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At the heart of general practice since 1960

Local failing pharmacy is endangering patient safety

Three GPs share their approach to a practice problem

Case history

When the local pharmacist retired last year his shop was bought by a chain. Since then there has been a string of problems, not helped by constantly changing staff.

Patients often report that the shop doesn't have enough stock, so they have to return the next day to collect even common prescriptions. This is inconvenient for the ill and elderly and causes medically unacceptable delays.

Patients also accuse your practice of not giving them enough tablets. It turns out the pharmacy often doesn't have a full month's supply so gives patients credit notes for tablets that they then forget to collect. You wonder whether the pharmacy forwards the full script to the Prescription Pricing Authority and suspect some patients are requesting their repeats early, inflating your prescribing costs.

On two occasions patients were given the wrong drug, although the pharmacist spotted the error in time and was suitably upset. On the plus side, the chain has instituted a prescription collect and delivery service.

You are concerned about the safety, cost and workload implications. How would you proceed?

Dr Jo Thompson

'Although unlikely, we should consider whether the pharmacy is acting fraudulently by forwarding full script amounts to the PPA'

This scenario illustrates the importance of maintaining a good working relationship with the local pharmacist.

It seems the main problem here is no one is responsible for ordering and dispensing stock. Obviously patient safety is paramount and a rapid turnover of locum pharmacists, whose standards may vary enormously, may lead to errors not only in dispensing but also in stocktaking.

I would start by finding out who is in charge of the pharmacy. Is there a regional manager or a superintendent pharmacist I could contact? I would invite them to a practice meeting to discuss our concerns.

Outlining the demographics of the local population and auditing a random selection of repeat script requests may give an overview of their prescribing needs. PACT data may help us identify frequently prescribed medications and establish a list of drugs that one would expect to be in constant stock.

This would help patients avoid potentially serious delays to the start of their treatment, thereby reducing further consultations. A critical incident analysis of the dispensing errors may prevent future problems.

As far as cost implications are concerned, it may be prudent to ask the prescribing adviser at our PCT to take the lead in trying to negotiate a way around the pharmacy's lack of stock. Although unlikely, we should consider whether the pharmacy is acting fraudulently in not fulfilling the scripts and forwarding the full amount to the Prescription Pricing Authority.

To manage the workload implications for the practice I would ask for a 48-hour turnaround between repeat prescription requests and drugs being collected.

This would allow the pharmacy time to order drugs that aren't in stock, and avoid patients having to make numerous trips. Also, because the pharmacy would be able to honour the full script, requests for early repeats would fall, reducing the cost and workload for our practice.

Obviously a collection and delivery service would further enhance patient satisfaction.

Jo Thomson completed the VTS in 2001 –

she is a part-time salaried GP in Hurstpierpoint, West Sussex

Dr Jason Twinn

'No doubt we can trust the PCT to deal with the issue with its usual efficiency'

This sounds like a management problem with the pharmacy rather than a case of fraud, but it has become an issue we can no longer avoid.

How I would proceed would depend very much on the pharmacy's set-up. If there is a resident pharmacist or manager then we need to discuss the problems with them, perhaps by inviting them to a meeting with the practice. But if the pharmacy is being run by a series of locums and temporary staff then we need to take up the issue with the owners.

It would probably be useful to discuss this at a practice meeting before we approach the pharmacy, be it the manager or the owning company. Keeping a written record of events for a couple of weeks with specific details would mean the facts are more definite than heresy, speculation and second-hand rumour.

Of course, if we feel patient safety is being compromised or we are concerned about misuse of controlled drugs, then we may need to contact our PCT immediately, either for advice or to ask them to take whatever action they can. No doubt we can trust them to deal with the issue with their usual level of efficiency.

However, the latter avenue would be a last resort because it is likely to damage the relationship between the practice and the pharmacy, and this would only make our life difficult in the long-term.

I have little doubt that much of what a pharmacist will agree to do, such as taking telephone prescriptions from the practice, and certainly delivering medicines to patients, lie outside the black and white of their written obligations.

But without these the service will be poorer for GPs and patients.

Jason Twinn completed the VTS in 2001 and has recently become a full-time locum in Scotland

Dr Peter Moore

'We could take action only

on sound evidence, not innuendo and rumour'

We have a responsibility to ensure our patients receive a safe and competent service from all the professionals we work with in the NHS. If we believe a colleague is failing we must take appropriate action. Colleagues include pharmacists. This is not unique to doctors. A pharmacist seriously concerned about the level of care from a GP should also take action. But we can act only on sound evidence, not innuendo and rumour.

We should document the past cases where patients were not given enough tablets or where there are other specific complaints. For the next month the practice should keep a detailed list of problems arising so there is an ongoing audit. If the figures confirm our fears we should write a formal letter to the company asking for a meeting with the regional manager.

The meeting needs to be formal and minuted. We can raise the specific complaints at this time. We should then arrange a follow-up meeting in a month where the manager can answer the specific queries. This should be possible because all pharmacies are obliged to keep records of prescriptions, including the numbers of tablets given. The PPA keeps prescriptions for two years so the pharmacy's records can be checked. At the follow-up meeting the regional manager should also explain what measures have been put in place to improve the situation in the future.

If the pharmacy fails to listen to our concerns and provide satisfactory solutions there are two avenues to follow. We could send evidence of our concerns to the PCT, detailing the action taken by the practice and including all correspondence and minutes of meetings. It is the PCT's role to oversee pharmacists as well as GPs. The second option would be to send the evidence to the Royal Pharmaceutical Society.

Peter Moore completed the VTS in 1979 and is a partner in Torbay and is also senior police surgeon for the area

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