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We sometimes need to let some patients go elsewhere for the sake of our own integrity and duty of care, particularly with some OTC medications, writes Ultan Molloy

I’ve been thinking, again, about the increasing volumes of correspondence and administration that has come our way over the last few years. This is of course in tandem with increasing volumes of prescription items as our population ages. More and more patient pharmacy visits looking for emergency supplies and advice because they ‘can’t get a GP’, or can’t get through to their own GP, seems commonplace in many areas. It often feels quite overwhelming from a pharmacy point of view. We want to do a good job by our patients at the counter, and also have a responsibility to ensure we’re dispensing safe and effective medicines for patients. One can’t be everywhere or do everything when working as a pharmacist of course, so we depend heavily on the team of people we have around us. Not everything can be a priority and managing and educating ourselves and our teams continues to be a challenge. 

“Being an owner, a manger and a pharmacist are three different jobs” someone said to me some time back, but they’re often all wrapped-up in the one. Especially now, with the increasing costs of pharmacist cover resulting in decreased viability of some pharmacy businesses. I would speculate that Lloyds letting all of their nursing home business go countrywide (from what I understand), is likely due to the costs associated with running what is a time-consuming and often demanding service.  “Profit is for sanity and turnover is for vanity,” another colleague said to me some time back.  It’s taken about 10 years to sink-in for me.  The viability of one’s business isn’t determined by how busy you are, but rather, are you making enough in profit to cover one’s bills, heaviest among them of course being the wage bill that we invest in our teams on a monthly basis. It is clear when it comes to the ‘busy’, though, that not all business coming our way is equal. I had friend who had a technology solutions business, and I always thought he was far too fond of being busy. Mer died at 44 years old this time last year.

The ‘poor relation’ in terms of our time allocation as pharmacists can often be the OTC (over the counter) section. It’s mentally, and physically, impossible as I’ve said before to ‘supervise’ every sale, so we rely heavily on our already-stretched team of colleagues. There are a few things to consider here.

The elephant in the room is there’s a commercial incentive to ‘selling’ something to a patient. There is a limited time to build any relationship or trust in order to ensure the patient, or customer, gets the safest and most effective medicine for their symptoms, in order to guide the person toward what’s most suitable for their symptoms. Then there’s the ‘just give it to me’ brigade, whose friend, mother, third cousin once-removed, or Google has told them that X is the best thing for their self-diagnosis. ‘Sure, they’ll just go down the street and get it someplace else.’ Maybe. See the elephant above! Sales targets aren’t always helpful here, but there is a win-win-win available. I saw a quote some time back that up to 50 per cent of requests by customers (aka patients) are for a medicine that isn’t optimal for their symptoms. The win-win-win is the customer gets the most effective and safest medicine for their symptoms, pharmacy gets a sale, and perhaps some additional sales through exploration of their symptoms and getting products as an exercise ‘link advising’, and the person looking after the customer can have the satisfaction that they’ve done right by the customer.

We don’t have everything in our control though, do we. The ultimate assertion of control is to refuse to sell something. Now, how often does that happen? Otherwise, we are dependent on the customer being open to advice, and/or our soft influencing skills to guide them toward what’s best for them. The additional value for everyone can be, ie, where someone comes in for a cough bottle… ‘how’s your head, sinuses and throat?’ Lots of the time, people will end up taking something else with them for other symptoms, or perhaps a course of probiotics or multivitamins to support their recovery. Is that not ideal? Customer gets sorted, pharmacy staff member supports their recovery through advice and caring, and the business has some money in the till to pay said staff member, etc. Collaboration with the patient takes time though, and isn’t always welcomed by them. Often, we don’t always have the availability ourselves with the ongoing administration squeeze and competing priorities at the back end of our businesses.

I’ve lost a lot of custom over the years trying to hold the line. I’ve requested prescriptions before further sales of OTC medicines from a number of visitors who brought their custom, and probable addictions, elsewhere. I suspect that many of those addictions were born out of passive selling of pharmacy-only medicines at the outset. We have an obligation to educate people though, don’t we? There’s a reason this stuff isn’t sold in supermarkets on self-select. Solpadeine addiction is just one of the issues. Addiction to other codeine-based products is also an issue. Who gave them clear guidance on their use at the outset? Did anyone say, ‘if you keep taking these after your headaches are gone when you can get away without using them, you’ll end up dependent on the codeine, and then get codeine withdrawal headaches instead, and have to keep taking them?’ I don’t think so. Do we even do this now, or is it a token ‘no longer than three days with these’ as we cash-up the sale?

How many people were told not to use Otrivine and its peers for more than seven days, lest their nose get dependant on it, and rebound congestion become an issue to be solved by ongoing use of same? How many people who didn’t want to ‘bother’ their GP are taking regular ibuprofen that could be creating a stomach ulcer or damaging their kidneys? We have pseudoephedrine that can affect blood pressure, in the unhelpful direction, or indeed be used to manufacture amphetamines. We have haemorrhoid and bowel medicines that can result in atonia if used excessively, or indeed mask or manage symptoms of something much more serious, when a referral rather than a sale is much more appropriate. None of this is helped, of course, by constant changeovers of pharmacists, where patients aren’t recognised or known to the pharmacists to support appropriate intervention. Lots of other medicines to consider too, when keeping front-of-mind that we are not a self-select shop, and that we have a duty of care. I’m saying this to myself as much as anyone else, lest you read into this that I’m suggesting I’ve it all figured out and running perfectly! 

“Catch 22; a dilemma or difficult circumstance from which there is no escape because of mutually conflicting
or dependent conditions.”

We are not usually in a Catch-22 situation, is what I think my overall point is. With some self-education, creativity, and a willingness to let some business go for the sake of one’s integrity and duty of care, perhaps we can feel better about the good work we do on a daily basis as community pharmacists. We can be even more proud to be part of the most accessible and engaging healthcare professional teams available to patients, and back ourselves for the sake of our patients and our profession. ●