Superheroes don’t all wear capes

I was invited to speak at the Association for Prescribers’ Annual Conference last November. Being of a bolshie disposition, I chose to ask whether our prescribing is really patient-centred. Of course, we’ll all say it is, but when you look at some of the prescribing policies that commissioners seek to introduce you have to wonder whether the patient’s needs are coming second to the organisation’s priorities, particularly to keep saving money.

There is no pot of gold, but on the other hand pharmacy has met savings targets over and over again when other functions within CCGs have come nowhere near doing so. If the pips are not squeaking it may be because they have already been fully crushed.

Couple this with regular comments from patients in practice satisfaction surveys that they no longer feel that they have a personal GP, and you might wonder who is looking out for the patient. Patient advocacy groups complain that they are not listened to, local government complains that it sees no action from its comments, and the one potentially consistent voice the patient has is their pharmacist.

So how do pharmacists rise to this challenge and influence others to advocate for their patients? This is exactly the kind of practical question that we will be addressing in the 14th series of PM Academy meetings starting at the end of April. You can book your place at www.pharman.co.uk/events.

The value of values

What is a sea view worth? According to a holiday brochure just received, the answer seems to be £6.44 a night, because the supplement for an ocean view cabin for a 9 night cruise of the Greek islands is £58. On the other hand, it’s also £58 for 5 nights in the Norwegian fjords, so presumably the Norwegian coast is 1.8 times as desirable. Whether that is actually the case depends on whether our assessment of the value of these experiences tallies with the cruise companies. If it is, we’ll pay the extra. If we think it isn’t, we don’t. As a tall person, I don’t often think the extra legroom seats are good value on short flights, but there’s a price I am willing to pay on long ones. Even then, I draw the line at paying an extra £150 each way, but I’ve paid £60.

This is an example of the difficulty of comparing the value of benefits when they are not expressed in cash, and it is a major problem for healthcare, because when we make business cases for interventions we commonly have to reduce everything to money and pose the question “Is this a good use of resources?” This process might work if judgements were objective, but often they are not. For example, the value of saving the sight of an eye depends upon whether it is the first or second eye. Should we be prepared to spend more on treating the hand of a concert pianist than a roadmender?

The standard NHS approach is to use Quality Adjusted Life Years, or QALYs. This a good attempt to reflect that extending a life is less valuable to some than others, but it has limitations. There are some people whose quality of life is so bad that they would objectively be better off dead; that is, a QALY value <0. And back in 1987 John Harris pointed to a concern about the way in which we use QALYs that he called the double jeopardy. His argument was that if someone is disabled such that they will never again have a QALY of 1, they will be disadvantaged in any resource allocation based on QALYs because they can never benefit as much as the rest of us, although a move from 0.2 to 0.3 may make more of a difference to those patients than a move from 0.7 to 0.9 in others. The counter argument is that we should be rating the expected improvement of an intervention regardless of prior impairment and comparing it with other interventions on the same basis, so the starting point of any particular patient is irrelevant. And the counter argument to that is that if the entire class of patients requiring a particular intervention are starting from a low base it may be that no intervention for them will pass the benefits threshold that sees them introduced.

In the next series of the PM Academy we’ll be looking influencing decision making. This is not just about influencing the things that affect us personally. How we demonstrate value in the things that we care about and do is also an issue.

The same, only different

NHS England has set a target for the uptake of biosimilars. In order to save £200-300m p.a the aim is that at least 90% of new patients will be prescribed the best value biological medicine within 3 months of launch of a biosimilar medicine, and at least 80% of existing patients within 12 months, or sooner if possible. That is a fairly challenging target for many health economies.

The difficulty that immediately springs to mind is that the users of the originator drug may have no real incentive to switch. They’re happy with what they’ve got. They’re reimbursed for what they use, so they have no financial incentive. And from the quality point of view, they know the characteristics of the treatment they’re using, whereas there may be a little question mark in their minds as to whether the new product will prove to be as satisfactory in practice as it has apparently been in clinical trials.

So how does the commissioner encourage change? One or two commissioners may decide simply to tell providers what they expect them to do, or to use financial penalties if they do not switch promptly. However, there may be good clinical or service reasons why an abrupt change is unwise.

This is just one of the questions we will be addressing at our Biosimilars conference on 1st November. You’ve never had an opportunity like this to discuss the introduction of biosimilars with all stakeholders present. We’re working with UKCPA, the British Oncology Pharmacy Association (BOPA) and Rheumatology Pharmacists UK to make this a day to remember. Come and be part of it.

