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Tony Guest, MRPharmS, is superintendent pharmacist, Festival Health Ltd
Jim Hutchins, MRPharmS, is managing pharmacist, Arena Pharmacy
Lucy Philpott, MRPharmS, is managing pharmacist, Festival Pharmacy
Sue Beveridge, MRPharmS, is support pharmacist, Arena Pharmacy
Sally Tothill, EN, and Louise Flower, BA, are staff managers, Festival Health
Ltd
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Glastonbury is the place to be seen. The annual festival of contemporary
performing arts has a world reputation for its diversity and attracting
the best. From its humble, free beginnings in a farmer’s field
in 1970 celebrating “peace and love” it now occupies a site
of 900 acres, one and a half miles across, with 11 major stages and numerous
minor ones.
Because of the concerns of the police and local authorities the site
is now enclosed by a five mile long, 10 foot high fence, separated from
a second fence by a no man’s land patrolled constantly by teams
of security staff.
The present licence is for 120,000 paying visitors and an additional
34,000 site staff, stage crews and exhibitors. All of these effectively
occupy a tented township for up to seven days in isolated Somerset fields
at the end of June each year.
Visitors and staff effectively occupy a tented township in isolated
Somerset fields |
Medical care is needed to cover problems
with pre-existing conditions, acute health problems and accidents and
emergencies on site. There is
a separate welfare provision team that issues condoms and operates
a needle exchange scheme. The medical facility has had to expand from
its
early days in a farmhouse bedroom to a full scale field hospital at
the top of the site and a secondary unit at the other extremity. There
are
now 500 medical staff, including pharmacists, nurses, midwives, doctors,
anaesthetists, surgeons, psychiatrists, social workers, physiotherapists,
podiatrists and dentists. The medical unit provides teams of paramedics
with their own ambulances and an on site medical communication system,
as well as the first-aid units around site.
The first registered pharmacy premises with an NHS dispensing contract,
essential for large numbers of people on limited incomes to obtain
necessary medicines, was set up in a cabin unit in 1994 by John Higginbotham.
It
was staffed by employees from his Shepton Mallet pharmacy. One of the
authors (TG) ran the on site pharmacy from 1998 with a remit to restrict
the stock to a limited formulary, which was agreed with the medical
unit, and to obtain additional items when required from the Shepton
Mallett
pharmacy.
On his retirement in 2000, John Higginbotham sold the dispensing contract
and pharmacy title of Festival Pharmacy to Festival Health Ltd.
Drug misuse at Glastonbury
In the past six years the problems associated
with misuse of drugs at Glastonbury Festival have been no worse
than those encountered by a community pharmacy in any deprived
inner city area, and, in fact, seem to be improving. There seems
to be a greater emphasis on the use of “recreational” rather
than “hard” drugs. The range is similar to that encountered
by many drug welfare workers in a city with a clubbing scene,
although most years the medical unit deals with the consequences
of some new “exotic cocktail” being circulated. An
additional unknown factor may be the wide range of recreational
herbal products on sale on some market stalls.
We liaise closely with the police, both those seconded to the site force
and those from the surrounding areas. They have major concerns about
the security of a dispensing pharmacy in this environment. Traditionally
this unit has not dispensed addicts’ prescriptions and we have
continued this policy in line with renewed police concern. Our approach
is that any addict on a programme, including methadone use, should have
made arrangements to bring either a supply or daily prescription with
them. Along with site welfare services, we will help them to obtain a
supply from a pharmacy off the site.
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With no festival in 2001, we took a long look at the organisation of
the pharmacy and identified several areas that required attention.
These included:
· Service provision to the medical unit
· Online medicines information
· Dispensary stock
· Wholesaler delivery
· Opening hours
· Staffing
· Health promotion
· The need for a second pharmacy on site
Service provision to the medical unit
The Festival Pharmacy, based within the medical unit, dispenses all
prescriptions written by the medical staff. This provides several challenges
that
are not always faced in community pharmacy.
First, many of the medical staff are usually based in hospitals and
may not be familiar with general practice prescribing. Secondly,
there is
a lack of patient medication or disease history, and finally, there
is an increased risk of interactions with drugs of abuse.
Part of our new remit is to facilitate supply of surgical and clinical
items. The medical unit starts off with an envisaged level of stock
but inevitably finds it has exhausted some items or requires emergency
supplies
of more specialised medicines. As a dispensing pharmacy we do not have
access to hospital wholesalers. We resource items from hospitals as
far away as Bristol but this is unsatisfactory during a night-time
emergency,
although in one critical situation we did succeed in getting a supply
flown in. We have identified a hospital wholesaler that will supply
directly to the doctors, however this method has the same limitations.
