Wednesday, 27 November 2013

The Tale Of The Pencil Woman..

She used to visit us in waves. We wouldnt see her for a few weeks, then it would be up to three times a day, every day, for a week. First, it was pencils, so she became known as The Pencil Woman.
She would ask us each time if we sold pencils. We would reply that we didn't. She would smile a lovely, lopsided grin, and say oh yes she remembered now, silly her.

One day a rep came round, and in his catalogue we noticed some pencils. We ordered them in.

She came in and asked for pencils. We told her that yes, we did have some in stock now. We sold her one, and off she went. 

She came back the next day, and asked if we sold pencils. We must have looked a bit confused, as we knew we had told her where they were yesterday.
"Oh yes, I remember now. I bought a pencil, but you see, its my son. He's an artist and he draws all the time, and he had ran out of pencils so I gave him mine. Now I need a pencil."
This started happening a lot. Always the same story. We laughed about it because we didn't know what else to do.

The next time we saw her was about three weeks later. She asked if we sold reading glasses. We showed her where they were, on the counter. She selected some, paid her 99p, and off she went. She came back the next day and asked if we sold glasses.
"Oh yes, I know I just bought some, but you see its my son. He needs glasses for when he is drawing, and he has taken my pair because he lost his. So now I need another pair. "    
She would sometimes return just an hour later, and say exactly the same. She would come in when we were really busy with prescriptions, and sometimes we would be impatient with her.

One morning, we sold her a pink, flowery pair of glasses, joking that her son wouldnt want to steal those ones. She was back in for more in the afternoon.     

There were various other sundries that she cycled through.

Then one day she asked for aspirin. I asked her all the questions, and she Said she wasn't taking any other medicines etc. She said she just like to keep them in the house in case she got a headache. So I sold her them.
The next day she came in and asked for aspirin.
"Well its my son you see. He had a headache too (probably because he does so much drawing) so he took the pack of aspirin to  work with him so now I need one for me."

The same thing happened over and over again. I tried to question her more and more, but without accusing her of lying I couldnt get anywhere. I tried to have long chats with her, to find out her name, and who her doctor was. She told me she wasn't registered with a doctor and she didn't like going to see them.
I was worried. She was obviously forgetting that she had bought aspirin, and buying more. The son was a clever cover story, for the times when she could see the pity in our faces. One day, she came in for aspirin again and I saw a large bruise on her hand. She said she didn't know where it had come from, it just appeared one day. I asked her to promise me that she would see a doctor. She held my hand and said she would and how sweet I was. 
If she was forgetting that she had bought the aspirin, was she forgetting when she had taken  the aspirin. Was the bruising because she was bleeding because of taking too much aspirin?
I asked our delivery driver to ask around when he was out and about, to see if anyone knew her. We asked in the local shop and pub if anyone knew her name or address so I could look her up on our records and see who her doctor was. No luck. Everyone knew her, but no one knew her name.

One day, a woman came in with some medi-boxes that had been dispensed from another pharmacy. She said she had found them in her mum's house, but her mum had plenty of boxes, so could we dispose of them. I did so, and just happened to glance at what was in there. It was some Alzheimer's drugs. I didn't think anything else of it.

The same woman rang the pharmacy a few days later, to ask something about her health. She said she was feeling really run down, as she was finding it hard to work full time and look after her mother who had dementia.
Something clicked, and I asked her to describe her mother to me. It might have sounded like an odd question to her, but she described the pencil woman.   
What happened next might have been a breach in confidentiality, but I told her about the aspirin, and the bruising, and how I had been worried about selling it. I figured yes, I had broken confidentiality, but the pencil woman was in danger if I didn't.

Her daughter told me the story. It started with tins of soup. She had cupboards and cupboards full. Then it was loaves of bread, which went mouldy, and the daughter had to clean out her whole kitchen. There were tears, and I had absolutely no idea what the right words to say were.

We still used to see her. When she came in to ask for aspirin, I told her that her daughter had been in to get her some and would see her later. I had agreed this line with her daughter. It was a little white lie that saved her from more embarrassment, and kept her a little safer.

I still think about her a lot, especially now my own Grandma is approaching the upper end of the  moderate stage of Alzheimers. I think of all the times we were impatient, or didn't have time to stop and chat. I wonder what her story was, and what she had done when she was younger. I wonder about all the tales she might have had to tell, and how many of them are lost.

I wonder where she is now, if she is still alive. I wonder how her son and daughter are coping. 

I think of the embarrassment and terror in her eyes when she was telling us about how its her son, you see.

Today is Dementia Awareness Day. I think of The Pencil Woman.

Friday, 8 November 2013

Pharmacies, pharmacies, everywhere

"Phew, I tell you what, I can't move for pharmacies these days. They're everywhere I turn, and I can't walk down a street these days without tripping over multiple green crosses. Everywhere you go its pharmacy here, pharmacy there, pharmacies everywhere"- No-one, ever.

