Cover -August rev 6/8/07 10:49 Page 1 NO 200 AUGUST 2007 ВЈ3.25 In partnership with In this issue Page 14 What makes Fiona Cruickshank tick Page 17 Pharmacy вЂњspecialsвЂќ market still growing Page 26 Automating the dispensing process Page 29 Improving compliance in the community Is their medication ending up where it should be? Dysphagia, or swallowing difficulty, is a much more widespread problem than you might think.1 It leaves many people, especially the elderly, struggling to swallow their medicine and often leads to it being thrown away. Such non-compliance has serious consequences in that it can lead to poor outcomes, hospitalisation or even patient death.2 It also costs the NHS over a billion pounds a year in wasted medicines and the costs associated with adverse clinical outcomes.3 ThatвЂ™s why it makes sense to give people who canвЂ™t swallow solid medicines a more appropriate formulation such as a liquid - and the sooner this is done the greater the difference it can make in terms of improved compliance and patient welfare. Rosemont specialise in liquid medicines offering solutions across a wide range of therapeutic areas. Rosemont TM References: 1.Strachan I, Greener M. Medication-related swallowing difficulties may be more common than we realise, Pharmacy In Practice December 2005. 2. Richard Griffith, Medication Management and the law 2 вЂ“ Residents With Medication Related Dysphagia 2006. 3. Greener M. JME 2006; 9: 27-44. The source of liquid solutions. Rosemont Pharmaceuticals Ltd. Rosemont House,Yorkdale Industrial Park, Braithwaite Street, Leeds LS11 9XE T +44 (0)113 244 1400 F +44 (0)113 245 3567 E [email protected] Sales/Customer Ser vice: T +44 (0)113 244 1999 F +44 (0)113 246 0738 W www.rosemontpharma.com Information about adverse event reporting can be found at www.yellowcard.gov.uk Adverse events should also be reported to Rosemont Pharmaceuticals Ltd on 0113 244 1400. BP3526 Revised A4 LomaBrit Ad 22/1/07 15:20 Page 1 Something to smile about... A natural way to keep lips healthy Damaged, dry or chapped lips can create problems for health and wellbeing at any time of year, but particularly in Winter, so keeping lips in good condition at this time of year is always essential. Regular use of LomaBritВ® Lip Salve moisturises and protects lips to help keep them in good condition and looking healthy. The active ingredients in LomaBritВ® include an extract of Melissa (Lemon Balm) - a herb well-known for its restorative qualities since ancient times. 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For further information contact: Britannia Health Products Ltd, 41 - 51 Brighton Road, Redhill RH1 6YS Telephone: 01737 781410 Web: www.britannia-health.co.uk Available from AAH Pharmaceuticals Ltd: code LOM32V Ref: Wolbling RH, Leonhardt K. Local therapy of herpes simplex with dried extract from Melissa Officinalis. Phytomedicine 1994: 1 вЂ“ 25-31 Contents August rev 6/8/07 15:08 Page 1 ICP August 2007 Contents 6 Pharmacies hit by floods Editor Douglas Simpson, FRPharmS Pharmacies in Gloucestershire had to be adaptable after they were hit by floods, according to Peter Badham (right) Staff Writer Rebecca Derrington, BA 020 7534 7235 Rebecca [email protected] 6 NPA online stock scheme The National Pharmacy Association is a partner in a new scheme for exchanging pharmacy stock Designer Bil Brooks 8 IPF memberвЂ™s Pfizer solution Contributors Brian Collett, Steve Bremer, Sid Dajani, Gerry Green, Victoria Goldman, Mark Greener, David Parker Graham Phillips, a leading member of the Independent Pharmacy Federation (left) has a cure for вЂњPfizer syndromeвЂќ 9 Meeting the needs of animals Advertisement Director Julian de Bruxelles 020 7534 7233 [email protected] A leading veterinary surgeon, Professor Bob Michell (right), says pharmacists need to be educated to meet the needs of animals 16 Doctor dispensing Publishing Director: Paul Beard 020 7534 7236 [email protected] Doctors show no sign of wanting to curb their dispensing, reports business correspondent Gerry Green Chief Executive: Felim OвЂ™Brien 22 Oral health The health of the nationвЂ™s teeth is declining The official journal of the 32 100-hour contracts The difficulties of making them pay can be insuperable Circulation/Subscriptions The National Pharmacy Database, Precision Direct Marketing, Precision House, Bury Road, Beyton, Bury St Edmonds IP30 9PP. Tel: 01284 718912. E-mail: [email protected] Annual subscription rates including postage are ВЈ65 for the UK and ВЈ85 overseas, including postage Published by: CIG Ltd, Linen Hall, 162-168 Regent Street, London, W1B 5TB Tel: 0207 434 1530 Fax: 0207 437 0915 E-mail: [email protected] A Communications International Group Publication Member of the Audit Bureau of Circulation Regulars 4 Leading articles 16 Business Monitor 6 News 17, 22, 26 Special Features 8 The IPF Page 29 Clinical Focus 9 Opinion 32 Business Focus 12 WitheringвЂ™s Wisdom 33 Market Update 14 The ICP Interview 35 Bishopstoke Chronicles For the leading specialist lender in the Independent Pharmacy sector