't turn back the clock

From Mr B. N. I. Bloom, MRPharmS

The letter from David Miller makes little sense (PJ, February 3, p149). On the one hand, he argues that the multiples are exerting undue influence and on the other suggests that the demise of contract limitation will somehow alter this situation.

Nothing could be further from the truth. The six or seven large multiples would like nothing better than to be opening pharmacies where and when they pleased. He would do well to remember that most of these pharmacies are not associated with supermarkets. These companies have the financial muscle to outbid for sites and staff. Mr Miller has not given any thought to those of us who are single-handers and whose positions and business investments would be lost by good old-fashioned leapfrogging.

The profile of our profession has always been high in the minds of the general public as the first recourse for health advice. It is not the number of pharmacies that is important but the quality of service offered. What he is moaning about is money and the thought that pharmacists are not paid their worth. Or, perhaps, he cannot get what he considers his share of a pot of gold. It seems to me that the present shortage of pharmacists has resulted in increases in remuneration across the board.

I detect a sea change in the profession. My family has over 50 years in community pharmacy and through our three generations close to 100 years in all branches of practice. I can assure him that the old days were not necessarily the good old days. As a family business, we lost two units to leapfroggers and spent a good deal of our time trying to protect ourselves from such occurrences. As I observe the new developments and read government policy, it is clear that turning the clock back is, I hope, not an option. The employed pharmacist has no need to worry about VAT, revenue returns, long unremunerative hours, buying and staffing. And, if Mr Miller has his way, the employed pharmacist will also have no need to worry about whether the 50 yards to the health centre will be filled by another caring professional. The privately owned pharmacy is not all about money to which many will attest and I would suggest that within a few years the private pharmacy will be the exception as we follow what has happened in optics.

As the future unfolds pharmacists will be able to exercise their expertise most of their working time. There will also be opportunities for advancement within these large companies for the commercially ambitious. We are also seeing health authority posts being created at reasonable salary levels.

As to Mr Miller's comments on the EU issue as portrayed by a biased newspaper, it is sad that he believes that those of our colleagues correctly exercising their professional judgment are letting down the rest of us when in fact it is those who grace the pages of the Statutory Committee reports who do us the greatest disservice.

Bryan Bloom
Leeds

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Thalidomide

Cancer research

From Ms J. L. Potter, MRPharmS

I learnt recently from the television news that research has commenced on the use of thalidomide in the treatment of cancer. It is now 40 years since the news first burst upon us that thalidomide had been withdrawn from medical use as it was causing babies to be born deformed. The reason for this was that it inhibited the cell division essential to the formation of the embryo.

At the same time, although a comparative layman on the subject, my first thought was that if thalidomide could stop cell division in an embryo, then maybe it could also stop the cell division which was the cause of cancer, thus deriving a little good out of the tragedy. Indeed, I remember reading shortly afterwards of a case in Israel when a patient was successfully treated with thalidomide for a tumour. In spite of this most encouraging development, the whole issue disappeared from the news, never to be heard of again until now.

Naturally, I am sure that we all wish the research workers every success in their belated endeavours but there is one thing which I would like to know. In view of the many lives which could have been saved during the period, why has it taken 40 years to follow such a glaringly obvious lead?

J. L. Potter
Prestwich, Manchester

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Medicines management

"Clinical" or "strategic" prefix required

From Mrs H. St C. Remington, MRPharmS

Douglas Simpson asks "What is medicines management and what is pharmaceutical care?" (PJ, February 3, p150).

He suggests a Department of Health intent of patient-centred, medicine-related services such as review, support, and structured medicines management (which includes patient interview, problem identification, structured assessment of medicines, together with discussion of issues such as side effects, drug interactions, poly medicine, and improvements to regimens with the patient's general practitioner). This he suggests goes by the name of pharmaceutical care in certain other countries.

He also suggests that there are other types of medicines management, too, eg, formulary management.

I agree that the profession should be clear about this matter, since the Government is now prepared to invest in providing opportunities for increased pharmaceutical care of patients, through medicines management — if you follow!

