1. health and fitness
2. drugs

Cover -August rev
6/8/07
10:49
Page 1
NO 200 AUGUST 2007
£3.25
In partnership with
In this issue
Page 14
What
makes
Fiona
Cruickshank
tick
Page 17
Pharmacy
“specials”
market
still
growing
Page 26
Automating
the
dispensing
process
Page 29
Improving
compliance
in the
community
Is their medication ending up
where it should be?
Dysphagia, or swallowing difficulty, is a much more
widespread problem than you might think.1 It leaves
many people, especially the elderly, struggling to swallow
their medicine and often leads to it being thrown away.
Such non-compliance has serious consequences in
that it can lead to poor outcomes, hospitalisation or
even patient death.2 It also costs the NHS over a billion
pounds a year in wasted medicines and the costs
associated with adverse clinical outcomes.3
That’s why it makes sense to give people who can’t
swallow solid medicines a more appropriate formulation
such as a liquid - and the sooner this is done the greater
the difference it can make in terms of improved
compliance and patient welfare.
Rosemont specialise in liquid medicines offering
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Rosemont
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References: 1.Strachan I, Greener M. Medication-related swallowing difficulties
may be more common than we realise, Pharmacy In Practice December 2005. 2.
Richard Griffith, Medication Management and the law 2 – Residents With
Medication Related Dysphagia 2006. 3. Greener M. JME 2006; 9: 27-44.
The source of liquid solutions.
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E [email protected] Sales/Customer Ser vice: T +44 (0)113 244 1999 F +44 (0)113 246 0738 W www.rosemontpharma.com
Information about adverse event reporting can be found at www.yellowcard.gov.uk Adverse events should also be reported to Rosemont Pharmaceuticals Ltd on 0113 244 1400.
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Contents August rev
6/8/07
15:08
Page 1
ICP
August 2007
Contents
6 Pharmacies hit by floods
Editor
Douglas Simpson, FRPharmS
Pharmacies in Gloucestershire had to be adaptable after they were hit by
floods, according to Peter Badham (right)
Staff Writer
Rebecca Derrington, BA
020 7534 7235
Rebecca [email protected]
6 NPA online stock scheme
The National Pharmacy Association is a partner
in a new scheme for exchanging pharmacy stock
Designer
Bil Brooks
8 IPF member’s Pfizer solution
Contributors
Brian Collett, Steve Bremer, Sid Dajani, Gerry Green,
Victoria Goldman, Mark Greener,
David Parker
Graham Phillips, a leading member of the Independent Pharmacy
Federation (left) has a cure for “Pfizer syndrome”
9 Meeting the needs of animals
Advertisement Director
Julian de Bruxelles
020 7534 7233
[email protected]
A leading veterinary surgeon, Professor Bob Michell (right), says pharmacists
need to be educated to meet the needs of animals
16 Doctor dispensing
Publishing Director:
Paul Beard
020 7534 7236
[email protected]
Doctors show no sign of wanting to curb their dispensing, reports business
correspondent Gerry Green
Chief Executive:
Felim O’Brien
22 Oral health
The health of the nation’s teeth is declining
The official journal of the
32 100-hour contracts
The difficulties of making them pay can be insuperable
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4 Leading articles
16 Business Monitor
6 News
17, 22, 26 Special Features
8 The IPF Page
29 Clinical Focus
9 Opinion
32 Business Focus
12 Withering’s Wisdom
33 Market Update
14 The ICP Interview
35 Bishopstoke Chronicles
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ICP August 2007 3
Leader-August rev
2/8/07
14:13
Page 4
ICP
Leading Articles
Patients can have
more than two legs
P
rofessor Bob Michell is a good friend of pharmacy. He is one
of the Privy Council nominees on the Council of the Royal
Pharmaceutical Society and serves the profession with great
energy in that role. He is a veterinary surgeon and so he can
be expected to be — and indeed is — an authoritative voice
when it comes to matters to do with the health of animals. When he
tells pharmacists, as he does in a specially commissioned article this
week (p9), that they are in danger of missing out on a great
opportunity in veterinary medicines supply, it is a warning that carries
great weight and should be heeded.
The new opportunity stems from an Office of Fair Trading report
that called for the monopoly that veterinary surgeons enjoyed in the
supply of prescription medicines to be ended. The government duly
obliged, but only to find a pharmacy profession unprepared to exploit
the new situation.
Professor Michell’s main solution to this problem is to change the
undergraduate curriculum, so that graduates coming out of schools of
pharmacy are fully conversant with the use of medicines in the
veterinary field. But it would be many years before such graduates
emerged and so something else is needed in the short term.
Professor Michell suggests that this gap be filled by pharmacists
working more closely with veterinary nurses.
Whatever solutions are developed, responding to the new situation
will be something that pharmacists will find difficult to tackle by
themselves. Their representative bodies need to be more proactive. A
concerted effort is needed. It is alarming, to say the least, that Professor
Michell describes pharmacy’s principal representative body as “asleep at
the wheel” on this issue. He is, after all, in a position to know.
Three in a row
The announcement that Jeremy Holmes is to be the new chief
executive of the Royal Pharmaceutical Society (see p6) makes it the
third time in recent months that top posts in pharmacy formerly held
by members of the profession have gone to non-pharmacists. First we
had Christopher Hodges getting the job of chairman of the
Pharmaceutical Services Negotiating Committee (ICP April, p6). Next
it was Alison White being appointed as chief executive of the National
Pharmacy Association (ICP July, p6). Now we have Mr Holmes. Time
was when non-pharmacists would not have even been considered for
such posts. Now, it is generally accepted that an external perspective is
needed if the profession is to achieve its full potential.
4 August 2007 ICP
news
P6 [1] rev
2/8/07
14:16
Page 6
News
The Floods
Exchanging Stock
Pharmacies hit
by deluge
New online
service
Badham Pharmacy, a small chain of seven
pharmacies in Gloucestershire, was among
businesses caught up in the recent flooding.
Speaking on July 26, Peter Badham,
managing director of Badham pharmacies,
said: “Our pharmacy in Bishop’s Cleeve was
very close to being flooded; about half an inch
away. The only thing that stopped it was the
step up to the shop. We placed sand bags to
stop any water getting in. The road outside
looked like a river.”
Badham pharmacies remained open during
the floods although they experienced problems
and disruptions to services. There were power
failures and a lack of water supplies.
However, the dispensing delivery service
was kept running by the business’s vans. In
places where the roads were impassable staff
members proceeded on foot.
Mr Badham said: “We have only been able
to keep the pharmacies running because of the
support from our staff, who have been going
above and beyond the call of duty.”
When power failed, staff used torches to
help customers find what they needed.
The customers themselves have also been
supporting the pharmacies. Mr Badham said:
“One patient even brought in a collection of
candles for the staff to light the pharmacy.”
Lack of power also meant pharmacist couldn’t
print labels and enter data into patient
medication record systems, which had to be
done at a later date.
The local community was warned that there
could be a water shortage and so the staff
began collecting fresh water in containers for
dispensing purposes. Pharmacists were asked
to ensure they provide information on low
sodium bottled water for use by babies as some
of the bottled water given out free had too
high a concentration of sodium.
Professional secretary for Gloucestershire
local pharmaceutical committee Evelyne
Beech, commented on July 26: “The primary
care trust mobilised a supply of water to
pharmacies.” Before that pharmacists had to
bring bottled water for dispensing and
drinking. Gloucestershire LPC and PCT
helped healthcare providers in the area,
including co-ordinating a driver to collect
supplies and providing support staff to
pharmacies, such as extra technicians.
The National Pharmacy Association and
Rxchange Ltd have launched an on-line
pharmacy stock exchange system. Called
Rxchange, the system provides pharmacists
with the means to trade stock that is short
dated or is surplus to their requirements.
It has had a 3 month trial with 400 active
users.
The online system has sections for buyers
and sellers and search facilities to find stock a
pharmacist is in need of. The exchange system
is designed to eliminate waste.
It is subscription based with three price
plans: “priority club”, “partner club” and “pay
as you go”.
Bipin Patel, a pharmacist user, says: “On the
first day of using the system we put an item on
to sell and within 45 minutes got an offer.”
The Rxchange pharmacy stock exchange site
can be seen at www.rxchange.co.uk.
6 August 2007 ICP
Mrs Beech, who had been helping out in
Northway pharmacy in Tewkesbury, said:
“The volume of requests for urgent supplies
was overwhelming. Stocks were getting
through but wholesalers being out of stock on
some standard lines were causing extra
problems. We worked nine hours one day with
only 20 minutes for a quick bite to eat and a
drink.”
Staff Training
Badham’s Bishop’s Cleeve pharmacy in drier
times
Mrs Beech added: “The LPC will be sitting
down with the PCT in the near future to
ensure emergency planning is well and truly
put into place. It will be essential to have a
county wide debrief soon after the crisis so that
it is fresh in people’s minds and hopefully we
will gain high attendance.”
Much of the area was still under water and
many roads were cut off but Mr Badham said:
“We have managed during this time because of
support from staff and patients. We are a
family run business and have been since 1940,
I guess we must have survived the war so we
will survive this.”
Learning about pain
A staff training resource on pain — the
Nurofen Academy — has been launched by
Reckitt Benckiser Healthcare.
Pharmacists can register their staff for it by
telephoning the academy’s helpline on 01284
717693.
The resource includes five modules, and
makes provision for staff assessment, marking,
practical activities, staff progress reports and
incentives to keep staff motivated.
The process is managed in the pharmacy.
The first module is sent after registration.
Pharmaceutical Society
Numark
New chief executive
Hypertension book
Mr Jeremy Holmes has been appointed chief
executive and registrar of the Royal
Pharmaceutical Society. He will take up his
appointment on September 3. He replaces Miss
Ann Lewis, who is retiring.
Mr Holmes, who was managing director of
the Economists Advisory Group for 14 years, is
the first non-pharmacist to hold the post.
Numark has relaunched a booklet to help its
members identify and assist people with
hypertension. The booklet reflects revised
guidelines for the treatment of hypertension. It
has been devised in conjunction with practising
pharmacists.
ICP 297x210
3/8/07
12:59
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Nrt01/07 July 2007
Ipf news p8 rev
6/8/07
15:09
Page 8
The Independent Pharmacy Federation
Pfizer syndrome
Last October, I was privileged (first time in
years) to have a visit from a Pfizer Drugs Rep
(writes Graham Philips). The poor fellow
didn’t know where to put himself. He left me
with the required “Pfizer propaganda”
brochure, but could answer none of my
questions about future distribution, still less
discount structure. What he did acknowledge,
however, was that he had worked hard locally
to build up relationships with community
pharmacists only to have them destroyed
overnight by the unexpected distribution
announcement.
Today, eight months later, and despite
monthly requests for a visit, neither the rep nor
anyone else from Pfizer has had the courtesy to
contact me. So much for the “getting closer to
our customers” rhetoric.
Now, as a UniChem customer, it might be
assumed that none of this affects me — after
all, there’s only been a small change in the
paperwork and I have noticed no change to
UniChem’s usual high service levels. However,
a brief calculation of our Pfizer spend shows
that we will loose a massive £8,000 in discount
each year as a direct result of the new scheme.
I, for one, find it very difficult to believe that
the NHS will make up the shortfall, and I
don’t see why the contractors should have
to do so.
So if the NHS won’t pay, and if the
contractors (morally at least) should not have
to, then the bill should be footed by the
arrogant conglomerate which imposed this
upon us all.
“Pfizer syndrome” affects independent
pharmacists and independent wholesalers more
than any other sector. IPF’s recent members’
survey showed enormous dissatisfaction with
Pfizer’s scheme: 67 per cent said service was
worse, 87 per cent said discount was less and
75 per cent said that patients were affected.
So, is there a short-term cure for “Pfizer
syndrome”? In a word: “Yes”. Now would
seem a very good time to review the
pharmaceutical price regulation scheme, which
featherbeds the industry and allows the Pfizer’s
of this world to “get away with it”. IPF will, of
course, be fighting independents’ corner.
But what of the future? We clearly need a
long-term solution that protects us from such
vagaries. The obvious answer is to move
towards a more clinically-based contract and
contractors in England should be grateful to
our Scots colleagues for showing us the way.
This would be good for patients and good for
independents. The IPF will continue to battle
for an even playing field. It’s your future. Help
us to help you. Join the IPF.
News and Views
from The Independent
Pharmacy Federation
Join your LPC
The IPF says that independent community
pharmacy must have a strong voice at a local
level, writes Mark Collins. The changes that
practice based commissioning (PBC) will bring
will mean it is even more important that you
get involved with your local pharmaceutical
committee (LPC). The LPC is the focus for all
community pharmacists and is an independent
and representative group.
The LPC works locally with primary care
organisations such as local primary care trusts
and other healthcare professionals to help plan
8 August 2007 ICP
healthcare services. The LPC negotiates and
discusses pharmacy services with local health
bodies and is available to give advice to
community pharmacy contractors and others
wanting to know more about local pharmacy.
The LPC is your representative body, working
for you. If independent pharmacists aren’t on
board they won’t have an input into such
services as smoking cessation, emergency
hormonal contraception, and minor ailments
and any PBC developments. Contact your LPC
secretary now and ask to get involved.
The secret
war
How many pharmacists take for granted the
stream of prescriptions that is the lifeblood of
the pharmacy, forgetting that they are at the
centre of a tiny island, 1.6 kilometres in radius?
Their viability relies upon prescriptions from
residents in just over 3 square miles, writes
Noel Baumber.
True, if there are other pharmacies in the
vicinity a larger area might be carved out as
pharmacy territory, but they will then share
that finite prescription volume. Is that a
restriction the Office of Fair Trading wants to
see lifted? Would it allow pharmacies to
flourish, bringing delivery services and dosage
systems to patients in rural areas? I doubt it.
Given a choice, doctors are more likely to want
all the dispensing business there is than to give
up dispensing for good.
In some counties, local pharmaceutical
committees have managed to define “urban
areas” to make more sense of the boundary
between dispensing doctors and community
pharmacy services. Now there is an increasing
threat to our urban areas as dispensing doctors
and local medical committees ask their local
primary care trusts to change the rurality of
civil parishes into controlled areas.
What is rational about a parish boundary in
this modern world when it comes to providing
services? What have flood plains, ducks and
bucolic scenery got to do with patient services
and your livelihood?
If an urban area is redefined and part of it
becomes “rural in character” pharmacists lose
residents to dispensing doctors. There is even a
campaign to incite urban doctors to dispense or
to start their own pharmacies. LPCs fight a
running battle behind the scenes trying to fend
off this expansion. The committees that decide
such things at PCT level are part of the “cost to
consumers”. They are absolutely minimal costs,
yet essential to prevent the erosion and collapse
of the professional community pharmacy
service.
Contacting the IPF
The Independent Pharmacy
Federation can be reached by e-mail
at the [email protected], via its
website at www.theipf.co.uk or using
the insert in this issue.
