Pharmacist prescribing
Unwanted medicines
Exemption checking
Controlled drugs
Fraud
Drug administration
Depression
Acronyms
Industrial pharmacists
Foot and mouth disease
The Society
The Journal

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Unwanted medicines

Anything can be better than nothing

From Miss D. P. Browne, MRPharmS

With regard to the issue of drug donations to other countries, I feel that John Ferguson (PJ, March 10, p310) dismisses Tricia Gibson's letter (PJ, February 24, p251) too easily. But why are unwanted medicines being returned to pharmacies anyway? The answer is that they have not been used by the patient for whom they were intended.

The Royal Pharmaceutical Society is rightly promoting the idea of pharmaceutical care to ensure best use of medicines and hospitals are moving towards such ideas as use of patients' own drugs. Yet our wider society continues to return millions of pounds worth of unused medicines every year. Is it not incumbent on us, the richer countries, to use our resources properly?

In a developed country there is a choice between recycling returned medicines or replacing them with fresh stock.

In many economically poorer countries the stark choice is to use recycled returned medicines or to do without. Thus “anything” can be better than “nothing”, providing it falls within the required group of medicines. And let us not forget that “nothing” may well be what is donated by those who adhere to current guidelines; after all, who is willing to donate whole containers of useful, in-date stock?

Perhaps we in Britain have things to learn from less well-off countries about the economic use of medicines. Had Mr Ferguson ended his letter, “In the interests of the environment, the Health Service economy and the rights of our fellow men throughout the world, we are prepared to consider recycling suitable returned medicines”, I think that Ms Gibson and I would not have been alone in applauding.

Dorothy Browne
York

Recycling not ideal but necessary

From Mrs P. Bradshaw, MRPharmS

During the past 20 years I have been privileged to be able to visit many health care facilities in underdeveloped countries, mainly in Africa. Martin Palmer (PJ, March 10, p310) says that people should not be treated as second-class citizens with “cast offs”, but has he experienced the reality of the world? In one country in Africa that I visited recently the government spends £2 per person per year on health care, compared with, I believe, approximately £700 in Britain. People in these countries are often expected to pay for medicines they are prescribed and most inhabitants cannot afford to. The debt repayments of this African country to the west were £6 per person per year.

The levels of inequality and injustice in the world continue to rise. The United Nations has just stated that the gap between the richest 20 per cent of people in the world and the poorest 20 per cent has increased by 200 per cent in the past 40 years and that 1.2 billion people live on less than 60p a day. Furthermore, two billion people still do not have access to clean water, never mind health care and education.

Most countries now have a list of essential drugs that are appropriate to local conditions. Tricia Gibson (PJ, February 24, p251) states that some of us have links to hospitals and clinics in the underdeveloped world where shelves may be bare. However, ill-considered donations of any drugs will cause problems and, as John Ferguson (PJ, March 10, p310) says, drug donations should be based on the expressed needs of staff in clinics and hospitals and should also comply with the essential drugs list of the country. Drug donations are not the best solution, but parents of a dying would not care where the in-date antibiotic that they were offered came from. And patients dying painfully from AIDS would be grateful for any in-date, foil-packed painkillers.

Until the inequalities of this world are acknowledged and addressed by us all, there will, thankfully, always be some people who observe a particular need and try their best to help — hopefully in an informed and professional manner.

Pamela Bradshaw
Castle Donington, Derby

When respecting expiry dates is difficult

From Mr G. A. McCormick, MRPharmS

I have read with interest the correspondence on the charitable donation of unwanted medicines as I have been involved in it for the past seven years as a volunteer. Initially, medicines returned to pharmacies seemed to be the best source for charitable donation. However not only was this in conflict with all guidelines, but the donations were mainly unsuitable because they were damaged, opened or dirty. There were also stability considerations.

The charity that I assist is small and cannot afford to purchase significant quantities of medicines. We have managed to supply medicines valued in excess £100,000 for several years. We obtain our supplies from casualties of the distribution and storage chain. For example, a cough medicine does not need an undamaged carton if the bottle and label are clean, undamaged and carry the batch number and expiry date. The unsuitable materials are returned to their source for destruction. The medicines are sorted into therapeutic classes as defined in the British National Formulary.

To qualify for donation they must carry the batch number and an acceptable expiry date, normally six months later than the sorting day. This is shorter than the World Health Organisation requirement but the circumstances are different. The WHO sets its standards on the advice of the industry which is keen to see that its interests are served. The industry insists that the materials must have a shelf life of one year on receipt in the recipient country and be accompanied by an analytical certificate. These certificates are only available if a significant purchase is made. Companies want to sell medicines but most charities are poor. Companies supply to a distribution chain, whereas we deliver direct to the clinic.

