|
Bob Gartside is a pharmacist from Caernarfon,
Gwynedd
|
Mother Nature, God or Darwinian evolution intended the span of human life to be three score years, give or take a decade, yet many people today are living to be 80, 90 or even 100 years old. This is partly because of improved nutrition, partly because of central heating, partly because of improved education and television, and partly because of improved medical management and drug treatments for the infirmities of old age.
Yet our process for delivering medicines to patients has not ostensibly
changed since Lloyd George’s National Insurance Act of 1911, which
set the framework for the later development of the NHS. Indeed, until
recently, GPs kept patient records in “Lloyd George envelopes” and
prescription forms are still printed to roughly the 1911 dimensions and
layout. Even the introduction of electronic prescriptions will make little
difference because the system under development is little more than an
attempt to computerise an essentially paper-based operation, with some
added bells and jingles to “guide” prescribers in the writing
of prescriptions and a facility for repeatable prescriptions, which does
not yet appear to have been specified.
What is really needed is a fresh look at the whole ordering and delivery
system for medicines, making the fullest possible use of the possibilities
latent in modern systems. I will confess freely that I do not know what
form such a system might take but there may be pointers in current practice
(which may not necessarily comply with the strict letter of the law and
professional ethics but, most assuredly, does comply fully in spirit).
Bearing in mind that patients are human, forgetful, prone to dropping
and losing things, and generally do not behave as the book says they
should, let us look first at common, present-day problems in medicines
supply. Over the years a system has spontaneously evolved in which pharmacies
store patients’ repeat requests and submit them to surgeries on
patients’ behalf. This system is little documented (North Wales
Local Pharmaceutical Committee conducted a pilot some years ago which
was reported to the Welsh Office) but is almost universally used. Similar
systems are in place for the management of medicines in care homes but
these are frowned on by the NHS for reasons that are difficult to discern
and which do not stand up to analysis.
I would submit that one major problem is that it takes most GP surgeries
from one to four days to produce a prescription for authorised repeat
medicines, and perhaps even longer for a new medicine requested by a
consultant or suggested by test results. There is no reason why matters
should improve following the change to e-prescriptions. Unfortunately,
our feckless patient, used to nipping round to the corner shop for a
box of matches and therefore only thinking of requesting a new supply
when there are only two or three tablets remaining, can be expected to
experience involuntary drug-free days despite the fact that all other
therapeutic effort is concentrated on maximum concordance and compliance.
A further problem is that few surgeries are now open on Saturdays so
that even when a prescription is produced there is a fair chance that
it will be locked up in a closed surgery. There is no point is saying
that patients should be more organised; other aspects of their lives
are probably fairly well disorganised and they are only human. And many
of them are old.
Many surgeries will only issue prescriptions when they think they are
due, and
this may mean monthly on set dates. But 28
days’ supply means that 13 supplies are needed in a 365-day year.
It seems likely that
e-prescribing systems will be even tighter in this area than present
systems and this will create problems for those patients who lose their
tablets, drop them down the toilet, leave them where the dog can find
them, or simply forget where they have put them (it happens). In passing,
it is a great pity that the UK decided to go with a 28-day month while
the rest of the world works to a 30-day month.
There may be additional problems over non-availability of medicines when
the production or distribution mechanisms suffer dislocations and there
are even more problems when a surgery leaves some medicines off a requested
prescription, whether by accident or by design.
For all these reasons, modern community pharmacy practice can include
a style of pharmaceutical care that pushes the legal and ethical boundaries
within which pharmacy operates. Confronted late on Friday by a distraught
80-year-old who has been convinced by his consultant that he will die
if he has to go for three days without atenolol and bendroflumethiazide,
what is a responsible pharmacist to do? A retail sale of an emergency
supply is out of the question: the old age pension income leaves no room
for such
procedures.
In Scotland such dilemmas have been recognised by an ad hoc arrangement
under which emergency supplies can be made by means of a patient group
direction and the NHS pays the cost. Wales may follow suit. Pharmacists
in England seem likely to be left to fend for themselves, yet this is
such a simple problem for them to solve by the exercise of professional
judgement. Sadly, our rulers appear to believe that trust must be replaced
by accountability, despite the vast cost implied by the need to employ
an army of checkers and accountants. Professional responsibility is actually
cheaper than any other method of management.
Bearing all of the above in mind, what sort of system for the management
of maintenance medication should we be considering? I would suggest that
the prescription needs to be replaced by a treatment plan. Instead of
the prescription saying “Give Mrs Jones 28 bendroflumethiazide
2.5mg every morning (as a single supply)” or even Give Mrs Jones
28 bendroflumethiazide 2.5mg every morning once a month for six months”,
the treatment plan would say “Mrs Jones is to have 2.5 mg of bendroflumethiazide
every morning; supply at approximately monthly intervals provided that
her blood pressure remains within a specified range and she has no other
untoward effects or symptoms; she is to attend surgery annually for checks.”
Such a treatment plan would preferably be used by one pharmacy for every
dispensing of Mrs Jones’s medicines but, with sufficiently efficient
IT, could be used by any pharmacy in the country. The essential thing
is that day-to-day management is to be transferred from the prescriber
to the pharmacist who would be expected to help the patient in every
way possible. I submit that the introduction of e-prescriptions calls
for such a change from prescriptions to treatment plans for the management
of maintenance medication and that the profession should take a lead
in seeking it. |
The
Pharmaceutical Journal