Opinion p 9 -10 rev
6/8/07
10:57
Page 9
Opinion
Taking care of
four-legged patients
There is a big role for pharmacists in caring for animals but they
have to prepare themselves for it. Professor Bob Michell, a vet
and a member of the Royal Pharmaceutical Society’s Council,
spells out what needs to be done
There is still a cadre of veterinary
pharmacists represented in the Veterinary
Pharmacy Group of the Royal Pharmaceutical
Society whose everyday practice is substantially
or wholly concerned with veterinary patients.
(Unfortunately, its links to the Society’s
Council are weaker than they should be,
despite efforts to strengthen them.) Mostly,
VPC members deal with farm animals and
horses rather than pets. The real problem arises
not on farms, or in stables, but in the high
street where Government policy expects
pharmacists to replicate for animals the role
that they already fulfil for humans: “The
scientist in the high street”. They probably
could, but only with suitable transitional
strategies, specific training and a sense of
urgency. It is essential that veterinary
SOLO Plus: Building the future
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shopfittig
W
hen I was a young veterinary
graduate in the ’60s it was not
unusual to find vets writing
prescriptions and local
pharmacists dispensing them.
This was based on mutual goodwill so that
pharmacists knew what to stock; and it
reduced the range of drugs which veterinary
practices needed to keep.
Professor Bob Michell: pharmacists
need educating for new role
The SOLO Plus package includes everything you need
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SOLO Plus comes to you at a fixed price of £25,000 plus
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A consultation room is included and there is a choice
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NPA Finance & Leasing is available to NPA members,
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ICP August 2007 9
Opinion p 9 -10 rev
6/8/07
10:57
Page 10
Opinion
pharmacy, especially of companion animals,
becomes part of the core pharmacy curriculum.
Regrettably, there is as yet no sign of this
happening. Training in human medicine and
therapeutics is not a sound basis for veterinary
clinical advice.
A handicap
It is a pity that the putative renaissance of
veterinary pharmacy is driven by a flawed
report from the Office of Fair Trading. It
objected, among other things, to the fact that
veterinary practices cross-subsidise some of
their more expensive services, such as out-ofhours emergency care, from sales of medicines.
Yet cross-subsidy is a feature of most
businesses; no-one imagines, for example, that
the wine at a restaurant really costs anything
like the menu price.
Futhermore, would pharmacists be happy to
be compelled to dispense prescriptions free of
charge ? Clearly not, but vets are compelled to
write them free of charge for a trial period.
What other profession operating in an open
market without a government income stream is
obliged to provide a free service? And what
kind of level playing field obliges vets, unlike
doctors, to provide a 24 hour emergency
Product update
Chapter Pet Health provides a “wide” range
of products to treat both pets and their
homes. The range is supported with
merchandising materials, patient
information leaflets and pharmacy staff
training aides. The company says: “Flea
populations routinely
peak during late
summer and early
autumn and
infestations can make
life a misery for both
pets and pet owners.”
Chapter Health also
comments: “That
successful treatment
and prevention of flea infestations requires
more than just treating pets directly. 95 per
cent of fleas live in the pet environment
including carpets, sofas, cushions, pet
bedding and even owners’ beds. It is
essential therefore that any treatment
regimen also works to eradicate fleas in the
pet environment.” For more information
email [email protected].
Chapter Pet Health 01480 436633
10 August 2007 ICP
service? This point, ignored by the OFT, is
pivotal because the true cost of providing such
a service, especially with working time
restrictions and increasing risks of drug-driven
crime, are enormous and would be prohibitive
without cross subsidy.
So the opportunity to restore and foster the
links between veterinary practices and
pharmacists were poisoned from the outset by
resentment of unfair impositions and flawed
logic. I say this not as a vet but as one who
believes that pharmacists could do more for
animals if the approach were sound — even
though animal owners, for the most part,
appreciate the fact that they receive their
advice, and their medicines from vets without
the need to take a piece of paper to a separate
location, as confirmed by a Quo Vadis survey in
2001.
Added value service
I suggest the following should be the basis of a
pharmacy service:
Dispensing must add value, ie, add to the
effectiveness and safety of the medicine in the
bag through sound advice, based on
demonstrable, verifiable competence, not
casually acquired experience.
Provision must never be divorced from
competence: the fact that a veterinary medicine
might be cheaper in a high street pharmacy is
irrelevant.
All future pharmacists must receive a
baseline training in companion animal
medicine and species differences in drug
handling and responses. Every adult, scientist
or not, has a baseline awareness of human
health and disease but this is not true of animal
health, unless the person has kept pets. The
core syllabus is the only place for such training
for two reasons:
Unlike farm animal or equine pharmacy,
which have specialist providers, the idea is to
enable the “scientist in the high street” to
capitalise on the presence of animal owners in
the shop and offer advice without the need for
appointments. It cannot be left to owners to
discover whether or not a particular pharmacy
is capable of dealing with their prescription —
imagine if some pharmacies could provide
children’s medicines but others could not.
It cannot be left to preregistration training
to acquire the necessary knowledge and skills
because, at present, there are too few
pharmacists with companion animal expertise
to provide the training. For those who say it
does not need much training to sell flea
remedies and wormers, there are at least two
replies. First, how do you distinguish between
flea allergies and other allergies? Second, you
could say the same for routine remedies for
occasional headaches or stomach upsets.
Bridging the gap
None of this provides a rapid route to
competence, nor will the Society’s veterinary
diploma course, simply because, despite its
merits, too few undertake it. There is an
answer which could also promote a rapid and
harmonious growth of collaboration between
the worlds of pharmacy and of veterinary
practice. Veterinary nurses, many of whom are
already responsible for ordering drugs and
some for selling them to practices, have the
baseline knowledge of companion animal
health and disease, and the ability to handle
and medicate animals and to show others how
to do it. What an animal owner may most
want to know about a medicine is how to safely
get it into their cat or dog. There is an
important opening for veterinary nurses to
work alongside pharmacists, and there should
be specific courses designed to top up their
”
Government policy
expects pharmacists to
replicate for animals the
role that they already fulfil
for humans
”
knowledge of pharmacy to fulfil this role.
Teamwork between pharmacists and veterinary
nurses could not only deliver a new and
valuable stream of veterinary healthcare, but it
could also help to bridge the chasm between
veterinary practice and pharmacy.
Time is short, because the fulfilment of
these opportunities will eventually come under
Government scrutiny when the imposed period
of free veterinary prescriptions ends. The
question will be: what added value did the
public gain from receiving prescriptions rather
than medicines from their veterinary surgeon?
As things stand at the moment, the answer is
likely to be “not very much”. Sadly, where the
importance and urgency of seizing the
opportunities open to the profession is
concerned, the Society is asleep at the wheel.
But there are encouraging trends; the
newest, mould-breaking veterinary school at
Nottingham is taking up the challenge of
bringing veterinary and pharmacy education
together. Let us hope that such trends gain
momentum, for the benefit of animal patients.
wwisdom AUG p12rev
2/8/07
14:32
Page 12
Withering’s
Wisdom
Colluding or helping?
It’s funny how a relatively minor
incident can lead to a great deal
of soul-searching. I was recently
presented with a prescription for
three months’ supply of
temazepam. I can’t remember
the last time I saw a prescription
for more than one month’s
supply. I was so taken aback I
went to speak to the patient to
inquire whether this was the
first time that he had been
issued a prescription with this
quantity. He told me no; when
he had been prescribed
fluoxetine to treat symptoms of
depression, his sleep had gone
from poor to completely
intolerable, so his GP had
prescribed temazepam. That
had been nearly a year ago and
he was still taking both the
fluoxetine and the temazepam,
and, because he had to pay the
prescription charge — and
because it was more convenient
— his GP was kind enough to
prescribe three months’ supply
at a time. Had it been explained
to him, I asked, that taking
medicines like temazepam in the
long term could lead to
dependence? He asked what
business was it of mine?
Indeed; what business was it
of mine? This was not his usual
pharmacy, and, to the patient,
my concern appeared to be
misplaced. After the patient had
left I felt I needed to find out
more — was I wrong to be so
concerned? The British National
Formulary, of course, says that
the use of these medicines
should be restricted to a
maximum of four weeks and the
National Institute for Health
and Clinical Excellence (NICE)
guidance relating to newer
hypnotics reinforces this advice.
My interest aroused, I decided
to see how many prescriptions
for benzodiazepines were for
repeats: even if they were for
only one month’s supply at a
time; in principle, there is no
real difference between these
and a three-month supply. The
answer was most of them. This
surprised me because my
perception was that the use of
these medicines had been in
decline. So I went to the
Prescription Pricing Authority,
website where I found that the
numbers of prescriptions for
these medicines have not
changed for the past five years.
I asked the primary care trust
what services were available to
help people come off
benzodiazepines and they
directed my question to the local
drug and alcohol team. It seems
to me that this is an entirely
inappropriate response: the
stigma attached to drug and
alcohol services would deter
most benzodiazepine users from
attending. So where did that
leave me? I now have the
nagging doubt that dispensing a
repeat prescription for a
benzodiazepine may not be
doing the best for the patient.
Nationally, there must be tens of
thousands of people taking
long-term benzodiazepines.
Every time a repeat prescription
is dispensed we have to face the
question of whether we are
really helping or colluding in
questionable practice of epic
proportions.
Mixed messages?
In implementing “Care closer to
home: convenient quality care
for patients”, the Department of
Health recently issued guidance
relating to the provision of more
specialised services closer to
home with the emphasis on the
role of practitioners with special
interests, including pharmacists.
Don’t get me wrong, I think
this is great: the more services
that can be provided at local
level, the better, both for
patients and for people like us.
So what am I worried about?
I recently saw a news item
about the development of socalled polyclinics that had been
established in London. These
establishments were essentially
super health centres bringing
together several GP practices,
dentists, and other services, and
acting as satellites, where
specialists from the hospital
service would hold out-patient
clinics.
On the face of it, this kind of
service does appear to be
bringing healthcare down to
local level, but there are
potential problems in
concentrating primary care
services in this way. We’ve all
seen how pharmacies have
clustered around conventional
health centres, reducing the
viability of pharmacies that
remain genuinely communitybased because they have now
become remote from the places
where prescriptions are
generated.
Ultimately, this leads to a
reduction in the accessibility
that patients have, not only to
the provision of medicines but
also to all the other services that
pharmacies have to offer.
Attractive as the idea of the
polyclinic may be in some highdeprivation metropolitan areas,
I sincerely hope that this model
does not become widespread.
Care closer to home? That’s not
how I see it.
Putting the boot in?
Boots the Chemists is set to put
the status quo in community
pharmacy into turmoil with
their plan to offer in-store
doctors following the success of
a pilot scheme in a store in
Dorset earlier this year. Boots
contends that it is difficult for
patients to obtain an
appointment with their GP at
times that are convenient to
them, especially during
working hours.
In the Boots scheme, a local
GP rented space in the store to
see patients from their practice
who had made an appointment.
In parallel with this
development, as I’m sure most
of us will have seen from the
TV advertising, Boots is
putting consulting rooms in its
stores so that shoppers can get
advice instead of having to see
their GPs. Consulting rooms,
and advertising I don’t have a
problem with; many, if not
most pharmacies now have at
least a consulting area. But I
view the establishment of instore GPs with deep misgivings.
Boots, no doubt, will argue that
what they are doing is
improving access to primary
care services for patients.
Others will see it as a cynical
use of their prime locations on
the high street to create
unusually close relationships
with local GPs. What is
particularly troubling is the
prospect that patients will see
the presence of their GPs instore as some sort of
endorsement of Boots’s
expansion of services in ways
that will not be available to the
vast majority of independents.
Pen name of a practising independent community pharmacist. Withering’s views are not necessarily those of ICP
12 August 2007 ICP
teva new campaign development
31/5/07
10:59
Page 2
choice
You have a choice.
So why not choose the best?
Buying generics isn’t easy, but it should be.
Price is vital, of course, but so is the assurance that there’s
customer support if you need it. A wide range from one place
saves time, and a livery that’s modern and designed to reduce
dispensing errors in a busy pharmacy or dispensary.
Teva UK Limited offers all those things, and more.
For example our Ultimate scheme gives you discounts paid back
to your business each month, not quarterly; and on many lines our
‘Pricewatch’ offer tracks market prices so you can be sure you
won’t be out on a limb by the end of the month.
Ref: 038/COP/07 Date of preparation: May 2007
We know you have a choice. But we think the obvious
choice is Teva.
Making generics easier
Morley, Leeds LS27 0JG Tel: +44 (0)113 238 0099 Fax: +44 (0)113 201 3937 www.tevauk.com
interview p14 -15 rev
2/8/07
15:17
Page 14
The ICP Interview
A special career
Fiona Cruickshank,
managing director of The
Specials Laboratory,
manages to combine her
love of the industry with
her qualification in
pharmacy and her desire to
run her own show. Douglas
Simpson talks to her about
how she does it
F
iona graduated in pharmacy from the
School of Pharmacy in London
University in 1987 with a respectable
2.2. She did a split preregistration year
at Charing Cross hospital and the
Wellcome Foundation.
“I was desperate to work in industry and I
managed to secure one of the six industrial
places available at the time,” she says. “ The
Wellcome Foundation paved the way for the
whole year and I was able to go to a hospital of
my choice. I got the best of both worlds.”
What did she enjoy about her
preregistration year?
“The six months at Charing Cross came
first. It was brilliant. I particularly enjoyed the
manufacturing and radiopharmacy. We did a
lot of clinical trial work.”
What about the industry bit?
“I started in sterile products manufacturing
at Dartford. I also experienced Wellcome’s
quality control and development laboratories,
tableting and packaging.”
Where next?
“After the preregistration year I just carried
on in industry. There was no question about it.
That is what I wanted to do. I did a year on
full-time night shift and had my first
management experience running a team
labelling ampoules and vials on the Dartford
site. I learnt about freeze-drying, sterile and
aseptic processing. It was an absolutely
brilliant way to learn.”
Had she shone at pharmaceutics at the
“Square”?
“I didn’t really shine at anything. I’m not
like that. What I shine at is people
management and getting things done.
14 August 2007 ICP
Fiona Cruickshank: spurred on by a spurned buy-out
“But I also like the concept of making stuff.
I like the concept of ending up with a good
quality widget. I am interested in processes. I
love machinery and equipment.”
How long was she with Wellcome?
“I stayed with them for three years. But it
was a huge site, with 3,000 people and I was
worried about becoming specialised in one area
of activity. So I left and worked as a pharmacy
locum in the community.
“After a few months I realised that that was
not what I wanted to do and I went back into
the industry, with Fisons at Holmes Chapel.
Again it was shift-work and I had the dubious
pleasure of looking after the water system
overnight and things like that. But it was the
people management and the manufacturing
process that was attractive to me.”
So is she a “people” rather than a “nuts and
bolts” type of person?
