The Pharmaceutical
Journal Vol 267 No 7172 643-649
3 November 2001
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The Pharmaceutical
Journal Vol 267 No 7172 643-649 |
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Supervision
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Community pharmacy (4 letters)Promises, empty promisesFrom Mr O. Supyk, MRPharmS For many years now and following numerous reports, the Government and the Department of Health have promised an extended role for pharmacists. We have seen clear progress for nurses via Government-funded schemes such as NHS Direct, walk-in centres and nurse-led clinics. To me, the reason is clear: nurses operate from establishments already paid for out of the public purse. They work for doctors who are paid for by the tax-payer. In the light of the ongoing (for as long as I can remember) clampdown on public expenditure, do contractors seriously believe that significant new money will come our way? Instead we will be strung along for another two or three years only to find the same inflationary pay increase on offer. Any new services will be paid for by a reduction in pharmacy contracts. Perhaps this is the DoH's plan. By then, many of our colleagues will have closed down or sold their contracts to a multiple for relocation into a supermarket. The character and diversity of pharmacy will change forever because of a lack of vision on the part of the Government. Those losing out will be the public for they will not have ready access to the high street professional that they know and take for granted. I would urge the Pharmaceutical Services Negotiating Committee to demand a clear strategy from the DoH for pharmacy's extended role, together with details of funding. We need to know how much and when it will be available so that pharmacy can move into the 21st century. Action has to be taken now, otherwise pharmacists will be missed only when they are gone. Orest Supyk Put customers in their placeFrom Mr G. Diamond, MRPharmS I could not agree more strongly with John Wilson (PJ, 13 October, p504). Pharmacists to some extent have themselves to blame by being too soft on the issue of irate customers. If someone is trying to push ahead in the queue, then it needs to be explained to them, politely but assertively, that there are others in front of them and as soon as their prescription is ready then they will be told immediately. If they persist, their attention should be drawn to all the frail elderly patients that are sitting waiting for their shopping list of medicines and they should be told to stop winding up everyone else in the pharmacy. I can assure you with people being stabbed outside the pharmacy, muggings in the health centre, and sword-wielding gangs holding up local stores in central Manchester, an irate customer is the least of my worries. Gerry Diamond Bag designFrom Mr R. Leach, MRPharmS Most pharmacies miss a splendid opportunity to emphasise the personal service they provide to patients. The bag used for dispensed medicines should be designed to integrate better with the label produced by many pharmacy computer systems. This label, which includes the patient's name and address, is used to seal the bag. Immediately under this bag label the words "For your personal use" could appear. This gives prominence to the patient's name and it is be more likely to be read and checked when the bag is opened. This change should contribute to patient safety. The design could be further improved by removing most of the other safety slogans to reduce clutter. Different slogans could be printed on different bags. Many patients receive repeat prescriptions and over time would see all the slogans. Elegant design solutions should be sought. Robert Leach Pharmacy head lice scheme unkind to parentsFrom Ms J. Ibarra Community Hygiene Concern is a voluntary organisation set up in 1988 to help parents cope with head lice. Documentation of the everyday experience of affected families leads us to question the fairness of the pharmacy-based management scheme described in the PJ (8 September, p317). The reality is that "the failure rate for malathion ranges from 22–64 per cent and a staggering 87 per cent for permethrin" in the UK.1 Where there is resistance, the second pyrethroid in use, phenothrin, also fails.2 Why have the pharmacists in the scheme not been trained to tell it as it is? Suggesting two applications will overcome failure to kill the egg is intrinsically flawed. Apparently, the British National Formulary experts, the cited source of the advice, have a poor understanding of the life cycle of the head louse. Eggs take seven to 10 days to hatch and some lice are ready to leave the head, if the opportunity presents, six days after hatching. Any course of treatment must therefore be applied four times at half-weekly intervals to prevent the patient from becoming contagious between applications. However, such a harsh protocol is precluded by the product warning against exceeding one dose per week for three consecutive weeks. Fine-tooth wet combing with conditioner (Bug Busting) three to five days after medication, as proposed by the Department of Health,3 provides an excellent performance check.1 Substituting oil for conditioner is messy and causes havoc when it drips on clothes and soft furnishing. Ian Burgess, who expresses qualms about some conditioner ingredients, should bear in mind that the same ingredients