Comment

Don't treat medicines like fruit and veg!

By Joy Wingfield

We live in an era of rising consumerism and of diminishing respect for expertise and authority. At the same time there is a growing assumption that the discipline of the marketplace is all that is needed to achieve quality goods at the lowest price. Retailers compete vigorously for a share in the fast-moving consumer goods market where people buy regularly and often, and for which the main driver of choice is convenience and price.

As pharmacists, we cling to a deeply held conviction that medicines are not ordinary items of commerce when everywhere around us are signs that neither politicians nor the public agree. Decades of advertising for over-the-counter medicines have contributed to the notion that these are considered by the public to be ordinary purchases to be dropped in the shopping basket or trolley along with the toilet rolls, nappies and hair spray. In short, they are commodities whose purchase is not perceived to warrant, in the main, any additional guidance or support, and when it is, “We'll ask for it, thank you”.

RPM challenge

Such sentiments are at the root of the challenge to resale price maintenance; they underpin the concept of the empowered consumer who can buy ever more sophisticated goods via the internet and they are behind pressure for wider access to, and direct-to-consumer advertising of, prescription-only medicines. When a Parliamentary Under-Secretary of State (Lord Hunt) states that “there is no reason in principle why medicines should not be sold or dispensed electronically, or by other forms of distance sale and supply, like mail order and delivery” and “[we] will introduce further controls if they prove to be needed”¹ (thus abandoning at a stroke the “precautionary principle”), then we pharmacists should examine closely which aspects of our practice are justified in the public interest and which are merely part of our heritage.

If goods are “commoditised”, then they become candidates for the full panoply of marketing techniques. We are all familiar with offers of “buy one, get one free”, “three for two”, “money off” vouchers, “100ml extra free” and “collect three labels and win an exotic Caribbean holiday”. As pharmacists we would recoil at seeing such techniques associated with medicines but there is little evidence that the Government or consumers feel the same way. There are no laws which proscribe such measures. There are simply two long-standing but shaky bastions: resale price maintenance and the pharmacists' Code of Ethics.

The RPM challenge has now recommenced. If RPM disappears, either sooner or later, there will only be a collective culture within pharmacy which maintains that it is unethical to persuade consumers to buy a medicine that they do not need or in a greater quantity than they need. The Code of Ethics only binds pharmacists and their employers; it cannot constrain other retailers. Such constraint could continue to operate in respect of pharmacy medicines, which at present are available only from pharmacies. There is a justification for RPM or a “margin” on this category of medicine to reflect the added value which should be delivered at the time of purchase and to maintain an adequate infrastructure of pharmacies from which to obtain pharmacy medicines.

At present, however, this constraint also applies to general sale list medicines when they are sold in pharmacies but not elsewhere. Is it a “public good” for pharmacies to protect the interests and sensibilities of their customers for both P and GSL medicines in this way? If so, then should not all purchasers of medicines be similarly protected? If not, should we acknowledge that our efforts are not recognised or appreciated and abandon them? Or are there alternatives?

Pharmacists would not readily accept a reduced duty of care over the medicines they sell to the public. Primarily, such a move would be an abdication of their training and professional vocation to use their knowledge to help the public to use medicines safely and effectively. There are also strong social policy objections since, if the pharmacist's input receives no tangible recognition, the public will gradually lose a readily accessible source of informed advice on the use of medicines. Requests for advice will revert to general practitioners and nurses; a complete reversal of the current policy trend to foster self-care and make full use of the pharmacist's expertise.

Alternatively, one might suggest the imposition of a duty of care equivalent to that in pharmacies on all retailers of medicines. If it is necessary for assistants selling medicines in pharmacies to be knowledgeable about medicines, is this not an equally valid safeguard which should apply in all outlets, including virtual vendors on the web? Should there be compulsion to provide an advisory service in all retailers to replicate the support which is available in pharmacies, at least on request? If a pharmacy undertaking more than 100 transactions an hour can implement training and the following of a protocol, then why not a newsagent? Simply to rely on labels and leaflets to be both comprehensible and pertinent to every consumer (“one size fits all”) is not enough. Explanation and discussion of the relevance and personal importance to a specific user of generic information is so often necessary for the optimal use of medicines. If it is necessary, it should be available everywhere.

Such a proposition is already probably too late. It is not too late, however, to protect all consumers of medicines from unwarranted commercial pressure. This would require new law, but scope already exists in secondary legislation to effect controls over availability of medicines and there are precedents to prohibit certain forms of medicines promotion.^2–5 While recognising that RPM should continue to be defended as the mechanism which secures for the public wide and varied access to the full range of medicines and to the services of the pharmacist, the profession should be pressing for other strategies to address the inequalities operating in the market for GSL medicines. Where pharmacy and non-pharmacy retailers are competing in the same arena the arguments for a level playing field are incontrovertible.

Public indignant

If RPM goes on GSL medicines, the general public is unlikely to register that their interests are being protected by self-imposed restraints in pharmacies. They are far more likely to be indignant that the incentives so freely available at their local garage convenience store never seem to be repeated at the local pharmacy. They will also not recognise the insidious risk of morbidity from over-medication or unwise self-treatment which will develop if “incentivisation” and the taste for conspicuous consumption spreads to medicines. If no positive measures are taken to resist the further “commoditisation” of goods that were once correctly and helpfully labelled as poisons, then pharmacists collectively will have missed an opportunity to restore a respect for medicines which should rate more highly than their price.

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