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MP rebukes colleague's dispensing Smarties slur

Politics Tory MP and GP Phillip Lee's claim last week that dispensing is like counting Smarties has been derided as a "simplistic assumption" by APPG on primary care and public health chair Nick de Bois (pictured).

Tory MP Nick de Bois has rebuked his colleague's attack on pharmacy, dismissing Phillip Lee's claim that the profession is paid to count Smarties.

GP Dr Lee had based his call for doctors to take over dispensing on "simplistic assumptions", MP for Enfield Mr de Bois said in an exclusive interview with C+D.

Conservative MP for Bracknell Dr Lee had failed to see the substantial opportunity to improve care by working together, argued Mr de Bois, who chairs the all-party parliamentary group (APPG) on primary care and public health.

"I think it just isn't dealing with the substantial opportunity to improve the whole patient experience" Nick de Bois, Conservative MP

More on dispensing

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Peter Dawson: I'm a Smartie counter, apparently

NHS Alliance chief: focus on services over       dispensing in new NHS

Mr de Bois' comments came a week after GP and Bracknell MP Dr Lee argued that taxpayers were subsidising pharmacies to "check the box and then sign".

Dr Lee said he couldn't understand why all GP practices could not be dispensing as it was just "like counting Smarties, you don't have to be terribly intellectual to be able to do it".

"To make a challenge like that based on such a simplistic assumption... I think it just isn't dealing with the substantial opportunity to improve the whole patient experience," Mr de Bois said at the APPG's annual reception on Wednesday.

Mr de Bois urged GPs to stop seeing pharmacies as purely profit-making ventures. "We need a complete package of care and, through the role of pharmacists, we can improve the patient experience," he said.

"The problem is we look at GPs, pharmacists, nurses and physiotherapists [as separate groups] and actually we should be looking at them as a whole."

He added that pharmacists were particularly well placed to offer preventative care and tackle chronic illness. "The more we make use of pharmacists' skills, the more that will be to the patient advantage," he said.

The Conservative Party has not responded to Dr Lee's comments officially, but the Royal Pharmaceutical Society has written to the Prime Minister and government chief whip to seek confirmation that the comments do not represent party policy.


What do you make of Dr Lee's comments?

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12 Comments

Rob Morris, Community pharmacist

Running a pharmacy and dispensary is a highly itellectual job as you have to be both scientist and business person. The average pharmacy does over 8,000 items a month and this is a big responsibility. We do not have the benefit of practice managers and nurses doing a lot of the work for us and we work considerably longer hours than most GPs. We also do not enjoy an NHS gold plated pension fund or the sort of salaries that GPs enjoy. Who is the better value for money then for the tax payer then? I am certain it would cost a lot more to put all dispensing, counselling, buying, managing etc. etc. via GPs. Is Dr Lee really trying to deflect attention away from the fact that what GPs actually do could be done a lot cheaper by other means. If it weren't for the considerable "power" the BMA wield then Tesco et al would have moved in years ago!

Annalise Gerrish, Dispenser Manager/ Dispensing Assistant

I think another aspect that has not been brought out in the discussions so far is that some people will not go to see a doctor but will pop into a pharmacy - there may be a lot of different reasons for this. However, these are the people that can really benefit from the services of a qualified pharmacist who can give timely advice and possibly spot symptoms that do require further looking in to which would otherwise go undiagnosed or played down / ignored by the patient.

Paul Thomas, Other GP

I am pleased to see this story is continuing to run although I am slightly disappointed the DDA or BMA have not commented. I apologize for the duplication as this post follows from my response to the original article.

Strictly speaking doctors are not qualified in pharmacy but, unless the training of doctors has deteriorated significantly, we are most certainly qualified in pharmacology and therapeutics, although we admittedly receive very little training in pill making. Times have changed; car mechanics are not qualified blacksmiths and do not need to be. In saying doctors were equally qualified in pharmacy I was quoting from a recent Court of Appeal Finding when the pharmacy establishment attempted, but failed, to require all doctor DISPENSING to be supervised by a pharmacist.

Rob, we also run our own businesses with the significant handicap of an anticompetitive and exclusive single-customer contract with NHSco (supported by an entire government department), who insist we spend most of out time performing box-ticking exercises with QOF and QP, rather than being allowed the time to diagnose illness and otherwise care for our patients.

Independents make up half of the ownership of pharmacies in England and Wales but as with us front-line GPs few of us have any influence on the policies adopted by our (fat-cat part-time) representatives and managers-with-medical-degrees, who regularly let us down badly, most recently with their ineffectual opposition to the NHS Act, by tarring us all with the same brush; The the multiples may not be the only pharmacy owner/ operators out there but the independents do not have the same lobbying power and influence as they do in a world dominated by the interests of big business.