And yet, apparently there are too many of the blighters, according to some pharmacy leaders. About 3,000 too many, give or take. Funnily enough, I beg to differ. And here's why.

I have worked in two newly-opened pharmacies in my career. In each, I was inundated with customers wandering in and telling me how lucky they were to have a pharmacy in their area. In one, the residents of the local area had campaigned for years to get their own pharmacy. Within months, the pharmacy was busy and the delivery service was thriving- and this was in a very small pit village.

We weren't, however, busy enough to justify a second pharmacist. This meant that I-despite good, efficient staff- would have to work many a late night-for no extra pay or lieu time- just to keep my head above water. The pharmacy closed at 5.30pm. I was regularly there until 10.30pm on a Thursday night, dispensing and checking prescriptions to make sure we were clear for Friday morning so that we could get all the prescriptions done and delivered in time for the weekend. This was just to keep on top of the day to day dispensing and didn't take into account any of the routine business things I had to do, like writing SOPs, Business continuity plans, finances, etc etc etc as a pharmacy manager. The pharmacy opened at 9am. I would turn up at 7:30am (again, unpaid) to get the till float done, prescriptions counted etc before we opened.

Its not that my time management or organisation was bad. It was just the sheer volume of work that needed to be done. I got away lightly- one of my fellow pharmacists in a different branch was known to be still at work at 2am at least once a week, just to keep afloat.

This was a few years ago now, but I locum fairly regularly and I still see busy pharmacies, with staff working flat out to get their work done as efficiently as possible. Not that much seems to have changed. What I don't see is empty, quiet overstaffed pharmacies filled with bored staff who have nothing  to do.

One day, the managing director for the company came round, and had a go at me because I hadn't been doing enough Medicines Use Reviews (MURs). Now, I was initially enthusiastic and excited about MURs. I couldn't wait to sit down with patients and get my teeth into providing a good quality service.

But I just couldn't do it. I didn't have time to do as much training, preparation, and CPD as I wanted to, and as a result I was nervous of doing MURs. What didn't help was the fact that, throughout each one, a large part of my brain was taken up with worries about how many prescriptions were piling up in the dispensary, when I wanted to give the patient my full attention. Each 15-20 min slot I spent in the consultation room with a patient meant I was behind with prescriptions- and because most of mine were deliveries, this had a huge knock on effect on the delivery drivers, and ultimately, the patients, who would then ring up in a panic wondering why their medicines hadn't been delivered by the usual time, putting us even further behind schedule. Thus began a vicious circle, worsened by my own constant feeling that I was so thinly stretched I just wasn't able to do enough justice to every aspect of my work. I'm by no means a perfectionist, but I like to do things well, and the fact that I just didn't have the resources to do so constantly played on my mind.

I ended up frustrated at my own inadequacies and inability to get on top of the situation, stressed to breaking point, and incredibly disheartened. I'd even go so far as to admit that resentment started creeping in too. I know I'm not alone here, and suspect that the majority of community pharmacists have felt this way.

MURs are just one example of a service of course. In the year and a bit I worked at that pharmacy, we started doing MURs, morning after pill, over 50 men's health checks, diabetes screening, a minor ailments scheme, smoking cessation schemes, and a weight management scheme, amongst others. I was desperately swimming against a tidal wave of more and more jobs to do in the same amount of time.

Each time I read a pharmacy magazine like Chemist + Druggist, there seems to be yet another call from yet another pharmacy body or the other for pharmacists to be involved in delivery of yet another service. And my heart sinks, because I wonder just how on earth this is supposed to fit in with all of the other jobs that need doing.

Now, I'll admit that I haven't read the Now or Never report from the Royal Pharmaceutical Society commission (on account of being a cash-strapped non-member pleb). Nor have I kept up to date with the response to it on social media, blogs etc (on account of a fairly severe bout of anxiety-induced apathy over the last few days). With that in mind, though it still seems to me that the following metaphorical conversation is going on:

Pharmacy leaders: "And, and, and, you would be really good at delivering all these new services, so you should start doing that."

Pharmacist (from underneath a large pile of prescriptions that need checking, in between phone calls, and being called to the counter to speak to patients): "Yeah, I probably would be good at that. And I would love to do it, if only I had time."

Pharmacy leaders: "Good, well that's settled then. We'll pay you less for dispensing, but because you'll be doing all these services that will definitely be okay because you'll make up the money elsewhere."

Pharmacist (desperately attempting to gulp from a cold cup of tea to avoid dehydration): "Erm, right. Sorry, I need to go and talk to a patient now hold on... right, sorry, I'm back, what were you saying again? oh hang on, that's the phone ringing, I'll just have to get that..."

Pharmacy leaders: "We're so pleased you're co-operating. Oh, and by the way, we've decided there's too many pharmacies, so we're going to close all the ones near you, so you'll be getting more prescriptions to do, and more customers."