Our donations do not harm the sales of the industry as we supply to the poor who do not receive free or cheap medicines from a health service. My recipients are in a second world country in Eastern Europe where there is a great disparity in the wealth of the population. The normal wage is £15 per week and the Western medicines are more expensive there than they are in Britain. Hence a visit to a pharmacy is out of the question for most patients. We only supply to a few doctors who have proved to us that they are honest and caring. It is rewarding to visit them and see that all that we send is being used for the patients.

The whole activity of charitable supply must be of the highest quality and integrity and be conducted on a personal basis to ensure that the right products are used to treat the patients. Continuity of supply is important, as it is here.

We all saw Anneka Rice take the accident and emergency department from Scotland to Romania. At the end of the programme she walked through the stockroom and thanked the companies for their donations of medicines, etc. A few months later the stock had all been used and it was left to charities to maintain the supply. The original donations had been written off to special advertising. That unit is still operating with no government support but totally supported by Western charities. It is still the envy of the rest of the country.

I was talking with a consultant from one of these countries who wanted me to send out all the materials I had received. I disagreed with him and insisted that I respected the expiry date. He said that he had successfully treated a patient with an antibiotic that was five years out of date. I replied that I thought that his action was criminal. His reply was: “What else could I do? I had nothing else to use!”

G. A. McCormick
Bingley, West Yorkshire

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Exemption checking

Risk of violence

From Mr S. S. Kalsi, MRPharmS

It is almost a year on since we were dragged unwillingly into performing point-of-dispensing checks and the going is not getting any better. At the counter, my staff struggle with variations of “Why do you not pay a prescription charge?”. Customers simply shrug and admit to the first exemption that sounds good to them, or get belligerent, saying “you are the only people to pester us”. Some sound threatening and a few just look at us in disbelief.

At the moment we reach for the circle and plant a tick, letting us off the hook. There will be a time though, when we will not be able to do that and at that point the potential violence, only imagined now, will materialise. I speak from experience because I am also a postmaster. We do not pay Girocheques without identification and we see violent, abusive and threatening scenarios almost every week.

Is this what pharmacists and scientists should be doing? For 2p we are losing goodwill and credibility, painstakingly built up over the years. Additionally, I believe that this is creating a barrier between the pharmacist and the patient.

This is an exercise that demands a better-thought-out rebirth, if not a total death.

S. S. Kalsi
Barking, Essex

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Controlled drugs

Record keeping

From Mr A. Bellingham, MRPharmS

I disagree with Stephen Axon that the additional recording suggested for Controlled Drugs in the Shipman report would not solve anything (PJ, March 10, p302). Records of batch numbers would allow tracing of supplies of CDs providing a good audit trail. Dr Shipman kept patients' drugs — a record of batch numbers would have allowed his stocks of CDs, if inspected, to be traced to individual patients.

In addition, I do not believe that pharmacists would expect to be paid for additional record keeping. Apart from the fact that it would take little time to note a batch number in the CD register, it would be a positive move for the profession in helping to solve the problems that the Shipman case has revealed.

Andrew Bellingham
Staplehurst, Kent

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Fraud

Situation clarified

From Mr M. Siswick

In response to G. C. Trask (PJ, February 10, p187), I write to say that the Prescription Pricing Authority (PPA) has not undertaken any “undercover checks at pharmacies”, nor has the authority any plans to implement such a programme. Since June 5, 2000, the responsibility for investigating pharmaceutical fraud has rested with the Counter Fraud Operational Service, a part of the Directorate of Counter Fraud Services (DCFS).

The PPA fraud investigation unit, now retitled the PPA compliance unit, is the body responsible for undertaking checks on claims by patients for exemption from prescription charges, recovery of charges unpaid, the application of penalty charges to wrongful claims to exemption occurring on or after December 1, 2000, inquiry into potential irregularities and the administration of the Pharmacy Reward Scheme.

Checks of the type referred to by Mr Trask are not part of the PPA's responsibilities and are carried out by DCFS personnel or staff managed by that section within the Department of Health.

I hope this clarifies the situation.

Mike Siswick
Director of Human Resources and Compliance
Prescription Pricing Authority
Newcastle upon Tyne

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Drug administration

Forcing functions

From Mr A. C. Greenberg, MRPharmS

The prevention of errors of drug administration to patients is of major concern to hospital pharmacists. The recent inadvertent intrathecal injection of vincristine at Nottingham is a tragic case which demonstrates the catastrophic results of some errors. One way to reduce errors is with forcing functions.¹

Forcing functions are design features that make it impossible to perform a specific error. They are used with oxygen and nitrous oxide connections in anaesthesia to prevent errors of translocation.

