Self-Selection Pressures

Self-Selection Pressures

Next time you are waiting outside a doctor’s surgery, imagine that instead of rummaging through some old golfing magazines, you could wander around looking at shelves full of empty packets of prescription only medicines. Perhaps you have a bad chest? Self-select some ciprofloxacin. Worried about your weight and your ancestors who dropped to the ground clutching their chests? Pick up a box of rosuvastatin. When your name is called, present your proposed treatments to your GP. What could be more empowering for patients? What could be the objection?

After all, you are protected by the fact you still need a prescription from a doctor.

In fact, this system already exists, in the form of Direct-To-Consumer-Advertising (DTCA) of prescription medicines. Common in the US, in the early 2000s there were attempts to soften up the EU and UK for DTCA by the pharmaceutical industry. Thankfully, we don’t have DTCA in the EU, but some arguments for self-selection of P meds in the UK seem very familiar to those for DTCA, particularly those surrounding patient access to medicines, and the final protection afforded by pharmacist supervision (in DTCA the doctor was the supposed final hurdle).

The same arguments against DTCA can also be used against P Med self-selection. Firstly drugs are not ordinary consumer items, even when used as per instructions they carry a risk of harm. Secondly, DTCA was primarily to provoke sales of medicines, self-selection clearly has the same strategic purpose. Finally, just as DTCA does not provide the information individuals desire about the medicine in the context of their own situation, reading the packs of P medicines does not put the medicine in the correct evidence-based individual context for a pharmacy customer.

The costs of prescribing in the US and rapid uptake of new drugs like Vioxx (later withdrawn) show both the effectiveness of DTCA on sales and the problems doctors had in mitigating its effects. Why put pharmacists in the same position with self-selection of P medicines? Pharmacists are already under immense pressure, with high levels of professional dissatisfaction. Placing them in a conflict situation with P medicines from the outset of a consultation (assuming they managed to get involved in the sale) is retrograde step.

Some might argue that many patients turn up with a particular product already in mind, but self-selection automatically sets up the encounter between the pharmacist and patient around a product, rather than leaving some potential to discuss the patient and condition. It potentially undermines the professionalism of the pharmacist by both devaluing the P med as an object on open sale “It’s only tablets.” and framing the encounter with the patient as a negotiation over the suitability of a specific product, rather than their actual health needs.

David Reissner has written a blog arguing that self-selection is a “good move”. The reasons he cites are as follows:

  • The sale of P medicines is an obvious way of helping pharmacy owners claw back their slashed NHS income.
  • The GPhC has ample powers to prosecute anyone who sells a P medicine without supervision.
  • All sales with still require supervision by a pharmacist.

Hardly compelling. Selling P Medicines should be on the basis of clinical need, made as part of a professional encounter between a pharmacist and a patient, not provoked as part of a sales drive.

As for the supervision and GPhC powers, the recent Which? report, and other academic work, has shown we already have problems with the supply of P medicines. Are we really in a place where self-selection is going to benefit patients? This isn’t a piece criticising pharmacists, it is quite clear that pharmacists can contribute massively to primary care through minor ailment schemes, but the self-selection move is a misstep that makes the false assumption that access to medicines an inherent good. The most important part of being a pharmacist is knowing when a drug is and isn’t required. Making the latter judgement harder to arrive at benefits no-one, least of all patients.