“You need to know about the process — I
did pharmaceutical engineering as my
specialist subject in my third year at the
“Square”. From a people perspective, I also
learnt how to work in a unionised
environment. But you are right. It is dealing
with the people that I enjoy.”
How did she get involved in specials?
“After another spell of locum work, I took a
post in a specials laboratory run by wholesalers
AAH in rented space at the Royal Victoria
Hospital in Newcastle upon Tyne, my home
town. There I was in this totally different
world doing more real pharmacy than at any
time in my career.
“When I started that job, AAH asked me to
do a business plan to look at growing the
business. I produced the plan but they decided
not to go ahead with it. They had just been
acquired by Gehe, which decided that
manufacturing did not fit in with their type of
business.”
How did she deal with that?
“I decided, with the help of some top class
advisers, to buy them out.”
What happened next?
“They decided to sell to Martindale’s!”
How did she feel about that?
“It was the best thing that ever happened to
me. My father, who had been in business all
his life, said: ‘Why don’t you just start up
yourself?’ So, with a business partner, I did
just that.”
Where?
interview p14 -15 rev
6/8/07
15:11
Page 15
The ICP Interview
“Martindale’s did not want the RVI facilities
so I approached the hospital and agreed to
rent the space, which we re-equipped. That
was in July, 1999. We had to wait three
months for a licence and we started trading in
the September.”
How did she market the business?
“We bought a mailing list and sent a mailshot to all independent pharmacies from Leeds
up to Scotland. The letter went out on a
Friday and by the following Monday the
telephones started to ring.
“Within a short space of time, we knew we
were going to outgrow the premises. I started
with three people and by the time we left the
RVI in 2001 there were eight of us. We have
now moved to a purpose-built facility in
Northumberland.”
What was the first order?
“Four bottles of calcium carbonate
suspension. The husband of one of my staff
delivered it. I wish I had kept the payment
cheque and framed it.”
Presumably a lot of the products were
standard formulae?
“A lot were, but others were non-standard
formulations. We started from scratch and
built up a database.”
What about staff levels in the early days?
“I was the pharmacist. I had to check the
formulation and sign it off. I had one
technician, who is still with me now, and a
person in customer services, who is also still
with me.
“Things are different now. We have a quality
control department and a pharmacy
department.”
How does she feel about pharmacists
passing on this traditional area of activity?
“I think it is a real shame. But having been
in dispensaries and seen the way that the
workload has gone, and the way that the
emphasis has changed, I think it is nigh on
impossible to dispense these preparations
properly. There are few pharmacists who can
invest in the equipment, have the calibrations
done and all the rest of the things that are
needed. Even if there are the facilities, they are
used infrequently, so there is a danger of skills
getting rusty.”
The skills are still taught in schools of
pharmacy, and the calculations section is a
“must pass” section of the pre-registration
examination. Is Fiona saying most pharmacists
will not make use of these skills?
“Judging from the number of
extemporaneous preparations ordered from us,
there is still a need for them. But having said
that, there are few pharmacies experiencing a
high volume of them — maybe one or two a
month. It is not really core to what they are
doing. If it were it would be reimbursed better.
“I still think the skills need to be taught,
though, because pharmacists need to
understand the concepts behind the service
they provide and they must have the ability to
calculate.
“We do a lot of student placements in the
summer and Easter holidays. The ones that
come to us love their pharmaceutics. They love
formulation. The place for that, though, is in
the industry nowadays.”
Is she happy with pharmacy education
becoming more clinical?
“I think it is a shame. ‘Pharmacy’ should
remain a good, all-round science degree. But,
speaking to graduates now, they don’t think of
themselves as scientists, which is an absolute
shame. They are, in fact, far better equipped to
go into the industry than graduates in
microbiology and chemistry, who are very
specialised. If we do not promote the scientific
side, there will be fewer pharmacists going
into industry. The talk now among students is:
‘I want to look after patients’ or ‘I want to
build a retail empire.’ The pharmacy schools,
in their recruiting literature, emphasise the
clinical side.”
What is the full extent of the business?
“As well as the specials side, we manufacture
phase one and phase two clinical trials
materials for customers. In addition to the
specials sites, we have a clinical trial materials
manufacturing area, a distribution area and a
head office with support services.
“We have grown like that because we don’t
own our buildings. We have acquired leases as
we have gone along. We now have to decide
whether we want to put everything in one big,
new, shiny building or not.”
What about further expansion of activities?
“We are moving into providing over-labelled
medicines for the National Health Service.”
What are these?
“We are making over-labelled packs that
can be taken off the shelf and given to you if
have been patched up at an accident and
emergency department. Or the short course of
”
Pharmacy
graduates are far
better equipped to
go into the industry
than graduates in
microbiology and
chemistry, who are
very specialised
”
First order was for four bottles of calcium
carbonate suspension
Should more students be thinking of a
career in industry?
“Yes, they should. There is a fabulous career
path for the qualified person and in other
areas, too. There are terrific opportunities for
pharmacists in the industry.”
Is she doing anything about this?
“We will be offering preregistration
placements in the future. I have to put my
money where my mouth is.”
Does she want to see an increase in
industrial placements?
“Definitely. We have a relatively short
window of opportunity, because there are only
a few pharmacists left in the industry.”
How is the Specials Laboratory doing?
“Extremely well. We are seeing about 22 per
cent year-on-year growth in revenue terms.
“We now have two manufacturing sites for
specials in Prudhoe, Northumberland, and a
staff of nearly 150. There are 10 pharmacists
in the business and about 20 technicians.”
antibiotics that an out-of-hours doctor might
give you to tide you over until you can see
your GP for a full course.”
The Specials Laboratory remains a private
company with Fiona as the main shareholder.
She has a business partner, Brian Dougherty,
who is a pharmacist and a qualified person.
Turnover at the end of 2006 had reached
£8m a year. It is expected to hit £11m in
2007. Fiona reckons that her company is the
second largest in the market, although there is
no way of being certain about this. The main
focus of her specials business is independents,
but some of her business comes from the
multiples.
“There are some managers that like to deal
with The Specials Laboratory even though
their head offices would prefer them to look
elsewhere.”
And Fiona has enjoyed external recognition
of her achievements with the company, which
was listed in the Sunday Times Fast Track 100
of Britain’s fastest growing private companies,
and was recently profiled in the Financial
Times . She is a former North-East Woman
Entrepreneur of the Year.
Will she be slowing down soon?
“No chance!”
ICP August 2007 15
business monitor
AUG rev P16
2/8/07
14:27
Page 16
Business Monitor
Profits as prescribed
The ambition of doctors to earn money from dispensing is
undiminished. Gerry Green reports
T
he NHS Fraud Department has once
again hit the headlines by taking action
against generics manufacturers. And it
appears to regularly put under severe
scrutiny pharmacy contractors who are
accused of such practices as witholding
inexpensive “charged” item prescriptions. So is
it not time that this organisation put under its
“microscope” the whole business of dispensing
doctors in this the 21st century?
Way back when the health service was
founded, GPs in remote country areas where no
pharmacy existed were rightly concerned to
organise a supply of urgent medication for their
patients. In those days, only the better off
members of society owned a motor car. In this
day and age, as country folk frequently
complain, one cannot survive in the country
unless one owns a car.
Thus the rule allowing GPs to supply
medicines to patients living more than one mile
from their nearest pharmacy is an anachronism
that has survived from those bygone days of 60
years ago. The only reason that GPs have
insisted upon maintaining this right to dispense
is because they make a profit out of whatever
they prescribe. It is also well known that the
average value per item and the total ingredient
cost per annum is much higher per patient
when supplied by a dispensing doctor than if
supplied by a pharmacy contractor. And
dispensing doctors receive a higher dispensing
fee and better discounts from Pfizer, amongst
other companies, than does the normal
pharmacy contractor, thus giving them an
average gross profit in the mid-twenties
percentage-wise, while pharmacies typically
have one in the upper teens.
Many once small villages in the southern half
of England and some of those in the Lake
District and North Yorkshire have had their
populations swollen by “long distance”
commuters, city folk with second homes and
retirees, so that many now have local
populations at or about the 5,000 mark, which
is the average population per pharmacy in
England. Yet many of these still carry on with
their NHS medicines being supplied from the
limited inventory of a typical dispensing
doctors’ practice and without the opportunity
for the local population to be able to purchase
“pharmacy only” medicines over the counter.
And, when a potential pharmacy contractor
applies to open in what the “control of entry”
regulations describe as a “controlled area”, ie,
where dispensing doctors supply medication to
patients, the process is greatly protracted
before the application gets to be considered.
16 August 2007 ICP
Even when a pharmacy is allowed, after the
due process, to open, the GPs, ever greedy to
continue making profit from their prescribing,
seek a “gradualisation period” before patients
are switched to the pharmacy for their NHS
medical supplies.
Gradualisation used to mean just that; so
that, over a six-month period, say, one sixth of
the patients affected would move over to the
pharmacy each month. This allowed the GPs to
adjust their pharmaceutical stocks to
accommodate the change.
This was another historic practice
constructed 30 or 40 years ago when
dispensing doctors and pharmacies held the
equivalent of around three months’ stock based
upon their turnover. Today, most dispensing
doctors and pharmacy contractors have average
stocks of three weeks or less.
Gradualisation
In my view, this gradualisation process should
be reduced today to one month only and the
new pharmacy should be obliged to buy at cost
price the dispensing stocks then held by the
dispensing doctors, assuming they give up
dispensing altogether. In actual fact, most
dispensing doctors do go on dispensing for
some of their patients who live beyond the one
mile limit even though most have to call in at
the surgery to see a GP or collect a repeat
prescription, which the nearby pharmacy
would, almost certainly, be happy to collect,
dispense and even deliver where a patient could
not wait. So here again, we have rules which
modern practice has overtaken and there is no
need to continue them in their original form.
Many GPs still try to obtain a 12 month
gradualisation and some even seek two years.
They know that, without the income from
dispensing, most new pharmacies will not
survive economically and so might be forced to
close.
Some GPs even organise patient resistance
by secretly encouraging village meetings to
condemn the primary care trust for allowing a
new pharmacy and put forward all kinds of
spurious arguments about the quality of the
new service, with no mention, of course, of the
value of having “an expert in medicines”
available within the community as a “first port
of call” without an appointment (including
Saturdays).
I am aware in two current client cases
involving “dispensing doctors” of vigorous
attempts to persuade landlords of village retail
premises not to let them to a pharmacy. Some
doctors have bought up leases or freeholds or
bought a restrictive covenant on retail property.
Some have actively sought local objections to
“change of use” of property to a pharmacy. It
takes courage on the part of a villager to fall
out with their GP because he or she allows a
pharmacy to open in their premises! Unless
GPs are making a big profit out of dispensing,
why else would they battle so hard to prevent a
pharmacy contractor from opening on their
patch?
Some GPs, when forced by other pressures
from pharmacy applications, have resorted to
applying to open a pharmacy themselves,
which might look to be a reasonable answer to
my criticism. However, I know of some GPowned pharmacies where a part-time
pharmacist is employed and for the rest of the
surgery hours the dispensing is claimed to be
“supervised” by the GPs!
I am also aware of cases where a GP-owned
pharmacy is opened and run for a couple of
years and then closed down as “uneconomic”
by the GP owners who simply then revert back
to the much more profitable doctor dispensing.
In 2004, when finalising the new contract
for pharmacy in the NHS, the Pharmaceutical
Services Negotiating Committee assured all
contractors that it had reached an agreement
with general practitioners’ representatives to
restrain any further growth in dispensing
doctor activities. Why, I wonder, did the PSNC
not seek to persuade the Department of Health
to remove all dispensing doctor practices on the
back of the generous 2004 pay award to GPs?
The Daily Mail of July 17, quoting the
Information Centre for Health and Social Care,
reported that the 2004 contract upped the
earnings of a GP by 22.8 per cent to an
average £103,654 per annum in 2004-05, with
dispensing doctors average earnings reaching
£119,566. No wonder the doctors are keen to
keep dispensing to themselves.
Some 15 or so years ago, a Health Minister
in the then Conservative government said she
believed it was in the taxpayers’ interest, as
well as that of patients, for no prescriber to
benefit from the medication he or she
prescribes.
As a taxpayer I can only agree.
specials AUG
P17-21
rev-rev
2/8/07
14:46
Page 17
Specials
Forging a quality
relationship
Independents are
increasingly trusting
specials manufacturers for
quality products and good
service. Steve Bremer
reports
D
emand for specials continues to
increase and the industry remains
optimistic about the future, despite
some lingering uncertainty about the
Department of Health’s plans for
price regulation.
Although no decision has apparently been
made following the DH’s 2005 consultation
on adding the top 100 most popular specials
to the Drug Tariff, the issue has not gone away.
And some specials products, such as menthol
and aqueous cream, are now listed in the tariff.
Phil Richardson, commercial director at
Quantum Specials, believes that potential
pricing regulation is still the main issue facing
the industry.
“If it’s not applied fairly by the DH it could
have a negative impact on the core
manufacturers’ ability to meet both the needs
of community pharmacy and patients,” he
says.
The DH is still looking at ways to regulate
pricing in the specials industry, says Mr
Richardson.
Quantum has invested in new facilities that
will be opened in the Autumn, but, by
carefully managing its costs, Mr Richardson
believes that his company will still be able to
maintain a quality service even if pricing
regulation is applied. But this will only hold
true if the regulation is “fair and sensible” and
allows for manufacturers to maintain the high
standards required by the Medicines and
Healthcare products Regulatory Agency
(MHRA).
The Drug Tariff issue has not changed
strategy at the Specials Laboratory, says
managing director, Fiona Cruickshank.
“We believe we get a fair price for what we
do,” she declares. “We are well within the
BCM Specials has invested £75,000 in a cream and ointment manufacturing unit
framework that the Association of the British
Pharmaceutical Industry would expect. We’re
about providing a whole, end-to-end service.”
A period of change
The specials industry is going through a period
of significant change, says Dr Andrew Inchley,
general manager for BCM Specials. He
declares: “The market is becoming more and
more focused on the provision of patient ready
(ready-to-use or administer) medicines as
illustrated by the dramatic growth BCM
Specials has experienced over the past 18
months in demand for liquid medicines,” he
says.
Dr Inchley believes this is due, to a large
extent, to increased awareness among
healthcare professionals of the dangers and
increased liability implications of crushing
tablets or opening capsules to administer
ICP August 2007 17
specials AUG
P17-21
rev-rev
2/8/07
14:47
Page 18
Specials
Courtesy of the Association of Commercial Specials Manufacturers
medicines to patients with swallowing
difficulties. As a result, BCM Specials now
prepares and delivers over 250,000 bespoke
medicines every year.
The NHS “Purchasing for Safety” initiative
is highlighting the need for more ready-to-use
medicines.
“Going forward, I expect this to place
additional pressure on specials manufacturers
to invest further in both product development
and the people and facilities required to
provide extra capacity,” says Dr Inchley.