Agenda and booking at https://www.pharman.co.uk/events/2017/11/biosimilars-how-will-pharmacy-manage-the-challenge

Invictus

Sometimes the story behind a poem or article gives it extra point. I was musing on this recently when I read a short biography of W E Henley, whose poems I vaguely remember being instructed to read at school.

If the name is familiar, that is probably because he was the author of the poem Invictus, which inspired Nelson Mandela among others, and which contains at least three well-known quotations. My primary school’s motto was Invicta, which may have been why we were encouraged to read Mr Henley’s work.

The sentiment behind Invictus is more striking – and more painful – when you know something of his life. Henley suffered as a teenager from tuberculosis, which entered his bone and caused the amputation of one of his legs when he was just 19. The surgeon wanted to remove the other foot too, but Henley refused and his foot was saved by Joseph Lister, no less. Henley spent three years in hospital during this treatment, where he wrote a volume of poems, including Invictus.

Robert Louis Stevenson was a friend and later wrote that he based the character of Long John Silver on Henley, a testimony to Henley’s refusal to allow his disability to restrict him or to seek pity for it.

Henley married and had a daughter. Sadly she died at the age of 5, but J M Barrie immortalized her when he created the character of Wendy in Peter Pan. Eventually Henley succumbed to tuberculosis at the age of 53.

The next series of the PM Academy will be looking at resilience, the ability to keep going regardless, which is, perhaps, the reason why Henley is in my mind, because Invictus expresses exactly that note of being able to cope whatever is thrown at you.

Out of the night that covers me,
Black as the pit from pole to pole,
I thank whatever gods may be
For my unconquerable soul.

In the fell clutch of circumstance
I have not winced nor cried aloud.
Under the bludgeoning of chance
My head is bloody, but unbowed.

Beyond this place of wrath and tears
Looms but the Horror of the shade,
And yet the menace of the years
Finds, and shall find me, unafraid.

It matters not how strait the gate,
How charged with punishments the scroll,
I am the master of my fate:
I am the captain of my soul.

Guest blog – locum governance

From time to time we offer our pages to partners. Here Seán Webb of Locate a Locum discusses the importance of ensuring compliance.

In such a highly regulated industry, where lives are on the line, compliance is key to both pharmacists and hiring managers. We’ve recently seen stories of fake doctors working within the NHS, putting institutional reputations and lives at risk.

Pharmacy owners, hiring managers and locum coordinators place a huge degree of trust in the agencies that they use to fill shifts, but where does the responsibility lie for ensuring that workers hold the required documentation and have amassed the desired experience? Is the agency model transparent enough?

Locate a Locum’s robust compliance methods have ensured transparency, thus changing the traditional recruitment model.

We do not let anyone register on our booking platform unless we can first verify the GPhC or PSNI/PSI number that the individual has claimed to own. This process has ensured that only registered pharmacists can access our booking platform and only then can they begin to build a profile that is visible to employers. That’s a very important factor to us, we empower employers to view the profile of those whom apply for shifts within their pharmacy.

After we approve someone’s account, we then embark upon a CPD-focused, document gathering exercise to prove that said pharmacists hold the qualifications they claim to have. Depending on the hiring pharmacy, they require a variety of specific qualifications. Some insist that pharmacists have their Dementia Friend Training certificate, others insist that locums have their Repeat Dispensing accreditations. We require all pharmacists to have an up-to-date DBS or police check before we allow them to work through us.

As pharmacists build their profile, they store documentation within their accounts so that their experience is as transparent as possible for hiring managers to see. By doing so, we give power to the hiring pharmacy and locum coordinator to decide on who to hire.

The final bit, and most recently developed piece of our technology with regards to compliance, is our new facial and document recognition software. Before any pharmacist can apply for their first shift, they will take a photograph of their documentation, using their web cam or telephone camera. They then take a photograph/selfie and our technology can verify the identity of the locum, in correlation with the proof of identity that they have provided.

The result of our checking processes and the technology that we have invested tens of thousands of pounds in, is that the hiring manager can choose the pharmacist of their choosing with the certainty that they are who they say that they are, and that they carry the necessary qualifications and experience. Locate a Locum’s compliance checks and pharmacy empowerment means that the best pharmacists gain work.

Our booking platform and its built-in compliance features mean that hiring managers are booking pharmacists directly in less than one minute, without the added cost and time created by traditional agencies.

Interested? Find out more at www.locatealocum.com