Our on-call
arrangement with a pharmacy wholesaler is mentioned below.
We have increased the proportion of pharmacists who have relevant clinical
experience and are working towards one clinical pharmacist and one
experienced community pharmacist working during each shift.
Underlying these changes is the stark responsibility of an adequate
pharmacy response to any of the major incident scenarios on site. Major
incident
planning involves the police, local authority, off-site emergency services,
site organisers and on-site medical services. Medicines information online
In 2003 we established a dedicated online medicines information facility
within the pharmacy.
The aim was to: · Back up the internal activity of the pharmacy
· Provide a level of expertise to the medical staff in their clinical
activities in the “field hospital”
· Provide specialist information on the interactions of suspected drugs
of abuse in contemplated clinical interventions
Dispensary stock
One of the many entertainers who roam around the festival site |
The original, limited prescribing formulary is still in place although
subject to yearly review using data from the previous festival. Its
aim is to help doctors, many of whom are from an exclusively hospital
environment, to prescribe the simplest, most effective medicine.
We have now vastly increased the range of dispensary stock based
on previous festival experience. As with any NHS dispensing pharmacy
our stock is
influenced by expected demand. One problem is that usage varies each
year, often depending on the weather. For example, during a hot, dry
year many people suffer from hay fever, sunburn and dehydration, leading
to an increased demand for antihistamines and rehydration sachets.
If stocks are exhausted it is the responsibility of the pharmacist
on duty to resource a signed order supply from a community pharmacy
in the
local area, a hospital pharmacy, or from the wholesaler (either next
delivery, emergency or out of hours on-call delivery).
Wholesaler delivery
A direct wholesaler supply has been set up. In order to address police
concerns over wholesaler van delivery into the site we are required
to use a dedicated courier. This has imposed a cost burden on the
pharmacy but has proved of benefit in that the courier is on call 24
hours a
day. This provides an acceptable way of delivering emergency supplies
out of hours. In a critical situation the police have offered to
escort or even fly the supply in themselves.
Opening hours
The opening hours have been extended (from 10am to 7pm before 2000)
to complement the medical unit requirement. Festival Pharmacy is fully
staffed
24 hours a day for six days, starting three days before the festival
begins. Staffing
In 2003 we had 26 pharmacists with a range of specialty experience,
including community, clinical and industrial pharmacists. They were supported
by 37 qualified dispensing staff, again from community and hospital,
other pharmacy staff and some assistants.
Traditionally all medical services staff —
from consultants to pharmacy staff — are volunteers. They get free
tickets to the festival, car parking and secure camping with their own
showers and toilets (a real bonus at Glastonbury!) and access to hot
meals and medical mess facilities.
Selecting staff and organising work rotas can be a major headache. Many
volunteers have individual requirements and the dates they are on site
vary enormously, although part of our selection criteria is now the number
of days that they are available to work. It is not until volunteers are
on site that most find their choice of stage acts conflicts with rota
commitments.
One problem for me, as superintendent pharmacist, is to ensure that professional
standards are met by all staff. It is easy to be misled by the apparent
informality of “pharmacy in the field” in festival surroundings.
To this end, four pages of protocols and information are sent to all
staff. The signing and return of these constitutes the basis of their
contract to work.
The working practice protocols in place in each pharmacy unit are subject
to yearly review. In setting the detail we try to keep in mind that they
need to be practical and not irksome in their execution.
We are looking for pharmacists and qualified pharmacy staff interested
in joining us this year and onwards. Festival 2004 dates are 9am Wednesday
23 June to 5pm Monday 28 June. Staff should be prepared to participate
in the spirit of our serious objectives and be available on site for
as much of our opening time as possible, and to either set up or clear
away. We may be unable to accommodate all shift preferences but try and
limit these to six hours in any 24. Shifts can be busy and might be at
unsociable times. Health promotion
The proportion of festival-goers from “hippy lifestyles” or
travellers’ backgrounds has decreased over the years but we still
see a disproportionate number. Their health status needs to be considered
when giving advice from the pharmacy. There is an active welfare provision
team on site and the pharmacy is available for liaison with it. It is
encouraging that the medical and nursing staff refer patients to the
pharmacy for advice on health issues.
