Neil Trainis

Pharmacists were told to embrace the future in a country that is trying to move on from a traumatic past. Neil Trainis reports from Nha Trang and Ho Chi Minh City, Vietnam….

 

It was never likely that the 6,230-odd miles separating Vietnam and the UK would insulate pharmacists who had made the trip from the pressures, anxieties and hopes consuming them back home.

 

Yet the distractions offered by the Avicenna conference from funding cuts, sustainability and transformation plans, supervision and the rest, no matter how brief, were welcomed with open arms.

 

“It’s been a busy, busy time in the pharmacy. Tough at times. This will be a nice, much-needed break,” one pharmacist said en route. The conference brought them first to the coastal city of Nha Trang then to Ho Chi Minh City to sample the cultural delights of a country that in part had made an astonishing recovery from that war.

 

There were, of course, reminders of the struggle against what the Vietnamese still regard as the resistance war against America. Reminders that had been preserved in time like mosquitos trapped in amber.

 

A trip to the Củ Chi tunnels, a large network of underground passages used by the Viet Cong and north Vietnamese fighters, momentarily took the Avicenna delegation back in time to that awful war. Some delegates took up a playful invitation to squeeze into the camouflaged holes leading to the tunnels. A sense of claustrophobia might have gripped them. Sinking with little breathing space might not have been an alien sensation to many of them.

History’s grip did not relent. On April 30, 1975 a north Vietnamese tank smashed through the gates of Independence Palace, or Reunification Palace as it is also known, to mark the end of the Vietnam War. It provided a dramatic backdrop to a gala dinner.

 

Those who had never visited Vietnam might have been surprised. Ho Chi Minh City nudged those who trod its streets towards a past that will probably never be forgotten but it also produced flashes of an exciting future. The city’s skyline was furnished with buildings of skyscraper proportions which gave the sense that in years to come it may rival the New Yorks and Londons of this world.

 

Normality had to make its presence felt at some stage during the conference and a business session examined some burning issues. Noel Wardle, a partner at Charles Russell Speechlys, warned pharmacists may not be immune from prosecution from dispensing errors even if the pharmacy profession finally secures a legal defence.

 

“A lot of concern has been raised and what we might have is a statutory defence to (dispensing errors). The problem is the statutory defence is really complicated. You have to fulfil a lot of tests to come within it,” he said somewhat depressingly.

 

Wardle would go on to suggest pharmacy is better off being regulated by the General Pharmaceutical Council (GPhC) than the Care Quality Commission (CQC) despite a perception amongst some within the profession that pharmacy is over-regulated by the GPhC.

 

Revealing the GPhC had taken action against a superintendent pharmacist just four times since 2010 and had launched “some sort of investigation even if it started and never went anywhere” against 3 ½% of the 50,000 pharmacists on the GPhC register, he said: “Whilst (the) threat might feel real in terms of the GPhC, the reality is the great majority of pharmacists have no problems at all with the GPhC and certainly no serious problems with the GPhC.

 

“If you don’t have regulation by the GPhC you’ll have it by somebody else. My experience of the CQC is much less positive than the GPhC. My own personal view is you’re better with the GPhC than you would be with the CQC which is what the doctors and dentists have got.”

 

There had also been “talk of scrapping the GPhC” he would add. But “be careful what you wish for.”

 

Joe Mckenna, head of sales at AAH, insisted it was important for pharmacy to engage in digital healthcare, with 71% of UK citizens possessing a smartphone, 60% choosing to monitor their chronic condition using a mobile app, 80% wanting to look at their medical records online and 80% preferring to consult ‘Dr Google’ first.

 

John Pignone, sales director at Alliance Healthcare, insisted the electronic prescription service had saved the NHS £130 million and prescribers £327 million in the last three years. But he warned that community pharmacy had not “fully adapted to changes in the NHS. It needs to diversify.”

 

Pignone soon confronted the difficulties pharmacists have had sourcing drugs by insisting Alliance Healthcare “appreciate the impact shortages are having on pharmacies.”

