This week of rotation was to give us a chance to see life in a community pharmacy. Before I tell you about it I thought I'd explain the structure of the next few posts. I figure, since I did mostly the same thing everyday I'll go ahead and devote and entry to what life in the pharmacy is like. A following post will contain the touristy things we did during the evenings this week. So, no pictures for this post.
Ashlyn and I were each assigned different pharmacies to attend for the week. They were both independent pharmacies, though there are big chain pharmacies here. The biggest chain pharmacy is Boots, which is similar to a CVS/Walgreens/Rite Aid except more welcoming. They have nice layouts and Ashlyn and I have even spoken with a Boots pharmacist about pharmacy in the States one day when we stopped in for some purchases. But, like I said we were assigned to independent pharmacies which was interesting for us because both Ashlyn and myself have worked in the independent pharmacies in the States. Ashlyn was assigned a pharmacy in Central London and I was assigned a store in the far reaching corner of the London Borough of Lewisham in the neighborhood of Grove Park.
I should start with getting to the pharmacy. Luckily, I could take a bus directly there (the 136 to Grove Park). The only problem is that the 136 is potentially the most unreliable bus route in the history of all bus routes. There were days when I left the house 10 minutes early and arrived to work 10 minutes late and days were I left the house 15 minutes late and arrived to work 10 minutes early. You never know when the bus is coming, which could potentially be why people don't seem to get as irritated when others are late. If you left it up to the 136 bus you'd have to leave at a ridiculous time to insure you arrived in a timely manner. The bus ride is between 20-30 minutes depending on how many people were on and and how long it takes to load and unload at stops. I'm not sure that I've clarified this, but when you ride a bus in London those are the double decker red buses you see when you think of London. I always thought those were tour buses, but that are actually legit transportation. So, there's something to make Atlanta's MARTA buses look even worse. As I may have mentioned before London has the most expensive transportation in the world and a bus fare (whether you're going one stop or ten) costs £2.00 without an Oyster Card and £1.35 with one. We pay for the unlimited pass at £29.99 a week, so I don't have to worry about that. It's hard to decide if you are getting a good deal (besides the 136 inconsistencies London transportation far surpasses that of any other city I have been to in the States or internationally) or if you are getting ripped off. The 136 bus has to pass through some nice and not so nice areas. In runs right through the neighborhood of Lewisham, which I was consistently told was not a good place to be. When I asked why, they said I would get my bag stolen. Interesting perspectives. When I tell someone not to go somewhere in Atlanta, my usual reasoning is, "you might get shot," which makes getting your bag stolen look like a cake walk. Either way, passing through various neighborhoods with their mixtures of socioeconomics makes the bus ride interesting to say the least. It basically ends up looking like the "People of Wal-Mart" website, but with British accents. There are also always teenagers who I think should be in school, but aren't. Including one who I'm 99% sure was wearing an ankle bracelet. That's the 136 for you.
The pharmacy I am at is in a small strip mall within walking distance of a Tesco Express. Tesco is a grocery chain. They have big Tesco's that are similar to like a Super Wal-Mart and also small stores at gas stations. I also went past a Tesco Extra once, but I'm not sure what made it extra. Anyways, they have good pasta and sandwiches that you can grab and go with. They also have candy, so each day I tried another candy bar. Bad for my health, but you do what you have to do to get cultured. Cadburry is the main candy here (as popular as Hershey's back home). Sorry, for getting derailed, but I figure if you're reading this in the States Tesco means nothing to you, but it's major here so I wanted to explain. Independent pharmacies here are just smaller in general than at home. My store is long and narrow and sits adjacent to a train track so you have to get used to the entire building shaking every 15 or so minutes. The pharmacy floor plan is long and narrow with a small behind the counter area. Even with such little space they managed to fit one pharmacist, six technicians, a pre-reg (equivalent to me) and me. They have really figured out how to work in a small space. They have a computer system that works fairly similar to how ours works in the States with one HUGE difference. For us, when a prescription is filled electronically the information goes directly to the insurance company (private or federal) so all the payment and reimbursement is handled right then. Here EVERY, SINGLE paper prescription must be mailed to the NHS (the National Health Service) to be processed. Meaning it often takes the pharmacy two months to get their payment. This is how things used to be done in the States, before the internet existed.
At this point I will explain community pharmacy here further in question and answer format to keep me on track and to hopefully not confuse the few people who will actively read this.
Since they have nationalized healthcare in the UK how are the medications paid for?
Good question! There is an option to get your own private insurance in the UK (but it is expensive, much like getting your own plan in the States is expensive if you are self employed, etc.) Medications are paid for by the NHS, discussed earlier. Every prescription carries a one time fee of £7.65. No matter how much the medication costs (expensive or cheap) or how often you get the medication in the year you pay this one time fee per new prescription. There are certain exemptions. People who are exempt do not pay this fee. They include children under 18, pregnant women (and those 1 year post giving birth), those with diseases such as diabetes, those with severe handicaps and the unemployed. Much like the debate here it seems everyone I talked to does not like the fact that the unemployed don't have to pay. It's funny that they can't believe that in the States our insurance will reject medications the doctor wants us to take. They just looked at me dumbfounded. If you think you will be getting a lot of new prescriptions during the year you can pay a one time fee of about £140 and then you get your medication unlimited.
