Learning to use skills

We have really started to get to grips with using the skills of our recently qualified checking technician to best effect. We had started trying to use these skills with patients waiting for scripts but found this to be difficult because it can be hectic and inevitably she had already had something to do with the labelling and assembly of the prescription by the time it needed checking.

So we have started to use her skills to greatest effect when we prepare the repeat prescriptions we have collected. For these prescriptions we make sure that a pharmacist assesses them first, other dispensary staff label and assemble them, and then our checking technician can check them all off.

This really is team work to its best effect and once the PCT can persuade the local GPs to start implementing repeat dispensing we will be able to use the skills of the dispensary team even more.

That'll teach me!

I had hoped to attend an evening training session this week for new pharmacists wishing to become accredited for the PCT EHC PGD scheme. These sessions are run by the PCT every 4-6 months.

I duly completed my CPPE open learning pack and booked some annual leave to ensure I could get to the event on time. However, on faxing my confirmation of attendance to the PCT I was immediately told by them that this event had been cancelled due to lack of numbers, and I would need to wait for the next one.

I do appreciate the need to cancel events that are poorly attended, but I was slightly irritated we hadn’t been proactively informed.

Behind bars

Had a couple of interesting comments from you regarding the patient we recently barred from using the pharmacy (see Taking a Tough Line).

One comment asks if we can actually do this within our terms of service, and another suggests that we can as long as we direct the patient to an alternative source of pharmaceutical services (there is another pharmacy a few doors along from us).

Well I’ve had a look at the online NPA Information Database for advice and it states that ‘the NHS (Pharmaceutical Services) Regulations 2005 now mean that a pharmacist may decline the supply of a medicine in certain circumstances’, with one of these circumstances being where ‘the pharmacist or other persons on the premises are subjected to or threatened with violence by the person presenting the prescription form’.

It also states in the Medicines, Ethics and Practice Guide (albeit in the section concerning services to drug misusers) that ‘pharmacists may decline to provide a service to a patient whose conduct is unacceptable’.

So hopefully that helps to clarify things. I appreciate the comments that have been fed to me on this.

About a child

I’ve had some interesting OTC consultations recently. For example:

• The mother who brought her 15 year old son into the pharmacy to buy some sleeping tablets. Apparently her son hadn’t been sleeping properly for three weeks and wanted something to help. I asked what they thought could be causing the sleepless nights but I got the distinct impression that he wasn’t going to tell me with his mum there.

So I printed off the PRODIGY PIL on insomnia and asked them to follow the advice in there before resorting to OTC sleeping tablets. I haven’t seen them since but whether that’s because the problem is cured or they have gone elsewhere to buy some tablets, I simply don’t know.

• The mother who brought her 11 year old in with monthly migraines. It seemed that these were linked to the onset of menstruation and she had been to the GP practice to ask for advice since it usually ended up in her daughter being sent home from school in tears once a month.

The GP had simply recommended pain killers for the time being and I felt mum was after some further reassurance. So again I used PRODIGY to print off the relevant PILs and recommended some quick and easy painkillers that the daughter could take to school to use as soon as she felt the onset of the headache. So we will wait to see how she gets on next month.

Reboot when busy

Had a nightmare this week when the computer system started to get rather twitchy and then crashed!

We battled with it during two very busy days of dispensing and all we could do was keep apologising to everyone for the delays.

The main problem boiled down to the labels being printing out – either not at all, or with no quantity on them, or worst of all, with a completely different patient name to the one that we had entered.

The software company were pretty good at getting it sorted out, but it was the last straw when they kept asking us to re-boot the system at our peak time of dispensing.

The whole pharmacy team ended up very stressed and my usual wine consumption has definitely doubled this week.

Switch doctors

One of our local GP practices is busy switching a number of drugs following the PCT’s pharmacy team intervention. This switching either involves changing patients on a particular drug to another drug in the same class, or to the same drug but in a different form.

The drugs concerned are statins, antidepressants, ACE inhibitors and PPIs.

We did receive a phone call from the GP’s practice pharmacist to let us know, which was gratefully received since one of the switches is already making a difference to our stock levels. However we had already got wind of some of the switches from patients who had been sent letters by the GP practice and had brought them in to show us.

We even had one patient who had received such a letter but had never been prescribed the drug in question, so understandably was rather confused!

As an ex-pharmaceutical adviser, I know what impact these simple changes can make to the drugs budget, and the switches in question do seem reasonable ones to me.

But from a patients’ point of view, these switches must be handled carefully and I’m pleased that most of the patients concerned are receiving letters in advance to inform them. So we are busy noting these changes to our records and making sure that the patients know about them when we hand the scripts out.

Dad and a grapefruit

Had a few ‘interesting’ customers in the pharmacy this week. Here’s just a couple of them:

• The young lad that came up to the counter to collect a prescription I had called out. He said it was for his Dad and so as usual I asked him to confirm the address. Well he didn’t know it; neither did he know the name of the street where his father lived or his father’s birthday.

I did feel really sorry for him since he was obviously very embarrassed, but I didn’t think my questions were unreasonable (!) and all I could do was explain that I couldn’t hand the prescription out to him since he couldn’t verify who it was for.

Five minutes later a rather irate ‘Dad’ came into the shop to tell me, in a loud voice, where he lived and when he was born. Oh well….

• The lady recently started on simvastatin who, on counselling about not eating grapefruits / drinking grapefruit juice, exclaimed “wash your mouth out young lady”. She apparently loves grapefruit and had even “pre-ordered a grapefruit for her holiday breakfasts” in a couple of weeks time.

So I told her that, in my opinion, she was on the best statin with the most evidence behind it, but that if it was a real problem there were alternative statins available.

May I intervene?

And now over to some of the interventions that we have made this week:

* The patient who was prescribed bromocriptine at ten tablets daily, who after further investigation, should have been prescribed a dose of two tablets daily.

* The number of patients who are prescribed the ramipril starter packs with no counselling what so ever. We always make sure that we open the box to show then the different strengths, and explain about the side effects and to take the first few doses at night. I know that this information is all contained in the PIL, but it’s a lot for patients to take in without some sort of verbal backup.

* The patient who was newly prescribed ISMN at a TDS dosage. I explained about the side effects and not to take the last dose after 4pm, but I was curious about the TDS dosage particularly when the patient would have had enough tablets to last to her follow up appointment if she took them at the correct BD dosage but not at the prescribed TDS dose. Therefore further investigation resulted in the patient taking them twice daily.

Patient advocate

The pharmacy owner had an interesting chat with a long standing regular customer this week.

She’s on warfarin tablets and told him that she had had the brilliant idea of him using his counselling room to start taking blood samples from patients on warfarin to save them trailing to the local hospital and waiting hours for this to be done.

This did make us smile, and it took a little bit of explaining that a number of pharmacies are already successfully providing this service around the country and that it would ultimately be the decision of the local PCT if we were to start providing this type of service or not.

However it’s great that patients are obviously beginning to view community pharmacies as not just places where they buy nappies and get their prescriptions dispensed.

And if we do decide to pursue this avenue, it’s great that we already have our patient advocate for the service.

No move on DAT

I previously told you that we had been approached by the local DAT to start supervising patients, but had refused due to the lack of a formal enhanced service structure and payment.

Well the LPC are still in talks with the DAT about setting up a proper supervised consumption scheme and we hope that this is resolved soon.

We have already taken on a new patient who takes Subutex. We were asked to supervise this patient but again had to refuse, so this patient has simply been picking the medicine up from the pharmacy and walking away….. Lets hope that the DAT and PCT can soon be persuaded that this enhanced service is really needed in the area.