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Have dispensing practices had their day?

Community pharmacist Noel Baumber says the system has been abused and it's time for a change. But Dr Lisa Silver argues that the one-stop shop service offered by dispensing practices should be a model for the NHS, not a relic to be phased out to appease the pharmacy lobby

Community pharmacist Noel Baumber says the system has been abused and it's time for a change. But Dr Lisa Silver argues that the one-stop shop service offered by dispensing practices should be a model for the NHS, not a relic to be phased out to appease the pharmacy lobby

Yes

The long-awaited Pharmacy in England white paper is primarily about raising the service level of community pharmacies. But it has also been bundled with the problem of how to develop pharmaceutical services in rural areas, which is why many rural practices have sensed a change of direction and begun to buy local pharmacy contracts.

Doctor dispensing has a long history, but how essential is it? Some 4,300 doctors now work in 1,170 dispensing practices - an average of nearly four GPs per surgery - which blows away the pastoral image of the singlehanded practice. They are perceived as expensive prescribers and are certainly more expensive dispensers compared with pharmacies. And many of the practices are in close proximity to pharmacies in market towns - so where is the patient benefit?

Doctor dispensing was a good business. Overheads were covered twice, pensions were linked to dispensing income and there was an additional profit margin from certain medicines. Some of the largest urban surgeries are dispensing practices and doctors own some of the busiest pharmacies. The relationship between practices and rural pharmacies varies from helpful to hostile and inevitably gives rise to tensions among patients who don't understand the ground rules.

Over the years, pharmacy organisations have put a lot of effort into making doctor dispensing a fairly practical issue to administrate at PCT level, but it is anything but a simple demarcation dispute.

What all parties want is stability and the rational distribution of facilities.

But politicians want competition, and the introduction of pharmacy exemptions in 2005 has put an end to stability and meant chaos in urban areas.

There is nothing to prevent GPs from owning pharmacies or shares in pharmaceutical companies, but let's have fair competition. Let the same payment rules and standards apply - the same qualified pharmacist, dispensary staff and counter staff, working to the agreed staffing levels that pharmacy provides.

An ideal solution would assess the needs and requirements of a community and provide an equitable solution for all - one where (if viable) both the surgery and the pharmacy could co-exist to benefit patients.

Changing legislation using the distance between the surgery and the local pharmacy is curiously timed. Any new solution must take account of the new Electronic Prescribing Service which has serious implications for fair and open competition in rural situations. It would affect all patients in the practice, not just those who consider themselves affected by 'serious difficulty'. It could be a classic case of using a sledgehammer to crack a nut. Cases of serious difficulty are rare but increasingly used as a weapon to annex patients in the continuing battle. Measures with such far-reaching implications need sound principles to reach a lasting conclusion.

Both professions are fearful of losing their individualism under a mountain of unaccountable state bureaucracy. Do we have the champions to work out a win-win solution? Do we have a robust political system to carry though the change needed?

But there has been no point since National Insurance began in 1911 at which the conflict of interest issue could be resolved so that the two professions became beneficially separated and rural practices properly supported out of GMS funds.

There are many factors at work, the largest of which is the need to create an infrastructure in rural areas which can survive in the new age when oil and credit are scarce. For the benefit of patients, we'll need to have both professions working harmoniously at local level and well supported by the PCT.

Noel Baumber is a community pharmacist in Grantham, Lincolnshire, and company secretary of the Independent Pharmacy Federation

No

'Care closer to home', 'convenience', 'choice', 'patient-centred' and 'one-stop shop' are just some of the descriptions that are part of the new NHS and typify dispensing practices.

Dispensing offers patients the ultimate one-stop shop. You see the GP, a prescription is generated and without having to travel more than a couple of paces, your medicine is dispensed. If the NHS is about delivering care for patients at the right time in the right place, this should be the model for the future rather than something from a bygone era.

With many pharmacies sited on high streets, patients have to go to considerable trouble to have their prescription medicines dispensed.

A great service, that patients really welcome, is theoretically going to be destroyed, condemning rural patients to long journeys to try to access medicines. This is the reality of one aspect of the pharmacy white paper, which has so enraged the thousands of patients who have written to their MPs in support of their dispensing practices.

Pharmacists will tell you that dispensing medicines in rural areas is not viable. But on the back of dispensing, rural practices deliver a wealth of other services for patients - bus services picking patients

up and bringing them to surgeries, home delivery services for medicines and first-rate levels of access.

Clearly we are not altruists and delivering a service means that we generate an income in the same way that pharmacy generates an income from dispensing medicines - nothing wrong in that.

But when money is involved the inevitable next question is: 'What about cost-effective prescribing?' And when you look at the September 2008 prescription pricing division data, net ingredient costs prescribed by dispensing doctors are £8.67 as opposed to £9.93 for prescribing practice costs. Let me dispel the myth - we are not expensive prescribers, there is no incentive to prescribe expensively.

In addition to the proposals to change the rule on dispensing practices, the white paper proposes that pharmacy takes on

a variety of clinical services including sexual health services, vascular screening checks, medicines use reviews, PBC, detection and prevention of cancer and smoking cessation.

PCTs will have to commission services from trained pharmacists who will need to undertake the above services in the knowledge they will have to be responsible for their acts and omissions.

If this actually improves service provision for patients it will be a good thing. But if it duplicates services it will be an additional expense to the taxpayer and will disjoint the patient pathway, putting pharmacists in the invidious position of having to deliver clinical services in the absence of an integrated care record.

The moment pharmacists move from the act of dispensing medicines to the act of providing clinical services, they will have to move from front-of-house dispensing to seeing patients in consulting rooms and becoming more like doctors with an appointment system - leaving pharmacy assistants to do the dispensing. This strikes me as being exactly what we do in dispensing practices. Our dispensers are NVQ trained and dispense to the highest standards under the aegis of the GPC nationally negotiated Dispensary Services Quality Scheme.

Before we condemn dispensing practice to the dustbin, we need to ask ourselves what patients want. The Government is driven by legislating for the sake of it, and legislating against dispensing will deliver poorer services for the eight million patients registered at dispensing practices.

Dr Lisa Silver is a dispensing GP in Nettlebed, Oxfordshire

Have dispensing practices had their day? yes quote

Relations between pharmacies and rural practices vary from helpful to hostile

no quote

Let me dispel the myth - we are not expensive prescribers

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