Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 960 - 979)




  960. Even on occasions their Member of Parliament.
  (Dr Gerada) No, they cannot name their Member of Parliament.

Mrs Dean

  961. Lastly, again with regard to both primary care and community pharmacies, what is the involvement in harm minimisation actions? For example, we have been told about shooting galleries, safe places to inject, and also the Needle Exchange which is really fundamental.
  (Mrs Glover) Pharmacy is certainly very involved and harm minimisation plays a major role. They are making a safe supply and they may be supervising it. A number of pharmacies are involved with the Needle Exchange. We have an ironical situation where we are not allowed to supply the paraphernalia which also helps with harm reduction. We may have the Lord Advocate turning a blind eye and so on, but it is not appropriate that we are in a situation where we cannot make a supply of citric acid or a swabs order for injection because we are breaking the law, and I do think that is something that this Committee could really look at. It is a nonsense. Pharmacists are desperately law abiding people and they really find it very uncomfortable to be put into a position where they want to help with harm minimisation but the system says, `you should not be selling citric acid'.

  962. Would pharmacists be happy if patients had somewhere on their premises to inject?
  (Mrs Glover) I think that injecting needs to be done in a more formal clinic and more supportive clinic than in pharmacies.
  (Dr Thompson) As far as GPs are concerned, everything we do is from a harm reduction perspective. The prescribing of methadone takes the drug user out of the requirement to go to the black market and to the criminal underworld to obtain their supply of drugs; it takes them out of the situation of needing to fund their habit, very often illegally through acquisitive crime. We encourage and promote the immunisation against viral illnesses and the testing of viral illnesses and give appropriate advice depending on those results and we advise them on safe injection techniques. So the whole process is not just about giving them a methadone script although that in itself is harm minimisation activity, but the whole process is about harm minimisation and harm reduction.

Angela Watkinson

  963. I would like to ask another question of Mrs Glover, if I may. Towards the end of last year, I understand that the dispensing fee for pharmacists was reduced by 10 per cent from 90-something pence to 80-something pence. At a time when we are trying to involve pharmacists more and encourage them to provide a wider service, what sort of effect has that had?
  (Mrs Glover) Not a good one. I think that really the money for this particular part of pharmacy ought to be separate; it should not be taken out of the global sum because the global sum deals with all the prescriptions that you are dispensing and I think it should be different money so that, when they are negotiating on the total joint budget, this portion is separated out. It is certainly not very encouraging when you are offering a good service, and in a number of cases you are putting in investment to make the service work better, to then have the grass cut from underneath your feet. You think, God, what am I doing here? Why am I doing this?


  964. You say in your evidence, Mrs Glover, that you need to update existing regulations to enable pharmacies to improve the services they are able to offer. Is one of the problems that pharmacists do not have sufficient discretion?
  (Mrs Glover) Yes.

  965. And that, if they stray over the boundary, they get done?
  (Mrs Glover) It may be that if they stray over the boundary they get done and the really sad thing is that we have a situation where, if you get an incomplete prescription . . . Supposing the prescription requires that you put the amount to be given daily, you sum it at the end and, if it is 14 days, it is 14 times 75 etc and supposing the arithmetic is wrong—you have to put it in words and you have to put it in figures, so you have to look at it all—and I dispense it, then I have committed a criminal act. It cannot be appropriate to have regulations that leave us in that situation. It is a nonsense. You have actually just reviewed the regulations and you have missed the opportunity to do something about this.

  966. Who has?
  (Mrs Glover) The Home Office. I have seen three ministers about this who have been very sympathetic and have said, "Yes, Mrs Glover, we can quite see what the problem is" and absolutely stuff all has been done about it. It is partly because it crosses the Home Office and the Department of Health. I will give you another example. If you have a prescription which says it is to be dispensed on Monday, Wednesday and Friday and you give Monday's two days' supply and then you give Wednesday and so on. If they do not turn up on Monday for whatever reason, I cannot give them Tuesday's supply without having to send them back to the GP and they get all the hassle at reception and they need to get an appointment. I have a really cross bunny in the pharmacy who wants his stuff and I cannot give it to him. It is quite clear what the clinician wants, 75 mls a day, and I am unable to give it to him. Now we have a really difficult situation to manage in the pharmacy, and I have old Mrs Jones alongside who finds it all rather upsetting because I have somebody screaming at me that they want their stuff and I am unable to give it to them and, if I give it to them, I am a criminal.

  967. I suppose it might be argued that one reason for the very tough rules in this area is the danger of leakage in that pharmacists could get conned into parting with more than they should do.
  (Mrs Glover) I understand that the rules have to be clear and defined. I think the problem is that they were layed 30 years ago when we had one odd prescription once a week. Fine. We now have a situation where we have people doing 50 or 100 of these a day. That is a nonsense. The other thing is that we have to enter every dispensing into a register by hand every day for every prescription. For my chaps who are doing 100 a day in Edinburgh, it takes them two hours. We do have a perfectly good computer record because we have patient medication records on computer, but there is not a facility to allow us to use that and the opportunity for that data that could be collected from these computer records has been missed.

  968. It could be done, in your view?
  (Mrs Glover) Absolutely. It needs safeguards of course but we are certainly missing an opportunity and it certainly needs overhauling.

  969. What is the reason for the insistence?
  (Mrs Glover) The Home Office.
  (Mrs Glover) Not the Health Department?
  (Mrs Glover) No, I think it is the Home Office.

