regulation

Customer walks into a pharmacy...

...and chooses what medicine they want to buy, before taking it to the pharmacy counter. Yes, that's right folks, instead of telling a daft joke, I'm going to witter on yet again about the self-selection of P-meds. This time I want to think about it from a patient's perspective. Some of these considerations may seem small and petty, but i just want to put my thoughts down on virtual paper and you can see what you think.

When I walk into a shop, I can be pretty easily intimidated. I'm shy, and I don't like to bother people. I also hate that uncomfortable feeling when you walk into a shop and you feel like you're being watched by someone and then you feel terrible about not buying something. I can get anxious about the smallest of things, in particular not quite knowing what you're supposed to do in a shop- if I can't find the til, or there's an empty box and i don't know who to ask, or if I can't find something, for example.Of course this is worse when I am feeling a bit poorly and I can be particularly skittish- im likely to go home without buying anything, even if i need it, because i can't be bothered to have to work out what I'm supposed to do. This brings me onto my first point about self selection

1. It could be different everywhere.

 Not all pharmacies will take up the self-selection option, so I'll need to ask at the counter as i am used to. But in some pharmacies, the packs may be out on the shelves, whilst in others, they might be in security packs or might be empty packs that I need to take to the counter, like an early nineties video rental shop. It sounds daft, but this sort of thing could be quite off-putting.
 

2. How the hell am I supposed to know what to buy?

 I tend to acknowledge people who know more than I do about a subject and listen to their opinion. If I go to the hairdressers, for example I tend to ask them what style they think would best suit my hair type and face. After all, they've done some training in cutting hair whilst I am utterly clueless about it. If I walk into a pharmacy, therefore I don't expect to have to do all the hard work of product selection myself. My product selection process for most things usually goes like this:

Its either that, or I stand around reading every single box of every single product. This would take me bloody ages, and would be pretty inconvenient.

3. What If Its The Wrong Thing?

 After I have found the shiniest product, I take it to the counter, where I am then told that I've picked up the wrong thing and I'm not allowed to buy it. This, frankly, pisses me off and adds even more inconvenience o the whole affair. I've chosen the product, and now some jobsworth glorified shop assistant is saying that I've chosen the wrong thing? how dare they! (I've lost count of the number of times I've been called a glorified shop assistant by patients-and on occasion non-pharmacist managers over the years, by the way). You know like when you're in a hurry, and you've picked something up in a shop and you take it to the counter, and they tell you that its on buy one get one free, but there is a huge queue behind and you're going to be late for your train so you just say "oh its fine, I'll just take that one". I suspect that would end up happening quite a bit as well.

4. Advice Isn't Quite So Forthcoming.

 When I ask for a specific product in a pharmacy, the counselling and advice I am given tends to be minimal (if at all), whereas if I ask what they would recommend for a particualr symptom (not that I usually have to bother doing that myself, but you know), I tend to be given fuller, more rounded advice as part of the product selection process- I've written about this before. If I want to know something about a product, I have to ask about it, and I might feel a bit stupid doing that when I'm supposed to have picked the product myself. In addition, I might not actually know that I need to ask for advice unless it is offered. With self-selection, I fear that offering routine advice would become the exception rather than the norm, and instead of being proactive in giving advice, we would instead get into a pattern of waiting to be asked.

5. Medicines Are Commodities And Its My Right To Buy Them.

 I've written before about the paracetamol problem- its so widely available that people think its safe and innocuous, and they can take extra or dismiss it because they've sort of forgotten that its a medicine. I think this may become a wider problem. If medicines are available on the shop floor for me to handle and choose myself, I assume that they're either not very good medicines, or they are so safe that I can use them how *I* like. If I want to take three times the amount of antihistamines that it says on the pack, then I can do, just like how if I want to eat peanut butter out of  a jar with a tablespoon then I should be allowed to, because its my choice to buy it and who is anyone else to judge me and tell me otherwise? this is going to be particularly problematic with codeine-containing medicines and similar.

Anyway, those are a few thoughts for now. I may add to them as time goes on. What do you think?

