Under control

Had some great fun with the changes to the CD regulations in July, but we think we’ve got them sorted out now. I’ve written a memo on all the important changes around the NHS scripts to keep all the staff on the right track, since there’s been a number of changes for everyone to contend with.

For example, yes it’s good practice for a GP to issue no more than 30 days supply but it’s still only good practice and so we can’t send patients back to the particular practice that does issue large supplies (although we have politely sent over a copy of the Societies guide to the changes!).

We’ve also had to get used to asking people to sign the back of scripts when collecting Schedule 2’s and 3’s (even for temazepam which we do keep forgetting about!). It’s been quite a challenge to get the right wording with patients when explaining why they now need to sign, but we’ve settled on describing changes with “with certain types of strong painkillers” since it seems to sound so much better to a patient than describing changes with “controlled drugs”.

And it’s been marvellous to be able to make minor amendments to CD scripts rather than send them back to the GP. We must get at least two CD scripts a week where the total quantity isn’t written in words and figures and now we can sort this out ourselves, rather than messing the patient around.

Breath taking patient care

Hurray, I now have nearly all my placebo inhalers and how I’ve used them. I must demonstrate an inhaler device to a new patient at least once a day and that means making a real difference to patient care, so come on you companies, what’s the problem with readily providing them to us community pharmacists!

The drugs don't work

Well you remember that we have a supervised methadone area. Other pharmacies in the area that do supervise consumption have now taken their full quota of clients and so the local drug action team (DAT) are delighted that we have suitable facilities and are keen to start providing this service. But there’s a hitch; the DAT and the PCT doesn’t have any standard paperwork to provide to us (e.g. SLA, clinical guidelines, patient agreements, SOPs, etc) and can’t agree with the LPC on a fee for the service. So we’ve been put in a difficult situation between wanting to meet patient need, but not wanting to set a precedent by going ahead and proving this, after all enhanced pharmacy service, without any formal agreements or payment structure being in place (we’re not sure how the other local pharmacies already providing the service are working this one). So for the time being its all ground to a halt until we have this structure in place, and it’s so frustrating. Will keep you posted.

Accident and emergency

Had a couple of interesting examples this week of where communication channels and discharge procedures from hospitals can go wrong and leave patients uninformed and confused. I know that the evidence-base suggests that there is always room for improvement in discharge procedures, not least of all actively involving the patient’s community pharmacist. And the local hospital here does, since we are regularly faxed discharge summaries of our patients. However, these are a couple of patients who slipped through the loop this week:
- One parkinson’s disease patient who had been changed from one levodopa combination to another by the hospital. We received their new prescription from the GP with the directions of ‘MDU’ and so enquired if the patient knew how to take their new medicine. They didn’t and neither did the GP practice when we checked it with them. So we left it with the GP practice to ring the hospital and get back to us and the patient.
- A patient who had gone into hospital for ‘some checks’ and come out with a HF prescription for an ACE inhibitor starter pack, spironolactone, digoxin and a beta blocker; no counselling and a follow-up appointment in 2 weeks time. So I particularly made sure that he knew how to take the first doses of the ACE inhibitor and what the ‘warning’ side effects were with digoxin.
And of course these ‘significant’ interventions were recorded in the patients’ PMRs as part of the new pharmacy contract.

The placebo effect

Well I’ve been a largely fruitless mission this week to get hold of a set of placebo inhalers. I don’t want to harp back to the ‘good old days’ but it used to be so easy to get hold of the various placebo’s. I was really surprised just how difficult companies are now making it to get hold of these, especially in the light of MURs, etc. Just how am I supposed to do my job competently with new asthma / COPD patients if I haven’t got the appropriate placebo inhalers to hand!
One company told me that they only supplied placebo inhalers on written authority from a doctor (which did lead to some rather negative feedback from me). Two other companies told me I had to order them through my wholesaler but the wholesaler knew nothing about it. In the end I contacted some local reps who kindly supplied some of what I needed, but what wasted effort on my part to get hold of some of the tools of my trade!

Listen and learn

Well you know that I love talking to patients and there never ceases to be countless opportunities for pharmacist’s and their staff to counsel patients and make a real difference, for example:
-The patient on a reliever inhaler, who had been prescribed a brown one and didn’t appreciate that she should:
1. Keep using the blue inhaler as a reliever on a prn basis.
2. Use the brown inhaler on a regular basis and rinse her mouth out afterwards.
-The number of patients taking regular simvastatin who are also prescribed a course of erythromycin, and don’t know to temporarily stop taking their simvastatin (well this is the advice of one of the local GP practices and it seems very sensible to me).
-The number of women taking the COC who are prescribed a broad spectrum antibiotic and given no counselling on what to do to avoid potential pill failure.

Getting to the bottom of things

Well it’s coming to end of my first week back in community pharmacy and I’m starting to feel like an old hand already.

I’ve always really enjoyed talking to patients ( for me this is what community pharmacy is all about) and I always make an effort to counsel patients taking new medicines, or with any alterations to their existing repeats. The rest of the dispensary staff have quickly cottoned onto this and give me all the patient counselling to do which is fine by me. I’ve had some interesting encounters already, for example the patient who dropped his trousers when I invited him into the counselling room to show me a burn on his stomach.

Like riding a bike

All the dispensary staff and the other pharmacist are being a great support to me this week. I’ve made it well known that I haven’t practised for a number of years and so I will need a gentle reminder on some issues! I am up to date clinically, and with all the processes of the new pharmacy contract but I’d forgotten the vast range of different issues that a community pharmacist is expected to deal with on a daily basis. For example, medicines that can and can’t go into dosette boxes, how to measure and fit someone for a stocking, medicines that have long term manufacturing problems (e.g. Heliclear), and the expiry date on Zineryt once its made up!