"Mr Smith, I'm afraid we don't have this in stock."
It's never pleasant having to tell a patient that you can't dispense his prescription, especially when the drug in question is a neuroleptic.
Mr Smith looked quizzically at me, and then gave me a fixed stare – the sort of look you don't want from someone on an antipsychotic.
"You haven't got any quetiapine?" he asked. "Yes," I replied. "I have got quetiapine, but just not the brand that your doctor has prescribed." And this is the point from which readers who work in community pharmacy will definitely recognise.
"You didn't have any last month," Mr Smith stated, quite correctly. I nodded, smiled, and said: "You're right, and we ordered extra so we could fulfill your next prescription. But this month your doctor has prescribed a branded-generic called 'Kwixotipine XL'.
"This is now the cheapest branded generic. So when he ordered your repeat script, his prescribing software will have popped up with a message from the clinical commissioning group's (CCG) medicines management person, saying 'Prescribe this as Kwixotipine XL and you can save a shed-load of money!' So that's what he's done."
“So you're giving me something different?” asked Mr Smith. I sighed.
“It’s like this," I started. "We make a small loss dispensing branded drugs, but a profit on generic drugs. So overall, patients get their drugs, we make an agreed profit, and I get to keep Mrs Xrayser in new clothes and prosecco – so everyone's happy.
“But then some twisted bastard came up with the idea of branded generics – a fine bit of double-speak, straight out of 1984 if you ask me.
"The makers of Kwixotipine XL give it a list price below the drug tariff generic price, so the CCG wins because it costs less and the manufacturer wins because they sell more.
“However, I don't get any discount on Kwixotipine XL. So after the discount clawback I make a loss, and Mrs Xrayser wears last years' clothes and drowns her sorrows with supermarket value cider.
“Also, branded generics are hard to order because they’re often either a special order, not listed by the wholesaler as generic, or out of stock," I told the patient. "Your last branded-generic has been out of stock for months, so we had to get your script changed. But every repeat was amended by the GP software back to the out-of-stock brand, until finally, the company admitted that their brand was being discontinued. So now the CCG has chosen Kwixotipine.”
Another question: "So he's not prescribed me quetiapine?"
"Yes he has prescribed quetiapine, but not as quetiapine. He's prescribed your quetiapine as Kwixotipine XL. I've got generic quetiapine, and I have other branded-generic quetiapine. But I don't have Kwixotipine-brand quetiapine. So I can't dispense this!"
Mr Smith stared at me for a moment, leaned forward and whispered: "Have you heard what you just said? I thought I was the one who was delusional."