Who does the clinical check in a Dispensing Drs?

The GP writes a prescription for simvastatin 40mg and hands this to the patient. The patient was already taking 20mg for a good ten years…

Image Courtesy of WHO Archive 1997

The GP writes a prescription for simvastatin 40mg and hands this to the patient. The patient was already taking 20mg for a good ten years, but after a recent blood test and review, the strength has been increased. The patient takes this prescription to their local pharmacy, where the counter staff hands the prescription to the dispensary assistant who process the prescription and hands this to the Pharmacist for checking. A notification came up regarding an interaction, but the patient has the medicine before, just a different strength so the dispenser did not flag this with the Pharmacist. The Pharmacist clinically screens the prescription and phones the Doctor. The PMR shows the patient is also taking amlodipine 10mg and there is a black dot interaction between amlodipine and simvastatin and 40mg simvastatin in this instance is regarded as ‘off-label’ use. The Doctor was unaware and after a conversation with the Pharmacist, reviews the patient with the aim of changing them to atorvastatin, as recommended.

This scenario above may seem trivial, but happens too commonly (I had one recently). The combination of amlodipine and 40mg simvastatin can increase the risk of myopathy and/or rhabdomyolysis which are potentially fatal, an interaction the MHRA has published guidance on. Therefore the clinical intervention of the Pharmacist was key in preserving patient care. Should harm have been done to the patient, the Pharmacist and the Doctor would have both been liable (not the dispenser who had first instance access to the PMR and flagged passed the interaction).

In a Dispensing Doctor’s, what would have happened in the above scenario? Who does the clinical check? Even in Community Pharmacy, there is a second dispensing check. So why is there a difference when it comes to Dispensing Doctors and a second clinical check? In hospital, during my cross-sector placement, medicines were not issued without a Pharmacist signing off on it, so why in Primary care?

I have also found patients speak to their Pharmacist when it relates to medicine-pregnancy interactions which they may not have mentioned to their Doctor. Can a dispensing technician make such a clinical decision and understand the clinical trial data for the patient?

The mentality of a few Doctors with respect to this is unfortunately arrogant. About 4 years ago, during the summer of my first year, I was told by a registrar Doctor that there is no need for a Pharmacist. A Doctor can do the job of a Pharmacist just as well, that is why there is such a thing as Dispensing Doctor. They went forward saying how they can walk into any pharmacy and know what they are doing. Quite unbelievable. Thankfully most Doctors are not like this.

With the cuts in Community Pharmacy, many Pharmacy owners are distraught about the way their business will be affected, let’s compare the dispensing fees — the primary way both a dispensing Doctor and a Community Pharmacy earn their money. In both cases, they are paid a Dispensing Fee per item dispensed against an NHS prescription. Recently, in Community Pharmacy this has changed to include all fees into 1 ‘Dispensing Fee’, whereas in Dispensing Doctors, the fee is a sliding scale on the quantity dispensed. The PSNC states, that Community Pharmacy earns a Dispensing Fee of £1.13 (as of 27th March 2017). The Dispensing Doctors Association states that Dispensing Doctor’s earn from £2.149 to £1.903 depending on the number of items they dispense (From 1st April 2016). What is the additional fee for?

However there are reasons for the existence of Dispensing Doctors, but in reality, where there are no longer a shortage of Pharmacists (but in fact a shortage of GPs), and the role of Pharmacists becoming more clinical and more patient facing, should there really be an excuse where there are medicines without a Pharmacist?

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