visit, www.medicalfinancelimited.co.uk For more information call: 01275 462 665 ICP August 2007 3 Leader-August rev 2/8/07 14:13 Page 4 ICP Leading Articles Patients can have more than two legs P rofessor Bob Michell is a good friend of pharmacy. He is one of the Privy Council nominees on the Council of the Royal Pharmaceutical Society and serves the profession with great energy in that role. He is a veterinary surgeon and so he can be expected to be вЂ” and indeed is вЂ” an authoritative voice when it comes to matters to do with the health of animals. When he tells pharmacists, as he does in a specially commissioned article this week (p9), that they are in danger of missing out on a great opportunity in veterinary medicines supply, it is a warning that carries great weight and should be heeded. The new opportunity stems from an Office of Fair Trading report that called for the monopoly that veterinary surgeons enjoyed in the supply of prescription medicines to be ended. The government duly obliged, but only to find a pharmacy profession unprepared to exploit the new situation. Professor MichellвЂ™s main solution to this problem is to change the undergraduate curriculum, so that graduates coming out of schools of pharmacy are fully conversant with the use of medicines in the veterinary field. But it would be many years before such graduates emerged and so something else is needed in the short term. Professor Michell suggests that this gap be filled by pharmacists working more closely with veterinary nurses. Whatever solutions are developed, responding to the new situation will be something that pharmacists will find difficult to tackle by themselves. Their representative bodies need to be more proactive. A concerted effort is needed. It is alarming, to say the least, that Professor Michell describes pharmacyвЂ™s principal representative body as вЂњasleep at the wheelвЂќ on this issue. He is, after all, in a position to know. Three in a row The announcement that Jeremy Holmes is to be the new chief executive of the Royal Pharmaceutical Society (see p6) makes it the third time in recent months that top posts in pharmacy formerly held by members of the profession have gone to non-pharmacists. First we had Christopher Hodges getting the job of chairman of the Pharmaceutical Services Negotiating Committee (ICP April, p6). Next it was Alison White being appointed as chief executive of the National Pharmacy Association (ICP July, p6). Now we have Mr Holmes. Time was when non-pharmacists would not have even been considered for such posts. Now, it is generally accepted that an external perspective is needed if the profession is to achieve its full potential. 4 August 2007 ICP news P6  rev 2/8/07 14:16 Page 6 News The Floods Exchanging Stock Pharmacies hit by deluge New online service Badham Pharmacy, a small chain of seven pharmacies in Gloucestershire, was among businesses caught up in the recent flooding. Speaking on July 26, Peter Badham, managing director of Badham pharmacies, said: вЂњOur pharmacy in BishopвЂ™s Cleeve was very close to being flooded; about half an inch away. The only thing that stopped it was the step up to the shop. We placed sand bags to stop any water getting in. The road outside looked like a river.вЂќ Badham pharmacies remained open during the floods although they experienced problems and disruptions to services. There were power failures and a lack of water supplies. However, the dispensing delivery service was kept running by the businessвЂ™s vans. In places where the roads were impassable staff members proceeded on foot. Mr Badham said: вЂњWe have only been able to keep the pharmacies running because of the support from our staff, who have been going above and beyond the call of duty.вЂќ When power failed, staff used torches to help customers find what they needed. The customers themselves have also been supporting the pharmacies. Mr Badham said: вЂњOne patient even brought in a collection of candles for the staff to light the pharmacy.вЂќ Lack of power also meant pharmacist couldnвЂ™t print labels and enter data into patient medication record systems, which had to be done at a later date. The local community was warned that there could be a water shortage and so the staff began collecting fresh water in containers for dispensing purposes. Pharmacists were asked to ensure they provide information on low sodium bottled water for use by babies as some of the bottled water given out free had too high a concentration of sodium. Professional secretary for Gloucestershire local pharmaceutical committee Evelyne Beech, commented on July 26: вЂњThe primary care trust mobilised a supply of water to pharmacies.