Do we really need pharmacies? UK GP mag asks

doctor and pharmacist armwrestle

The editor of a UK GP publication has posed the provocative question, “Do we really need pharmacies?” on his blog.

Nigel Praities, editor of Pulse, admits that he is “deliberately being a bit provocative to stimulate debate” in publishing the column.

He cites the opinion of Pulse columnist Tony Copperfield, who suggested “Ten easy cuts to save the NHS” in July 2014 with “sack pharmacists” as step number one.

“Let’s face it, if you were designing the NHS from scratch, you wouldn’t invent pharmacists, would you?” Copperfield, whose bio reads: “Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder,” wrote at the time.

“They’re just GP wannabes who, medication-wise, duplicate what we do, but badly. To stock shelves and count pills, you just need a level of consciousness, not a pharmacy degree.”

Praities repeats the suggestion that anyone designing the NHS from scratch would not invent pharmacies.

He makes the point clear, however, that he feels pharmacists themselves should play a bigger role in the provision of health care.

“With so many more people living longer, and on a cocktail of medicines to do it, access to their expertise is badly needed,” Praities writes.

“They are brilliant at what they do, but I question the current position, where their skills are based in a building a few streets away, tucked behind shelves of corn plasters and toothpaste.

“Why are we continuing to support this bizarre arrangement when everyone recognises that NHS services must work better together to improve care?”

He says the General Practice Forward View, in which NHS England pledges that every GP practice in England would get access to a clinical pharmacist, could be much more ambitious if all practices had a fully-funded clinical pharmacist service in house.

He also questions the “archaic” restrictions on GPs being able to dispense.

“If pharmacies are able to set up – and charge fees for – services that compete with GP practices then surely every surgery should have the option to dispense medicines right there and then.

“Repeat dispensing could be done by post – so shorter opening hours would not be a problem – and the non-NHS ‘drug store’ part of the business would still exist in the larger chains.

“I am deliberately being a bit provocative to stimulate debate, but with the NHS facing a £22 billion black hole we have to think differently about how our resources can be used for maximum effect.”

Tim Logan, president of the Pharmacy Guild Queensland Branch, told the AJP that pharmacies in the community setting bring several advantages to the health landscape, and that prescribing and dispensing are separated for a reason.

“The more steps there are in the process, the more chances you have to detect errors,” Logan told the AJP.

“That’s not to say that if you have infinite steps you’ll be infinitely safe, but if you’ve got the same people being involved in prescribing and dispensing you’re losing that independent audit.

“A pharmacist might see a perfectly legal prescription for morphine 100mg and be aware that they’ve never had that strength of opiate before, and for an opiate-naïve patient it might be too much, even though the prescription is legally and rationally written in every other aspect.

“Having that separate set of eyes has paid dividends in terms of safety and the avoidance of harm on countless occasions.”

Logan says that pharmacies’ placement in the community pays off because they are highly accessible – Guild data has shown pharmacies are more accessible than GP surgeries, supermarkets or banks – and are not only visited by consumers when they are sick.

“Pharmacies are often accessed when people are not in acute mode – which is when they typically are attending surgeries or hospitals – but once you’ve got their health in maintenance and treatment mode. You don’t always need clinical services in those instances and it’s why you wouldn’t restrict pharmacy to just being in medical practices.

“I think you could file this column under the same genre as Professor King’s speech at APP: let’s ask some provocative questions, even though we’re pretty sure there’s a good answer to them.

“Let’s ask those questions, and just remind ourselves of why things are the way they are.

“While ever pharmacists are detecting misadventure from either one prescriber’s misstep or interrupting the bad consequences coming from two or three different prescribers doing two or three different things for one patient without one knowing what the others are doing, there’ll always be a place for pharmacists in pharmacies.”

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  1. Jarrod McMaugh

    Well said Tim.

    “Start with the Why” was the title of a session at a great conference I attended recently, and I can say that this is more relevant here than anywhere

    Why do pharmacies exist? To separate supply from diagnosis; To have clinical decisions vetted by a third party; Because no matter how good the local GP may be, they can’t know everything relevant to a patient’s treatment when they initiate, augment, or perpetuate it.

