Examination of Witnesses (Questions 960
- 979)
TUESDAY 15 JANUARY 2002
DR CLAIRE
GERADA, MRS
CHRISTINE GLOVER,
DR ROB
BARNETT AND
DR ANDY
THOMPSON
Chairman
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?
Chairman
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.
977.
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?
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