Pharmacists most certainly have an extremely important role to play but I firmly believe, when financially possible, that should be within the primary care team, not in competition with it! While, even in pharmacies, dispensing is undertaken by technicians counting those smarties, few practices can afford that even if, like me, they wanted that additional resource. Perhaps I am naive, but I would happily have a pharmacist as a partner to supervise our dispensary and provide therapeutic advice, if the post was self-funding or even generated a bit of income, and he/she was accountable in law, for his own acts and omissions, and not me. My views have not changed in 20 years - Thomas P D, British Medical Journal, 1992; 305: 650.

I would most certainly prefer prescribing errors to be detected BEFORE the prescription left the premises. Counting smarties it may not be, but dispensing largely consists of counting the correct smarties of the correct dose and, even when this is performed on site, with the protection of bar coded scanning, errors do occur as last year’s fatal incident highlighted in the doctor-friendly Daily Mail; http://www.dailymail.co.uk/news/article-2014204/Grandfather-dies-GP-surg...

Dhanoa posted, “If you really wish to have a multi disciplinary team working under one roof then you must also be willing to champion the cause of pension rights for the clinical pharmacist”. Quite so! I think my credentials are genuine as, I once owned a pharmacy. The pharmacist was employed by the practice (his services as superintendent subcontracted to the pharmacy) so he was entitled to an NHS pension (which we are obliged to pay for ourselves and is no longer anything like it was). As for salary, a medical, dental, veterinary or pharmacy business will only retain a partner, engage a pharmacist, nurse, healthcare assistant or whatever, if their industry justifies that investment. Currently that is far from the case. (Even if we employ a pharmacist we cannot dispense NHS prescriptions and are not even permitted to sell paracetamol but must prescribe it at £7.65 a pot, even though it can be bought from the local petrol station.)

Lance Roth, Community pharmacist, posted a reasoned comment, with which I entirely agree;

“Dr Thomas I applaud your willingness to engage with us in debate - for only when we exchange ideas/feelings can we move towards a better future. The bottom line is that, and this is my personal opinion, pharmacy, as a profession, has never been about being in competition with that of medicine, but rather to strengthen and compliment it for the benefit of the patient.

I have not been trained to diagnose various diseases. My pathology and anatomy training was cursory compared to that of a doctor. But you are not going to find a better partner when it comes to assisting you in the medicine treatment of your patient! . . . our biggest goal should be to max the benefit for our patients, and our biggest stumbling block is our collective pride.

I think we both have now acknowledged that to err is human. My question is then: Why put our patients at greater risk, just because we cannot overcome our pride?”

Sadly, it is nothing to do with pride and all to do with restrictive practices corporate giants and NHS monopolies.

Sachin Badiani, posted “I have become frustrated so I have stopped. As a GP, how can you help me to break down the barrier with the local medical practice?” I only wish I could but I do not run NHSco, with their policy of divide and rule.

I note Mr de Bois urged GPs to stop seeing pharmacies as purely profit-making ventures but find his advice very hard to take, when the giants most certainly are. He said, "We need a complete package of care and, through the role of pharmacists, we can improve the patient experience," I do so agree but this can only be achieve if there were a level playing field and we worked together in the same practice, which I think he may accept when he admits, "The problem is we look at GPs, pharmacists, nurses and physiotherapists [as separate groups] and actually we should be looking at them as a whole. The more we make use of pharmacists' skills, the more that will be to the patient advantage,"

Hmmm, I wonder what particular skills he is referring to? (sorry:-))

Sadly, the political vision for the new NHS is us all to be employed by Virgin Healthcare.

Emma Weinbren, Marketing

Thanks for your comments Paul - the DDA and BMA have now both put out a response to Dr Lee's suggestions so we will be publishing a story on this soon.

Clare Hoekstra, Community pharmacist

A lecturer from the Brighton Medical School in charge of the undergraduate doctor pharmacology courses recently compared the number of lectures that doctors and pharmacists receive in the subject. The pharmacists level of training far exceeded that of the doctors it was not merely equivalent! He was very much in favour of combining skills and knowledge when it came to patient care in practice. As part of the training pharmacists will take more chemistry related courses but this does not detract from their understanding and knowledge of medicines and human physiology.

I have previously worked for many years in a doctors dispensary and the level of input from the doctors was minimal. I returned many scripts for alterations or suggested different medicines for the patients when I could clearly see that the new diagnosis was a result of a side effect from a new medicine. I could pick up interactions and predict future problems that my fellow technicians could not forsee. I often helped the junior doctors select acute medicines as they were unfamiliar with the products and their uses. I did the Btec course to see what it was like. It was the equivalent to A level not a university degree. This is the level of skill that people running doctors dispensarys have!

