Lessons from Hungary
LPC chairman Dilip Joshi casts an enviable eye over Budapest pharmacies in a break from his routine of practice and challenging meetings
Wednesday February 1
I am attending a Lambeth Borough Prescribing Committee meeting today and meet the local medical committee (LMC) secretary, who is new. In the past, the LMC felt the committee would adequately reflect the view of GPs as practitioners, but recently, a rift appears to have developed between the (largely GP-controlled) CCG and the LMC. Many of the targets and initiatives foisted upon GPs are unwelcome and have had a negative reaction from practitioners. The divide-and-rule policy appears to have caused tensions between GP federations, the CCG and the LMC. At the event, some prescribing targets are softened with the robust input of the LMC secretary. There is a discussion on surgerybased pharmacists. Surgeries are compared according to how much money these pharmacists have saved instead of patient benefit. A hospital-based cardiovascular specialist pharmacist reports that increased prescribing of anticoagulants has led to a significant reduction in predicted stroke numbers. I point out that cost reduction in isolation does not necessarily result in better outcomes and get support from the LMC rep, who suggests there should be better links between GPs and community pharmacists. I feel our similar agendas might make us allies in future discussions with commissioners â€“ even with GP-led CCGs.
Wednesday February 15
Partial decommissioning of the Minor Ailment Scheme (MAS) is an agenda item at a Lambeth CCG medicines management meeting today. â€œWe are overspent on budgetâ€ is now a phrase that I seem to hear at every meeting I attend. The scheme has been a victim of its own success and is apparently valued enough to continue but will be offered from fewer sites in an attempt to save money. I speak to theÂ CCG chair later. He does not attend these meetings and simply says there is no money. Furthermore, he says the Greenwich scheme where GPs are asked not to prescribe OTC medicines is being considered. There is mention of self-care and patient empowerment but he privately confesses that it may take a long time (and more money) to reverse some of the problems being stored up. I protest that deprescribing (ie, reducing or stopping medications that may no longer be of benefit) as well as scaling down the MAS will reduce access to medicines disproportionately for the most disadvantaged in our community. This would have a huge negative impact on the much-trumpeted aim to reduce inequalities. I truly believe the CCG chair is sympathetic but his hands are tied by policies with which he is patently uncomfortable.
Tuesday February 21
An 82-year-old patient walks to my pharmacy using a stick. He is tired and out-of-breath and speaks to staff with a loud voice, clearly upset. He demands that we change him from weekly dosettes to monthly dispensing and only believes three out of his four tablets are working. I speak to him to understand his underlying problem, which turns out to be the time it takes to walk to the pharmacy. He lives alone. His family feels, he says, that he is too old to bother with. It takes him 14 minutes to get to his bus stop instead of four. He says this is to illustrate his point since he does not need to get a bus to reach us. He also says that he had been happy taking three tablets daily and did not like his doctor adding a fourth. This patient is an example of someone with multifactorial issues and is typical of many people colleagues see in everyday practice. There is an adherence issue as well as social care problems and I explain the importance of taking medication as prescribed. I arrange weekly deliveries so he doesnâ€™t have to walk to the pharmacy and promise to contact social services on his behalf; apparently, he had contact from social care through his doctor three years ago, but â€œgave up on themâ€ when there was no response to his calls. I reflect on how many such patients would slip through the net without a community pharmacist getting involved and lament the fact that we have no recognition for this work from paymasters â€“ although patients are very appreciative.
Monday February 27
I am in Budapest for a few days (fashionably described as a city break), but cannot help visiting community pharmacies during a walk. Their bright, clinical environment impresses me and I wonder if the confidence enjoyed by community pharmacies in Hungary is due to a vibrant independent sector. Since the introduction of a new law in 2011, the rules governing pharmacy ownership in Hungary have been made stricter, in spite of lobbying by European chain owners. The purpose of strict requirements is to protect the interests of local individual private pharmacists by excluding (typically non-Hungarian) institutional pharmacy chains from the market. In new pharmacies, at least 51 per cent of the shares must be held by local, individual pharmacists and, during 2017, there is an obligation on investors to sell at least 51 per cent of the pharmacy to the pharmacists, thus effectively putting all pharmacies under the control of individual local pharmacists. There is an additional restriction limiting the maximum number of pharmacies owned by one individual pharmacist to four, with the evident intention of outlawing pharmacy chains. I am not sure if this model will ultimately be able to resist challenge from European courts, but small certainly appears to be beautiful in Hungary â€“ for the time being.