BCM Specials remains committed to
continued investment in people, facilities and
product development to ensure it meets the
”
The market is
becoming more and
more focused on the
provision of ready-to-use
or administer
medicines
”
Labelling pre-filled syringes under GMP conditions
Concentrating
independently focused
on your Special needs
What makes The Specials
Laboratory different?
Attitude, approach
and people...
for the Pharmacy
Our Sunday Times Fast Track 100 listed
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Oral Liquids
Capsules/Sachets
Ointments/Creams/Lotions
Coal Tar Products
Oral Syringes
•
•
•
•
•
Nasal Drops
Lollipops
Eye Drops
Reefers
Potent Products
•
•
•
•
•
A Modern Company Providing
Pharmaceutical Specials
for your Pharmacy
To try out this service:
FREEPHONE
0800 0439372
FREEFAX
0800 0439378
Suppositories
Ear Drops
Cytotoxics
Imported Products
Unit Dose Vials
We also make a variety of other toxic products (e.g. hormones) in a range
of dosage forms.
Orders can be placed by telephone (answer phone service for out of hours
calls), fax, or email. Parcels are delivered before 1pm the next day. When
even speedier delivery is required, we can offer earlier deliveries or a same
day courier service.
97% of orders delivered within 24-48 hours...
For further information on how to become Special or to place an order:
tel 0800 028 4925 fax 0800 083 4222 email [email protected]
www.specialslab.co.uk
...that’s what makes The Specials Laboratory different!
18 August 2007 ICP
* Imports or unusual items may take
longer, check with Customer Care on
Freephone 0800 0439372
Quantum’s range includes,
oral solutions and suspensions, pastes,
creams and ointments, unit dose
powders, capsules, reefers, suppositories,
sterile injectables and eye drops.
Tel: 0191 262 6800
Fax: 0191 262 6833
specials AUG
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Specials
needs of customers, adds Dr Inchley. In the
past six months the company has invested
£75,000 in a “state of the art” cream and
ointment manufacturing unit to produce
small batches of product. This facility, in
combination with separate investment in
product research and development, leads to
BCM claiming it can now develop and deliver
cream and ointment specials at a significantly
reduced price point.
The Specials Laboratory has been in
business eight years, making it a relative new
comer to the market, but was recently named
in the Sunday Times Fast Track 100 of Britain’s
fastest growing private companies. The
company was listed at number 78 in the 2006
league table, following annual sales growth of
nearly 75 per cent over the past five years.
Managing director Fiona Cruickshank
believes that specials manufacturers have
earned their trust from pharmacists over this
time.
“Pharmacists are a lot happier to use
manufacturers because the service level is
where it should be and it wasn’t before,” she
says. “People are more confident about the
service and happier to outsource.”
More players in the market and improved
access to product information via the internet
have also helped raise awareness.
Increased demand for specials is driven by a
number of key factors, says Jan Flynn,
marketing manager at Rosemont
Pharmaceuticals. These include the demands
placed on pharmacists by their contract to
provide additional services, the British
National Formulary for Children and the
Disability Discrimination Act. This Act gives
patients with swallowing difficulties the legal
right to receive their medication in an
appropriate way — which may be a liquid
variant.
Why should independents choose you?
Dr Andrew Inchley, general
manager, BCM Specials:
“BCM Specials has a 70 year history of
being a centre of excellence in the provision
of special medicines that meet the
individual needs of pharmacists and their
patients. We pride ourselves on the
outstanding levels of service we offer, from
the expert advice we provide during any
initial inquiry using the information we
have on over 35,000 existing specials
formulations, to the way in which our
experienced team of formulation scientists
develop new one-off products tailored to
meet a patient’s needs. Our delivery
performance reinforces this service
commitment in that greater than 85 per
cent of all products are delivered direct to
the pharmacy ordering the product within
48 hours.”
Fiona Cruickshank, managing
director at the Specials Laboratory:
“We’re a totally independent company.
We’re not owned by a wholesaler. We’re
independently run by pharmacists and it is
the experience, the service level, the work
we do and the quality we produce that is so
important. We haven’t got an agenda of
shoring up margin from elsewhere in the
business because we don’t do anything else.
That’s the reason for coming to us. As a
business, our strategy is to sell the right
product for the right customer at the right
time.”
particular benefit to those pharmacists
looking after nursing homes. Included in our
pharmacy support package are: a new
medicines management DVD and booklet,
training materials, a liquid protocol and new
guidelines developed for administering
medicines to people with swallowing
difficulties.”
Jan Flynn, marketing manager at
Rosemont Pharmaceuticals:
Phil Richardson, commercial director
at Quantum Specials:
“We work closely in partnership with
pharmacists to ensure that we are meeting
their needs. Rosemont supplies a wide range
of liquid medicines, with guaranteed quality
and delivery within 48 hours for over 99 per
cent of orders. When required, we can offer
a 24-hour delivery service.
We aim for a minimum 3-month shelf-life
wherever possible and we manufacture
specials to the same standards of good
manufacturing practice (GMP) as our
licensed products. On-line ordering via our
new website is being introduced at
www.rosemontpharma.com.
We support the pharmacist with a wide
range of training materials, which are of
“With rapid service turn around,
pharmacists can build strong patient loyalty
as part of their overall offering to the
community that they operate in. Patients
will know (because of confirmed day of
delivery) that if the pharmacist promises that
their specials medication will be ready for
collection the following afternoon, that this
statement can be trusted — therefore, this
contributes towards strong patient loyalty.
Quantum has always ensured that our
customers get a next-day service delivery by
12 noon. This means that patients can very
often have their medication by the following
afternoon after presenting their prescription
to pharmacy the previous day.”
specials AUG
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Specials
The future
Dr Andrew Inchley, press officer,
Association of Commercial Specials
Manufacturers, makes some
predictions for the future:
“For the majority of independent
pharmacists, dealing with a prescription for
a special item will be a relatively rare event.
Nevertheless, when a patient is prescribed a
bespoke medicine the independent
pharmacist will have a pivotal role to play
as the professional point of contact between
the prescriber, the patient and the specials
manufacturer.
“The most important point in terms of
looking further ahead to the provision of
specials in the future is that ACSM
members are in this for the long term.
Investing in people, facilities and systems in
order to achieve an MHRA approved
specials manufacturers licence is not
something for the short term. In fact,
ACSM members have a history of making
consistent investment in their businesses to
ensure that they are able to react to change
and continue to meet the needs of
pharmacy customers. They also have to
”
In an ageing
population a greater
proportion of patients are
likely to need medicines
in a format that is
appropriate to their
specific needs
”
build flexibility into their service and any
business plan ACSM members work up in
the area of specials needs to include a view
on how the market is going to change.
“Although no-one has a crystal ball, there
are changes, or drivers of change, that
ACSM members are able anticipate with
some confidence. Demographic changes and,
just as importantly, the changing attitudes
that go along with these demographic
changes are among these.
“In an ageing population a greater
proportion of patients, generally, are likely to
need medicines in a format that is
appropriate to their specific needs. Different
drugs come on stream every day, but when
they do so it is often in a solid dose format,
which is inappropriate, for example, for
elderly patients with dysphagia. ACSM
members are able to use their formulation
expertise and skills to translate the solid
medicine into a liquid format more
appropriate to patients with swallowing
difficulties.
Increased awareness of the dangers and
liabilities from crushing tablets by those who
care for patients in care homes has led to an
enormous increase in the volume of “ready
to use” liquid medicines being ordered from
specials manufacturers. We could not have
met this need without predicting that we
would need to have volume capacity
available for the future and investing in our
businesses accordingly.
“In addition to changing attitudes and
demographic shifts, major health initiatives
can also be expected to bring about changes
that will impact upon the specials market.
The NHS initiative for patient safety, “Right
Patient, Right Care”, which aims to match
patients with their care, will significantly
increase the growing focus on safety. Within
this initiative, NHS hospitals have to have
an action-plan to say how they will provide
all medicines, including specials, safely. This
can be expected to put pressure on NHS
pharmacists and compounding units in
hospitals and. ACSM members need to plan
how to make our specialist expertise and
facilities available to provide safe ready to
use medicines to meet NHS patients’ need.
“While we cannot always predict what
challenges lay ahead we can say with some
certainty that ACSM members will continue
to build the flexibility and responsiveness
into their systems to enable them to deal
effectively with today’s challenges and plan
for tomorrow’s.”
Mandeville Medicines, a pharmacy
specials manufacturer, says: “When
specials are called for, it is the
pharmacist who arguably carries most
liability: liability for safety, efficacy and quality. Pharmacists can
only mitigate these liabilities if they are able to show that the
specials they dispense are clinically justified and that they are of a
quality that befits their intended use.” The company advises that
if not extemporaneously prepared in the pharmacy then pharmacists should as a minimum
be confident that the specials they buy have been manufactured under strict GMP
requirements. Mandeville Medicines supplies specials in accordance with its MHRA Licence
No 10410/01 and is able to provide certificates of analysis, GMP compliance and
conformity. For more information email [email protected]
MANDEVILLE MEDICINES 01296 394142
Product update
Oral care AUG
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James King-Holmes/Science Photo Library
Oral Care
Keep on smiling
Victoria Goldman discovers a paradox: oral care sales are
booming but oral health is declining. More pharmacy
input could be the answer
T
his year saw the 31st National Smile
Month run by the British Dental
Health Foundation (BDHF), with the
aim of encouraging more people to look
after their teeth. But despite over 30
years of campaigning, the oral health of the
nation is still as bad as ever. In fact, research
by the BDHF found that oral health habits in
2007 are actually eight times as bad as in
2006.
So why isn’t the oral care message getting
through?
“We don’t actually know why people aren’t
taking notice,” says Karen Coates, dental
helpline advisor at the BDHF. “But there is an
urgent need for more education on how to
brush teeth, how often to brush them and
which products to use.”
22 August 2007 ICP
Dental experts are particularly worried, as
oral hygiene has such a big impact on people’s
overall health, not just on the state of their
teeth.
Dr Nigel Carter, chief executive of the
BDHF, says: “Good oral healthcare is needed
to prevent a wide range of conditions and, in
particular, tooth decay and gum disease —
which has been linked to heart disease, heart
attacks, diabetes, strokes and low birth-weight
babies.”
Product usage
Oral health may be on the decline, but the oral
care market is still booming. According to the
February, 2007, GlaxoSmithKline (GSK) Oral
Care Category Report, the oral care market is
currently worth over £700m. It makes up over
one-tenth of the total toiletries and healthcare
category and is up 6 per cent compared with
category growth of only 3 per cent.
But why is the market still doing well when
oral hygiene is so poor? According to Karen
Coates, more dental practices are stocking
products and there is increased
recommendation by the dentist and oral
hygienist, so people are still buying products
even if they don’t use them regularly.
She says: “People are buying on
recommendation, especially products like floss,
but unfortunately many of them lack the
confidence to use the products properly.”
There are so many different oral care
products available that it can be difficult for
pharmacy customers to know which ones will
be suitable for their individual needs.
Jon Sandy, GSK oral care category manager,
says: “The oral care fixture can be confusing.
In particular, consumers find the brush
segment difficult to shop and they are unclear
of the technical benefits of different brushes.”
So it’s not just buying oral care products
Oral care AUG
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Oral Care
Product update
Saliva Natura, a spray intended to relieve
the symptoms of dry mouth, has been
launched by Medac UK. Saliva Natura is
said to be the “first” sugar-free mouth spray
that has a “pleasant” lemon and lime taste
and is designed to relieve symptoms for up
to two hours. Saliva Natura’s formulation
contains natural extracts of the Yerba Santa
plant and is “suitable for vegetarians and
has not been tested on animals.” Medac UK
says that the product “is clinically tested to
relieve dry mouth conditions associated with certain
therapeutic treatments and prescribed medication, a range
of medical disorders and advancing age.” Saliva Natura is
available as a 50ml spray (list price £3.43, RRP £4.95, PIP
code 325-6302) and a 250ml spray (list price £9.75, RRP
£14.95). Saliva Natura is available from wholesalers.
MEDAC UK 01786 458086.
“The Oral-B Triumph is the most stylish,
technologically advanced rechargeable toothbrush
ever,” says manufacturer Procter & Gamble
“Built-in smart-technology” is designed to enable
the brush to work together with the brushhead; it
recognises each user’s brushhead as unique and
tracks their usage, informing them when it’s time
to change. It also has a new polishing mode for
“natural whitening.” The product has an RRP of
£164.99. The company says: “The pioneer of
rotate–oscillate brushhead technology and creator
of the most technologically advanced power
toothbrush ever in the Oral-B Triumph
(ProfessionalCare 9500), Oral-B’s current power
portfolio is second to none. This is shown by
Oral-B’s 82.8 per cent market share and the
brand currently being worth £37m and growing at a rate of
17.4 per cent year-on-year.”
PROCTER & GAMBLE 01932 896 000
GlaxoSmithKline Consumer Healthcare is increasing its focus
on oral care for children with the launch of the Aquafresh
Children’s Range. The
new range covers “Milk
Teeth (0-3 years)”, “Little
Teeth” (4-6 years) and
“Big Teeth” (6+ years)
providing a “clearly
defined range to help
parents make the right
choice for their children as
they develop and grow,”
says the company. A
specially formulated
toothpaste and brush is
available at each stage
and “Big Teeth” also includes a sugar and alcohol-free
mouthwash.
GlaxoSmithKline plans to support the new range in
September with a major £2m through-the-line marketing
package. The range offers different fluoride levels at each
stage.
GLAXOSMITHKLINE 0845 762 6637
Endekay Disclosing
Tablets, “mentioned in
The Sunday Times (15th
July 2007)”, are designed
to show the user where
they need to brush more
carefully to remove
plaque. Tablets are to be
crushed between the teeth,
any plaque is then stained
red. “Incorporating Endekay
disclosing tablets to an oral care regime
ensures a consistent good brushing technique, which can
help to prevent tartar build-up and decay,” says
manufacturer Manx Healthcare. “Pharmacists should
approach the oral hygiene opportunity as an extension of
their healthcare offering.” Endekay Disclosing Tablets are
part of the Endekay range of products, which follow the
“brush…floss…rinse” approach to oral care. In packs of 12
tablets, Endekay disclosing tablets are available from fullline wholesalers; PIP code 032-5282, RSP £1.95.
MANX HEALTHCARE 01926 482511
Snug Denture
Cushions, from
manufacturer The
Mentholatum
Company, are
designed to offer a
temporary solution
to the problem of illfitting dentures while the wearer waits for a chance to see a
dentist and they are now “softer and more pliable.” The
product is tasteless and odourless, and the company says, is
easy to apply and fit to upper and lower plates to restore a
firm fit to loose dentures. Snug’s soft, plastic liners do not
need to be removed for cleaning, and they are intended to
give up to three weeks of “cushioned comfort.” Snug
Denture Cushions come in packs of one or two, retailing at a
recommended £3.15 for one and £4.09 for two.