Pharmacists check the final prescrption and are checking the doctors prescribing too. They are not out to find a mistake but are well aware that they happen and should be seen as protecting the doctor from harming their patient unwittingly. Why are pharmacists and their skills sidelined or derided. A couple said to me last week that they had learnt more from me in ten minutes in the pharmacy about their new medicine than they had in half in hour with the consultant.
Pharmacists are also more than capable of prescribing, and they should be allowed to for chronic conditions and acute ailments in much the same way that patients are being prescribed medicines by nurses. Hopefully the NHS can change even further and include them fully in the future.

Paul Thomas, Other GP

Clare Hoekstra confirms, "A lecturer from the Brighton Medical School in charge of the undergraduate doctor pharmacology courses recently compared the number of lectures that doctors and pharmacists receive in the subject. The pharmacists level of training far exceeded that of the doctors it was not merely equivalent!"

I understood doctors were selected for their academic prowess so did not need such an intense undergraduate course in any subject as they studied so many whose content overlapped, particularly as they continue to taught during the extended hands-on learning period as, doctors in training, which lasts about nine years in total.

I suspected medical training had deteriorated but this post may suggest it has gone one step too far.

Once more my cynical personna raises its ugly head; I have no reason to doubt your friend's observations, Clare. Since medicine in this country is dominated by the various NHSco (Trusts) branches. It is as if Tesco was responsible for training the country's shopkeepers; It makes no commercial sense for Tesco to train potential shopkeepers too well since, on qualification, they might take the custom Tesco wished to retain for itself . More appropriate, by far, to limit their training and engender a climate of fear so they understand their significant limitations and to (refer) pass all their custom to the local Tesco branch, rather that retain the customer for themselves.

An extremely good example of this is early specialisation in training of medical students and GP registrars in maternity care, the latter now receiving little or no hands-on obstetric training. In consequence most newly qualified GPs feel unable to offer maternity medical services and even if they did, following the 2004 contract, they are no longer paid for it and no Trust will allow GPs to use their facilities, probably because we are only seen as commercial competitors. In the late 1980s, once I was considered safe, as an SHO I effectively ran my consultant’s maternity ward performing numerous instrumental deliveries. We once also had a GP maternity ward in our local district general hospital, which I regularly used to provide intrapartum care. (Hospital) Trust managers would laugh at me now if I were to I suggest I wished to perform a delivery on THEIR premises. (P D Thomas, British Medical Journal 1996; 313: 1148. GPs' responsibility for midwives actions.)

A similar story applies to out-of-hours services. (Thomas P D. British Medical Journal 1995; 310: 1268 Emergency care in general practice.)

Clare also confirms that “pharmacists are also more than capable of prescribing, and they should be allowed to in much the same way that patients are being prescribed medicines by nurses.” As you know this is already the case for GSL and P list medicines, even for the NHS in some cases, but I do worry about the ongoing erosion of POMs. I would be more concerned if pharmacy supply were to be extended to all POMs that currently may only be supplied by “appropriate practitioners” i.e doctors, dentists or vets;

If this were to happen I have little doubt that this would only apply to those pharmacist/paramedics employed by Trusts, but not to community pharmacists, again for commercial reasons. However I note the anxieties of the Department of Health and RPhS in respect of the NPA proposals for pharmacies to supply a number of POMs by means of patient group directives. Who is medicolegally responsible for the inappropriate acts and omissions that will surely follow and wonder as to the costs of their liability insurance ? I pay about £700 per month.

Oh, I forgot, the employees of NHSco (Trusts) branches are covered by their employers, whose liabilities are underwritten by the taxpayer.

David Hoyle rashly, perhaps, avers, “The idea of allowing all GPs to diagnose, prescribe, dispense and sign the death certificate is most unwise. Doctors should be subject to more supervision of their prescribing not less. Although the majority of GPs are honourable I am reminded of John Bodkin Adams and Harold Shipman.” NHSco has been quick to tar all doctors with their brush David but, in case you didn’t know it, these two criminals were held to account. I am not so sure this will be the case when employees of the state or multinationals are the only persons who routinely diagnose, prescribe, dispense and sign death certificates?

To emphasise, we are in the same position as the physicians and apothecaries in the mid 1800s with infighting detracting us from the real issues.

We should not be squabbling between ourselves when we should be fighting a devious and unscrupulous enemy and must act together for the sake of our respective professions and for the benefit of our communities.

