Posted on

Being on the receiving end of all kinds of healthcare professionals brings more questions than answers, writes Ultan Molloy

Having had more recent experience personally, and with family, on the receiving end of healthcare, it has offered some interesting thoughts and insights. Firstly, my mother-in-law, who we thought we were going to lose
at Christmas, passed away early this morning. She was helped along with a palliative care cocktail of morphine and midazolam, but from when she “took a turn” to when she passed away, took over a week. A bedside vigil held by her family in the nursing home, where staff were very kind and understanding, went on 24/7 for that duration. Everyone wanting to make sure she was comfortable and not alone when she needed someone and when she eventually did pass on. Peacefully as it happens, although she held on longer than palliative care predicted, the third time around.

It caused significant upheaval for our young family, with one adult pretty much out-of-action for the last week, and no school happening or childcare booked. I’m lucky to have a great team that allows for flexibility
at work and to be able to be here for our kids, well I was up to yesterday. In a more usual home situation where both adults are working full-time with little flexibility it would have been much more challenging.
I think this offers a different perspective to consider when we have people coming to us at the counter a little tired, stressed or ratty in their demeanour. The value of having an established relationship in our community pharmacy with our patients, is often underestimated in such situations by patients, ourselves, and our paymasters, among others.

We also have an opportunity as employers to show that we care enough about what’s going on in our employees lives from time- to-time, to offer them what we can, when it is important to them. Goodwill works both ways, and doing what we can to position our business model so that our team members are cared for like family, is the ideal situation. There are challenges to this of course, as I found out myself more recently, where a business isn’t generating enough income to resource such good intentions and initiatives, which can leave one in a financial bind.

Our local GP practice has recently taken on a fifth practice in a neighbouring town, and in the middle of summer holidays, we had a longer than usual spin, albeit not excessive, to one of their practice bases to meet Neillí’s usual GP. It was a last minute appointment, and I’d taken a voice message from said GP a few days earlier, that if we needed anything, given my mother-in-law’s situation, to reach out to him directly. Very kind and thoughtful of them. I’m beside her asleep in her hospital bed now, where she’s on IV antibiotics for suspected pneumonia. Neillí’s grandmother (the one that’s still alive as it happens) had brought her to said GP appointment, and found the GP to be “quite abrupt” and “all business”, which is of course understandable with two of his GP colleagues on their summer holidays and him spreading himself through several surgeries. He was never much of a chatter as long as I’ve known him, but he’s certainly overstretched now, and in my own experience of him, the interpersonal relationship price is what’s being paid. Maybe there’ll be something lost through the lack of chat, given that what often comes out after chats at the counter is relevant, but we’re here tonight thanks to his concern about high ketone levels, and dehydration.

We can be part of the solution to overstretched GP services as pharmacists of course, given that 96 per cent of Irish adults would welcome community pharmacists being able to prescribe for minor ailments, and most people would also approve of them being able to repeat prescriptions without them having to go back to their GP. Huge potential for pharmacies to expand the healthcare services we provide, but at what cost we must consider. Given the shortage of pharmacists, we have to further consider what needs oversight and sign off from
a pharmacist, and what needs hands-on supervision, or personal intervention. Why have we not got checking technicians yet? They’re working that role in the UK since God was a boy. I’ve worked with technicians who were more intelligent, sharp, accurate, and wise than many of us pharmacists. I’m reminded of Atul Gawande’s The Checklist Manifesto, for example, if we have a robust start to finish a checklist for a process or interview, with for example, a “consult pharmacist” if an answer is yes/no, and final sign-off by the pharmacist completed with the patient by a trusted and diligent staff member, why would that possibly not be enough. Overstretched pharmacists and burnout is already a serious issue, that we must anticipate, and be sensitive too, and an expectation of excessive interruptions and multitasking on a given day, will lead to greater levels or distraction, burnout, and ultimately affect patient safety.

