The Pharmaceutical Journal
Vol 269 No 7228 p844-845
14 December 2002

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Letters to the Editor

Community pharmacy

Consequences of skill mix changes not fully discussed

From Mr P. Cattee, MRPharmS

If I may be allowed to respond to the letter from Brian Curwain (PJ, 30 November, p779) and expand these complex issues a little. It seems to me that he is calling for substantial amounts of pharmacist time to be based in medical practices, rather than pharmacies, and that he is prepared to accept the consequences of that with little regard for what they may be. Although he may see this as defending what I would call "today's", rather than "yesterday's" territory, we should remember that what we are really talking about is the provision of services from pharmacy premises.

Presumably a decision has been taken in New Forest Primary Care Trust that the medication review clinics mentioned are more effectively carried out in a surgery setting. This may well be a sensible decision, particularly given the reluctance of the National Health Service to allow community pharmacy to become integrated into the patient information network. But it seems to me that it will continue to drive the divide between the provision of service development and the supply function.

My own experience in community pharmacy reminds me not so much of a place of "outdated rules and working practices" as a service stretched beyond sensible limits as it tries to accommodate repeated volume increases against a background of insecure funding. Indeed I would suggest that the effects of the pressure caused by this are one of the prime reasons for the current "shunning" of community pharmacy by increasing numbers.

Although we should undoubtedly review working practice I do not believe that we have yet fully discussed the consequence of potential skill mix changes. We have certainly not provided sufficiently robust dispensing and checking systems to facilitate a rapid move to technician-led services. We have no idea of a potential financial model for such service provision, although the Royal Pharmaceutical Society already seems to have embraced it. And as the most practical objection of all, I see no sign of an abundance of staff being able to take on this responsibility for a considerable period.

I would hope that in the future more PCTs will see fit to provide funding for the development of new services from community pharmacies, otherwise I agree that we risk losing parts of the network, and this will undoubtedly become a local issue in the next few years. When that time comes I suspect the talk will not be so much of trapezes as of safety nets.

Peter Cattee
Chairman
Associated Independent Multiple Pharmacies

New contract needed now

From Mr M. T. Bland, MRPharmS

I read, with interest, Brian Curwain's letter concerning "Past mistakes" (PJ, 30 November, p779). As ever, Dr Curwain makes a succinct and powerful case and one finds it difficult to disagree with his beliefs in theory. In addition, his background in community pharmacy gives strength to his views unlike that of some other primary care trust advisers. Regrettably, however, his letter tends to indicate that he believes his community colleagues do not wish to change. The situation is not that simplistic.

Although I agree that we need to remove ourselves from the dispensing bench to a wider role, it becomes more difficult to leave the premises for any length of time in the current situation. What will happen to the numerous patients, encouraged by many years of the National Pharmaceutical Association campaign to "ask your pharmacist", and now those also referred from "NHS Direct"? How will they react when they arrive at the pharmacy and find the pharmacist absent? Skilled support staff may be trained to advise in certain situations but will be unable to sell any P medicines, if they are indicated, as the law stands at present. It is the sale of such items that helps to subsidise the dispensing fee. Who will provide the many other services offered by the resident pharmacist during the working day?

Furthermore, it is not only the pharmacist workforce that has shortages. In many pharmacies, particularly company owned, there is a severe shortage of technicians and counter staff. Dr Curwain may not be aware that some pharmacies, including a few in his own PCT area, only function because ancillary staff are moved from site to site on a daily basis to plug staffing gaps. Many staff are recruited and fully or partially trained before leaving to become checkout operators or care assistants (or in the case of technicians moving to the hospital sector or PCTs) because the salaries are more attractive due to the inadequacy of community remuneration.

What community pharmacy needs, and needs now, is a new pharmacy contract that will make it possible for pharmacists to take on the new and extended roles that both Dr Curwain and I would like to see. There are many scenarios on how these roles could evolve, such as two pharmacist pharmacies or technicians carrying out domiciliary work that could be monitored back at the pharmacy. However, new funding is needed for any extended or additional roles, there is no more blood to get out of the existing stones.

Finally, in response to Dr Curwain's last paragraph, the greatest service that the PCT boards could render is to persuade the Department of Health that only a properly costed new contract will enable community pharmacy's new roles with PCTs to move forwards for the benefit of us all — particularly patients. Perhaps then, we will not continue to feel that, as we swing from our trapeze, the mandarins in the Department are removing the safety net and cutting through the ropes.

Mike Bland
Eastleigh, Hampshire

Consider alpha drug order

From Mrs J. B. Groushko, MRPharmS

I have been practising as a locum pharmacist over the past six months, the nature of which means I have experienced a variety of dispensaries. This, along with the recent emphasis on reduction of medication errors and the training of dispensing technicians, has prompted me to write this letter.

I suggest that all medicines should be placed on dispensary shelves in alpha drug order. Dispensary shelves should be thought of as a filing cabinet for drugs. As with all filing systems, the simpler it is, the easier it is to access the information, or in this case, the medicines. The packaging of the drug is irrelevant, be it proprietary, generic or parallel import.

Using this system, uniformly packaged generics and similarly named drugs are separated by their proprietary equivalent, making a distinctive differential between the two (eg, amiodarone and amlodipine are separated by the distinctive Cordarone and Istin packaging). Similarly named proprietary drugs are split (eg, Lipitor under "A" and Lipostat under "P").There is no problem with unknown names on PIs (eg, Iscover is under "C" for clopidrogel, next to the distinctive Plavix). When a drug loses its licence there are no worries about whether the generics should be next to the old proprietary or moved to the generic name because the proprietary preparation is already in position. For basic stock, there would be only one position on the shelves to look for any particular drug, with generics, PIs and proprietary preparations ready to be appraised at a glance.

When in place, dispensing is quicker, dispensing errors may well be reduced, and stock control is easier. Training dispensary staff to find medicines on the shelves is more straightforward, especially since most prescriptions are now written generically.

I appreciate that reorganisation of dispensaries is not undertaken lightly but I would urge anyone considering doing so to think of the merits of alpha drug order. It only takes a couple of weeks to get used to the change — after all, locums do it every day.

Jane Groushko
Bushey, Hertfordshire

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