The pharmacy displays health promotion leaflets and staff wear T-shirts
that sport the pharmacy logos and a health promotion motif. We were worried
that health promotion leaflets might be a little dull but have been enthused
by the selection available and have found a wide range that “cut
to the chase” in targeting the areas of need among festival-goers.
Apart from those displayed within the pharmacy we allocate two display
benches outside to promote these leaflets. Opening a second pharmacy
Before the 2002 festival, an application to register a second pharmacy
premises (Arena Pharmacy) in the main festival market area was approved.
At the end of 2001, because of increasing objections to the festival
licence, the site organisation was passed to the Mean Fiddler group,
which is more business-focussed than the original festival management
(which still organises the line up of acts). Our main problems in setting
up this unit centred on reconciling the concerns and requirements of
the police, the local authority and the Royal Pharmaceutical Society
with the approach of the site organisers, who viewed this unit as just
another market stall. The function of this unit is: · To make pharmacy services more accessible to festival-goers, in terms
of health advice, health promotion and supply of pharmacy and general
sale list medicines. The police require that no prescription medicines
are held in this unit.
· To generate profit to support the activity of the Festival Pharmacy
at the medical unit, which is effectively a loss maker. Even with this
contribution the whole pharmacy operation on site has proved only marginally
profitable. By arrangement with the medical unit, any overall profit
is donated to their charitable funds, in keeping with the spirit of Glastonbury
Festival.
One requirement of the police was that the area behind the counter of
Arena Pharmacy should be secure. Counters were to enclose the customer
area completely and were required to have high fronts. These were custom
built to satisfy police requirements.
When we placed Arena Pharmacy in the Glastonbury Festival marketplace,
we had no idea what to expect. By the end of the second festival we had
a good idea of what to stock and how best to serve the festival-goers.
Last year we dealt with thousands of customers. We offered health advice,
treatment for minor ailments and made referrals to the doctors in the
medical units when appropriate.
The Arena Pharmacy was staffed by two experienced pharmacists last
year |
An adequate level of trained staff was
not a problem last year and most of the time Arena Pharmacy was staffed
by two experienced pharmacists.
In addition to the service being constantly praised by customers, the
pharmacists found it enjoyable and educational to work alongside others
with different styles and areas of expertise.
Daily stock checks and a close relationship with our wholesaler meant
that we stayed on top of stock issues. If a product was unavailable an
alternative was found — back orders are useless when everyone has
gone home.
Big sellers included paracetamol and ibuprofen, but a wide range of medicines
were sold in small quantities. There were some surprises. For two years
we have stocked emergency hormonal contraception, and had pharmacists
trained to sell it, but there has been no demand. This may be because
family planning services are available at the festival and prescriptions
for EHC are written by festival medical services. Perhaps everyone simply
waits until the party is over before worrying — this may be the
basis for a health promotion slogan for Glastonbury 2004.
There are enhanced cash security precautions in place and we have a “no
heroics” staff policy. To date there has been no trouble but we
cannot be complacent.
As with the existing Festival Pharmacy, the new Arena Pharmacy has to
conform to the requirements of any pharmacy premises in respect of Data
Protection registration, professional indemnity, third party, public
liability and contents insurance, health and safety regulations and fire
regulations as well as site risk assessments and other requirements to
operate on site.
Any provider of a temporary pharmacy at an event or festival will know
of the
organisational and logistic problems to be overcome within a short time
frame. Glastonbury is no different but has the added factors of its scale
and the provision of two units on site. Each year we are faced with two
secure empty cabins to be fitted out, stocked and staffed within two
days and the whole operation to be dismantled and removed within two
days of the end of the festival.
At Glastonbury, as with the other major events that we are proposing
to target with showcase temporary pharmacies, the involvement of appropriate
sponsorship is important. As well as the benefit of product promotion
on site there is the spin-off from promotional copy resulting from the
event. Our first objective in setting up the new organisation at Glastonbury
was that it would absorb the considerable costs of the enhanced service
and be seen to stand up financially in its own right. Although still
marginal, it has succeeded in doing this. We are now seeking sponsorship
for Glastonbury and future events elsewhere.
Profit cannot be the motive for being involved in provision of pharmacy
services at Glastonbury Festival. The motivation comes from the challenge
of setting up two professionally based pharmacies that function as required
and the refreshment of using professional skills in an informal setting —
and the sheer buzz of taking part in such a major event. |
The
Pharmaceutical Journal