Monday, 18 March 2013

The troubled life of a community pharmacist: Emergency Supplies

I've spoken a little bit about the sort of conditions I've come across in the community pharmacy setting. Today I want to talk about one specific issue which affects community pharmacists time and time again: the emergency supply.

Having worked for many years in community, I have definitely experienced a large amount of anti-pharmacist opinion. I can understand where it comes from: it's a very weird setting for a professional service, in a shop. Patients tend to build up a relationship with their GP, and the very setting of a surgery, with its closed-off rooms and offices free from distractions lends itself more to a professional image. There's a public perception that because pharmacist work in a shop, they're less important, less professional. This is a real shame, and often not the case. I suspect that many members of the public don't even realize that pharmacy is considered a profession: anecdotally I know of occasions where people with no qualifications have applied for pharmacist jobs and have been surprised to learn that you actually need a 4 year masters degree plus one year pre-registration training. It's a great shame that, in the eyes of many members of the public, we are nothing but glorified checkout operators. People are used to a "The Customer Is Always Right" attitude, but unfortunately in pharmacy, which is governed by specific laws that make it different from other retail situations, this isn't always the case.

It seems to me that this often leads to an assumption that where things go wrong with medicines supply, it's always the pharmacist's fault. We are the faces across the counter from you telling you that for whatever reason, you can't have your medicines. We are therefore the obvious target for the complaints, the "well if I die its all your fault!" statements which we hear regularly. But is this fair?

Let's imagine its a Saturday morning. You go to your local pharmacy to pick up your repeat prescription which the pharmacy picks up from your surgery for you, and its not there. Lets consider what might have gone wrong here:

1. The pharmacy has picked up the prescription and lost it. Rare, but it does happen. Most pharmacies/ surgeries will have records of what's been picked up though so its usually easy to find out if it is in the pharmacy or not. In this case, its fairly obvious that the pharmacy is at fault. The solution to this is also pretty obvious: you hunt high and low around the pharmacy until you find it.

2. The prescription is still at the surgery. Either it's been put in the wrong box for collection (a really easy mistake to make, used to happen at the surgery local to my pharmacy loads) or it hasn't been issued in time for the weekend. It might be that there is a query on the prescription or similar, so it hasn't been issued for a reason. However, its Saturday morning and the surgery is closed, so there is no way for the pharmacist to know why the prescription hasn't arrived in the pharmacy, only that it isn't there. In this case, it would be the surgery who is at fault as they've failed to ensure the patient's prescription arrives at the pharmacy ready for them to pick up.

3. The patient hasn't ordered the prescription in time for it to be ready for the Friday evening collection. Most surgeries will take 48 hours or so to process a prescription, and depending on the pharmacy you might have to add another 24 hours on to make sure it's dispensed. If the patient hasn't ordered their prescription on time, there's a good likelihood that it wont be ready at the surgery for the pharmacy to pick up.

Now don't get me wrong, option 1 definitely does happen, but in my experience the vast majority of cases are because of options 2 or 3. The pharmacy often doesn't know whether to expect a prescription for a particular person, so without telepathy is unable to do anything about it when the surgery is still open, on sometimes a prescription hasn't been issued because a patient is overdue a review, or there's been a change in their therapy, or just because of a genuine mistake.

With some patients none of this matters. It doesn't matter how much you explain to the patient that it still seems to be at the surgery, or that if they've ordered their prescription on Thursday and it takes 48 working hours for the surgery to process it, in their eyes you're still the one to blame. It's common to have patients shout at you that if they die because they haven't gotten their medicines, it'll still all be your fault. There are a combination of reasons for this: a mistrust of pharmacists, a belief that GPs can do no wrong so it *must* be your fault, distress that a patient will be without their medicines, and most of all the fact that you're there stood in front of them in a retail setting, so they vent. This might sound a bit over the top but it really does happen all the time. I've been shouted at, sworn at, and and had things thrown at me over the counter on an alarmingly regular basis in these kind of situations. And because I'm a professional, and I believe in good customer service, I stand there and respond politely, and do my best to try to resolve the situation, whilst all the time I'm thinking "hang on a second here, this isn't actually my fault, yet I'm the one getting shouted at."