POWERMED HEALTHCARE 0845 222 0555
GlaxoSmithKline has launched the
Sensodyne Pronamel toothbrush. The
new toothbrush has been specially
designed to help protect tooth enamel. It
uses “gel pad” technology with “3D
flexibility and micro-fine rounded
bristles”. “An easily recognisable and
attractive blister case — which doubles
up as a hygienic, re-closable travelling or
storage case — ensures strong shelf
stand out,” says the company. The
product is priced at £2.99
(recommended retail price) and is
available in four colours. The Sensodyne
Pronamel toothbrush features a small,
compact head. The new brush will be
supported by TV with a “10 second tag”
following the existing Sensodyne
Pronamel toothpaste advertisement later in the year.
GLAXOSMITHKLINE 0845 762 6637
ICP August 2007 23
Oral care AUG
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Oral Care
that will improve customers’ oral health, as
customers need clear guidance on how to
choose the right products and use them
effectively. According to the GSK report,
pharmacists can help by making the fixture
easier to shop, and involving more educational
messages at the site of purchase.
Effective brushing
A correct brushing technique is essential to
clean effectively to reduce tooth decay and
prevent problems like gum recession. The
toothbrush needs to be tilted at a 45-degree
angle to the gum-line, and moved in short
circular movements several times on the outer
and inner surfaces of all the teeth. Customers
should also clean the chewing surfaces and
their tongue, which is a common site for
bacteria.
Dr Carter recommends a habit of brushing
for two minutes twice a day with a fluoride
toothpaste. Yet BDHF research has found that
most people brush for a maximum of 45
seconds, while one in five brush less than twice
a day.
Dr Nigel Carter says: “The number of
people who don’t even brush once a day is
eight times that of last year, while the number
of people who can’t remember when they last
changed their toothbrush is up by a similar
amount.”
Toothbrushing tools
The toothpaste sector shows £304.2m worth
of sales, says the GSK report, but there has
been no recent growth. According to the
report, trading up to premium pastes (for
example, whitening or superior cleaning
products) is the way to grow the market.
Examples of products with extra benefits
include Aquafresh Extreme Clean Tooth &
Tongue, Macleans White and Shine, Retardex
(for bad breath) and Colgate Total Professional
Weekly Clean. However, BDHF research
found that there is still confusion among
consumers about the benefits of the basic
toothpaste ingredients — for example, 13 per
cent believed fluoride is mint flavour, 12 per
cent a whitening product and 15 per cent a
marketing gimmick.
The toothbrush is just as important as the
toothpaste, but sales of brushes are not as high
(less than £225m sales). And while toothpaste
has 82 per cent penetration, there is only 62
per cent penetration of toothbrushes.
Brush heads have become increasingly hitech, with multi-angled bristles, different
filament lengths, crossed or waved filaments,
rounded bristles, etc.
Karen Coates says that consumers should
use a medium-textured, small-headed brush
with a long neck so that they can reach the
back of their mouths. A flat-topped brush is
suitable if someone has a good brushing
technique, but a brush with mixed length
filaments is better if brushing technique is
poor, as it will reach more surfaces of their
teeth.
Another way to ensure that brushing is
24 August 2007 ICP
more effective is to use a power brush rather
than a manual one.
“Electric toothbrushes with an oscillating or
pulsating head get into difficult-to reach
areas,” says Karen Coates. “Studies show that
electric brushes remove more plaque and
debris than the manuals, although technique is
also important as the brush needs to be at a
45-degree angle. Many people do think that
by using an electric brush, it is doing the work
for them, when this is not the case.”
According to Steve Davey, Oral B brand
manager, power brushes are a key growth area
for pharmacists to tap into.
Power brushes range from entry-level
products like the Oral B Vitality range
(including new Vitality Sensitive Clean for
sensitive teeth and gums) to premium
products like new Philips Sonicare Elite e9500,
which is the only angled sonic toothbrush, for
better access to hard-to-reach parts of the
mouth.
”
Oral hygiene has
such a big impact on
people’s overall health,
not just on the state of
their teeth
”
“We believe there is huge potential to
extend the number of consumers who buy
power toothbrushes and increase household
penetration,” says Steve Davey. “All the
brushes within the Oral-B Vitality range
provide unique end benefits for consumers
and, combined with an entry-level price point,
are set to continue to act as a stepping stone to
encourage consumers to trade-up from manual
brushes, driving the market and reaping
profits for retailers.”
Good regime
Brushing only cleans 60 per cent of the tooth
surface, so the BDHF recommends that people
use floss and mouthwash, too. But research on
behalf of Oral B has found that less than one
in 10 of manual toothbrush users buy
interdental products, while, according to the
GSK report, floss has only 12 per cent
penetration.
“Floss and tape are hard to use,” says Karen
Coates. “The dentist or hygienist will show
patients what to do, but many patients don’t
use the products enough to turn it into a
habit. There is also a time restraint to a certain
degree, as flossing takes longer than just using
a brush.”
Pharmacists can encourage customers to
buy flossing products like Oral B
Hummingbird (power flossing) and Sensodyne
Total Care Expanding Gentle Floss and Gentle
Tape (for tighter areas), as these make flossing
easier and more comfortable.
Mouthwash is outperforming the total oral
care category and with penetration at just 42.6
per cent, but rising, the sector offers the best
potential for category growth.
Several new mouthwashes have been
introduced to grow the sector. New Listerine
Softmint Sensation, a milder flavour than
other Listerine mouthwashes, is expected to
attract three quarters of a million new users to
the mouthwash sector in its first year of
launch. New Aquafresh Extreme Clean
Purifying Mouthwash cleans the tongue, an
important source of bacteria, whilst also
promoting healthy gums and protecting
against decay.
Oral care problems
A regular dental check-up reduces the risk of
not just tooth decay, but related problems (eg,
sensitivity, gum recession and bad breath) as
teeth last longer in the ageing population. Yet
only just over half of the population is
registered with a dentist, and many of these
make an appointment only when they have a
problem. A survey by Colgate found that 40
per cent of the population are solely motivated
to visit the dentist’s chair because they love the
clean feeling they have afterwards — rather
than because they are aware of the importance
of regular check-ups.
Increasing numbers of people are consuming
more fruit, fruit juices and smoothies as part of
a healthy lifestyle, but they don’t realise that
they are causing damage to their teeth.
Dentists are noticing more acid erosion
(wearing down of the tooth enamel) among
their patients. In October 2005, 91 per cent of
dentists reported seeing cases of acid erosion
on a weekly basis, and GSK believes that acid
erosion is one of the most important issues
since cavities facing dental health.
Early signs of acid erosion are sensitivity,
discolouration and rounded teeth. In severe
cases, teeth become cracked, transparent and
severely sensitive. Although a good fluoride
toothpaste will remineralise enamel to a
certain degree, the use of products like
Sensodyne Pronamel and Arm & Hammer
Enamel Care can help to protect against acid
erosion and reharden tooth enamel. Since overvigorous brushing aggravates acid erosion,
sufferers should use a more gentle toothbrush,
such as new Sensodyne Pronamel, which is
specifically aimed at people with, or at risk of,
acid erosion. Pharmacy customers also need to
check their eating and drinking habits, if they
want their teeth to stay healthy. “Pharmacists
should tell customers that they shouldn’t
brush their teeth for an hour after eating, as
saliva needs to be able to neutralise the acid,”
says Karen Coates.
“Eating cheese, nuts or seeds after an acidic
meal will also help.”
Oral care AUG
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Oral Care
Product update
Aquafresh Extreme Clean
Purifying Mouthwash has
been launched by
GlaxoSmithKline. The
new “clear” mouthwash
is intended to clean the
tongue and “kill 90 per
cent of the bad breath
causing bacteria found
on the tongue, whilst
also promoting healthy
gums and protecting
against decay,” says the
company. The pack
design employs the
existing Aquafresh Extreme Clean blue and
orange livery for “maximum shelf stand out”,
with front of pack copy explaining the product’s
key benefits. Support for the Aquafresh Extreme
Clean Purifying Mouthwash will include national
TV, on-line activity and sampling. The
mouthwash is available in a “clear mint” flavour
with a recommended selling price of £2.49 for
500 ml.
GLAXOSMITHKLINE 0845 762 6637
Orajel is a “leading range of products for the
rapid relief of mouth pain associated with
toothache, mouth ulcers and the discomfort of
wearing dentures,” says manufacturer Accura
Health. Orajel is applied directly to the sore
area within the mouth and is designed to act
within seconds to relieve pain. It is intended for
short-term use until the patient can consult a
dentist for treatment of the underlying cause of
the pain or discomfort. The range includes:
Orajel Extra Strength, only available from
pharmacies, while Dental Gel, intended to
relieve the pain associated with toothache, and
Mouth Gel, indicated for the relief of the pain of
mouth ulcers and minor mouth irritations, are
on the general sale list.
ACCURA HEALTH 01294 275800
GlaxoSmithKline is
“revitalising” the Macleans
brand with a major relaunch
based on the proposition
“strong foundations for healthy
teeth”. The initiative, which
“embraces” whole tooth
health involves new pack
designs and the introduction
of a new Macleans Total
Health franchise. The packs feature an enhanced logo, followed by a
“strong foundations” legend, with each product featuring its own new
icon to assist variant differentiation. The new packs have recommended
selling prices ranging from £1.89 for Macleans Freshmint to £2.59 for
Macleans White & Shine, with new Macleans Total Health and Macleans
Total Health Whitening both priced at £1.99 for 100 ml sizes. “Travelfriendly” 50 ml tubes and 100 ml pumps will also be available on most
variants over the coming months.
GLAXOSMITHKLINE 0845 762 6637
Wockhardt UK’s ConfiDent
Denture Care range has recently
been expanded and now includes:
ConfiDent Denture Cleansing
Tablets, ConfiDent Denture
Fixative Cream designed to hold
dentures firmly in place all day
long and impart a “fresh and
hygienic feel”, ConfiDent Denture
Bath (designed for use with
dentures or removable braces),
Confident Denture Care Brush (a
large multi-tufted brush to remove
particles and food stains plus a
small angle-trimmed brush to clean hard to reach surfaces), and
ConfiDent Trial/Travel Pack (a “handy” pouch containing essential
denture care items for use when travelling away from home). A free
merchandising Unit is available for a limited period in conjunction with
an agreed minimum order.
WOCKHARDT UK LIMITED 01978 661261
Hygienists
recommend
interdental
brushes more
often for
interdental
cleaning than
floss, says
manufacturer, Molar Ltd, supplier of TePe interdental brushes. “The
reason is simple: most people find interdental brushes extremely effective
and easier to use than floss,” states the company. TePe is claimed to be
the “UK’s number 1 best selling brand” and also the “most recommended
and personally used brush amongst UK dentists and hygienists”. TePe
interdental brushes are available in seven colour-coded sizes “ensuring
that there is one to fit most interdental spaces”. They are manufactured
in Sweden. Molar has a new pharmacy starter pack. For further
information either telephone Molar Ltd or email [email protected].
MOLAR LTD 01934 710022
ICP August 2007 25
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Automation
The robots are coming
It’s never too early to invest in new technology and pharmacists could benefit from a
robot in their dispensary sooner than they think. Steve Bremer reports
An ARX Rowa Speedcase
at Prestwich Pharmacy
W
ith prescription numbers rising
at 6-7 per cent annually, the
prescription fee falling, and the
emphasis increasingly on
pharmacy services, a dispensing
robot is an ideal way for busier pharmacies to
free up time. The technology is relatively new
and automation is not yet suitable for all
pharmacies but it is bound to become
increasingly popular.
Almost every pharmacy can benefit from
some sort of automation, says Dave Harper,
retail pharmacy sales manager for ARX in the
UK. For example, any pharmacy can benefit
from a final checking system to ensure the
accuracy of the operation, he says.
ARX has over 1,600 robotic dispensing
machines installed throughout Europe, around
10 per cent of which are in the UK. About a
third of those in the UK are in community
pharmacies. ARX says it is the only company
that offers systems operating on both main
types of automation:
channel/vending
robotic, or “chaotic” solutions.
It also provides some lower level softwareonly solutions due to be released shortly.
26 August 2007 ICP
In a robotic or “chaotic” system, a robot arm
picks the packs. In a channel system, packs are
loaded into channels like a cigarette vending
machine and are dispensed one at a time at the
bottom. The two types of system should not
be confused, warns Mr Harper, and the correct
automation solution will vary according to a
pharmacy’s workload and needs. One size does
not fit all.
Channel systems appeal to lower volume
pharmacies with large floor space because the
systems tend to be cheaper but take up large
amounts of space as they need room both in
front and behind for loading and access. And
full robots usually attract the larger volume
pharmacies and/or those with limited space, as
the systems are more space efficient,
automate significantly more of the process, are
more flexible, but are usually more expensive.
For example, a company installed a robot
last year in a pharmacy with a total floor
space of 5 square metres, which included the
shop floor, consultation room and the
dispensary area. The pharmacy staff have
found the machine to be highly beneficial,
describing it as “a much smoother way of
doing business”.
The pharmacist says: “Automation is
certainly very useful if you are struggling for
space”.
Mr Harper declares:“ARX provides the
unique service of being able to discuss each
possible solution, and, using over a decade of
experience, can guide pharmacies through the
options available and how these can be
justified for each business model.”
With a UK market share in excess of 80 per
cent, and well in excess of 1,500 sites across
Europe, ARX product development ensures
that every aspect and every product is
developed well beyond any other system
available, adds Mr Harper.
ARX has installed over 180 machines in the
UK and says it has more service engineers than
any other pharmacy automation supplier. Its
systems have been tailored to the UK market
to allow part (open) pack integration, generic
and parallel import inclusion and links to
labeling/patient medication record systems.
The system integrates with all major patient
medication record suppliers including:
Cegedim Rx, AAH Link Evolution, Positive
Solutions, Systems Solutions, McLearnons and
Eclipse.
The Healthpoint view
Healthpoint Technologies and Willach +
Heise (supplier of FAMA, the continental
drawer systems for pharmacies) are working
together to market the Consis dispensing
robot in the UK and Irish markets.
“The synergy between the two companies is
obvious as they both seek to give pharmacists
the tools, the knowledge, the time and the
space to fulfill their new role in this new age of
pharmacy,” says John White, managing
director of Healthpoint Technologies.
One of the most common preconceptions
about dispensing robots is that they are
outside the reach of most community
pharmacists, costing in excess of £100,000.
The fact that the Consis A and B modules fall
substantially beneath this figure and deliver
real benefits to the pharmacist was one of the
motivating factors in Healthpoint’s decision to
take on the Consis franchise, says Mr White.
