Stuart Notman with methadone bottles
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The highest number of methadone patients that pharmacist Stuart Notman
has dispensed for in a day is 206. He averages somewhere between 160
and 170 “but we often have a surge”, he says.
It is not just the large number of methadone patients he has, but also
his
approach that is unusual. With the Shipman Inquiry expected to recommend
new regulations for Controlled Drugs this summer, Mr Notman’s practice
might reflect some of the ways of working that other pharmacists will
have to adopt. He has applied an impressive level of technology in order
to cope with the demands of dispensing this amount of methadone. Although
methadone makes up a large part of Mr Notman’s regular trade (at
least 50 per cent of his NHS income), he has not specialised completely. “It
is mainly methadone, but we do everything else too.”
Mr Notman explains how his business has evolved. He bought his pharmacy
in Aberdeen in 1990 and, at that time, it was
opposite the main office of a hydroelectric plant. “It was busy,
with plenty of passing trade and lots of shops in the street,” he
explains. That changed when the electric plant closed. “Overnight
there was no one around anymore,” he says. This coincided with
the local introduction of a shared care scheme for addiction in 1998
and Mr Notman was happy to become involved. “At that point I had
about 30 addicts,” he says. “The pharmacies were all asked
to suggest an upper limit to the number of addicts they could take. Some
shops used this as an opportunity to downsize. But I decided to try to
take it forward and said the maximum we could take was 100. I never seriously
thought that it would reach that number.” As nearby pharmacies
reached their self-selected capacities of 15 to 20 addicts, Mr Notman
found his numbers increasing.
Technological innovation
As the number of patients increased, the pharmacy systems evolved.
Initially, Mr Notman used a paper-based system to track each prescription
and
the person collecting it. A grid was used to mark if people missed
more than three days’ treatment. Then times of collection were
added. This evolved into a computerised database of all the prescriptions.
Each patient record now contains the doctor’s details, the serial
number of the prescription, the start and finish date of the prescription,
how often the methadone should be dispensed, whether the methadone
is to be consumed on the premises, the dose and total volume of methadone
to be dispensed, the number of dispensings and the number of in-pharmacy
consumptions. It also matches new prescription data with old prescriptions
to ensure that their dates are continuous.
In 2001, Mr Notman introduced bar coding. Patients are given a unique
bar code. The bar codes are printed on bottle labels. Each patient’s
methadone is dispensed in bottles that never leave the dispensary: the
methadone is poured into a cup and given to the patient to consume in
the pharmacy. Photographs can be added to the label to confirm a patient’s
identity. When patients come to get their methadone, the bottle label
is scanned. This information is fed into a computer that records the
patient’s name, the quantity supplied, and the time and date it
was collected. This is matched with the patient’s prescription
record which is updated accordingly. Sunday doses are dispensed on Saturdays
in standard bottles to take away.
At the end of the day, any doses not collected are scanned into the computer
so that a record of the non-attenders is produced. A print-out of the
doses collected is made and stuck into a bound CD register: Mr Notman
is exempt from having to hand write the CD register. “The CD register
alone used to take three hours every day,” he says. So, some years
ago, he got agreement from the Home Office, a Royal Pharmaceutical Society
inspector and the Scottish pricing bureau to computerise the system.
In the dispensary, Mr Notman uses methadone pumps. It took some time
to find a manufacturer who could produce pumps that offered variable
volumes, good accuracy and could cope with a sugary mixture. But eventually
he found one and now, in the Lothians area, they are issued to all pharmacies
that dispense large amounts of methadone regularly. “The pumps
are more accurate than glass measures, being accurate to within 0.08
per cent,” says Mr Notman.
The inevitable question is, what happens if the computer crashes? First,
says Mr Notman, he has the whole system backed up on a laptop. He also
has a back-up copy of the computer program on a CD-ROM so that can be
plugged into another machine.
But if all this fails, then there is always a paper-based system. Forms
are stored in the pharmacy, just in case. “I can go back to the
paper system because that it what the computer system came out of,” he
says.
Mr Notman has rules with which any person wishing to obtain methadone
from the pharmacy has to agree. No shouting, swearing, loitering or shoplifting
are just the basics. If patients miss doses then their doctor is informed.
All patients have their photographs taken with a digital camera to be
used for reference when methadone is dispensed. “I can e-mail them
to the doctor to check it is the right person too,” he adds. Since
the pharmacy’s latest computer system was installed in 2000, the
pharmacy has had 1,138 different methadone patients. “There is
no way we could remember them all without photographs,” he says.
Video cameras cover every inch of the pharmacy. These record the time
and date so there is never a dispute over whether someone has collected
their methadone or not. It is not always patients trying to beat the
system: some genuinely forget that they have collected their dose. The
pharmacy has numerous security measures including strengthened windows
and doors, metal bars, steel shutters, a trip step into the dispensary
and an alarm. Future planning
Could these systems be implemented elsewhere? “We have had visits
from representatives of three health boards in Scotland,” says
Mr Notman. “The problem is finding pharmacists who are prepared
to take on this number of methadone patients.” He has seen this
in his own pharmacy when trying to get locums. Luckily he found a pharmacist
who now works regular part-time hours for him as well as providing holiday
cover. But Mr Notman enjoys his work. “I prefer our group of patients
to so-called ‘normal’ patients. They are less hassle.” He
adds that as the number of patients has grown, it has got easier. “There
seems to be an element of self-policing: they don’t want there
to be a problem because of the danger that we will throw everybody out
and they would have to find somewhere else to get their methadone.”
One of the reasons for Stuart Notman’s success is that he never
stops evolving his business. He has just started training to become a
supplementary prescriber and plans to use prescribing to expand the services
he offers. |
The
Pharmaceutical Journal