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Bob Gartside is a pharmacist from Gwynedd
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It’s fairly widely accepted that the pilot studies of electronic
transfer of prescriptions (ETP) have not been an unqualified success.
Certainly, there are no immediate plans to implement any system with
the rapidity one would expect if the trials had been a striking success
and had exceeded initial expectations. This is not, of course, surprising.
If one deconstructs the concept it is a little difficult to see real,
solid, practical advantages in ETP. The patient still has to visit his
or her GP, who has to write a prescription, which the patient then has
dispensed at a pharmacy. In at least one of the pilots it was found necessary
to issue
patients with documents which identified them and authorised them to
receive their medicines. Occam’s razor suggests that one might
as well have issued a prescription as normal and have done with the job.
Indeed, if e-prescriptions have to be each individually authorised by
the GP this will involve them in more work than the present system requires.
On the other hand, if the
authorisation is not individual then you are handing prescribing to essentially
unqualified receptionists or other ancillary staff. This is the real
Achilles heel of e-prescribing and one which appears not yet to have
been
addressed.
What is equally surprising is that the NHS is so reluctant to carry out
trials on electronic pricing of prescriptions despite the solid
advantages in cost, accuracy and speed — not least because electronic
pricing of prescriptions can provide prescribing data within a week of
the prescriptions being issued rather than four months later as at present.
There is little to be achieved by a prescribing adviser wishing to go
through four-month-old prescriptions with a GP. More can be achieved
with “hot”, week-old data. Systems for electronic pricing
of prescriptions are in widespread use in other countries. The systems
development work has been done and the systems manufacturers are keen
to get into the undeveloped British market. Yet it is
obvious that the NHS wishes to have nothing done even though electronic
pricing of prescriptions could be a natural lead into ETP, if one still
wishes to pursue that chimera.
Another puzzle is the slow progress of trials of systems of repeat dispensing.
Here is a development desired by both patients and professionals and
which promises substantial time and effort savings. It has the added
and not inconsiderable merit that the pilot trials showed cost savings
of around 14 per cent — equivalent to £1,000m per year on
a UK-wide basis if repeat dispensing were used for all maintenance therapy.
Again, like electronic pricing of prescriptions, fully developed systems
of repeat dispensing exist in other parts of the world, needing minimal
adaptation to the British market. And again the NHS is dragging its feet.
The
excuse is that ETP will provide a repeat dispensing
system. There is, however, no intrinsic reason why it should do so automatically
and no information on possible ways of working, just a vague reassurance
that the black boxes will work their magic, perhaps just as they have
done in so many other Government big computer projects.
Now let us consider automated dispensing in hospitals. Large sums are
being spent on this system. Moreover, there is much “hidden” expenditure
on major building alterations, which are not counted against the project
cost. The machines are extremely large, extremely expensive and extremely
slow. This may seem a sweeping statement, out of line with the spin but
it is based on
examination of systems in use.
Of course, with time and more money their speed will improve and it might,
one day, be possible for the machines to be fully proficient and accurate
so that they do not need the present army of human attendants. It is
also worth bearing in mind that there are reports of a major near miss
in the US
involving almost 5,000 wrong dispensings, all of which had to be retrieved
from patients.
When these machines go wrong they do so on a grand scale. Yet work on
these expensive monsters is being pressed ahead in a way that contrasts
strongly with the lackadaisical progress in repeat dispensing.
Finally, there is the strong growth of supply direct to the patient from
the manufacturer and the recent announcement that new internet pharmacies
will be exempt from the control of entry regulations. Direct supply is
more expensive, cumbersome and inconvenient than supply via wholesalers
and retailers — as many dot-com companies found to their cost — and
there seems no clear reason why new internet pharmacies should have special
treatment.
So what is going on? One strong rumour is that the Treasury (not the
Department of Health) has had a vision of a future medicines supply system
that involves big, automated central dispensaries fed directly with e-prescriptions
and posting medicines out to their customers. The major pharmacy multiple
groups are also known to be carrying out market research
into similar systems: much cheaper and far less messy than all those
little community pharmacies.
We may call this the “motor car parts counter approach” because
it treats medicines as mere articles of commerce, perhaps slightly complicated
articles but no more so than motor car parts. Of course, as side effects
of this system of supply, patients no longer
receive advice with their dispensed medicines and community pharmacy
ceases to exist —there is no gain without pain.
The drawback to this approach is that it misses the essential point:
that medicines are not items of commerce as the term is normally used.
They are literally life and death
affairs for millions of people. If the lambda sensor for my BMW does
not arrive until Thursday it is an inconvenience, perhaps a
severe inconvenience, but not life threatening. In contrast, if my Ikorel
and enalapril
arrive three days late, I will likely have an angina attack, go into
heart failure and will be lucky to survive long enough to be admitted
to hospital. There is a degree of exaggeration here, but not much.
All practising community pharmacists know these things in their bones
but it may be that as a profession we should begin to
assemble an evidence base for community pharmacy. What are the proven,
peer
reviewed, reasons for having community pharmacy? Does it, overall, diminish
morbidity and mortality to an extent that is distinct from the actions
of the medicines which it provides? Is the large amount of unrecorded
medicines management that quietly takes place having a beneficial effect
and, if so, how large an effect? In the last analysis, can we justify
the expense of community pharmacy?
In short, we should, perhaps, begin to prepare to justify the continued
existence of community pharmacy to an increasingly sceptical government.
General medical practice faced a similar need in the 1970s and
facing and dealing with that need, produced profound, and beneficial,
changes in general practice. We may need to do the same. |
The
Pharmaceutical Journal