 

Recounting the Theresa May P45 hoaxer moment, Rajiv Shah, a director at Sigma, pondered with a smile “what if that happened to Keith Ridge?” Cue chuckles from the audience.

 

Kantilal Agravat, an inspiring community pharmacist from Manchester, talked about his experiences working with charities in an attempt to help hard-to-reach people such as the homeless and asylum seekers. He asked how many pharmacists in the room were “homeless-friendly.” Not a single hand went up.

 

Maybe they wanted to forget about home. Momentarily at least.

 

Pharmacy may not be immune from prosecution from dispensing errors even with statutory defence
Noel Wardle, a partner at Charles Russell Speechlys, warned pharmacists may not be immune from prosecution from dispensing errors even if the pharmacy profession finally secures decriminalisation.
Wardle told the Avicenna conference that a statutory defence to section 64 of the Medicines Act 1968, which has still to materialise despite years of campaigning by pharmacy leaders, may not offer protection from prosecution because of the requirement to fulfil what he described as “a lot of tests.”
“A lot of concern has been raised and what we might have is a statutory defence to (dispensing errors). The problem is the statutory defence is really complicated. You have to fulfil a lot of tests to come within it,” he said.
“You as the pharmacist have to demonstrate that you meet the statutory defence, the burden of proof is reversed is what us lawyers would say.
“Whilst that might feel more comfortable because you know there’s a defence out there, I suspect (there) will be less certainty in a way which is counterintuitive.”
Wardle added: “But at the moment you really know that, except for very exceptional circumstances, you won’t be prosecuted. If you’ve got a statutory defence is it more likely prosecutions will be brought? Because there’s a defence to it if certain circumstances are met.”
The rebalancing medicines legislation and pharmacy regulation programme board is continuing to work towards bringing about decriminalisation but progress had been painfully slow.
Wardle also warned there was a statutory requirement on pharmacists to provide patient information leaflets when they supply medicines including those in MDS trays. “If you supply that tray without a patient information leaflet you are committing a criminal offence,” he said.
He suggested pharmacy is better off being regulated by the General Pharmaceutical Council (GPhC) than the Care Quality Commission (CQC) despite a perception amongst some within the profession that pharmacy is over-regulated by the GPhC.
Revealing the GPhC had taken action against a superintendent pharmacist just four times since 2010 and had launched “some sort of investigation even if it started and never went anywhere” against 3 ½% of the 50,000 pharmacists on the GPhC register, he said: “Whilst (the) threat might feel real in terms of the GPhC, the reality is the great majority of pharmacists have no problems at all with the GPhC and certainly no serious problems with the GPhC.
“Some action was taken against 1.4% of pharmacists and by some action that could mean a letter of advice or a warning or all the way to a fitness-to-practise hearing. In relation to fitness-to-practise hearings only 70 pharmacists were struck off or suspended last year. That’s 0.1% of all pharmacists.”
He went on to suggest that “if you don’t have regulation by the GPhC you’ll have it by somebody else. My experience of the CQC is much less positive than the GPhC. My own personal view is you’re better with the GPhC than you would be with the CQC which is what the doctors and dentists have got.”
Wardle touched on the possibility that the GPhC could be abandoned as pharmacy’s regulator by suggesting the major health professions may be governed by “a central healthcare regulator.”
The Department of Health last month launched a consultation on proposals to reform health professional regulation and explore how a system with a reduced number of regulators might function.
“There is also talk of scrapping the GPhC by the way. There has been talk for quite a few years now of having one overarching regulator for all healthcare practitioners,” Wardle said.
“And you wouldn’t have regulatory proceedings at the GPhC, you would have a central healthcare regulator and they would hear all cases against pharmacists, doctors, dentists, opticians and everybody else. My view is you might feel more comfortable with the GPhC so be careful what you wish for.”

