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Independents' Day

Leave prescribing to the experts

Clumsy execution and lack of common sense - the DH needs to call a moratorium on schemes making POMs available in pharmacies

A GMC review published in May this year received a lot of attention for its finding that as many as one in 20 GP prescriptions contains an error.

What received less attention was the study’s conclusion that serious errors are rare and the majority of GP prescribing is safe, proportionate and responsible. But despite this, there has been a steady erosion in recent years of the role of the GP as gatekeeper of the FP10.

First there were patient group directions, then supplementary prescribers and independent prescribers, and the dangerous rise in the availability of mail-order prescription-only medicines via the internet.

But most divisive of all has been the drive to make more medicines available without a prescription in pharmacies.

This move – first mooted in Labour’s NHS Plan in 2000 – was designed to increase the availability of prescription-only medicines and enable patients to self-care. A laudable aim, but clumsy in its execution.

The Medicines and Healthcare Products Regulatory Agency (MHRA) made it a high priority, leading to a number of drugs being declassified from prescription only to the pharmacy sales list, including simvastatin, sumatriptan and chloramphenicol.

This was a massive boon to the pharmaceutical industry and the status of pharmacists as a profession – but GP leaders questioned whether adequate safeguards had been put in place and if the commercial imperative in pharmacies could interfere with good medical care.

Then the MHRA approved a trial of making the antibiotics azithromycin and trimethoprim available without a prescription in 2008. This move led to uproar from microbiologists, who argued it would undermine the campaign to minimise antimicrobial resistance.

In 2010, the Government’s own advisers asked the DH to exclude antibiotics from the POM-to-P reclassification drive. It was a welcome injection of common sense into what was becoming a free-for-all.

But as we learn this week, the National Pharmacy Association has continued quietly making prescription-only medicines – including several antibiotics and salbutamol inhalers – available under patient group directions.

The list of 16 medicines it is planning to make available in all 12,500 pharmacies from January has incensed GP leaders and led to urgent talks with the DH after being alerted to the scheme.

Pharmacist leaders claim the service is more convenient for patients and will free up GP time, but that completely misses the point. A prescription may only be a flimsy bit of green paper, but it represents a whole process of medical training, checks and lines of responsibility to ensure that patients are kept safe.

The MHRA guidance is clear that patient group directions must only be used when there is an ‘advantage for patient care without compromising patient safety’.

There were no adverse events in the pilot of the NPA’s scheme but, particularly in the case of antibiotics and asthma medicines, prescriptions should be part of a wider care plan for patients and an appreciation of the wider health of the population.

The DH must call a moratorium on this and all other such schemes, at the very least until appropriate approval procedures are put in place to consider their wider impact.

Nigel Praities is the deputy editor of Pulse

Readers' comments (7)

  • aptaim Unknown

    Agreed: even as a pharmacist I think these schemes do not represent the best interest of patients - and probably not pharmacists either. There are already other mechanisms in place for patients to get these treatments relatively conveniently (WICs, extended GP hours etc) and in my mind the availability of salbutamol via PGD is the pinnacle of unnecessary, and potentially undermines a GP's knowledge of their patient's asthma control.

    However I don't think that people should see the GP's role as 'FP10 gatekeeper': nurse and pharmacist prescribers have proven themselves as safe and capable and I'd say a focus on these routes (plus using retail pharmacies for minor ailments and public health schemes) is an clinical and cost effective way of releasing GP time and improving patient care.

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  • As a pharmacist I would like to see what line needs to be crossed to differentiate a serious error from a minor error. All errors, no matter how insignificant have the ability to affect or even harm patient care.
    An error rate of 5% means millions of NHS prescriptions are passd to patients each year that contain mistakes. A pharmacist who had a dispensing error rate of 5% would be struck off no matter how 'minor'.

    Although some POM to P switches and certain PGDs have been developed with the aim boosting the profits of the pharmaceutical industry, others have increased access to medicines and healthcare professionals. Emergency Hormonal Contraception and Nicotine Replacement Therapy are two pharmacy success stories that have greatly increased access without compromising patient safety and have the additional effect of freeing up limited GP time.

    I feel GPs should concentrate on reducing their own error rate and improving the quality of their own prescribing before passing judgement on the abilities of others to provide access to medicines.

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  • if they want to take the responsibility then fine...but the vast majority will still be told "go and see your GP" as responsibility is something no one wants...just the power to do things

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  • Trimethoprim for cystitis. Hardly earth shattering. Seen hundreds of patients prescribed 3 day courses without ever being seen by the doc.

    Doxycyline for malaria prophylaxis. Not available on FP10 for this indication. Cipro for travellers diarrhoea. Again, another private indication, nothing to do with NHS prescribing. Completely understand the argument about resistance, but do GPs genuinely refuse to prescribe these medicines on that basis? Thought not.

    As for the recent POM to P switches, the only commercially successful product from those that you mention is chloramphenicol. Many sales of these products happen at the weekend, or when patients have already tried to book an appointment but are told none are available (quite rightly taken by people who actually need the skill of the GP).

    The bigger argument is actually about where the responsibility for an individual's health lies. To my mind, it is entirely responsible for a person to make an informed decision about initiating any medicine. Therefore it is the patient, and not the GP who is the gatekeeper. Patient Group Directions are very rigid tools, there is no room for professional judgement or leeway, either the individual fits the inclusion criteria (and the medicine is therefore indicated), and doesn't meet the exclusion criteria (in which case the medicine cannot be given). Lest we forget that PGDs have to be signed off by a Medical Director of an IMO?

    This article is a 19th century reaction to a 21st century problem: choice.

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  • i have to agree with the some of the critiscism of these pgds ,although i can see the logic in some others are totally out of the loop . For instance dovonex for psoriasis a chronic condition which modst gps really dont understand the mangement of should not be self managed by way of PGDS from pharmacies.I speak as a independent pharmacist pescriber who presciribes within a gp practice full time . i Believe pharmacist should first have appropiate taining for dealing with minor ailments and the government should then roll out a nationwide minor ailment scheme .By this i mean that all consultations should be recorded and audited and then Poms can be prescribed either by independent pescribers or by use pf PGD , In this way phamacists could reduce 50 percent of the everyday worlkload of gps.

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  • As a patient, I find that pharmacists are more careful of prescribing appropriate drugs, and avoiding clashes between drugs than some GPs. After all, that is what pharmacists do all day long. They are an essential second line of defence against "inappropriate treatment."

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  • This is cheap labour.
    This is creating supporting staff to become DOCTORS by proxy

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