  2. Anthony Tassone

    Doctor’s groups arguing that they should be able to dispense, if pharmacists are advocating for an expanded role is hardly new.

    Rather than viewing the issue or debate from a ‘turf’ or ‘territory’ perspective, it’s essential that we consider it from a consumer or patient need perspective. As has been pointed out by Acting National President of the Guild Tim Logan, and Jarrod in this discussion thread, there is a clear safety imperative with the separation of prescribing and supply.

    Furthermore, advocating for an expanded role for pharmacists is done in the context that pharmacists are underutilised in a health system that is under pressure. There is a consumer benefit. Are consumers experiencing a lack of accessibility to receiving prescriptions being dispensed from a pharmacy? The evidence doesn’t suggest that with 87% of the Australian population living within 2.5km of a community pharmacy.

    Is there evidence that patients are having delayed wait times to have an appointment with a GP? There is evidence to suggest that this is the case with some evidence suggesting that 23% of Australians in capital cities and 42% in other areas wait at least three days for a GP appointment.

    Hypothetically speaking, if GP’s were to take on a dispensing role would these wait times increase? Would an accessibility problem be made worse?

    Suggestions by some doctors groups of ‘if you pharmacists take on a greater role, then maybe we should take up dispensing and some of your role’ should ensure the patient is placed at the forefront of our considerations; their safety and whether it addresses a clear need. On their previous arguments – it doesn’t appear as they’ve been able to make a strong case.

    In our Australian community pharmacy network – accessibility is a hallmark of what we enjoy today and should be made an absolute priority to be maintained.

    Anthony Tassone
    President, Pharmacy Guild of Australia (Victoria Branch)

  3. k

    Another way to save health budget in Australia is to reduce reimbursement for each patient that the Drs seen and all drs in hospitals should receive pay cut so the more resources can be utilised for better medications. A lot of pharmacists are better than the Dr, it is just AMA is ignorant to accept this fact.

  4. william

    Well country doctors used to dispense and it was very sensible in isolated areas.
    It is no use trying to bring up reasons why they should not.
    How many errors or suspected errors do pharmacists actually catch? How many do pharmacist make that get out to the consumer.
    When there was a need for the apothecary to compound substances there was a real need of specialised knowledge and the operation took a lot more than sticking a label on products and collecting the money. Very few pharmacist would actually know how to make compound mixtures these days as we area all at the end of our career.
    Something needs to be done to decrease the total costs to the community of healthcare.
    The age of computers and technology has opened up endless possibilities and they will increase in these exciting time.
    Like it or lump it, pharmacy has to face the constant change that is and will continue to happen.

  5. nuggettyone

    In Singapore, where I grew up, and lived for over 30 years (I’m in Melbourne now, and it’s awesome!), doctors all dispense.

    Before taking a job in the pharmacy industry, I’d never knowingly spoken with a pharmacist in my life.

    I think Australia’s system of separating dispensing from prescribing is far superior to Singapore’s. It doesn’t just help with the detection of adverse interactions, medications checking, and an additional pair of eyes with better pharmacological knowledge. It is a system with innate checks and balances that protects the sick from opportunism.

    In Singapore, it’s pretty much a fact of life that your GP bills can vary wildly – it simply depends on how much the GP feels like ‘padding’ with additional vitamins, unneeded medications, etc etc.

    Have a cold? Have an antibiotic (even if you didn’t ask for it). Also take a box of Panadol (which you could buy for cheaper from the supermarket). And some multivitamins. And a bottle of cough syrup. All sold at whatever price the doctor feels like selling them at. Could you refuse, as a patient? Possibly. But culturally, it’s just not done. Before coming to Melbourne, I never even realised the system could be different.

    And all this is paid for out of your own pocket, unless you’re a civil servant. No Medicare rebate, or anything like that. Especially not if you’re living on or around the poverty line.

    Australia’s system protects the general public, as well as the poor and needy. I’d be very sad if things were to go the way they do in Singapore.

  6. Big John

    I’m not advocating for GP dispensing. Who in their right mind would? But I will warn pharmacy: don’t take turf off the Doctor’s! In this fight with the Government and big corporations Pharmacy doesn’t need enemies – it needs allies.

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