The Profession
Pharmacy plan
The Council
Council election
Primary care pharmacy
Exemption checking
Packaging
The Journal
Unwanted medicines
Diabetes testing

Pharmacy plan

Separate responsibilities

From Mr C. Ranshaw, MRPharmS

Maurice Hickey (PJ, February 3, p148) states that the "national pharmacy plan" is relevant to both England and Wales. "Pharmacy in the future — implementing the NHS plan", launched by Lord Hunt at the British Pharmaceutical Conference last year (PJ, September 16, 2000, p397) refers only to England. The foreword by Philip Hunt states: "This document is our vision for the place of pharmacy in the new NHS in England."

It is important that your readers in all parts of Britain are clear that the Government administrations in each of the three countries (England, Scotland and Wales) are entirely responsible for their country's policy development and implementation for health and social services.

The National Assembly for Wales has recently published the strategy "Improving health in Wales — a plan for the NHS with its partners" (PJ, February 10, p175). The strategy clearly acknowledges pharmacy as an integral part of health and social care provision. It gives a commitment to consider the recommendations of the Assembly's Task and Finish Group on Prescribing, whose remit includes improving prescribing and provision of pharmaceutical services. There is also emphasis in the strategy on the development of the public health role of all health professionals. More detail will emerge when the Primary Care Strategy for Wales is issued for consultation later this year.

Colin Ranshaw
Chairman, Welsh Executive, Royal Pharmaceutical Society

Why not pharmacy?

From Mr D. J. Livingstone, MRPharmS

Following the lavish praise bestowed on Lord Hunt by the President following the publication of "Pharmacy in the future", can we assume that Mrs Glover will be equally vehement in her condemnation of the exclusion of pharmacists from the NHS web plan (PJ, February 17, p206)? May I also suggest that the President addresses her comments to the organ-grinder (Mr Milburn) rather than the monkey (Lord Hunt); it appears that other health care professions deal with Secretary of State, so why not pharmacy?

Duncan Livingstone
North Lancing, West Sussex

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The Council

Who is in charge?

From Mr W. B. Rhodes, FRPharmS

Congratulations on your appointment as editor of The Pharmaceutical Journal. You are obviously highly qualified and in the opinion of the appointing panel must have been the best candidate for the post. As a profession we must wish you well and support you in your efforts on our behalf.

However, it does seems strange that your appointment appears not to have been considered by the Officers of the Royal Pharmaceutical Society (PJ, February 17, p213), that the staff of The Journal had cause to complain to the Council (ibid, p219) and that Dr Appelbe, a senior member of the Council, complained to the President (ibid, p213).

To adapt the well known definition, "democracy is government of the profession by the profession". If your appointment was not made by the Officers and the Council knew nought about it until after the event, who is in charge?

The Council would surely not allow major decision making to bypass them and be in the hands of administrators who are nowadays very largely not members of the profession?

W. Bruce Rhodes
Winchcombe, Gloucestershire

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Council election

Attendance records

From Mr I. M. Caldwell, FRPharmS

The Journal of February 10 (p200) gave notice of the 2001 Council election. Among the tiny print on a dark background, under the heading "Retiring members", was recorded the attendance at Council meetings by those members. This nod to transparency was agreed by the Council some time ago but it does not quite tell the whole story. It does not let the membership know if any Council members have snapped shut their briefcases and departed before the agenda is completed. More importantly, it does not give any account of members’ attendance at meetings of the committees of the Council to which they may have been appointed.

If the attendance records are intended to guide voters, would it not be better to set them out in full?

Ian Caldwell
Larkhall, South Lanarkshire

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Primary care pharmacy

Controversial scenario

From Dr T. Beard, MRPharmS

We are a PMS Plus pilot practice in North Derbyshire. As such we have considerable latitude to develop services and explore new ideas which may be of wider benefit to primary care. Our budget in all key areas is set by agreement with the health authority. The exception to this arrangement is the prescribing budget which is set, in the usual way, by our primary care group.