So anyway, back to our Saturday morning situation. You've ran out of  your meds and the prescription isn't there for whatever reason. So what can the pharmacist do about it? Well, there is provision for pharmacists to provide an emergency supply of a prescription only medicine to cover just such scenarios. This involves us essentially selling a prescription only medicine without a prescription. It's legal, provided we are able to justify the sale in accordance with the law. It's worth remembering that the worst case scenario for a pharmacist is that you can be done for manslaughter, so every pharmacist sort of learns to constantly think to ourselves "will this harm the patient?" and "Could I justify this in court?" So there are a couple of things that the pharmacist will be considering in the case described:

1. It must be an emergency situation: so it needs to be a situation where harm would be caused if the drugs were missed. The definition of this might vary from pharmacist to pharmacist: some might not supply an emergency supply of the contraceptive pill for example, because there's a perfectly suitable alternative available in the guise of condoms. That's fine, and its at their discretion. I tend not to do emergency supplies for statins, because missing a couple of days of a statin is highly unlikely to cause such an enormous raise in cholesterol levels that the patient has a heart attack. However a patient missing a few days of an anti-epileptic medication can mean that they get rebound seizures, which could go on to have a huge impact on their lives.

2. The patient can't obtain a prescription within a reasonable time: If the surgery is open, then we really shouldn't be doing emergency supplies. It's worth noting that "reasonable" does not always mean convenient to the patient, but we would be unable to justify an emergency supply if a prescription can be obtained in a reasonable timeframe. If a surgery is closed for the weekend, this is exactly the sort of situation an emergency supply is handy for, but do remember that there is always out of hours doctors or hospitals that could potentially supply a prescription.

3. The pharmacist needs to be pretty sure that it is a patient's regular medication. This is fine if you're a regular at that pharmacy, but can be terrifying if you don't know what the patient is on. I've had patients asked for their "epilepsy tablets, you know the ones that are purple" or "the blue blood pressure tablets" or something suitably vague. If I gave the wrong thing, and the patient was harmed, it would be me in the dock and me who would never be able to live with the guilt.

4. How much should we supply? The guidance used to state a maximum of three days supply in most cases. That's usually more than enough to wait until the surgery reopens to sort out an emergency prescription. This has now been changed to a maximum of 30 days, but it is important to realize why this guidance was changed. It was increased pre-emptively a few years ago when we were waiting for the bird flu pandemic to hit. The theory was that surgeries might have been overwhelmed or closed (due to the fact that everyone was dead from the flu!) so this would allow pharmacists to have some more leeway to provide medicines in that very specialized scenario. It's therefore difficult to routinely justify giving out 30 days supply when in most cases a prescription could reasonably (even if not conveniently) be obtained within a few days.

5. Pharmacists are able to charge for emergency supplies. If nothing else, it's a right faff to do, and it can take a while to dispense. But from a business perspective, if we didn't charge we're giving  away medicines for free with no guarantee of reimbursement. Think about it: you wouldn't expect that from any other retail situation. You wouldn't expect Tesco to just give you your weekly shop for free if you offer to pay for it later on in the week. Most places will be happy to reimburse the charge on presentation of a prescription, so its usually not too onerous. Again, its at the discretion of the pharmacist whether or not to charge. I remember a particularly aggressive patient who was very upset about how urgently he needed his cream for his skin condition that he hadn't gotten round to ordering. "It'll be YOUR fault when my skin flares up!" he was saying. "YOUR FAULT! I need it URGENTLY!". I explained that I would do an emergency supply for him so he wouldn't be without his cream. For some reason I can't quite fathom, he decided his skin wasn't actually that bad when he found out it would cost him over £65 for the cream. "Oh, it doesn't matter, it ummm, it feels a bit better now" he said, and shambled off.  

There are other laws and considerations that also need to be taken into account. but here's my overall point: The next time something goes wrong with your medicine supply, consider the fact that your pharmacist will and should do everything they can to help you, but they are bound by law and guidance and they need to be able to justify their supply. Sometimes, just sometimes, its not all their fault, and whilst I understand that pharmacists are visible and at the end of the line, so they might seem like the appropriate people to shout at, that isn't always the case. Pharmacies should have robust measures in place to ensure continuity of supply: not feeding back to the surgery if there is a recurring issue with their measures means they don't know to strengthen them. It sounds petty, but having to constantly hear customers who you do your best for assuming that something is your fault is wearing. It chips away at your professional pride and I know there have been times when I think "seriously, why do I bother?".

Pharmacists have feelings too. Some of them, anyway. Something as small as just saying "I know its not your fault but..." can be enough to make your day. 


Update: I am sorry if this post sounds a bit whingy. However I do think that there is a tradition in pharmacy (and probably many other areas of health care) of just sucking it up, and keeping quiet.  I think its useful to explain the kind of thought processes we go through so people can understand the often difficult position we are in.

And Another Update: Guys, I'm bowled over by you lot. This post has started a bit of a discussion on twitter which shows just how proactive we pharmacists can be once we start talking. There is talk of organising a pilot to see about reporting emergency supplies as systems failures to highlight where the problems lie and attempt to resolve them. This just proves to me that there are some really brilliant pharmacists out there, and that given the time, resources, and opportunities to be proactive, we can really make a difference. Do get in touch if you have any ideas or thoughts- leave a comment, email me, or tweet me @SparkleWildfire