This discussion about terminology recently took place in a meeting of the Council with the Royal Pharmaceutical Society's senior staff. The conclusions were, briefly, that "medicines management" as a strategy has many components. These include the development and use of clinical guidelines and monographs, clinical trials and ethics committee work, management of unlicensed medicines, management of medication errors, adverse drug reaction reporting, development and management of patient group directions, management of patient records, audits of medicines use and prescribing, medicine information provision, managed introduction of new medicines and formulary management.

Another component is pharmaceutical care, as described by Mr Simpson. Effectively, this is medicines management for individuals at a clinical level. It involves choosing the best medicine, or none, for an individual patient embracing concordance, provision and follow-up; it is all that clinical pharmacy practice represents.

Chief pharmacists in trusts and pharmacists working in primary care groups and health authorities are generally engaged at the strategic medicines management level. Clinical pharmacists in hospital and community, at the sharp end, are more closely associated with patient-focused medicines management. Directorate or "lead" pharmacists in trust sub-organisational units begin to breach the divide, taking the patient focus to inform strategic work.

I therefore propose that a prefix should be added when using the term "medicines management": clinical medicines management (or pharmaceutical care) for the patient, and strategic medicines management for the organisation.

Helen Remington
Chief Pharmacist Addenbrooke's Hospital, Cambridge

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Community pharmacy

Independents are a dying breed

From Ms J. M. Wood, MRPharmS

I read the letter "Life's too short" from Murray Mochan (PJ, February 3, p148) with interest and a great deal of empathy.

I too handed in my resignation because I was fed up with difficult working conditions and diminishing job satisfaction.

My experience of working for a large multiple has left me disillusioned and I will now only work for carefully selected, small independents that appreciate the work that we do. I have come to the conclusion that the "big boys" are only interested in huge profits to the detriment of their staff morale and customer satisfaction. Perhaps in time they will come to realise this, as resignations escalate and recruitment becomes a constant headache.

My worry is that the small independents are a dying breed as the multiples, with their buying power, swallow them up.

How can we practise our profession properly when we have no time to counsel patients and no private areas in which to do so? For obvious reasons we have an obligation to continue our education but what other professions are expected to do this in their own time, evenings and weekends, and for no payment. As a profession we have been too willing to take on more and more for less and less. We are now paying the price for taking on additional responsibilities too readily for which the remuneration is paltry or non-existent.

Julia Wood
Leeds

Change necessary

From Mr B. McRoberts, MRPharmS

I think Brian Stroh (PJ, January 27, p114) was trying to say, however inadvertently, and what A. E. Humphress (PJ, February 3, p148) realises is that community pharmacies are unsuitable for the practice of pharmacy as a profession, and I am in complete agreement.

The present-day community pharmacy is first and foremost a shop — there is no point in trying to convince oneself or anyone else otherwise.

If the necessity for a sea change is not admitted, and sooner rather than later, the practice of pharmacy in the community will disappear forever and the remains will be distributed among those ready and willing to take over. B. McRoberts London NW9

Shaun
Exeter

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Pricing

In Barbados

From Mrs E. M. Kirton, MRPharmS

I feel compelled to respond to MSD's pricing policy, which the company feels gives doctors greater flexibility (PJ, January 27, p114).

In Barbados we are subject to the same policy. However, it is my experience that whenever two strengths of the same drug are available at the same price, more often than not, the doctor opts to use the higher strength, since it will make no difference in cost to the patient.

Elspeth Kirton
Christchurch, Barbados

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MMR vaccine

Mystifying decision

From Mrs K. E. M. Coull, MRPharmS

The Department of Health is to launch a £3m national publicity campaign in order to reassure the public that the MMR vaccine is safe (PJ, January 27, p104). It would surely make more sense to spend that money on research into why so many children are developing regressional autism and inflammatory bowel disease. Such research would reveal the true safety of the MMR vaccine. The Department of Health's decision is a mystifying one, and will do its campaign no good at all.