Clare Hoekstra, Community pharmacist

I agree the forces are powerful and control the situation on the ground. However some myths should be countered. Yes, doctors are selected on academic merit but that does not mean that all high achieving individuals wish to become doctors or that those that miss out on the opportunity as places are limited, are less intellectual. As for on the job training that goes for all pharmacists working with others who have gained experience over the years and done further training, as well as the experience gained by dealing with customers who present with every degree of symptom and who require referral when needed.
I also remember a time at university 20 years ago when attending a histology lecture at the medical school when the whole cohort of midwives staged a walkout because the content was too difficult to understand. They didn't return for the rest of the module. It has also not escaped my observation that textbooks for nurses on pharmacology are watered down and do not have the depth of the gold standard types llike Rang and Dale. When doing the microbial infections and resistance to antibiotics module under Professor Hodge at Brighton uni (post grad diploma) we had several medical students on the course as this was one of their electives. These medical students will be seen as having a close understanding of the subject whereas the pharmacists will still be seen as a threat to indiscriminate antibiotic prescribing.

This brings me to my second point which is that it is fraustrating and nonsensical that pharmacists do indepth study of pharmacology and the diseases/ conditions that these medicines are designed to treat only to be relegated to otc sales of paracetamol and ibuprofen or treatments for minor conditions which constitute 0.1% of their training. On listening to a patients ailments and asking questions the appropriate POM springs to mind, you then tell the patient to make an appointment with the Dr/nurse and then you see the prescribed item on the script a few hours later! A waste of time and resources.

Insurance certainly is expensive but with the right NHS structure money saved by having widespread pharmacist's prescribing would go a long way to solve this. (Pharmacist are paid less that doctors hence the saving)

Pharmacists are well versed in reading the NICE guidelines and comparing clinical trials and can follow rules, laws and ethical behaviour. They also have a robust fitness to practice procedure to sanction any wrongdoers. One has to go back to where the money is held and distribute it across the professions in a more sensible proactive way.
I still prefer a system more like South African set up where patients visit the pharmacy first as you have to pay a fee to see a doctor. The patient is screened in that their minor ailments are treated (and paid for by the patient) , Medicines like contraceptives, antimalarials,antibiotics, chronic heart conditions and ashma dealt with. Any complicated scenarios are referred to the doctors for further diagnosis.

If the pharmacists in the UK could prescribe and therefore not charge the patient, patients would head straight to their local pharmacy. Doctors would have more time to really use their clinical skills of diagnosis to treat the patients who really need them. The doctors would be paid a much higher rate to prescribe for these patients as it requires a higher level of medical knowledge.

Roy Sinclair, Community pharmacist

Dr Phillip Lee has at least provoked a debate on the role of the Pharmacist - We can all waffle on about our importance forever but will change little because we know what we do and don't have to convince ourselves. Until we have convinced others and clearly demonstrated to them our worth and made them recognse that they need the benefits we provide, this kind of debate will continue.

Middle Way, Community pharmacist

Undeniably true. These forums shouldn't be about taking defensive positions and employing emotional arguments. The reality should be discussed without allowing ourselves to become flustered.

The truth is that we can pretend to be searching for a better tomorrow for our patients but the reality is that we are all struggling to simply survive right now. Independents are struggling and we don't need to ask why. Big corporates are...welll...not really alive and hence cannot possibly be expected to 'care' - the higher-ups in these organisations would never have reached that far if they had something like a conscience. Imagine a CEO/Superintendent of a corporate body walking into a meeting and saying to the board of directors 'guys, I know it's mad but let's spend £1m to save a few lives. There will be no reward and we will remain anonymous in this benevolent act but atleast we will have helped people'. He'd be floating in the River Thames the next morning.

Behavioural patterns can vary of course but when an animal is fearful, its attention generally turns inward. Right now everyone is fearful, worried, stressed or all of the above, and basically just trying hard to survive, whether it be GPs, pharmacists or anyone else. Asking us to gel together for the betterment of patient care at this moment is pointless. Unless there is mutual gain between a pharmacy and a GP surgery, they will not go out of their way to work together. If you would like to fix this little problem, get rid of corporatism. Go back to gold currency and the world's problems would probably right themselves overnight - oops, I hope I don't get 'whacked' by a multiple for saying that! :D

David W. Hoyle, Superintendent Pharmacist

The idea of allowing all GPs to diagnose, prescribe, dispense and sign the death certificate is most unwise.
Doctors should be subject to more supervision of their prescribing not less.
Although the majority of GPs are honourable I am reminded of John Bodkin Adams and Harold Shipman .
David Hoyle (retired)

Schar Minkel, Community pharmacist

Well it was obvious that the original comments by Lee exposed him as an idiot.I rationally deduced him as a dangerous hybrid - that of an egotistical MP and an egotistical GP.Thankfully he is a rare specimen in both professions.My question is this ... how can someone cream a vast salary as a GP and then also dirty his snout in the parliamentary trough???Will he be in the jungle next year?
Well done his colleague Mr de Bois.

Asmita Patel, Community pharmacist

At last someone who has a vision! Bravo Mr de Bois we need more people like you at a beaurocratic level to give the pharmacists a true representation.If everyone joined forces and worked like a team to promote patient care we would be wasting less money and producing more positive outcomes.

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