Pharmacist: "hang on, whaa- yes Mrs Brown, your prescription will only be a couple more minutes"

Pharmacy leaders: "Great! so to summarise, that's more prescriptions, more customers, more services, less pay. See you later!" (flounces off)

Pharmacist: "What in the hell just happened?... No no, Mr Smith, its okay, I don't need to see your haemorrhoids again, thank you"

Strategic decisions and the bigger picture are all very well, but at the end of the day they are just words if the people at the front line aren't able to deliver the vision because they are already overloaded. To me, it feels like new ideas, new visions and new services are bandied about by the top level folk, but what they neglect to do is look at the minutiae and check how the "little people", the folk on the ground are doing and what they think about any changes.

The realities of life on the shop floor are, in my mind, not conducive to delivering the sorts of services that the profession is calling for, unless there is a huge overhaul in how pharmacies are staffed, funded, and managed. And given that, in these austere and pressured times, everything possible is being done to reduce costs, pare down staffing, and maximise profits, I just cannot see the sort of situation in which we can do all of these things to the best of our abilities well panning out in real life. Yes, great changes in the direction of the profession need to come from the top, but they also need to come from the pharmacists behind the counter in the little pharmacy in the tiny pit village too.

The only way that I would have been able to deliver MURs in my pharmacy to the standard and quality that I so desperately wanted to acheive would have been to have had a second pharmacist present. And the only way a second pharmacist would have been present was if they had been paid. And the only way the company would have paid for a second pharmacist would have been if they were absolutely, just short of gunpoint, forced to.

I'd like to suggest that before the profession starts excitedly waving its hands and shouting "ME ME ME!!" to every available service going, we take a step back and decide whether or not we can actually deliver it, given everything else we also have to do. That enthusiasm is great, but if we can't follow it up with actions, we will end up an all-talk and no substance sort of profession.

So, in summary: are there too many pharmacies? No, although there might be the odd street or village which has more than its fair share. To be honest its a moot point. What's a more important question is: "what can we do to support pharmacists and improve the quality of services in the pharmacies we've got?"


Thursday, 7 November 2013

Stick a label on this...

Since before I began my career in pharmacy, there has been a drive to get pharmacists "out of the dispensary", in a bid to better utilise their medicines expertise with patients. This sounds great- we have unique clinical knowledge and skills that we have always wanted to use more to make sure medicines are used effectively, safely and efficiently.

For a patient to use a medicine effectively, they need to actually have it in their possession. There is no getting away from the fact that dispensing prescriptions remains a large part of the community pharmacy business model (leaving aside concerns about the contract and reimbursement etc for now). However, dispensing remains the frumpy friend of the drop dead gorgeous, charismatic clinical side of pharmacy. It seems that these days it is seen as repetitive drudgery: the smartie counting and label sticking that we hear so much about. It is, in short, a waste of pharmacists' time, and is something the profession as a whole seems to unquestioningly want to leave behind.

I believe, however, that it is pharmacy's unique selling point. Its only through dispensing that a prescriber's directions are translated into reality. We can prescribe and advise on the most efficient use of medicines imaginable, but if the patient doesn't physically have the right medicines and know how to use them, all of that is pointless.

Yes, there are ways to reduce the pharmacist's input in the dispensing process. There are robots, accredited checking technicians etc. But a prescription still needs to be clinically checked- and that requires the unique skills, knowledge, and abilities that only pharmacists have.

But lets say we step away from dispensing and move in a purely clinical direction. We sit in a room and do reviews of patient's medicines, answer queries, prescribe medicines, monitor and screen patients. Does this sound familiar to you? It sounds to me like the sort of thing a GP does. So, why do pharmacists exist? What do they add to the healthcare picture? Doubtless such pharmacists would be useful, but the profession would become more nebulous, the edges of our role more diluted and less defined.

In my eyes it is our practicality, our ability to supply essential medicines in a safe and effective way to patients that defines us as a separate profession. That, to me, doesn't have to just mean sticking labels on boxes, and doesn't mean that the profession has to be at a standstill. I just think that we need to stop putting ourselves down and accept and be proud of our role in supply. For years we have been declaring ourselves as able to provide new and more clinical services- and we can. But we need to make sure that we define and build on our niche to give us the solid foundations we need to start branching out.

We pharmacists are an interface. Our role is as go-between, and a bloody important role it is. We are go-between a patient and their GP or their consultant, or whoever. Or, we are a go-between the patient and complex medicines information- we can, crucially, convert difficult to understand evidence into patient friendly terms. We can explain what they read in the paper or on the internet, what the directions of a reducing dose are, help them to navigate through the overwhelming choice of medicines over the counter. We are a go-between the drug manufacturing plants and the patient's bathroom cabinet. And the thing that underpins this role is our accessibility. And the reason we are so accessible is because- wait for it- we dispense prescriptions.

If you ask me (not that anyone will), we need to stop thinking of dispensing as the poor relation and see it for just how useful it is.