Recent (internal) discussions have included the inefficiencies of the system by which we "buy" medicines for our patients. These have been widely considered and include the inequities of prescription charges, the lack of control over drug prices, the waste which occurs when newly prescribed drugs are ineffective or not tolerated and the pharmacy remuneration system which remains skewed to favour prescription volume. Would there be benefits to patients, the practice and the National Health Service if we were able to use our drug budget to purchase directly the drugs our patients require and to distribute them? Would such a system be legal and might it be financially viable?

We could, of course, purchase a pharmacy contract, although it is unlikely that one would be for sale within our area and this is an expensive option which addresses none of the above issues. If we were able to negotiate to receive our prescribing budget in cash (as we essentially do for all other aspects of primary care) we would be free to explore some radical ideas. We might set up a non-contract pharmacy. It would then be necessary for us to issue private prescriptions to all our patients. I understand that this is now possible for patients otherwise treated under the NHS, usually when there is a price advantage for the patient who pays prescription charges. This would allow us to explore alternatives to prescription charges for our patients such as no charge at all, a nominal charge, or an annual dispensing fee. We would negotiate with suppliers to maximise our discounts (with no clawback) to cover our costs. We could develop the idea of e-pharmacy to supply patients of our satellite surgery in a neighbouring town and would provide pharmacy services to the community. Repeat prescribing by instalment becomes possible and many of the issues around the electronic transfer of data from prescriber to pharmacy disappear.

Patients would benefit from a faster and cheaper service. We could issue starter packs for new medication. Our budget would purchase drugs at cost. Such a pilot scheme would provide a strong incentive to remain within budget and there would be no need for the bureaucratic intervention of the Prescription Pricing Authority. We would not need a large overdraft to fund tardy payment. Prescribing statistics could be extracted from the practice computer system. There would, I believe, be no need for an Act of Parliament. The logical extension of this, when other practices joined the scheme, would be for the health authority or PCG to negotiate prices and achieve better discounts to the ultimate benefit of the taxpayer.

But do the numbers stack up? A budget of £750,000 would yield a potential gross profit of £112,500 at a discount of 15 per cent. If we make savings we take control of our margin. Obviously there are considerable start-up costs. But savings can be made from reduced bank charges and lack of clawback along with the possibility of negotiating for container allowances or even a proportion of dispensing fees. Even taking into account the discount element within the budget and the loss of prescription tax revenue, this begins to look like a viable proposition.

The flaw in the argument, as I see it, is the nature of the "prescription" issued for the supply of medicines at NHS expense. Can we legally "give away", or charge a nominal fee for, the drugs we have purchased?

As an ex-proprietor I realise that this scenario is highly controversial, but if we have thought of it then others have too. I admit that we have done almost no research to support our ideas and look to your readers to save us the trouble by proving that this cannot be done. Or have we seen the future?

Tim Beard
Prescribing Support Pharmacist
Goyt Valley Medical Practice, High Peak, Derbyshire

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Exemption checking

Dirty work

From Mr A. R. G. Calder, MRPharmS

In response to the letters from Stan Wheatley and Andrew Low (PJ, February 10, p188), I would urge all community pharmacists to write to their local pharmaceutical committees prior to the March conference urging them to support the action that we or our staff are no longer willing to accept responsibility for or to participate in prescription exemption checks. My opposition to involvement in such checks remains stronger than ever, having seen the impact on pharmacy of the work involved.

The verbal abuse, resentment and loss of professional esteem as mentioned by Mr Wheatley are experienced by most pharmacists and their staff and there is now a great temptation to avoid it all by merely saying to the patient: "Sign the bottom section and tick which box you think applies" and let someone else check the declaration’s validity.

What happens now if the "sacred" Part 3 is not signed? Switching of prescriptions from "exempt" to "paid" occurs and the subsequent "theft" of payment from us. The Prescription Pricing Authority does not even have the courtesy to return any (obviously exempt) prescriptions to us for re-signing.

Let the LPCs voice the views of the majority of pharmacists and tell the Government to do its own dirty work in seeking out prescription fraud rather than expecting pharmacists to do it.

Andrew Calder
Wigan, Lancashire

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Packaging

Standardised expiry dates, please

From Mrs A. M. Brown, MRPharmS

It would be helpful if expiry dates on all medicines could be standardised throughout the world, and written in a clear manner.