are found in conditioners designed to be left on the head until the next hairwash. Very rarely would it be necessary to fine-tooth comb for two hours — most heads are clear of lice in 10 minutes or less of Bug Busting. When infestation is heavy, the number of lice removed at each stroke increases. It is really curly hair that takes extra time, not so much during fine-tooth combing, but in the preparation, which is when ordinary conditioner is helpful for straightening the hair comfortably, far excelling oils for this purpose. It is mistaken to suggest that two weeks' daily combing are necessary to clear an infestation. Four sessions of Bug Busting evenly spaced over the period are sufficient. What is essential, is assistance, enabling families to obtain the right combs and full, accurate instructions.3,4 Not to do so is to limit their chances of acquiring a useful skill, increasing dependence on failing insecticides at escalating cost to the public purse. The pharmacy-based management scheme aims to shift parents exercising their right to free head lice treatment for their children out of GP surgeries and into pharmacies.5 We are worried about ongoing support for families facing multiple episodes of infestation while their children go through primary school. There is hardly a parent who will not try medication promising a "quick fix" once, or twice, when recommended by a health professional. When access to the health professional is governed by registration at the GP practice, there is opportunity for privacy during consultation when a case history can be taken and adequate detection procedures explained. How can a pharmacist realistically instruct a client without a private consulting area and time, which many do not have? This is likely to be a confidence building exercise, requiring patience with clients who, as Matthew Shaw observes, have a certain reluctance to practise regular detection combing. Moreover, staff at a GP practice are made accountable for the advice given because the practice is responsible for aftercare, whereas in this scheme families are free to move from pharmacy to pharmacy making continuity of care difficult. This will impact particularly negatively on the most disadvantaged families, accentuating inequalities in health.
Joanna Ibarra |
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DINESH MEHTA, executive editor, British National Formulary replies: The BNF uses a wide range of expertise to construct its advice, taking into account formal evidence, clinical experience, drug information and current clinical practice. Its clinical advice is not just based on expert opinion. For head lice infestation, desirable clinical outcomes are eradication of head lice and a reduction of infestation in the community. Whereas the second outcome remains elusive, using an insecticide as advised by the BNF is effective and repeating treatment after seven days improves clinical success. In the face of this clinical outcome, speculation on how the advice relates to the life cycle of the louse is of limited relevance. The BNF follows developments on head lice treatment closely. This is manifested by constant adjustment of the text to reflect clinical research. We believe that the BNF's advice is consistent with current research and with recent advice from other authoritative bodies. JUDITH WELLS and MATTHEW SHAW, pharmacists involved in the Sunderland scheme, reply: The Sunderland service was set up to improve patient access to treatments for head lice infection. We recognise that wet combing has a place in detection and management of infection and also in proving the effectiveness of whichever method is used. In Sunderland, Suleo-M, correctly used, has proved to be 98 per cent effective and is the treatment of choice, with wet combing suggested as an alternative for families concerned about the use of chemicals. As medicinal products are subject to more stringent safety monitoring than cosmetic products, we recommend the use of olive oil BP as a detangling agent. During the training sessions (designed by the Medical Entomology Centre) pharmacists are shown the Bug Busting training pack to ensure they are fully informed on all treatment options. We note that the only published trial of Bug Busting (Lancet 2000;365:540) gives a cure rate of 38 per cent. We encourage pharmacists to decide the most appropriate treatment to recommend based on the evidence available. IAN BURGESS, director, Medical Entomology Centre, replies: Management of head louse infection has two components. Dealing with the individual case provides short-term relief. However, eliminating the infestation from the community must be the long-term goal. Currently we only have methods to achieve the former. Nobody has any realistic proposal for achieving the latter. Pharmacist prescribing initiatives are a step towards the first management option and can provide more information to the family than primary care medicine has been able to in the past. One suggestion for CHC , that the GP practice is best suited for these services, is not new (Maternal and Child Health 1996;21:142–6). It proved unsuccessful then because many GPs and their staff were just too busy, and some did not want to know. I do not suppose things have changed much. Thus, the most disadvantaged are probably more likely to benefit from the pharmacy prescribing schemes. |
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