I also had an experience as a patient of a different GP and pharmacy recently. Yes, the last 24 hours has been a s*@%t show. Having woken with a 41 degree fever in the morning, after being awake most of the night with aches, and alternating chills and sweating, my wife ignored my “I’ll be fine after another hour in bed” please, me putting my morning fragility down to a heavy gym session the day before, and booked me a GP appointment at
a nearby surgery. Needless to say, my “hour in bed” turned into five hours and I eventually arose at 2.30pm for a 3pm appointment nearby, kindly driven to by a friend, as Laura had gone to her mum in the nursing home. Like a narcoleptic rag doll I flopped into the car, and subsequently into the surgery, where I appeared to be the only patient. I do know that I was barely articulate, and nearly fell asleep in the waiting room again. Dr F showed little interest in having the bants about life in general, or indeed in listening to me at all as it transpired. He gave me no explanation, or diagnosis, and when I asked him what he was prescribing, he said Doxycycline, which I couldn’t tolerate some years back, having had to take it for malaria prophylaxis. After a couple of days of puking it up a half hour after taking it, I decided to take my chances. “I don’t get on with doxycycline, it cuts my stomach up a bit. Could I have Augmentin Duo if you’re prescribing for my respiratory symptoms?” Ignored. And honestly, I was too flaked to assert myself. I also knew I had a box of Augmentin Duo at home mind you. So €55 later, and a 10 minute visit to the doctor I had a prescription for some doxycycline, steroids, Ventolin, and casacol, but no diagnosis or discussion about why I was in bits, and I wasn’t able to drag any more blood from Dr Stone. I’ll never go to him again.

We went to a pharmacy in the town that’s handy for parking, and given the other two neighbour one another on a street with little parking, it’s not surprising that it’s the one that’s fastest growing in the town. What is surprising is that it took the best part of an hour to get my prescription. My friend and driver went in to collect the prescription,
over the course of his wait, I had two naps in the car, only to be woken by him each time apologising to me, and saying: “I don’t know what they’re doing… there are like six of them going around in the back behind the counter… but no sign of your prescription yet. I’m sorry.” I was sorry too. Sorry, that I brought him to that particular pharmacy for the sake of a parking place. So many pharmacy colleagues are obviously not workflow planning and predicting patient returns every 28 days to have prescriptions ready in advance. If you’re not doing this in your pharmacy, know now, that you are robbing your patients of their time, you are robbing your staff of their time, and you are robbing yourself of the resources required to pay them for the lack of your systems, and patient “pull” led bottlenecks. Figure out how to do it, and you’ll have plenty of time to deal with acute prescriptions coming in, as your chronic/ repeat prescriptions will be prepared already. Yes, yes, yes, I know about potential rework in returning items to shelves, and PMR file changes, and they mightn’t want everything every time… just exclude those handful of people, note on their files, suck up the proportional handful of return to shelves, and get on with it, for Christ’s sake.

My driver yesterday, and friend, were sitting together on holiday recently, having a late drink, and he mused about something being “just like” something else. Rather curtly, just as when my aged mother starts to lecture me on medicine matters, “It’s not, just like,” I said, “It is.” He continued on with his “well you know, it’s like…. “, and I more bluntly interrupted, “It’s not like… it is!” getting progressively more irritated in my tone, at which point he jested “easy tiger” and burst out laughing. I’ve seen the funny side of it since, and he kindly, and at every opportunity brings “It’s not just like… it is” up in conversation.

If you’re still thinking using a “push” system (preparing your patients prescriptions in advance, and letting them know they’re ready when they’re due) sounds like a good idea.
It’s not just “like” a good idea, for everyone’s sake. I’d be very surprised if anyone has waited more than 20 minutes in our pharmacy for an extensive acute or last minute prescription in the last three years. That is with the proviso that we hadn’t queries for the prescriber, or had a stock issue/shortage, which would be discussed with the patient to keep them in the loop. Nor should they have to. I should note that we have an excellent counter person and lead tech who are constantly scanning and touching base with people about what they’re in for, or if there’s any queries to discuss ( for example, if they step out to the shop next door and return). How we might operate additional services on top of our supposed core competencies (clinical review, dispensing, accuracy checking, etc) remains to be seen in this environment. If we can’t even get a four-item prescription out within the hour, then many of us could have a way to go to manage and incorporate this successfully into the service mix in our communities, with any reasonable level of service.

I am cautiously optimistic as always. Extended services through community pharmacies are not just “like” an excellent idea. I just hope that they’re looked at, and funded, taking in the bigger picture of our business model. Pharmacies come under the drugs budget, rather than the primary care budget, bizarrely. Any increasing service level, clinical scope and professional scope for pharmacists needs to be uncoupled from “the more labels you stick on boxes in a day, the more the pharmacy gets paid in order to pay you”. We presently have none of the perks of paid leave, practice supports, and so much more that’s in the GP contract. So, if you want more pharmacy services, you will ultimately need more pharmacists, who don’t come cheap, but can bring astounding value to our primary care setting and for the communities we serve.

Ultan Molloy is a business and professional performance coach, pharmacist, facilitator, and development specialist. He works with other pharmacists, business owners, and third parties to develop business strategies. Ultan can be contacted on 086 169 3343.