Having worked in a developing country and having had to sort out donated medicines, I have found it extremely difficult to ascertain when a particular medicine expires because of the many different methods of dating and the fact the some expiry dates were illegible.

Ann M. Brown
East Malling, Kent

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The Journal

A comment

From Mr H. R. Patel, FRPharmS

The Journal of February 17 (p214) quotes me as saying that Council election canvassing restrictions should be retained. In reality, what I had said was that, for the time being, in the absence of viable options which incorporate the principles of fairness, equity, and education about issues and democratic principles, I am not able to support any change in policy on canvassing during Council elections.

I also wish to make it clear that I have never voted in any forum for a non-pharmacist to edit The Pharmaceutical Journal. And this was clear in the closed session of the February Council meeting. It has to be said, however, that the vote in favour was an overwhelming majority and my view would not have made any difference to the outcome.

Hemant Patel
Brentwood, Essex

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Unwanted medicine

Time for a rethink

From Ms T. Gibson

The Royal Pharmaceutical Society, in its Code of Ethics, is rightly concerned about the redirection of unwanted medicines to developing countries. Guidance on obligation 1.21 of the code states that "no medicine supplied to or returned by an individual is included" and that "a specific list of which medicines are needed is provided". I believe it is time this guidance was rethought.

Until recently, most medicines likely to be returned to community pharmacies, would have been dispensed loose in bottles. There would have been no indication of batch number or expiry date, and the condition of the medicine would indeed be uncertain. Patient packs have changed this situation. Most returned medicines are sealed individually in foil. To suggest that they are no longer fit for use is tantamount to saying the medicines in people's homes are unfit for their consumption. Although it is not possible to verify the storage conditions in patients' homes, it would seem likely that most medicines would be viable and therefore safe to use.

Each day community pharmacies, including the one in which I work as a dispensing technician, receive returned medicines, usually accompanied by the fervent hope that they will not be wasted. At present our hands are tied. Disposal of the medicines is potentially damaging to the environment; morally, in a world with huge differences in wealth and access to health care, such wastage is not acceptable.

Regarding the "specific list", when doctors seeking our help are asked what medicines they require, they say "anything you can let us have". Many of us working in community pharmacy have had links with people who can safely deliver medicines to places where they are required.

When governments of the developed parts of this planet are beginning to break the chains of debt for developing countries, how can professions morally justify the denial of medicines, of no value, to those who can least afford to pay and who are in desperate need? After all, pharmacy is allegedly a caring profession.

Tricia Gibson
Great Dalby, Leicestershire

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Diabetes testing

Beware of false negatives

From Mrs I. Gummerson, MRPharmS

A pharmaceutical company is at present marketing its urine testing sticks, for sale in community pharmacies, for people to self-test for diabetes. Urine testing is not the optimal method of identifying potential cases of diabetes as it has a sensitivity of about 80 per cent (therefore potentially missing 20 per cent of cases). The concept of detecting glucosuria earlier than otherwise, and then visiting one’s general practitioner or nurse (to access diagnostic laboratory tests), seems a logical one. The earlier diabetes is detected and advice or treatment adhered to, the lower the risk of complications developing.

I have a concern about the possibility of false negatives occurring with the tests (especially in over-70-year-olds). A test showing a negative result may reassure a person that they do not have diabetes. But that person may in fact have a high renal threshold or impaired glucose tolerance (which has the same risk of complications as frank diabetes).

If pharmacists wish to sell such testing sticks, then perhaps they could reinforce the following information as appropriate:

• The test should be carried out two hours after a main meal
• Excessive amounts of fluid should not be drunk at that time
• Patients should be asked if they are on any medication
• If the person has risk factors (eg, obese, over 40, south-Asian origin) and symptoms of diabetes (eg, thirst, incontinence, lethargy), he or she should be referred to their general practitioner
• If the person has risk factors but no symptoms and the test is negative, he or she should bring up their concerns about developing diabetes next time they need to see their GP or nurse.

Irene Gummerson
Wakefield, West Yorkshire

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