Do they have to wait a long time to get their medications since governmental bodies are always slow?
No. It is true that they often have to wait for non emergency procedures, etc but medication is not a wait. They bring their prescription to the pharmacy and get it filled just as you would in the States, but with one exception. They are not given refills on their prescriptions. They either must get in contact with their physician or have the pharmacy send the physician a list of what they want. This theoretically would lead to a wait as physicians offices or "surgery" often take a while to get back in touch. Luckily, they are allowed to give 30 days of a medication (with the exception of narcotics) if they haven't heard back from the physician.
Speaking of narcotics how are those regulated?
Narcotics are regulated pretty tightly, just as they are at home. Interestingly, they don't use hydrocodone (the main ingredient in Lortab). Each narcotic prescription is written on a special, blue colored prescription pad and then must be organized and sent to the NHS for a review/audit every month. In the States the drug methadone (often used to help treat narcotic addiction) can only be filled in a pharmacy if they physician has clearly stated the medication will be used for pain. If the medication is being used to wean a drug addiction then the patient has to go to a "methadone clinic" and be given their dose there. In the UK pharmacists are in control of this process. The physician writes the prescription and the patient comes to the pharmacy where they are given the dose and watched by the pharmacist to ensure they took the entire dose (some patients do not have to be watched - this decision is made by the physician). My pharmacy used about 2 liters of methadone a day. Which is a TON. Speaking of regulation, in the States you have to sign and show identification for Sudafed or any product containing pseudoephedrine due to the way it abused and used as an ingredient in Meth. Here it is kept behind the counter, but there are no real regulations. I've discussed this with a few different people and apparently Meth use it just not an issue over here.
What other products are kept behind the counter?
While in the States we have really just began to have prescriptions kept behind the counter that you can buy with the pharmacists approval, over here this process is much more defined. Some things we can't get over the counter such as APAP with codeine (Tylenol #3) and Volteren gel can be purchased if the pharmacist reviews them with you. Ibuprofen is also kept behind the counter. There are other drugs you don't need a prescription or to talk to the pharmacist to get. My two favorite are generic Zovirax (for fever blisters) and generic Flonase (nasal spray for sinuses). They are OTC and very cheap here, which is interesting as they are prescription only and break your bank expensive in the States.
Is there anything a pharmacist in the UK can do that an American pharmacist can't?
Not really. I've been told pharmacists can immunize (just as we do), but no one seems to do it or show much of a desire to participate. They can run the methadone supervision as mentioned above, but for the most part they can do the same things. They offer MUR (Medication Use Review) to patients yearly and they can get reimbursed by the NHS for up to 400 of these patient counseling sessions. They also participate in smoking cessation and they are required to do weekly follow ups with patients who have started new, higher risk medications for the first four weeks. Pharmacists in the States can do all these things as well, but typically get no reimbursement. The big difference are the techs. Pharmacy techs in the UK get a lot more training then in the States and thus can often legally do the final medication check after the pharmacist has approved the original written prescription.
Who gets paid more?
We do, by a landslide.
What do they think about our healthcare system?
Overall, I have gotten the same feed back from everyone I've talked too. No one understands why we let insurance companies bully us. They love that healthcare workers get paid more and that there is very little wait time for most procedures. They do not love how much prescriptions can cost us and they can't even fathom the concept of how much you might have to pay out of pocket to meet your deductible (a concept they've never heard of). In addition, they can't believe how much we pay to go to grad school (thus leaving so many students under mounds of debt). We've often heard people say they don't mind getting healthcare that isn't as speedy as we have because theirs in "free." Ashlyn and I often remind them that their healthcare isn't free, they pay for it in taxes. The NHS is struggling for funding, so slowly more people are moving to a more privatized world. And I'm not saying America is right, because we have healthcare areas that MUST be adjusted, but as of right now I'll keep getting my medical care in the beautiful United States of America, even though I could potentially loose my house and life savings in the process. My favorite people to talk to are those who have lived in both countries. They all have pretty good things to say about America and how we do things.
This was a very informative week for me. Even though I often just stood around observing and asking questions I was able to help dose pack some medications. I also spent a good time reading the British National Formulary (BNF), their drug reference source and was shocked to find they have antibiotics we don't use and vice versa. I was able to counsel a patient on how to use his new inhaler and as education has always been my favorite thing it felt good to be able to help a little bit. Other highlights of the week included discussing American food and candy (jealousy over how many M&M flavors, free refills and me trying to explain what a biscuit is), the reason everyone should go to Las Vegas, popular television in America and American football. It always amazes me when people find American stuff interesting as I just find it boring. My favorite thing to happen all day was when I told them the morning after pill is branded "Plan B." Over here it has a much more fancy, floral sounding name. Everyone laughed for a quite a while about that one.
When I left on Friday afternoon I felt I had made some new friends, but I won't miss that 136 bus ride.
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