  970. On the general question of GPs' hand writing which is notoriously difficult to interpret, would it be helpful to you if it had to be a printout so that there was clarity?
  (Mrs Glover) I think it is probably helpful on all sides that there is clarity. The most difficult thing is the signature of the doctor if they come from somewhere that is not your immediate locality.

  971. Or they are a locum?
  (Mrs Glover) You have a requirement to authenticate the signature on the prescription in front of you . That is quite difficult to do if somebody turns up from Liverpool in Edinburgh with their prescription.
  (Dr Thompson) We did mention this in our evidence. It was clear from the inquiry into methadone-related deaths that there was a recommendation in there for the regulations to be changed. It is disappointing that the opportunity was not taken. It is not just a matter of our time and the workload on pharmacists and GPs when prescriptions need amending; it is also potentially fatal. If an addict is unable to get back to the GP to get the prescription amended, they are going to buy street heroin. That is the bottom line.
  (Dr Gerada) The technicality is you need hand writing dispensation if you have a computer printout. Otherwise, it has to be written in the doctor's hand writing. That needs to be changed as well. We need to have a review of what is called hand writing dispensation. That means you have to get a special dispensation from the Home Office if you do not hand write the prescription. You cannot generate a computer prescription and send it to a pharmacist.
  (Dr Thompson) On the other question of instalment prescribing, benzodiazepenes which are potentially as damaging can be prescribed by the bucket load on a normal prescription and cannot be prescribed for instalment dispensing, which means if I have someone who I think needs to have benzodiazepenes prescribed and dispensed daily I have to issue six prescriptions a week.

Bridget Prentice

  972. I am puzzled about the hand writing. Is it not common practice for prescriptions to be computer printouts?
  (Mrs Glover) Only for controlled drugs.
  (Dr Gerada) It is an anomaly. In Scotland, you can daily dispense benzodiazepines, so you can do it.

  973. Is this Scotland leading the field again?
  (Mrs Glover) Absolutely.

  974. I say that as someone who represents a constituency in south east London. I wanted to ask about methadone substitution treatment. I think you have already said that it is not universally available. I think you said about 75 per cent?
  (Dr Barnett) What I said was that there are some GPs who will not even issue prescriptions for methadone but the numbers of GPs who are prepared to do it are increasing.

  975. Do you think it should be universally available?
  (Dr Barnett) As with everything else in health care, it is something that GPs themselves have to decide. One of the problems has been the general lack of training. If GPs are perhaps better trained and there is better support, I think GPs would be more prepared to provide those prescriptions. It has to be part of an overall package. It is not just a matter of saying, "Will the GP issue a prescription for methadone?"; it is the overall care that goes along with it that needs to be taken into account.

  976. One of the things you also said earlier and was repeated by Dr Gerada is that GPs were reluctant to take on this training. Is this quite common for GPs to opt out of areas of training and are there others who are saying, "I do not want anything to do with that aspect"?
  (Dr Barnett) You have to take it into the overall workload that a GP has to undertake and the care that GPs are giving generally to patients. Looking after drug misusers is just one aspect of what a GP's workload is and we have a lot of other patients to see with a lot of other problems.


  You are saying some of them refuse to take on this training?
  (Dr Barnett) There are some who will not provide this specific care for patients and that goes against what both the BMA and the RCGP are suggesting because we believe that GPs should be providing this care for their patients. The fact is there will be some GPs, as there are GPs who will opt out of other aspects of care for patients, who have conscientious objections to referring patients for termination. There will be similar reasons why perhaps GPs are not wanting to get involved. Another aspect relates to the fact that GPs have been worried that, if it is known that they are going to provide methadone prescriptions for patients, they are worried about the effect of lots of people knocking on their door for such prescriptions. Again, there has been evidence in the past that that has been a problem but as more GPs become involved that becomes less of a problem across the patch. It is to do with education but you have to understand this is just one facet of the care that is being provided to the community and where there is a shortage of GPs or nurses you cannot provide everything.

  978. Is this fear that they will have hundreds of people beating a path to their door because they believe—and it may well be true—that most drug addicts are not registered with a GP?
  (Dr Gerada) I hope I was not saying that GPs are reluctant to take up training. What we found was the exact opposite. The Department of Health have recently, through the Royal College of General Practitioners, funded us for 400 training slots, just English GPs, for five days' training which involves doing course work etc. Within three weeks, we filled those 400 training slots. We now have a waiting list, with no further funding, of 100 GPs in England alone wanting to be trained. I think training has been offered to GPs in the past but it has been what you did at the end of the day, after a very busy day's work and, "Thank you very much. I would rather go home." The resources were not there to release you from your time. I think it is changing. In terms of beating down the door and drug users, that hopefully is changing. We are getting more organised services now. Whereas I first started in the field and felt all GPs should be involved, I have shifted slightly and there are those GPs, the equivalent of the conscientious objector—probably about 15 per cent currently—where I am not going to waste my energy trying to persuade them. As long as a locality is able to provide services within a primary health care setting, within the context of shared care, with well supported specialist care, I do not really think it matters too much. All GPs should be able to assess a drug user and to pass on if they really do not want to do anything else but within that health locality services should be provided.

  979. If you have GPs who do want to specialise in treatment of drug users, how easy is it to get hold of a licence from the Home Office?
  (Dr Gerada) You are talking about a diamorphine licence?

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 22 May 2002