Anyone considering investing in a robotic
dispensing system should consider the
following questions, suggests Mr White:
What logistics benefit will I gain both in
Automation p26-28 AUG rev[2]rev
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Automation
Case studies
George Romanes, proprietor of
Romanes Pharmacy in Duns
Mr Romanes was introduced to the Consis
range by John White, managing director of
Healthpoint Technologies. Consis robots
work in a similar way to a vending machine
and on the premise that 80 per cent of
dispensing is from 20 per cent of lines. So a
Consis robot is only loaded with the most
popular lines that make up the bulk of
dispensing. With a price tag of around £50k
this is a more affordable system. “Robots are
the way forward to deal with the volumes
we’ve got,” says Mr Romanes.
Willach + Heise, manufacturer of Consis
robots, have made pharmacy dispensing
drawers for a number of years and Mr
Romanes describes its products as “good
German engineering”.
The robot was installed in February, taking
only 48 hours to get up and running. Since
then, selecting which lines to put in the
machine has required fine tuning and AAH
Link has perfected the computer interface.
Mr Romanes is please that his robot is the
most cost-effective solution for his pharmacy.
“It will do what it says on the tin. You’ve got to
be doing an awful lot of prescriptions to justify
the costs of a chaotic machine.”
The Consis does the work of half a full-time
dispenser, says Mr Romanes. This has freed up
“useful chunks” of his time to carry out
extended roles.
Fin McCaul, managing director of
Prestwich Pharmacy in Manchester
and St Peters Pharmacy in Burnley
Mr McCaul has recently installed ARX Rowa
Speedcases in both his pharmacies, and
describes his robots’ stock storage capability as
“phenomenal” and their accuracy as “excellent”.
Mr McCaul chose this model because he
believes it is the best supported system and the
most sophisticated available in the UK. He was
aware of their “good history” in a number of
community pharmacies.
The robots have a hopper attachment that
sorts out and puts away stock. In addition, a
Max channel allows the robot to dispense 10-15
items at once. A typical two-item prescription
can now be picked in 20 seconds.
One robot was installed to facilitate
“upstairs” and “downstairs” dispensaries at Mr
McCaul’s Prestwich Pharmacy in Manchester.
The robot allows both dispensaries to operate
from a single stock holding. It has also created
the space for two consulting rooms and three
treatment rooms.
The robots are more accurate than a human
dispenser, with the only potential source of
human error being a failure to map bar codes
correctly.
“It’s given us an awful lot of flexibility and
variability in terms of working practices,” says
Mr McCaul.
Dispensing speed has not increased, as Mr
McCaul believes he has not yet optimised the
robot’s use, but is confident that he will have a
head start when ETP goes live.
“With ETP coming on line we can virtually
dispense everything by key strokes.”
A robot may not be suitable for every
pharmacy, but Mr McCaul believes that the
concept has huge potential. “It’s just getting
your head round using it and adapting how you
work. The public are very impressed with it.”
Mr McCaul recommends this model to other
independents. It works well in both his
pharmacies, achieving slightly different
objectives. The St Peters Pharmacy in Burnley
is an extended hour pharmacy so staff there do
not need as much help putting away stock but
it is effectively stored for access at any time.
Software and an interface from Positive
Solutions software work well with the robot,
says Mr McCaul.
ICP• Summer 2007
A R X Automation
Independant Community Pharmacist
2 Bespoke Choices, 1 Absolute Decision
'Automation is certainly very useful if you are
struggling for space'
- Shiv Bagga, Robot-Owner,
Manor Park Pharmacy, London
'I can now spend the time talking to my customers whilst the requested packs are being
dispensed'
- Tim Dobbin, Robot-Owner,
Herrington Pharmacy, Durham
The Rapid and Economical ‘AutoMax’
The Efficient and Flexible ‘Rowa Speedcase’
Automating your pharmacy is a big decision as it is, never mind choosing
what type! Thats why automating with ARX is simple. We supply both the
rapid, economical Channel-based systems and the more complete, efficient
Robotic dispensing machines. With a product range including both, ARX are
able to help you decide which technology will benefit your Pharmacy.
‘Script volume has increased, which has
increased turnover. We couldn't cope with current volumes without automation’
- Martin Bennet, Robot-Owner,
Associated Chemists, Sheffield
The UK’s Number 1 Provider of Pharmacy Robotics
For any information regarding ARX systems please contact us on (+44)01727 893360 alternatively email on [email protected]
ARX Ltd • Tel: +44(0)1727 893360 • Fax: +44(0)1727 893361 • Email: [email protected] • Web: www.ARXinter.net
ICP August 2007 27
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Automation
Figure 1: The benefits of robotics
terms of staff savings as well as stock
efficiency?
Will there be a tangible increase in
dispensing accuracy?
How much will I
improve my service to my
customers?
Are there space saving
efficiencies I will gain that I
can utilise?
Will my customers’
waiting times be cut?
“These
questions,
coupled with the challenges
of the new contract, really
will help focus your mind as
to whether the robotic
pathway is the right way
for your pharmacy,” says
Mr White.
Another important factor
to be considered is shown in
Figure 1. The UK pharmacy market operates
on the 80/20 rule, where 80 per cent of the
prescriptions dispensed are from 20 per cent of
the lines in the dispensary. As the graph
illustrates, any real economic or service benefit
from going beyond 90 per cent tails off
dramatically. “In other words, a combination
of a fast moving system and a Consis robot will
deliver all the benefits of automation at the
most realistic price.”
The first Consis robot in the UK was
installed at George Romanes’s pharmacy in
Duns in the Borders. The dispensing load on
Mr Romanes’s pharmacy and the fact that the
Consis system is modular helped him to choose
a Consis A2 module. This type of system can
grow with a business and be extended without
major disruption to the existing set-up.
Mr White predicts that robotic dispensers
will become increasingly common in
pharmacies: “One thing is certain — more
change will follow and the introduction of a
robotic dispensing system will put the
community pharmacist in pole position to
meet those challenges.”
Product update
“With over 2,500 units in use around the
world, the Baxa Repeater Pump is the most
widely used hospital pharmacy pump and fills
the need for accurate fluid handling in the
pharmacy through the automation of routine
filling procedures,” says manufacturer, Baxa
(UK) Ltd. The repeater pump is also used in
community pharmacies for methadone
dispensing for patients on community-based drug detoxification programmes; the pump is
designed to save time and resources in the pharmacy. The repeater pump features motor
strength powerful enough to pump viscous fluids, and is the “pharmacy’s most reliable
friend for fluid transfer and filling applications,” says the company. The pump delivers
volumes of between 0.2 ml to 9.9L with accuracy of +/- 1per cent above 2 mL.
BAXA UK LTD 01344 392902
The Methasoft Treatment Management
System (TMS), from Methsoft UK Ltd is a
computerised system that is designed to
help pharmacies and substance misuse
clinics better to manage the care provided
to service users. Covering the “complete
flow”, from triage and initial assessment,
through to care planning and dispensing of
therapeutic drugs such as methadone, the
Methasoft TMS is intended to save staff
time, improve clinical governance and
allow facilities to provide a higher level of
care to more clients. The dispensing system keeps full records of medication provided to a
client, and allows staff to dispense liquid drugs via the system using an electronic pump.
An audit trail is kept, including detailed inventory records of drug stocks, and an electronic
controlled drugs register is kept automatically. A “fully comprehensive” security module
ensures that the “right service client gets the correct dose”. The Methasoft TMS has been
“instrumental in preventing double dosing of service users”. The Methasoft TMS is currently
in use across both community pharmacy, the Prison Service and Drug and Alcohol Action
Teams across the UK. For further information or to request a product demonstration contact
Methasoft UK Ltd at [email protected]
METHASOFT UK LTD 0845 300 5243
28 August 2007 ICP
The MTS Medication Technologies PlusPak
is a patient concordance-support system,
now supported by automated filling
technology, the OnDemand Multi-Med.
Interfaced to the pharmacy software
system, the multi-med fills MTS multidose
cards, seals them and prints and affixes
labelling, providing a finished product
ready “just in time” for the patient. “The
multi-med maximises workflow, while
allowing easy checking and is equipped
with sophisticated software to maximise
accurate dispensing and efficient inventory
management,” says the company. Multimed is intended for use with a wide variety
of MTS mutidose card designs, including
tear-off cards which allow the patient to be
given medications in a single blister, or
perhaps a set of blisters for the day.
Further information can be found at
www.mts-mt.co.uk.
MTS MEDICATION TECHNOLOGIES
0870 7661462
Clinicalfocus AUG P29-31 V2rev
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Clinical Focus
Improving compliance
in community pharmacy
Mark Greener examines an
age-old problem and calls
for more research into the
ways that people use (or
don’t use) medicines
A common problem
Poor compliance is common with almost every
treatment in almost every disease, as the
following examples illustrate all too clearly:
Between 31 per cent and 44 per cent of
patients taking monotherapy for raised blood
pressure did not use their antihypertensive for
at least two months during the first year of
therapy.1 Up to half of patients discontinue
antihypertensive drugs during follow-up
lasting between 6 months and four years.2
Up to 30 per cent of patients stop within 6
to 12 months of starting osteoporosis
treatments taken daily or weekly.3 In another
study, 19 per cent of patients discontinued
within a year of starting treatment for
osteoporosis.4
Estimates of compliance with antidepressants range from 30 per cent to 97 per
cent, with a median of 63 per cent.5
Not surprisingly, poor compliance
undermines outcomes, as the following
examples illustrate:
Fifty-three per cent of patients taking
statins discontinued treatment during a twoyear study. The patients who persisted with
treatment were, depending on the dose,
between 20 per cent and 40 per cent less likely
to require hospitalisation for an acute
Mauro Fermarello/Science Photo Library
N
o matter how efficacious and welltolerated modern pharmacology
manages to make a medicine, it’s
useless if it remains in the blister
pack rather than in the patient. Yet
many, in some conditions most, patients don’t
adhere to their doctors’ and pharmacists’
recommendations. They miss doses. They
delay taking the drug. Sometimes they drop
out of treatment entirely. And it doesn’t seem
to matter whether the disease is relatively
trivial or potentially life threatening — poor
adherence is pervasive.
Yet the factors that influence adherence and
the most effective means to improve
compliance remain poorly investigated.
Nevertheless, community pharmacists can, by
going back to first principles, address factors
that contribute to poor adherence.
myocardial infarction compared with their less
adherent counterparts.6
Patients who complied with antihypertensives were 19 per cent less likely to
suffer a first cardiovascular event, 32 per cent
less likely to die from a cardiovascular event
and 42 per cent less likely to develop heart
failure than those who did not comply. 7
During an average follow up of 2.2 years,
13 per cent of patients with HIV or AIDS who
filled less than 50 per cent of their
prescriptions for therapy based on nonnucleoside reverse transcriptase inhibitors
showed a sustained suppression of viral load
(less than 400 copies per ml). This compared
with 25 per cent and 73 per cent for those that
“filled” 50-60 per cent and 90-100 per cent of
their prescriptions, respectively. 8
Each 25 per cent increase in the proportion
of time without inhaled corticosteroid doubles
risk of being hospitalised for asthma. 9
Futhermore, a confidential enquiry into
asthma deaths reported that just 20 per cent of
fatal attacks were sudden. Therefore, 80 per
cent of deaths from asthma were probably
potentially preventable. Behavioural and
psychosocial factors, such as poor compliance,
smoking, denial, depression and alcohol abuse,
contributed to 81 per cent of the deaths. Some
deaths had several contributory factors.
Nevertheless, poor compliance probably
contributed to 61 per cent of deaths.10
Enhancing adherence
Clearly, improving compliance is an imperative
for community pharmacists and other
healthcare professionals. Unfortunately, the
evidence base suggesting ways in which health
care professionals can enhance adherence is
relatively weak. For example, a review of 32
studies assessing compliance with
antidepressants found no “consistent”
indication of which interventions would
improve adherence most effectively. 5
Furthermore, many methods work in some
studies but not others. Moreover, most studies
rely on patient self-report or pill counting,
which do not necessarily accurately reflect
compliance.11
Lindenmeyer et al examined the literature
surrounding the role of pharmacists in
improving adherence in people with type 2
diabetes. They found that reminders and
specialised packaging, but not pill counts,
improved compliance. Integrated management
and education programmes led by pharmacists
and aimed at “under-served” patient
populations lowered HbA1c by between 0.8
per cent and 2.2 per cent. 12 In the UK
Prospective Diabetes Study (UKPDS), a 1 per
cent decrease in HbA1c reduced the risk of
developing microvascular endpoints and
myocardial infarctions by 37 per cent and 14
per cent, respectively.13 Nevertheless, while
pharmacists can improve outcomes in people
with type 2 diabetes, the authors conclude that
it is “unclear whether this resulted from
improved patient adherence”.12
Against this background, pharmacists can
go back to first principles and address factors
that could undermine compliance in some
patients. For example:
ICP August 2007 29
Clinicalfocus AUG P29-31 V2rev
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Page 30
Clinical Focus
Simplify complex regimens, such as those with
multiple doses and polypharmacy.11 Simplifying
antihypertensive dosing regimens increased
adherence (by 8 per cent to 20 per cent) in
seven of the nine studies assessed in a
Cochrane review. The reviewers suggest that
reducing the number of daily doses should be
the “first line strategy” to enhance adherence
with antihypertensives. 14
Address side effects.11 Patients who experience
problems with their medication (including
adverse reactions) are 3.5 times more likely to
reduce the dose or discontinue than those who
do not.2
Address patient concerns about the
appropriateness of medicine.11 Adherence is highest
when patients regard the necessity of the
medication as exceeding their concerns, for
example about toxicity. Conversely, compliance
is lowest when their concerns exceed their
perception of the medicine’s necessity. One
study looked at four characteristics that could
influence compliance: scepticism, ambivalence,
indifference and acceptance. Patients who are
highly sceptical about medicines are around 40
per cent less compliant than the mean. Those
who accept the diagnosis and treatment are
around 50 per cent more compliant than
average. The other traits fell between these
extremes. Pharmacists could tailor treatment
in line with these characteristics.
For example, indifferent patients may be
more likely to adhere to a regimen that is easy
to administer and drugs that produce the full
benefits rapidly. Those patients who are
ambivalent about treatment may benefit from
a regimen that minimises adverse reactions
and by healthcare professionals proactively
addressing any concerns. Those who are
sceptical may need considerable counselling
and education before they accept the need for
Product update
Tabtime Ltd is a
“leading supplier of
medication
management
products,” pill and
tablet timers, reminders, dispensers and
organisers and pill splitters, cutters and
crushers for those who find medication
difficult to take. The latest addition to the
product range is Tabtime 5 an “electronic
pillbox” with five daily alarms, five
corresponding tablet compartments and a
countdown timer for regular doses. Tabtime 5
is designed for Parkinson, Alzheimer’s,
multiple sclerosis and epilepsy patients. All
alarms on Tabtime products are “set it and
forget it”. The products in the “pill splitters,
cutters and crushers” range are all designed to
provide a storage space for whole or cut pills.
More details at www.tabtime.com.
TABTIME 01270 767207
30 August 2007 ICP
treatment.15 Uncovering and addressing these
concerns depends on taking a nonjudgemental, non-confrontational approach.
