Monday, January 29, 2007

Stupid things that patients do (1)

An elderly gentleman purchased some ranitidine for heartburn today (training point number one for staff there - heartburn in the elderly needs medical investigation as it could be cancer or an ulcer). When asked if he was on any other medication he said he wasn't (training point number two: its not 'are you on any other medication', it's 'what other medication are you on'. The difference between closed and open questions is amazing).

Ten minutes later the gentleman came back, saying he felt guilty for lying to the staff. So I gave him a refund (shouldn't do, strictly speaking according to company policy) and sent him to his GP. When I looked at his medication history he was on warfarin, amongst other things. Now that's just the sort of thing you want to be on if you have got a bleeding gastric ulcer.

Patients are just so helpful sometimes.

CDs are such fun

Thanks to that lovely Dr Shipman I now have to jump through so many hoops when dealing with controlled drugs (morphine, methylphenidate and so on) that I may have well trained as an acrobat rather than a pharmacist. One measure that has been introduced is running balances for our registers (though just good practice at present). Now this has caused some changes to be made. In the past there would be one register for all morphine preparations and one for all methylphenidate preparations. Now we have one register for each morphine preparation - so there is one for morphine 10mg modified release tabs and one for morphine 100mg modified tabs.

The pharmacy I have just started managing introduced running balances in July. Not much time for things to go wrong? If only. When reconcilling theroetical balances with actual stock there were about ten items that were wrong, and there were locums who did things like adding Durogesic 25mcg patches to Durogesic 12mcg patches. And lots of pharmacists can't add up: 134 - 30 = 104? not according to some.

So after lots of fun checking through invoices and looking through patient medication records I managed to sort most of the problems out. However there were some which I couldn't solve and have had to adjust the balances. In two cases we actually had more stock than we should have. I'm not too bothered about that. In two other cases I had less stock than I should have had. So I've sent letters to the superintendent and the owner outlining the situation and the stock levels I am prepared to be responsible for.

This mess probably took more than 15 hours to sort out, but hopefully it will all run smoothly from now. The RPSGB obviously live on a different planet as they recommend that stock is reconcilled with the running balance on a weekly basis. When am I ever going to have time to do that?

In other news, I had a meeting with the local GP surgery. They all seem very nice and were enthusiastic about MURs. They even offered to refer patients to me! They weren't to keen with me asking them to prescribe dressings and injections in complete packs - worried about their budget. In truth the impact on their budget will be minimal, especially given that I save them money by picking up people with silly prescriptions such as perindopril 2mg 2 tabs daily (for some reason the 2mg tabs are the same price as the 4mg tabs). I just hate having split packs of dressings on the shelf that are never going to be used again. Something to work on with the practice and district nurses I think.

Tuesday, January 23, 2007

Wales to introduce free prescriptions

Welsh assembly members have today voted to introduce free prescriptions for everyone in Wales. All I can say is I'm glad I don't work in Wales. Prescription volumes are increasing by around 10% a year at the moment as it is, due mainly to NICE guidance and the GP's QoF points.

I agree with the arguement that the current exemption system is unfair, but the way to solve that is to review the exemption system, not give everyone free prescriptions. Giving everyone free prescriptions will, without doubt, substantially increase the drug budget in Wales. I already see lots of prescriptions for cheap items that can be purchased cheaply from people who are exempt from prescription charges. I would not be surprised at all if the Welsh reconsider their decision within a year.

An article in the Pharmaceutical Journal discussed the cost of low dose aspirin to the NHS. To purchase a year's worth of 75mg aspirin costs around £4.50. If you get aspirin on prescription it costs in the region of £2.50 per month (£1.37 per 28, plus a 90p dispensing fee, plus 3.24p container allowance, plus various practice allowances.) So, if people can get something for free they will, which is why Wales will change their mind.

Monday, January 22, 2007

Vitamin D for prostate cancer

Interesting story here about using vitamin D to treat prostate cancer. In small scale trials patients taking the drug lived for an extra nine months. It is questionable how this will translate to larger trials as patients did not recieve optimal treatment with taxotere.

Wednesday, January 17, 2007

So much change

Having survived the annual chaos that is the Christmas period in primary care, is there any chance of me being able to sit back and relax? Not a chance! Firstly I've just moved in to a company flat and although I should be used to moving by now (eight addresses in six years) it's still a pain. Especially when you don't have internet access for a week and have the best part of 200 emails to read through.

But moving house was the easy part, compared to managing a new pharmacy which hasn't had a manager for a few months. So I've got stacks of paperwork to sort out and staff to get to know, as well as dispensing and checking. This pharmacy is very busy front of shop, and is doing c10,000 items a month. If the GPs were to switch to 28 day prescribing this would probably leap to 15,000 or more. I do have some help however in the shape of a shop manager who can take care of a lot of things for me. So although I've been thrown in at the deep end somewhat, with no management training or experience, I have got a bit of a lifejacket. Best of all, I am thoroughly enjoying it. I have a good set of staff, with all three dispensers working towards their NVQ 3s and the GPs actually phone me back within 15 minutes or so for non-urgent queries.

My long term plan for the pharmacy is to get one of the dispensers trained as a checking technician so that I can use my time speaking to patients and carrying out services. I'd also like to get the GPs to change to 28 day prescribing which will increase our workload (and income), but make it easier to manage stock levels. At present we run out of amlodipine 5mg, simvastatin 40mg, ramipril and so on because we haven't got the space to store the stock needed. I've had scripts recently for 500 oxytetracycline, 400 erythromycin and 504 metformin! I expect the GPs to be a bit resistant to this change, however there is a way of implementing it that will actually decrease their workload: repeat dispensing. This means if a GP decides a patient is stable on their medication at a review they can issue prescriptions there and then to cover the patient until their next review is due. This means no need to sign repeat prescriptions every month, so reducing the GP workload, and means that I can see which patients are due for their prescriptions and when, and actually plan my workload.

The is just one fly in the ointment at present: the local dentists. Although they are allowed to prescribe a wide range of drugs, I am sure dentists get very little training in therapeutics. I spoke to one of them recently about a prescription for metronidazole 400mg to be taken four times a day (it's normally three times a day and has a half life of around 8 hours). Neither the British National Formulary nor the Medicines Compendium mention four times a day dosing, and if it isn't mentioned in one of those sources it's a strange dose. So I spoke to the dentist about this, I was told to leave it a four times a day. When I asked if there was any particular reason why (like some really nasty infection that only dentists see and no one else knows about) I was told 'because that's how I want it.'
So I told the patient that their dentist wanted them to take this antibiotic four times a day, but added that it's always three times a day, and that's what I would do. I then wrote the dentist a lovely letter, asking for any evidence they had to support the use of metronidazole four times a day. Still waiting for a response...