Johnathan Laird
Isn’t it a shame that it has taken a major constitutional event like Brexit to trigger a conversation about the idea of community pharmacists making reasonable medicine substitutions?
As pharmacists, we should have been doing this years ago. I would actually go further and say that all pharmacists should qualify as independent prescribers but that is a whole other blog entirely.
So what of the issues surrounding the medication substitution idea?
There is a strong argument to allow pharmacists to make decisions about medicine substitutions but I do think it is a shame that it has taken the shambles that is Brexit to bring this proposition on to the table. I think there are a few things to consider. I come at the issue from the perspective of an independent prescriber.
I don’t know if every prescriber is the same as me but every single time my pen hangs over the signature area of a prescription that I am about to sign I pause and think. I do this every single time. The decision to pull the trigger will have been formulated over the preceding minutes but in this final moment I ask myself a few simple questions;
Do I need to prescribe this medicine?
Do I understand the risks and have I explained them to the patient?
Is it safe?
Have I demonstrated competence to prescribe this item?
Do I need to monitor or safety net the patient?
Once I’ve ticked these final boxes, in addition to the initial decision-making process, I pull the trigger. It is in this context I consider the stock substitution idea.
Emergency supply
I thought I’d wind colleagues who do not work in Scotland up a bit at the beginning here by putting in a reminder about how amazing Scottish pharmacy is. There are many reasons for making this claim but the aspect relevant to this story is the community pharmacy urgent supply scheme. The scope of the community pharmacy urgent supply scheme (updated in October 2018) is in my view impressive. This scheme is basically an NHS funded service that more or less mirrors what those of us who don’t work in Scotland know to be the emergency supply regulations.
Some relevant aspects of this Scottish service include the ability to alter the formulation if, for example, the patient can’t take it. Flavours can be altered of certain products if there is a compelling need. A good example here would be the flavour of an antibiotic that a child does not like. The precedent set in this Scottish scheme means that the leap to supplying alternative medicines is not huge and most importantly the funding and infrastructure is in place to make it happen.
Read more about the Scottish scheme here.
Although I am banging on about how great this service is I would suggest at this stage that the current emergency supply regulations provide significant flexibility to supply when there is a compelling need.
So now that I’ve mentioned the status quo and the existing arrangements I’ll now move on to talk about the outline idea of pharmacists being allowed to make medicine substitutions due to potential shortages as a result of Brexit.
Are all pharmacists competent to do this type of thing?
Maybe. As with anything new like this, I would never say no to most ideas but the massive caveat would be that pharmacists involved would absolutely need to have insight into the consequences of the decision made and also prove their competence. I think the main issue with competence is that initially at least it probably won’t be consistent across the piece. I’ve seen this locally where some community pharmacists are signed up to certain patient group directions and others are not. In this situation, the patient suffers due to inconsistency in service delivery.
In general, though this should really be ‘bread and butter’ activity for community pharmacists. I mean is there a significant risk in substituting Fucidin ointment for Fucidin cream? Absolutely not. There are plenty of medicines however that would require careful consideration, not least those that need to be prescribed by brand. On these occasions, careful knowledge and insight into the potential consequences need to be considered. There needs to be appropriate checks and balances to make sure pharmacists acquire and maintain this competence.
Insurance?
I did some work creating a report on independent prescribing last year and it led to me having conversations with a number of insurance brokers. This was very interesting because I quickly learned that these brokers don’t really care about the clinical activity per se instead they care only about how much risk is related to these activities. On discussion with them, they indicated to me that most activities can be insured. The variable is the premium. Higher risk = higher premium.
A question I would ask about this activity is if the additional risk associated with substituting medicines would lead to increased premiums and if so who would pay?
Will patients consent?
I think consent is a really important aspect of this issue. I don’t think we can assume informed consent instead it probably needs to be explicit i.e. we need to ask each time. My experience of running pharmacist-led prescribing clinics is that the majority of patients are quite happy to see me (i.e. the pharmacist) but there are some who will insist on seeing a doctor. Will every patient be willing to allow their pharmacist? I suspect the vast majority will but some won’t and we need to respect this.
Who pays for the extra work?
Given the extremely difficult working conditions for many locum pharmacists in particular whilst I think this is a great idea, I would say that extra responsibility should probably command higher rates of pay. I read recently that pharmacist locums in Northern Ireland command a wage of as little as £13 per hour. I suspect suggesting adding extra responsibility to the current role for no extra remuneration could, and probably should, be met with some resistance.
And this brings me to my core concern with this issue. I think this could be yet another example pharmacists collectively saying yes to something because we are absolutely delighted to feel needed to smooth over the crisis that is Brexit.
And I would suggest, and happily be corrected or proved wrong, that the bluster around this issue is a cynical political move to get pharmacists to work for free.
For once should we not collectively pause and negotiate effectively?
The views expressed in this article are Johnathan’s and should not be attributed to or be seen to represent any organisation he is associated with.