Indeed, this attitude should underpin all
conversations about compliance.
Address denial and other psychological issues.11
In patients with asthma, concurrent panic and
anxiety is associated with greater use (which is
another form of non-compliance) of
corticosteroids and bronchodilators as well
more frequent hospitalisations.16 As mentioned
in the June issue of ICP (post-traumatic stress
disorder article, p32) detecting anxietyspectrum disorders in community practice is
relatively straightforward.
Address any confusion and physical difficulties,
especially among elderly people . For example,
offering patients clear instructions in large
type, using ordinary, rather than childresistant, caps and linking medications to
events, such as meals when not
contraindicated, may help.11
Question patients. Simply asking patients
“Did you ever forget to take your medication”
identifies many non-adherent subjects with
hypertension who are prone to a cardiovascular
event. Patients who answered “yes” to this
question were, for instance, 28 per cent more
likely to experience a cardiovascular event or
death and 35 per cent more likely to
experience their first non-fatal event. Other
studies suggest that patient interviews identify
between a third and half of those with poor
adherence. However, pharmacists should be
aware that patients, usually unintentionally,
tend to over-estimate adherence and underestimate poor compliance. 11
Inquire about swallowing problems. Age-related
changes in swallowing physiology and
dysphagia arising from disease are relatively
common among elderly people and can cause
The Medidos tablet dispenser, from Dudley Hunt,
“is still the market leading tablet dispenser,” says
the company. Medidos has seven marked boxes.
Each box contains four adjustable compartments
labelled “breakfast”, “lunch”, “dinner” and
“bedtime”. To secure the box there is a Velcro
strap. Dudley Hunt also supplies Medimax, which
has nearly four times the capacity of Medidos,
with eight
individual
boxes. A
patient record
card and a
sleeve to
house a single
day box are
included and
both models are available in clear covers as well
as in a blue wallet. Dudley Hunt says: “The
Medidos and Medimax range of tablet dispensers
helps ensure the right pills are taken at the right
time.” For further details on the full range of
medication management products go to
www.dudleyhunt.co.uk.
DUDLEY HUNT 01796 482 105
problems when patients try to take capsules or
tablets. For example, a study conducted in
community pharmacies reported that 62 per
cent of patients over the age of 65 years had
experienced difficulties swallowing solid
medications. In 46 per cent of cases, a
community pharmacy study revealed,
swallowing difficulties sometimes prevented
patients from taking their medicines.17 Against
this background, a recent consensus guidelines
stress the importance of asking whether the
patient experiences problems swallowing
medicines.17
However, the community pharmacy study
found that only 11 per cent of patients or their
carers reported that the doctor or nurse asked
about swallowing difficulties.17 While prone to
recollection bias, the low rate suggests that
healthcare professionals rarely ask about
swallowing problems. For those patients who
experience problems, the guidelines suggests
considering alternative formulations, including
liquids.
Clearly, future studies need to characterise
evidence-based techniques that enhance
compliance.13 In the meantime, by going back
to basics pharmacists can address many of the
issues that appear to be linked to poor
compliance. As a profession, pharmacists could
lobby drug companies and other organisations
that fund research for further research into the
ways in which community health professionals
can enhance adherence.
Pharmaceutical companies bemoan the cost
of developing new medicines. Politicians and
providers lament the increasing costs of
medical care.
Yet better compliance could improve
outcome. But this means investing more to
investigates ways to address the many a slip
twixt pack and mouth.
The PlusPak is a
“simple, high
quality and cost
effective patient
concordancesupport system
widely used in the
UK,” says
manufacturer
MTS-Medication Technologies. The 7-day
pack with 28 blisters is available in heatseal or cold-seal, and in standard and tear
off forms. Now as part of MTS Medication
Technologies Ltd “constant innovation
program” the PlusPak, and the full range
of MTS care home blister cards are
available manufactured from
biodegradable materials. The packaging is
designed to biodegrade harmlessly back
into the earth and is eco-friendly “as the
process does not require external energy”.
For more information go to www.mtsmt.co.uk.
MTS MEDICATION TECHNOLOGIES
0870 7661462
11:21
References
1. Elliott W, Plauschinat CA, Skrepnek GH, Gause D.
Persistence, adherence, and risk of discontinuation
associated with commonly prescribed antihypertensive
drug monotherapies. J Am Board Fam Med
2007;20:72-80
2.Anon. After the diagnosis: Adherence and persistence
with hypertension therapy. Am J Managed Care
2005;11:S395-99
3. Papaioannou A, Kennedy CC, Dolovich L, Lau E,
Adachi JD Patient adherence to osteoporosis
medications: problems, consequences and
management strategies. Drugs Aging 2007;24:37-55
4. Rossini M, Bianchi G, Di Munno O, Giannini S,
Minisola S, Sinigaglia L, Adami S. Treatment of
Osteoporosis in clinical. Practice (TOP) Study Group
Determinants of adherence to osteoporosis treatment in
clinical practice. Osteoporos Int 2006;17:914-21
5. Pampallona S, Bollini P, Tibaldi G, Kupelnick B,
Munizza C. Patient adherence in the treatment of
depression. Br J Psychiatry 2002;180:104-9
6. Penning-van Beest FJ, Termorshuizen F, Goettsch
WG, Klungel OH, Kastelein JJ, Herings RM. Adherence
to evidence-based statin guidelines reduces the risk of
hospitalisations for acute myocardial infarction by 40
per cent: a cohort study. Eur Heart J 2007;28:154-9
7.Nelson MR, Reid CM, Ryan P, Willson K, Yelland L.
Self-reported adherence with medication and
cardiovascular disease outcomes in the second
Australian National Blood Pressure Study (ANBP2).
MJA 2006;185:487-9
8. Nachega JB, Hislop M, Dowdy DW, Chaisson RE,
Regensberg L, Maartens G. Adherence to nonnucleoside reverse transcriptase inhibitor-based HIV
therapy and virologic outcomes. Ann Intern Med
2007;146:564-73
9. Rau JL. Determinants of patient adherence to an
aerosol regimen. Respir Care 2005;50:1346-56
10. Harrison B, Stephenson P, Mohan G, Nasser S. An
ongoing confidential enquiry into asthma deaths in the
Eastern Region of the UK, 2001-2003. Prim Care
Respir J 2005;14:303-13
11. Hill J. Adherence with drug therapy in the
rheumatic diseases part two: measuring and improving
adherence. Musculoskeletal Care 2005;3:143-156
12. Lindenmeyer A, Hearnshaw H, Vermeire E, Van
Royen P, Wens J, Biot Y. Interventions to improve
adherence to medication in people with type 2 diabetes
mellitus: a review of the literature on the role of
pharmacists. J Clin Pharm Ther 2006;31:409-19
13. Stratton IM, Adler AI, Neil HA, Matthews DR,
Manley SE, Cull CA, Hadden D, Turner RC, Holman
RR. Association of glycaemia with macrovascular and
microvascular complications of type 2 diabetes
(UKPDS 35): prospective observational study. BMJ
2000;321:405-12
14. Schroeder K, FaheyT, Ebrahim S. Interventions for
improving adherence to treatment in patients with high
blood pressure in ambulatory settings. Cochrane
Database of Systematic Reviews 2004, Issue 3. Art
No: CD004804. DOI:
10.1002/14651858.CD004804.
15. Aikens JE, Nease DE, Nau DP, Klinkman MS,
Schwenk TL. Adherence to maintenance-phase
antidepressant medication as a function of patient
beliefs about medication. Ann Fam Med 2005;3:23-30
16. Strek ME. Difficult asthma. Proc Am Thorac Soc
2006;3:116-23
17. Strachan I, Greener M. Medication-related
swallowing difficulties may be more common than we
realise. Pharmacy in Practice 2005;15:411-4.
18.Wright D, Chapman N, Foundling-Miah M et al.
Consensus guideline on the medication management of
adults with swallowing difficulties. In Foord-Kelcey G,
editor. Guidelines —summarising clinical guidelines for
primary care. 30th ed. Berkhamsted: Medendium
Group Publishing Ltd, October, 2006, pp 373-6
Page 31
Health
Watch
MOVING TOWARDS RECOVERY
A five-year study of long-term recovery after strokes has started at Southampton University. Lack of
knowledge about how stroke survivors’ mobility changes over time makes it harder for therapists to
discuss long-term goals with patients and to predict the benefits of rehabilitation therapy.
Specialists at the university’s Rehabilitation Research Centre are working with local hospitals to
measure long-term recovery of mobility and to assess how improvements will enhance quality of
life.
EXTRA POUNDS OF RISK
Weight is confirmed as an important risk in endometrial cancer by a study of 223,000 women in
10 European countries. The risk to the womb lining was doubled in women with waists of more
than 34in, those who have piled on more than 44lb since the age of 20, and obese women. The
womb cancer tendency was seen as particularly strong in post-menopausal women and those who
had never had the contraceptive pill or hormone replacement therapy. A 2004 survey put British
women’s average waist measurement at 34in, compared with 27.5in during the 1950s, when
people had wartime diets and exercised more. The study, part-funded by Cancer Research UK and
Britain’s Medical Research Council, was published by the European Prospective Investigation into
Cancer and Nutrition.
ASPIRIN STANDS GUARD
Aspirin seemed to prevent asthma from starting in an American study involving more than 22,000
doctors. All the doctors appeared asthma-free when the study began. After five years, asthma had
developed in 40 per cent more of those who did not take aspirin. This is thought to be because
aspirin stops the airway inflammation symptomatic of asthma. However, the researchers warned
that aspirin does not necessarily help already diagnosed asthmatics. The research — the
Physician’s Health Study — also suggested that asthma incidence has soared in Britain, the United
States and Australia because children now usually take paracetamol for pain relief instead of
aspirin.
GO FAR ON MOTHER’S MILK
Breast-fed people appear to succeed socially more than
those fed by bottle. Bristol University researchers found they
were 41 per cent more likely to climb the social ladder,
possibly because breast-feeding aids brain development,
producing better academic results, job prospects and earning
potential. The findings showed the advantages were greater
the longer breast-feeding continued. In addition, the
researchers thought long-term health was improved and that
other social and economic benefits could eventually be
discovered. They had investigated 3,000 people in their sixties and seventies as part of a study of
diet and health in pre-war Britain.
TOOTH TOP-UPS
Surface damage to teeth could eventually be repaired with an enamel substance created in the
laboratory. Scientists at Tokyo University first prepared enamel from piglets’ teeth on a collagen
base. Then they placed it in the stomachs of young mice, where the cells developed into tissue
similar to tooth enamel.
BRAIN-DAMAGED SMOKERS
Cigarette nicotine has finally been shown to damage the brain and create dependence. Researchers
who conducted a study supported by the American National
Institute on Drug Abuse reported that smoking changed cerebral
tissue just like cocaine, heroin and other narcotics.
UNHEALTHY NOTE FOR SINGERS
Even opera singers face an occupational health hazard.
Researchers at the Catholic University of Rome have found that
all professional singers are at risk of developing oesophageal
reflux. Opera singers, however, were shown to be at twice the
risk because they put more stress on the diaphragm. The danger
is that reflux can inflame and damage the vocal cords and lead
to laryngitis.
IstockPhoto
6/8/07
IstockPhoto
Clinicalfocus AUG P29-31 V2rev
ICP August 2007 31
business focus p32 rev
6/8/07
15:18
Page 32
Business Focus
100 hour contracts:
threat or opportunity
Are 100-hour contracts a business threat or an
opportunity? David Parker sets the issue in
context
T
he changes to the control of entry
regulations in 2005 were precipitated
by an Office of Fair Trading
investigation that was highly critical of
the lack of competition that resulted
from the regulatory framework in place at that
time. Indeed, the OFT was so critical that it
proposed complete deregulation of entry to the
pharmaceutical list. The Department of Health
significantly watered down this advice by
making a limited number of changes to the
regulations with the aim of encouraging
competition and thus improve services available
to patients. These changes included four
exemptions to the “necessary or desirable” test
for entry to the list. The jury is currently out
on whether these changes have in any way met
their objective.
What is certainly clear is that the threat
posed to existing pharmacy owners is
significantly less than would have been
experienced had the OFT had their way. In
fact, apart from the odd, very rare, example the
only exemption that has put real fear into preexisting contractors is the 100-hour exemption.
It is easy to understand that an owner who
has paid a good deal of money for the goodwill
of a business, or has spent many years building
a solid customer base, would be unhappy about
the prospect of somebody joining the party for
free. On the other hand, it is very hard to find a
member of the public that considers a
pharmacy that is open to serve them from 7am
to 11pm to be a bad idea.
Whichever side of the fence you sit on, the
plain facts of the matter are that the
regulations are as they are, which for existing
owners represents a threat and for aspiring
owners an opportunity.
Substantial applications
But just how much of an opportunity or threat
does the 100-hour contract represent? The
number of applications for 100-hour contracts
has been substantial for obvious reasons. The
exemption is very straightforward: you simply
find premises, promise to open for 100 hours
per week, buy some stock and, as if by magic,
you are the proud owner of your very own
pharmacy. (Although 100-hour applications can
be rejected in exceptional circumstances)
The 100-hour opportunity has also coincided
with two other market conditions that have
increased the propensity for non-owners to
chance their arm in business.
32 August 2007 ICP
First, the locum market has changed quite
significantly over recent years. Where the
balance of power in the market was previously
held by the locum, with a ready supply of work
at healthy rates of pay, this balance has shifted
somewhat recently.
Secondly, there is buoyancy currently in
goodwill values for pharmacy contracts. The
values at which pharmacies change hands
simultaneously serves to both exclude many
independent first-time buyers and emphasise
the apparent opportunity of a “free business”
offered by the 100-hour route.
However, existing and aspiring owners
should take the threat or opportunity of the
100-hours contract with a significant pinch of
salt. For, while there are certainly some
opportunities to create a profitable business by
trading for 100 hours per week, such
opportunities are remarkably few and far
between.
As any existing owner will be aware, by far
the greatest cost line on his or her profit and
loss account are staff-costs. In fact, good
management of staff costs and opening hours
can mean the difference between healthy profits
and regular loss.
As most pharmacies only open for around 45
hours per week, it does not take too much
imagination to recognise that staffing a
pharmacy for 100 hours per week, many of
them unsocial hours, can cost at least twice as
much. The unavoidable fact that a pharmacist
is required to be present for 100 hours per week
means that a turnover of close to £500,000 is
required to fund his or her salary alone. Add to
this the other staff costs, rent, rates, heat, light,
etc, and a turnover of close to £1m could be
necessary just to break out of loss.
Of course, some operators of 100-hour
pharmacies will work many of the hours
themselves, and thus see some of the costs are
absorbable. However, this will only be palatable
in the short term if you are convinced that you
are ultimately going to earn more money than
you did as a locum or an employee.
The idea of a “free business” with nothing to
pay and little risk is also somewhat inaccurate.