 

General practice has been quicker than pharmacy to react to changes
Salim Jetha, the chief executive of Avicenna, criticised community pharmacy’s leadership by suggesting it has been slow to react to changes in the NHS compared with general practice.
The British Medical Association, he said, had reacted quicker to the NHS reforms than pharmacy and with a greater sense of purpose. This year Pharmacy Voice disbanded as community pharmacy’s representative body after the NPA withdrew its support.
“Do we want to bury our heads in the sand? Or do we take the future in our hands? It’s very difficult to predict what the future will be like. We cannot predict what (impact) the cuts (will have) on us but we can predict some things,” he told the conference being held at Nha Trang, a city on the south coast of Vietnam.
“I remember when the government made an announcement that there were going to be major changes in the NHS. The BMA (British Medical Association) were very, very quick, they put out a response within minutes but the pharmacies took two or three days to respond.
“And I asked this BMA, ‘how were you able to respond so fast within minutes?’ And they said ‘look, we have various options. If the announcement was this, this was our press statement. If the announcement was that, that is our press statement.’
“So they had it all planned out. And GPs had an action plan within minutes of the announcement. So they predicted the future. They had plans. They knew if this happened, we want to do this, we want to do that.”
Jetha also criticised GPs’ contrasting attitude towards pharmacists working in surgeries and those in the community setting. There have been reports that GPs in some parts of England have been resistant to community pharmacy providing flu vaccinations.
“Let’s take an example of pharmacists in GP practices. GPs are full of praise that pharmacy does a fantastic job in GP practices. But when it comes to flu jabs, they defend their outlets despite surveys suggesting that 99% of those who visited pharmacy are likely to come back again,” he said.

 

Centralised dispensing is not necessarily safe or efficient
Jay Patel, an executive director at Day Lewis, poured cold water on the government’s plans to introduce a hub and spoke dispensing model in community pharmacy by insisting the system does not necessarily save money and is not always safe.
Drawing on his experience of centralised dispensing at Day Lewis, he also described the idea of community pharmacy being replaced by mail order hubs around the whole country as a “pretty extreme view.”
“We’ve tried central dispensing for about four to five years for about 15 pharmacies in the network. We’ve taken those pharmacies out of the pharmacy (network). The criteria for that was when a pharmacy had hit its capacity and had got to the point where its dispensing too many items, it can’t do any more, it’s a health and safety issue,” Patel said.
“We haven’t been able to prove that it saves money. My belief is that the current models in place don’t necessarily save you money. If they did save you money, we would have done it already. We’ve never needed the Department (of Health) to tell us where we could save money in the past and it doesn’t necessarily work.
“The second thing we found with mail order pharmacy was disruption to the network having a dramatic impact on how the pharmacy works. So you’ve got electricity failure, broadband failure. We’ve had that issue in our hub and it shuts down.
“So people say it saves money. It doesn’t. Two, we talk about it being safer. It isn’t. It isn’t safer because if the broadband goes down, that pharmacy shuts down and the patients don’t get their medicines.”

 

Where has all the Category M money gone?
Bharat Shah, the managing director of Sigma, claimed an analysis carried out by his company showed the government has taken £28 million out of Category M over a three-year period and questioned where that money has gone.
Shah displayed a series of slides which showed the number of products in Category M had increased from 557 to 611 between July 2014 and October 2017. Reimbursement during that period however fell from just over £140 million to a little more than £112 million.
“Category M, I’ve just done a comparison for the last three years and you can see the government has added almost 50 products in Category M,” he said.
“And the reimbursement from Category M compared from July 14 to Oct 17 has actually reduced. This has been done by one of our IT guys who compared the Category M prices. The Category M goes up and down and this is just a comparison of two months.”
Shah showed another slide which revealed that 54 products were added between July 2014 and October 2017 at a value of just over £6.6 million.
“This is really 80% of your remuneration from generics,” he told pharmacists. “There was a reduction of £28 million between July (2014) and October (2017). Where has this money gone?
“Basically the money that has been taken out of Category M, much more than the £28 million, has gone when the products have come off patent. Off patent products have been very profitable to almost all pharmacy businesses (and) the government has clearly got out and saw the real impact of it in July this year.”
Shah also called on the pharmacy profession to lobby for generic substitution and for a pharmacist to sit on each Clinical Commissioning Group. He also urged the pharmacy profession to form one united body to represent it and called on pharmacists to get involved in Sustainability and Transformation Plans.

 

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