Hxxx 

Homeopathic Harms Vol 7: Professional Ethics

In February 2013, my friend @EBMScientist and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we decided to write a series of blog posts expanding on a number of points we covered in the talk:

"Ethics is the science of morals, or moral philosophy. The principles, written or unwritten, that are accepted in any profession as the basis for proper behaviour are the ethics of the profession" -Dale and Appelbe's Pharmacy Law and Ethics

As you'll know by now, I'm a pharmacist. And as such, I have to be registered with the General Pharmaceutical Council (GPhC) to practice in the UK. I'm therefore governed by the GPhC, and in particular their code of conduct, ethics and performance, which has seven main points:

  1. Make patients your first concern

  2. Use your professional judgement in the interests of patients and the public

  3. Show respect for others

  4. Encourage patients and the public to participate in decisions about their care

  5. Develop your professional knowledge and competence

  6. Be honest and trustworthy

  7. Take responsibility for your working practices.

If I-or any of my colleagues- were to act against this code of ethics, we could be held to account by our regulator and reprimanded accordingly. Other healthcare professionals- Doctors, nurses etc- all have similar codes of conduct produced by their regulatory bodies. They all have one thing in common- that the patient is central to everything you do, and if a member steps outside this code of conduct, there is a clear and organized route through which complaints or concerns can be raised. This is as it should be: healthcare professionals have the lives of patients in their hands, and need to be held to account if anything goes wrong. As I've written before in this series, homeopaths don't have to register with a regulatory body and anyone can set themselves up as a homeopath with no training whatsoever. Whilst some 'professional' bodies exist in the UK, they have no regulatory powers so are unable to reprimand anyone if they receive a complaint.

Health care professionals who also practice homeopathy still have a duty to ensure that they abide by their regulatory body's code of ethics. In my opinion, however, it is very difficult to reconcile some of the clear guidance with homeopathic principles. Let's take a look at what I mean, using some selected points from the  the first two standards of the  GPhC's Code of Ethics July 2012 as a guide. (I'll cover the rest of the points in another post)

1. Make Patients Your First Concern
Under this heading, the GPhC states that we must "Make sure the services you provide are safe and of acceptable quality". Given the lack of high quality information that homeopathy works, we are unable to guarantee that such a service is of acceptable quality. You'll also know if you've read the rest of this series of blog posts that there is a lack of evidence regarding the harms- both direct and indirect- of homeopathy- so how could we guarantee that it is safe?

2. Use Your Professional Judgement In the Interests of Patients and The Public
There are a couple of relevant points here. firstly we are told that we need to make sure that professional judgement is not affected by personal or organizational interests or incentives. If you're going to charge for a homeopathic service on the side of your usual practice, then there is already a clear personal incentive to promote homeopathy.  We can minimize the possibility of such things affecting our professional judgement by making sure that we use evidence to guide treatment decisions wherever we can: evidence-based medicine is not perfect, but its the most objective method we have at the moment. And, as you'll know, there is no good evidence at all that homeopathy works. 

We are also advised to:

 "Be prepared to challenge the judgement of your colleagues and other professionals if you have reason to believe that their decisions could affect the safety or care of others"

I myself-and other pharmacists-have done this: I've spoken out about Tony Pinkus, for example, a pharmacist who endangers patients' lives by promoting unlicensed homeopathic vaccines or sugar pills to prevent malaria. In Nancy's latest blog post, she covered some of this, and I know Adam at Dianthus Med has also been discussing this point on twitter and his blog lately. Its clear-from our own professional guidance-that where patient safety is in danger, we do not protect our own- we need to report, speak out, and denounce those amongst our colleagues who let the profession down.

Homeopaths, on the other hand, seem to have no such obligation. We've been struggling to think of one single example of where homeopaths have spoken out against other homeopaths where patient safety has been endangered. In a conversation on twitter, for example, no homeopath would say that it was inappropriate for a homeopath to have said that a homeopathic remedy could have saved someone who died due to injuries sustained in a horrific gang-rape and disembowelment.  I recently asked some homeopaths on Twitter whether they would speak out against a colleague who put patients in danger. The answer I received from one was shocking:

"When its so easy 2 wink at 1's own sins, seems impossible 2 find judge orjury before whom 2arraign the 1st law breaker. KENT" (sic)- @22VenkateshN

Admittedly this particular homeopath that responded (he was the only one) has a reputation for obfuscation, but this reply seems to suggest that no, he wouldn't report, in case someone did similar to him. I tried to clarify : "so to clarify: you wouldn't speak out in case someone else did the same to you? A yes or no would suffice, thank you". The reply:

"some questions can't be replied with a simple 'yes or no'. for example_ 'are you still mad ?'"- @22VenkateshN


I'm not sure what he is trying to imply by asking about being mad, but we'll give him the benefit of the doubt and ignore any insinuations he might have been trying to make. What is staggering is the reluctance to admit that he would put patient care first and report a fellow homeopath in a situation. As a health care professional-and a good person- the code of ethics  becomes deeply ingrained in your being. Its second nature- and pretty obvious- that you would put the needs of a patient first. I persisted further,  trying to make it easy for him to agree that you would report a colleague: "It's very easy, if you work under clear ethical guidance. homeopaths do have that, right?: patient safety comes first: therefore yes, you would report and denounce a colleague who endangered it." Again, the reply astounds:

"Its not that easy, every one accusing everyone else would result. That's why I tweeted the appropriate observations of Kent"- @22VenkateshN

Wow. So it would seem- on the basis of this sort of conversation and the complete radio silence from any other homeopaths- that no, they wouldn't report or denounce a fellow homeopath because some sort of petty slanging match would ensue. Instead of a clear referral process to deal with complaints, accusations would be flying all over the shop- and one very, very important aspect gets forgotten: patient safety. 