Although the “barrier to entry” is lower than
that for an existing contract, there are still some
significant costs to bear and the commercial
outcomes are somewhat less predictable.
The costs of entry into the 100-hour market
will include at least the following:
G Purchase of a property or entry into a lease
— a typical nine year lease can
amount to a tidy sum
G Fit out of a property —
£50,000 is easily spent on a
modest fit-out
G Stock — this is particularly
tricky for a new-start pharmacy
as it is impossible to know what
stock to hold (Hold too little or
the wrong products and you will
either have a reputation for poor
service or a lot of redundant
stock on your hands)
G Accumulated losses — this is
the biggest investment of all (Until the business
reaches its break-even point it will be running
at a loss. Under average operating conditions,
break-even could mean around 6,000
prescription items per month or almost £1m
turnover per year, no mean feat)
The losses to be made in the early stages of
the business are substantial and only when the
break-even point is passed will these even begin
to be offset. As many existing 100-hour
operators will recognise, break-even may be a
long time coming or may never be reached. In
fact, some are not even a quarter of the way to
this target and face either a long time under
water, or a tricky exit strategy.
Aspiring entrepreneurs should also recognise
that the value of a 100-hour pharmacy is, like
all other businesses, based on its ability to make
a profit for a buyer. A 100-hour pharmacy that
has a turnover of £500,000 will certainly be
making a loss and can therefore be viewed as a
liability rather than an asset. Only when a
business starts to make profit will it have a
value to anyone. Thus, the classical turnover
ratios that are heard in the market do not apply
in any way to 100-hour contracts. Based on its
lower profitability, the additional headache and
greater vulnerability, a 100-hour pharmacy
with anything less than a £1m turnover will
have little or no resale value. Above this the
value will climb with turnover but less steeply
than for a standard contract.
Wherever your opinions lie with regard to
the value of a 100-hour pharmacy service, what
is certain is that the threat or opportunity that
100-hours presents is of a limited nature and,
whether exploiting or defending against the
100 hour exemption, the key considerations are
the same:
G Can a 100-hour business in the particular
location ever achieve the level of turnover
required to make profit?
G Can the entrepreneur fund the cash-flow
shortfall until then?
G If yes to the above then what level of profit
might ultimately be made and will this offset
the losses, and investments made?
G Can the aspiring business owner afford to
take the risk?
David Parker is a specialist in pharmacy business
transfer and business development.
He can be contacted by e-mail at
[email protected]
(tel 0789 423 4873)
market update
p33-34 AUG rev
6/8/07
11:09
Page 33
Market Update
New wording for
Decapeptyl
The Decapeptyl licence wording has
been changed to state that the
product is indicated for the treatment of patients with locally advanced,
non-metastatic prostate cancer, as an alternative to surgical castration,
and for the treatment of metastatic prostate cancer. Decapeptyl is also
indicated for the treatment of endometriosis (3mg and 11.25mg),
uterine fibroids (3mg only) and central precocious puberty, where onset
is before eight years in girls and nine years in boys (11.25mg only).
IPSEN 01753 627777
Apotex launches perindopril
Apotex UK Ltd has announced
that it has won a patent dispute,
allowing the company to launch
its generic version of the ACE
inhibitor perindopril to the
NHS. Generic perindopril was
first launched by Apotex in the
UK in August last year, but was withdrawn because of the dispute. Colin
Darroch, UK managing director of Apotex, says: “It has been a long
legal process in dealing with the patent situation and we are delighted
that at last perindopril can be made available to patients in the UK at a
reduced cost to the NHS.” He adds that it is clinically equivalent to the
branded version.
APOTEX UK 01525 243550
WaspBane to take
sting out of summer
WaspBane is a “novel patented unique high
efficiency wasp trap that, unlike other wasp
traps, does not cause swarming,” says
manufacturer WaspBane. The product is
used by “major” theme parks, zoos and visitor attractions. The
company says that the WaspBane trap has reduced sting rates by over
97 per cent when compared to low efficiency traps. WaspBane is
pesticide, toxin and pheromone free, and has a disposable self sealing
bait chamber that is designed to only need to be replaced annually.
Some 300,000 people are said to seek medical attention each year for
wasp stings. The Waspbane product is available for retail sale. There is
more information at www.waspbane.com.
WASPBANE 01480 414644
Panda pack redesign
“Soft eating” liquorice brand Panda has
been given a new look with redesigned
packaging across the entire bag range.
“Clear” on-pack tick boxes now feature on
all bags with “free from” and “suitability”
information designed to make it easier for
consumers to select products from the fixture.
Lisa Gawthorne, marketing manager for Panda, says:
“Ingredients integrity is the core to Panda’s continued success. There
are so many great things to shout about with the Panda brand.”
BIO STAT 0161 419 6307
ICP August 2007 33
market update
p33-34 AUG rev
6/8/07
15:21
Page 34
Market Update
“Lavish Loo”
Optrex ointment from POM to P
Boehringer Ingelheim Consumer
Healthcare has launched a new
consumer marketing campaign with
the introduction of the “Lavish Loo”.
The DulcoEase “Lavish Loo” will tour
outdoor festivals. The facility is
intended for women only and is
decorated in bright pink and blue and
“offers a luxurious alternative to
standard outdoor toilet facilities,” says the company. Kate Evans,
senior brand manager, Boehringer Ingelheim Consumer Healthcare,
makers of DulcoEase says: “We believe we will be one of the first
manufacturers to create a luxury loo of this kind for outdoor events.”
New Optrex Infected Eyes Eye
Ointment is available over the
counter from pharmacies without a
prescription. The antibiotic
chloramphenicol 1.0 per cent w/v
eye ointment has been reclassified from POM to
P status. Optrex now has a range of treatments for acute bacterial
conjunctivitis. Optrex Infected Eyes Eye Drops were launched two years
ago. Manufacturer Reckitt Benckiser says the benefits of the new
ointment include: no need for storage in a fridge and preservative-free.
The launch will be supported by a “comprehensive, accredited” training
package and the brand will be on TV with a campaign from October.
RECKITT BENCKISER HEALTHCARE 0500 455 456
POWERMED HEALTHCARE 0845 222 0555
New Actavis packaging
Actavis is launching new packaging across its range of generics. It is
designed to make it as easy as possible
for patients to take medicines
correctly and to minimise dispensing
errors. Jonathan Wilson, marketing
director, Actavis, says: “We have
worked closely with our customers
to ensure that the packaging meets the
latest guidelines to maximise safety and compliance.” The new
livery includes “vibrant, contrasting and distinctive colours” designed
to improve product recognition and highlight essential information.
Sara Vincent, UK country manager, adds: “Being the champions of
first class generics is our primary focus, but we are also boosting our
OTC offering through POM to P switches.”
Pharmacy prizes
To celebrate 30 years of Sudocrem in the UK,
manufacturer Forest Laboratories is offering
independent pharmacy customers the chance
to enter a prize draw to win one of six
Hamley’s teddy bears (worth £59.99 each).
Sudocrem Antiseptic Healing Cream is
claimed to be the “UK’s number one selling”
treatment for nappy rash”. Forest
Laboratories is also running a competition in association with Infacol
Probiotic Drops. It is offering pharmacists and pharmacy assistants the
opportunity to win one of six sets of £50 Marks & Spencer vouchers by
answering five questions. Infacol Probiotic Drops are a food supplement
designed to help maintain a healthy balance of good bacteria in a child’s
digestive system.
FOREST LABORATORIES 01322 550 550
ACTAVIS 0800 373 573
Ricola marketing campaign
As part of its winter marketing campaign, Cedar Health, UK
distributors of herb-based confectionery
Ricola, is investing £100,000 in a 30 day
“guerrilla” sampling program. Ricola
sampling will visit “major UK towns and
cities to boost the profile of the brand with
consumers”. During September, 250,000
free samples will be given away that carry
money off coupons and offer the chance to
win a trip to Switzerland for two people. The
sampling campaign will be supported by a national radio
competition which will see more Ricola products given away.
CEDAR HEALTH 0161 419 6307.
New Oilatum shampoo
Oilatum Scalp Intensive Shampoo is a new addition to
the Oilatum range of dermatological products.
Manufacturer Steifel Laboratories says: “ The product
comes with all the gentle qualities of Oilatum Scalp
Treatment, but, used twice a week, its maximum
strength formulation helps soothe and clear more
serious scalp conditions.” Oilatum Scalp Intensive
contains ciclopirox olamine, an anti-fungal agent,
salicylic acid, to help with the removal of “stubborn
flakes”, panthenol to nourish and condition, and
menthol, to soothe “soreness and redness”.
STEIFEL LABORATORIES 01628 411500
New counter unit
Cegedim Rx is offering pharmacists a service for recycling old computer
equipment. The company
says: “This is especially
important at the moment
with many pharmacies
upgrading their
equipment to take advantage of the N3 connection within the EPS
programme.” The company will collect the equipment directly from the
pharmacy and then dispose of it in a way that is “environmentally and
ecologically friendly” — further information from a Cegedim Rx account
manager by telephone or at [email protected].
GlaxoSmithKline Consumer Healthcare, in
partnership with Ceuta Healthcare, is
“renewing its focus” on EarCalm Spray and
Joy-Rides tablets with a new counter display
unit designed to raise awareness and “drive
sales” of these pharmacy only brands this
Summer. EarCalm Spray is the “first and only”
branded OTC treatment for mild outer ear
infections. Joy-Rides tablets can help prevent
motion sickness in adults and children aged
three years and over. The “colourful” counter unit features a consumer
leaflet with advice about ear infections but pharmacy advice is also
encouraged to ensure appropriate recommendation. The units can be
obtained by calling Ceuta Healthcare Customer Services.
CEGEDIM RX 0870 8411233
CEUTA HEALTHCARE 01202 780558
Cegedim Rx recycling service
34 August 2007 ICP
bishopstoke
AUG p35
2/8/07
15:21
Page 35
Bishopstoke Chronicles
In the wars
Battling proprietor Sid Dajani ends up a local hero
S
ometimes I feel that “disorganised”
and “incompetent” are tattooed onto
my conscience like “love” and “hate”
are on the fists of thugs. The
increased workload and pressures
mean that multi-tasking in doing all my
different jobs results in me forgetting the odd
thing like updating a standard operating
procedure.
My “to do” list goes into pages and there
are not enough hours in the day to tackle
even half of the jobs on it. Sometimes it
seems I never get off the starting blocks!
I am trying to reach my quota of patient
survey forms, complete my tax returns, carry
out medicines use reviews, train staff, help
my patients, undertake smoking cessation
clinics and so on.
If anyone can tell me if pharmacists,
especially contractors, are allowed the luxury
of “life and where to find it” I would be most
grateful.
Like a mermaid
When work is going well, time glides by like
a mermaid on a millpond, but when it is bad
it is like swimming against a tide of treacle.
And just when things are going well, things
can turn sour.
But something must be going right — my
staff and I achieved record-breaking
prescription figures last month and the
patient survey forms we have had back are by
and large highly complimentary.
The smoking cessation service for which we
have now been accredited is a roaring success.
We have recruited over 50 clients to date
and, though that may be a small number for
some, it makes a big difference to an
individual proprietor like me.
Out of all those who have reached the fourweek period, 80 per cent have successfully
quit and carbon monoxide monitor rates
prove this.
One person had an initial reading of 33
and this fell to 2 in just two weeks; his
breathing had improved so much that his
wheeze was markedly less pronounced. His
reaction adds to the immense job satisfaction
that drives my motivation and feeds my
enthusiasm.
The great success of my smoking cessation
service when there are many pre-existing
non-smoking cessation clinics run by
pharmacists and others proves there were at
least 50 potential quitters who couldn’t be
helped anywhere else; we have made all the
difference to them.
The smoking cessation clients have also
filled in patient survey forms as part of the
deal!
Did it really need to take two years for the
PCT to get us accredited for this? How many
more people could we have helped in the
meantime? Why were we the last to get
accredited? Will it take another two years
before we get accredited to provide
emergency hormonal contraception and
weight management clinics? Does the PCT
benefit by not allowing people more access to
such services?
”
Why were we last
to be accredited for
smoking cessation ? Will
it take another two years
before we get accredited
to provide emergency
hormonal contraception
and weight management
clinics?
”
Generics set-back
To dampen my spirits, new local GPs have
decided to go down the branded generics
route, which means I cannot at present
source many of the items. And to open an
account with another wholesaler will mean
losing discounts with my existing wholesalers
as I will purchase less. To add to my misery,
the GPs implemented the formulary changes
within two days of me being informed. This
is one nightmare I didn’t need and I can only
wonder what or where the next blow is going
to be.
I was so ecstatic with my aforesaid end of
month figures that I invited my staff to a
meal. As I parked my car to meet my hungry
staff in the restaurant an hour after we closed,
I heard a commotion right next to me. A big,
bald, burly man was protesting his innocence
to a newsagent owner who had accused him
of putting items into his pocket without
paying for them. I didn’t want to interfere,
but I thought it would be a sensible thing to
do to call the police.
At my mere suggestion of this, the big
man elbowed the owner in the chest,
knocking him to the ground, and, before I
knew it, I got a punch in the mouth.
Someone came out of nowhere and
grabbed the assailant from behind, by which
time I gathered my senses. Without wishing
to incriminate myself in this age of human
rights legislation — where victims of crime
end up as defendants in court proceedings —
my next move gave “big boy” reason to
reconsider his position. It certainly brought
tears to his eyes and stopped him in his
tracks.
Altercation resolved and threat removed I
straightened my jacket and spent an
enjoyable evening with my staff, although my
lip was beginning to swell and the pain got
worse as the evening wore on.
Sore lip
The next day, my lip was so sore I couldn’t
even smile and the bruise didn’t look good in
front of the customers. It looked as if I had
been in a drunken brawl!
I was relatively lucky though; the
newsagent turned out to have a broken
sternum, which was only discovered after his
second visit to hospital in as many days, and
another passer by ended up with stitches,
which meant there were people worse off
then me. It seemed churlish to seek to milk
the situation for sympathy.
I was grateful for the 11 or so new
prescriptions that people brought in when
they thanked me for helping out in the street.
As news got round, my cover as the mystery
saviour was exposed and I ended up on a local
radio news broadcast.
However, I wouldn’t recommend tackling
local thugs as a new contractual pharmacy
service or as a way of getting new business or
prescriptions. After all crime doesn’t
normally pay!
No part of this publication may be reproduced without the written permission of the publishers. Published by CIG Ltd © CIG Ltd. Colour Repro by Willows Focus. Printed by Grange Press, Brighton. ICP is available on subscription to
individuals working within the community pharmacy sector. Unbranded pictures copyright Photodisc/Digital Stock. Some of the editorial photographs in this issue are courtesy of the companies whose products they feature. The
publishers accept no responsibility for any statements made in signed contributions or in those reproduced from any other source, nor for claims made in any advertisements.
28120 Ind Com Phar 297x210
23/7/07
17:36
Page 1
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