Stop gatekeeping S3s: Nankivell

Belinda Nankivell

Pharmacy tends to “gatekeep” S3 medicines and needs to move on from this behaviour in order to make the best use of this underutilised category.

So says Belinda Nankivell, practice pharmacist and QCPP state manager at the Pharmacy Guild’s NSW Branch, who told pharmacy assistants over the weekend that “we need to forge a pathway forward now from protecting these medicines.”

Addressing the Pharmacy Assistants’ Conference at SeaWorld, Nankivell said that pseudoephedrine and codeine have modelled how pharmacists and pharmacy assistants approach Pharmacist Only Medicines.

She said that pharmacy has done a great job handling them via Project Stop and MedsASSIST, but that pharmacists and assistants need to remember that many requests are from people who genuinely have congestion or pain, and that these products treat them effectively.

Other S3s don’t have the misuse and diversion complications of codeine and pseudoephedrine, but many customers feel interrogated when they ask for them, she said.

Nankivell said that it’s well accepted that symptom requests and direct product requests tend to be handled differently; when patients request an S3 by name, pharmacists and pharmacy assistants become “more defensive,” she told the conference.

“We seem to already jump into a gatekeeping mode as soon as they ask for the products,” she said.

“We need to acknowledge that we really are the key barrier to the growth of this category. Our approach really does need to evolve.

“What percentage of the time does your pharmacist reject an S3 sale? It’s a really small percentage of the time that we find it’s inappropriate, so why make it difficult for all our customers?”

She said that MedsASSIST is a great tool for flagging inappropriate use of codeine, and thanked pharmacy assistants for using the program, but urged them not to “tarnish the whole category of customers”.

She shared the experience of a family member who had, while on holiday, presented to a pharmacy to ask for pseudoephedrine to treat her cold symptoms, but who was faced with a pharmacist who called out, “are you a druggie?” from the dispensary.

Nankivell also said that it would be good to see certain prescription-only medicines, such as some contraceptive pills and asthma preventers, downscheduled to S3.

“There’s a whole scope of treatment that would be so exciting,” she said.

She encouraged pharmacy assistants to make a plan to overcome barriers to S3 sales in their pharmacies, and identify the opportunity inherent in the category.

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  1. Andrew

    Pharmacists should refuse sale of Pharmacist Only (S3 is an anachronism) where appropriate.

    To have Pharmacy Assistants developing “plans” to overcome this fundamental role of the pharmacist is unlikely to benefit anyone.

    Commerce and public health do not mix. Right drug, right dose, right time.

  2. James Lawson

    Shall we recommend doctors stop gatekeeping S4s too?

    • Ronky

      Exactly. After all, using the “logic” of this article, “It’s a really small percentage of the time that [doctors] find it’s inappropriate, so why make it difficult for all [their] customers?”
      So why not just give people everything they ask for, handed out by an unqualified salesgirl trained to “overcome barriers to sales” and “identify opportunities” to push them onto as many patients (I mean “customers”) as possible?
      Or why not take the argument to its logical conclusion and replace pharmacists (and doctors) with vending machines?

  3. Erin Threlfall

    Rather than down scheduling, as once this happens there is a general perception that they are now OTC vs. Pharmacist Only, I would like to see pharmacists be given more access to allow proper emergency supply. Without all the red tape that currently exists for continued supply for statins and the pill. Many in the community and even doctors have little understanding of the difference between Over the Counter and Pharmacist Only, evidenced by recent requests in my practice for prochlorperazine for vertigo, salbutamol MDI for cough, and chloramphenicol for a wound. Unfortunately there a fair few pharmacists, seemingly, supplying S3 meds outside the scope of which are allowed to supply which leads to confusion and frustration for the patient/consumer.

  4. Cameron Walls

    There is no reason that we can’t train our wonderful assistants and techs to initiate the recommendation of S3 products for those who would benefit from them, and they can follow it up by asking the relevant questions, as long as they know to involve the pharmacist every time.

    “I just have to run that by the Pharmacist”

    • Paige

      The assumption you’ve made that they don’t already do this is hilarious. Are you a comedian in your spare time?

      • Cameron Walls

        I have not made that assumption. I have worked with many great assistants and techs that do this really well every day. I was responding to the article and the comments which appear to assume that S3 sales can’t be done this way.

  5. Ronky

    So we should make S4s like systemic steroid hormones S3, and then treat all S3s as if they were S2s. Great. Sounds like a plan to abolish the S3 category altogether, and maybe S4 too. Pretty hard to justify why medicines shouldn’t be sold in supermarkets, if we’re going to treat scheduled medicines as if they were just ordinary grocery lines with particularly “exciting” sales opportunities.
    Yet another sign that the Guild has totally lost the plot.

  6. Brett MacFarlane

    I agree with Belinda, pharmacy does tend to gate keep access by consumers to S3 medicines. But data from the S2/S3 mystery shopper program indicates that the S3 gatekeepers are often the pharmacy assistants and not the pharmacist.

    It is clear from certain scenarios that when a consumer requests treatment for a health condition for which an S3,S2 and unscheduled medicine are all potential treatments that PAs prefer to recommend the S2 or unscheduled medicines while pharmacists prefer S3s. This can occur even when the S3 is the optimal treatment for the patient.

    PAs range between level 2 and 4 and are skilled at what they do (often not given the credit they deserve). They are trained about the limits on their scope of practice with regard to S3 supply. But we at the College suggest that pharmacy assistant training needs to focus more on the appropriate referral pathway to the pharmacist for a potential S3 recommendation in order for this gate keeper issue to be better addressed.

    The College welcomes the Pharmacy Guild executive director David Quilty’s recent comments that decisions impacting community pharmacy should be evidence based and informed by accurate facts and statistics.

    More quality data is needed to determine how pharmacy staff recommend scheduled and unscheduled medicines in order to design more effective S2/S3 training programs. This is important for all sectors of the pharmacy industry as well as consumers as the mystery shopper data also indicates that good clinical practice is intrinsically linked to good business practice.

  7. PrescribingSolutions

    Damned if we do, damned if we don’t ….

  8. Paige

    Gota get past the untrained power-trippin’ mid 20’s shop girls before you can get something that actually treats your cold and flu because you happen to have a tattoo or are wearing high-vis gear. Thats life.

  9. Owner

    You want to know the number one placebo in my shop? Phenylephrine!

  10. Nicholas Logan

    Pharmacy assistants triaging consumers for professional interactions with a pharmacist can only be a good idea. Customer satisfaction and health outcomes are the likely result. A confrontational default helps no one.

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