We use this principle to prevent errors of the Nottingham type. All intravenous doses of cytotoxic drugs are diluted to at least 50ml and supplied in minibags. This makes the intrathecal administration of an intravenous dose highly unlikely.

Reference
1. Cohen MR (editor). Medication errors. Washington DC: American Pharmaceutical Association; 1999.

Alan Greenberg
Jerusalem, Israel

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Depression

Under-active thyroid?

From Mrs M. E. M. Martin, MRPharmS

Why cannot all people complaining of chronic fatigue and depression be tested for under-active thyroid? Mine was only diagnosed last year when I had blood tests for arthritis. I had felt under the weather but thought the symptoms were mild depression, for which I took vitamin B₆ and which helped at 50–100mg daily. I never bothered my general practitioner unless my symptoms were severe.

I strongly suspect my mother had an under-active thyroid. She had had symptoms at the age of 16, for which she took iodine drops. However, from the age of 42 she always complained of unnatural fatigue and that she did not know why she was so tired. She had some serious attacks of depression, even having shock treatment in the 1970s. Her “depression” had started in 1947 and from the 1960s she was on antidepressants all the time, but they never helped her energy levels or stopped her getting severe nervous breakdowns. One of my sisters and two female cousins have also been diagnosed with underactive thyroid.

Tricyclics can mask slow heartbeat by causing palpitations but many symptoms of depression are the same as hypothyroidism: exhaustion, lack of energy, feeling cold, constipation (and irritable bowel syndrome). I think depression is more than a mood disorder and any physical symptoms should be treated seriously.

Margaret Martin
Cheltenham, Gloucestershire

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Acronyms

Driven to distraction

From Mr M. Goldin, MRPharmS

Nearly every article in a medical or pharmaceutical publication contains numerous acronyms, many of them introduced without explanation. It is driving me to distraction. I feel it is now time that somebody published a reference book listing all the known acronyms relevant to our profession. It would even be a good idea if a medical or pharmacy school could establish a department solely devoted to acronyms. Could we persuade a major drug company to sponsor a chair in this field? As a matter of interest is there anybody out there who knows what the acronym HONK stands for without having to look it up? And no cheating! I am thinking of getting myself a car bumper sticker with the words “Honk if you love acronyms”.

Monty Goldin
London NW11

Hyper-osmolar non-ketotic coma.

There is an internet website devoted to acronyms commonly used in pharmacy. (HONK is not on it!) The website can be found at www.pharma-lexicon.com.
— EDITOR.

Acronyms are now on the Notice-board; you can find them here. Please send contributions (that are not in pharma-lexicon.com) to gowan.clews@pharmj.org.uk.

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Industrial pharmacists

Benefits queried

From Dr C. M. Minchom, MRPharmS

I am an industrial pharmacist and I have been a member of the Industrial Pharmacists Group for the past 14 years and have worked in Canada for the past year. With the discontinuation of the Industrial Pharmacist and hence my primary link with the IPG, like Michael Gamlen (PJ, January 27, p113), I now query the benefits of retaining membership of the Royal Pharmaceutical Society. Unlike their community and hospital colleagues, unless an industrial pharmacist is a qualified person, membership of the Society is not mandatory.

I understand that the action of discontinuation of publication should save the Society approximately £22,400 per annum. From a back of an envelope calculation, I estimate that it would take less than 10 per cent of the remaining 2,055¹ practising industrial pharmacists to leave the register to annul the supposed savings, after making an allowance for the variable costs associated with servicing the individual members, eg, provision of the PJ.

Perhaps the bean counters should have talked to the membership or at least the membership's representatives before putting their figures before the Council.

Reference
1. Bone A, Twitchell A. Survey of industrial pharmacists, 2000. Industrial Pharm 2000;19:4–5.

Colin Minchom
Toronto, Canada

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Foot and mouth disease

Sympathy

From Mr A. G. M. Madge, FRPharmS

Our thoughts must be with our agricultural and veterinary colleagues. The effect in the farming industry and rural areas of the apparently uncontrollable advance of foot and mouth disease is catastrophic. The killing of fit animals on suspicion of contact with the disease has now brought farmers to query Government policy. There is no doubt that everyone in whatever position is doing their best. Our colleagues are caught up in the problem and our thoughts must go out to them.