One further point is that the inflammatory bowel disease suffered by those children with regressional autism is distinct from Crohn's disease and irritable bowel syndrome. The inflammation suffered by these children mainly occurs in the ileum and such inflammation has not been reported before in the literature.

Kate Coull
Abergele, Conwy

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Aseptic manipulation

Risky practice?

From Mr R. A. Lowe, MRPharmS

I was rapidly sorting and discarding the cascade of junk mail that seems to pour through my letterbox every day when to my delight I found I had been sent the latest edition of Baxter Healthcare's pamphlet IV eye. Dropping everything, I avidly read the first article "A risky business — can we handle it?" commenting on some of the risks associated with cytotoxic reconstitution. I subliminally absorbed the message that my life would be easier if I entrusted such a fraught pursuit to an expert multinational such as Baxter.

My edification was complete when I studied the photograph that accompanied the article. The picture was of a lovely young woman carrying out an aseptic manipulation. Her stylish hair-do was unencumbered by any kind of headgear. The collar of her no doubt expensive blouse peeked out above her loose fitting dispensing jacket. Sadly, the shot was in profile but I suspect that if we could have glimpsed her fair visage, it would have been tastefully made up.

Were this woman's flowing locks and loosely gathered clothing meant to represent the risky practices of the National Health Service?

Robert Lowe
Wymondham, Norfolk

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Probiotics

Not a panacea

From Dr M. Kouimtzi, MRPharmS

As a probiotics researcher, I read with great interest the article by Pamela Mason on "Probiotics and prebiotics" (PJ, January 27, p118). Given the plethora of probiotic supplements on sale, I am sure that my colleagues in the community pharmacy business read it with great interest, too.

The author is correct in pointing out that the evidence on the efficacy of probiotics is inconsistent. However, what has been consistent, is the strong positive evidence in favour of a particular lactobacillus strain: Lactobacillus casei strain GG (otherwise known as L ramnosus). The main reason behind the promising results lies in the ability of the GG strain to adhere to the human intestinal mucosa.

However, before pharmacists start recommending probiotic supplements to their customers, they should be aware that their inoculation in tablet or capsule form is a complex and troublesome procedure, especially when long-term survival of these sensitive organisms is the aim. Minimal legislative requirements imposed by the Food and Safety Act 1990 have resulted in an abundance of poor quality "probiotic supplements". Consistent with the findings of numerous studies, including those mentioned by the author, I have never found a supplement from which I could grow probiotics, even under optimum laboratory conditions.

Every community pharmacist should think twice before reaching out and picking up a probiotics supplement to recommend as a panacea for all digestive disturbances.

Maria Kouimtzi
London NW11

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Hospital pharmacy

Teams of professionals

From Mr K. D. Ball, MRPharmS

I was pleased to read Ian Maidment's "Broad Spectrum" article concerning technicians (PJ, January 6, p12). I wholeheartedly support him and would like to point out that his prediction of a technician managing pharmacy services by 2015 has already been met.

We had an MTO5 technician managing the pharmacy where I work from 1995. This person has since moved on to become risk manager for the hospital and plays another important role covering the entire hospital. We have others who have already demonstrated their capabilities and my wish for the future would be a department completely free of pharmacists. They should all be based on the wards as integral part of the various clinical teams. They can still have their specialties but will only gain true credibility when they are at the patient interface around the clock and functioning as part of teams of professionals.

Ken Ball
West Cumberland Hospital Whitehaven, Cumbria

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Murphy's Law

Unexpurgated

From Mr W. Hilton, MRPharmS

John Wilson’s allusion to Murphy’s law (PJ, January 20, p84, and January 27, p114) is incomplete.

There is an important corollary which ought not to be missed, since it is complementary to, and supportive of, his thesis. But then perhaps this too, like his odd/old socks, became lost, not this time in the wash but, in his own words, "during the editing process".

Community pharmacists of more than a few years’ experience will be able readily to endorse, if not to recite, the unexpurgated Murphy: "If it can go wrong, it will; if it can’t, it might."

Walter Hilton
Owermoigne, Dorset

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