I'd love to be proved wrong here. I'd love to think that medical homeopaths or pharmacists who also practice homeopathy would do otherwise, in accordance with their code of ethics. But I'm currently deafened by their silence. If I were one of the more professional, caring homeopaths who really did want to do the best for their patients, I would be utterly horrified and disgusted by some of the claims and actions of others, and I'd want to-nay I'd feel obliged to- speak out against them for the good of my own practice. I'd be embarrassed to be associated with them.

So here's your chance, homeopaths. Speak up against bad practice and drown out the previous deafening silence. Go right ahead: I'm listening intently. And while you're at it, please do take a few minutes out to respond to Adam's Challenge to the Society of Homeopaths too

 

The General Pharmaceutical Council: Let's hope they do the right thing

Many years ago, just after I qualified, I was working in a new 100 hour pharmacy in a very well known supermarket chain. 

To be honest, the working conditions were pretty terrible in that store. I had brilliant staff, but not enough of them. At the time, the policy of the supermarket for 100 hour pharmacies was to have no support staff there for the first hour and a half of the day, and the last two hours of the day. I argued tooth an nail against this, as we all know that pharmacists should ideally not self-check a prescription, no matter how quiet the pharmacy was between those times. The attitude of the company was that I was in the minority, and that I was complaining unnecessarily. 

At this time I was the only permanent pharmacist working there: the rest of the time we were running on locums. The company policy was to ideally use their locum booking system, but this was notoriously unreliable. I found myself setting my alarm for 6 am every morning, getting up and getting ready to wait for a phone call to tell me I would have to go in because the locum hadn't turned up, even on my days off. I found myself doing 16 hour shifts, occasionally one after the other, and with 3.5 hours of that spent on my own.

Even without the horrendous attitudes from other managers in-store (the daily battles, the snide comments about how much I was getting paid, the total lack of understanding about pharmacy law, and the outright sexism), these conditions were brewing for a dispensing error. 

The day it happened, I was working a 14 hour shift the day after working after a 16 hour shift. I was having to check a prescription whilst also being on the phone, because of the lack of staff. I checked that the drug, strength, directions etc were correct, but I didn't spot that the wrong name was on the label. 

The patient rang up to check that the cream was the right one for them. We apologised profusely, offered to redispense, offered to go through our complaints procedure etc. the patient was happy with the reassurance that it was the right cream and refused the other measures, stating that she was quite happy that the situation was rectified.

Next thing I know, I'm being investigated by the then-regulator, the Royal Pharmaceutical Society of Great Britain. You can't even imagine what this did to me. I was an absolute mess, convinced that I was going to lose the career I had worked so hard for. I co-operated entirely with the investigation, just as I had with the patient. I informed the inspector of the working conditions and my fears that it would lead to something more serious. None of this was taken into account in the final report, which gave me a warning, and the fright of my life. 

All this for a minor dispensing error, which caused no harm to anyone. 

You'd think, then, that the current regulator, the General Pharmaceutical Council, would come down hard on any pharmacist who actually endangered patients willingly. You'd think they would take decisive action, particularly where a pharmacist has had similar previous warnings which they have chosen to ignore. You'd think this would especially be the case where the pharmacist in question had been caught out by a BBC journalist posing as a concerned mother wondering about whether her child should be protected against whooping cough, a disease which can - and does- kill people.

See where I'm going with this? I'm hearing reports that the GPhC are suggesting that the Ainsworth's pharmacy case is nothing to do with them, and that as homeopathy is regulated by the MHRA it isnt their area. If that's the case, why is Mr Pinkus and the premises even registered with them?

I'm really hoping that this isn't the case, and that the GPhC are actually going to take decisive action. After all, what sort of a message does it give out to the public if they aren't being protected from harm? What sort of a message does it give out to the pharmacists that do their bet every day, trying their hardest to be as accurate as possible in working conditions that are ill-designed for such a purpose? 

Come on GPhC, be fair to the majority of your pharmacists who work according to your standards and actually do put patients first, and who do ensure that their recommendations are evidence-based and made with the best interests of the patient at heart. .

Hxxx