Perhaps I could echo what one farmer said which sums up the terrible situation of a lifelong devotion to an industry: “All I have left is two dogs.”

Mervyn Madge
Plymouth, Devon

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The Society

Consultation periods too short

From Mr S. A. Wheatley, MRPharmS, and others

The consultation paper from the Health Act working party, “Reform of disciplinary procedures and the introduction of competence based practising rights”, was distributed with The Journal of February 17. The deadline for comment was March 28 (we now believe that this date has been brought forward). Thus the Royal Pharmaceutical Society's members were given only five weeks in which to respond.

Revisions to the Code of Ethics were introduced for comment some two years ago. The Journal of March 10 contains a largely rewritten version of the 1999 proposals, comments on which are invited by “the end of March”. Thus members have but three weeks to respond.

The consultation paper and the code revisions contain significant implications for the future practice of the profession and impact upon all pharmacists. We suggest that the consultation periods are far too short for careful thought and proper consideration to be given to these important matters. It is impossible for the Society's branches, membership groups and special interest groups as well as other pharmacy bodies to convene appropriate meetings within these periods. We urge that the consultation periods be extended.

Stan Wheatley
Blandford Forum, Dorset

Peter Walker
Sowerby Bridge, West Yorkshire

Charles Smallwood
Croydon, Surrey

Mrs SUSAN SHARPE (director of professional standards, Royal Pharmaceutical Society) replies:

We apologise for the short periods given for consultation on these important papers.

In the case of the Health Act working party paper, the working party has had to respond to a tight deadline necessary to meet the timetable set by the Government for preparing the amending Order. There will be a further consultation on the draft Order itself when this is published by the Government, but the working party considered it important for the profession to consider the issues and make proposals. As is made clear in the paper, the substance of the proposed changes to the disciplinary machinery is in line with ideas that emerged from a full consultation in 1998.

The Ethics working party published its draft Code of Ethics in September, 1999. Since then changes have been made in the light of responses to that consultation and legal developments, and following further reflection and consideration by the working party. We decided that the profession should have an opportunity to see the results of this work, so that any additional comments could be submitted before the annual general meeting.

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The Journal

Widening of editor's duties?

From Mr R. Blyth, FRPharmS

Rightly or wrongly, I am suspicious of the claim by Ann Lewis (PJ, March 3, p284), dismissed as false by Douglas Simpson (PJ, March 10, p314), that the remit of the editor of The Pharmaceutical Journal had been extended to include “the wider world”. Miss Lewis will not, however, admit defeat and she provided a footnote to Mr Simpson's letter: “Surely, we want to communicate to (sic) this ‘wider world' of readers.” My suspicion is that this spurious widening of the editor's duties was put forward as some justification for a non-pharmacist editor who would, of course, understand better the mind of the “wider world”. I do not exclude some other hidden agenda.

I agree with all that Mr Simpson wrote, and would add that when I was editor I communicated through The Journal with a wide world, from threatening lawyers to all sorts of pressure groups, even people in dire distress like the father (not a pharmacist) whose daughter had disappeared in strange circumstances (he sought my help in publicising the matter), to medical editors, members of other professions, politicians of all hues and importance, and the rest.

I conclude by quoting a former President of the Royal Pharmaceutical Society (David Coleman), writing in the sesquicentenary issue of the PJ: “[The Pharmaceutical Journal] is certainly read widely throughout the world by pharmacists and by others who want to have definitive news of developments of pharmacy in the United Kingdom” (PJ, July 6, 1991, pJ1).

Robert Blyth
Milton Keynes, Buckinghamshire

Amusement

From Mr D. C. Shenton, MRPharmS

Well done! You have brought a little amusement into our lives just when we needed it. At a time when battles are being joined over the process by which you arrived in our professional world, when the Royal Pharmaceutical Society has notified its intention soon to unleash a fierce dog called Competence Based Practising Rights, and the Treasurer says he faces extreme financial pressures, you give us the wonderful news that immortality may perhaps easily be gained.

I refer to the piece based on a Lancet article (PJ, March 10, p307), headed “Risk of death reduced by eating just one serving of fruit or vegetables a day”. It tells me the risk reduction may be as much as 20 per cent with each extra portion. Thus, if I eat enough extra, it seems as though I can avoid the grim reaper altogether.

Disregarding the question of different sorts of risk, I fear that you have confused death (an event) and mortality (the pattern of occurrence of that event), at least at the start of the piece when you are not taking wording directly out of the Lancet paper, which presumably does not make those claims.

Never mind: it is a trivial thing (I very much hope) and it provided a giggle for the retired.

David Shenton
Staines, Middlesex

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