вЂќ Before that pharmacists had to bring bottled water for dispensing and drinking. Gloucestershire LPC and PCT helped healthcare providers in the area, including co-ordinating a driver to collect supplies and providing support staff to pharmacies, such as extra technicians. The National Pharmacy Association and Rxchange Ltd have launched an on-line pharmacy stock exchange system. Called Rxchange, the system provides pharmacists with the means to trade stock that is short dated or is surplus to their requirements. It has had a 3 month trial with 400 active users. The online system has sections for buyers and sellers and search facilities to find stock a pharmacist is in need of. The exchange system is designed to eliminate waste. It is subscription based with three price plans: вЂњpriority clubвЂќ, вЂњpartner clubвЂќ and вЂњpay as you goвЂќ. Bipin Patel, a pharmacist user, says: вЂњOn the first day of using the system we put an item on to sell and within 45 minutes got an offer.вЂќ The Rxchange pharmacy stock exchange site can be seen at www.rxchange.co.uk. 6 August 2007 ICP Mrs Beech, who had been helping out in Northway pharmacy in Tewkesbury, said: вЂњThe volume of requests for urgent supplies was overwhelming. Stocks were getting through but wholesalers being out of stock on some standard lines were causing extra problems. We worked nine hours one day with only 20 minutes for a quick bite to eat and a drink.вЂќ Staff Training BadhamвЂ™s BishopвЂ™s Cleeve pharmacy in drier times Mrs Beech added: вЂњThe LPC will be sitting down with the PCT in the near future to ensure emergency planning is well and truly put into place. It will be essential to have a county wide debrief soon after the crisis so that it is fresh in peopleвЂ™s minds and hopefully we will gain high attendance.вЂќ Much of the area was still under water and many roads were cut off but Mr Badham said: вЂњWe have managed during this time because of support from staff and patients. We are a family run business and have been since 1940, I guess we must have survived the war so we will survive this.вЂќ Learning about pain A staff training resource on pain вЂ” the Nurofen Academy вЂ” has been launched by Reckitt Benckiser Healthcare. Pharmacists can register their staff for it by telephoning the academyвЂ™s helpline on 01284 717693. The resource includes five modules, and makes provision for staff assessment, marking, practical activities, staff progress reports and incentives to keep staff motivated. The process is managed in the pharmacy. The first module is sent after registration. Pharmaceutical Society Numark New chief executive Hypertension book Mr Jeremy Holmes has been appointed chief executive and registrar of the Royal Pharmaceutical Society. He will take up his appointment on September 3. He replaces Miss Ann Lewis, who is retiring. Mr Holmes, who was managing director of the Economists Advisory Group for 14 years, is the first non-pharmacist to hold the post. Numark has relaunched a booklet to help its members identify and assist people with hypertension. The booklet reflects revised guidelines for the treatment of hypertension. It has been devised in conjunction with practising pharmacists. ICP 297x210 3/8/07 12:59 Page 1 NICOTINE LOZENGE TRANSDERMAL PATCH NICOTINE Front line pharmacists needed to defend customers against the symptoms of nicotine withdrawal Benefits include: NIC OT INE TRA NSD ERM AL PAT CH E TIN O NIC E ENG LOZ вЂў Brand quality nicotine replacement therapy вЂў Affordable consumer prices вЂў High impact point of sale materials вЂў Full patient support programme Patented 1.5mg lozenge presentation a new alternative to 2mg nicotine gum вЂў Great tasting, sugar-free formulation вЂў Very difficult to crunch - ensures nicotine is released in a steady dose www.helpingyouquit.co.uk Essential information for NicopassВ® and NicopatchВ® Indications: Relief of nicotine withdrawal symptoms, in nicotine dependency as an aid to smoking cessation. Dosage: Initially, NicopatchВ® transdermal patch 14-21mg/24 hours or 8-12 NicopassВ® lozenges/24 hours, according to degree of nicotine dependence. Not to be used with other forms of nicotine replacement therapy. Contraindications: Non-smokers/occasional smokers, hypersensitivity to/intolerance of ingredients/excipients. Precautions: Advise total smoking cessation. Avoid in children and adolescents, recent myocardial infarction, unstable or worsening angina (including PrinzmetalвЂ™s), severe cardiac arrhythmias, uncontrolled hypertension, recent cerebrovascular accident, pregnancy. Caution in stable cardiovascular disease, diabetes mellitus, hyperthyroidism, phaeochromocytoma, severe hepatic or renal impairment, peptic ulcer, lactation. Caution (NicopassВ® only) in active oesophagitis, oral or pharyngeal inflammation, gastritis. Side effects: Commonly, dizziness, headache, nausea. Also, (NicopassВ®): sore throat, hiccup, mouth irritation, dry mouth, vomiting, abdominal discomfort, (NicopatchВ®): insomnia, application site reactions. PL numbers and cost: All prices are RRP (inc VAT): Nicopass 1.5mg Liquorice Mint lozenge PL 05630/0034 - ВЈ2.93 for 12; ВЈ7.34 for 36; ВЈ15.67 for 96 lozenge packs. Nicopass 1.5mg Fresh Mint lozenge PL 05630/0035 - ВЈ2.93 for 12; ВЈ7.34 for 36; ВЈ15.67 for 96 lozenge packs. Nicopatch 7mg/24 hours transdermal patch PL 05630/0036 - ВЈ13.99 for 7-patch pack. Nicopatch 14mg/24 hours transdermal patch PL 05630/0037 - ВЈ13.99 for 7-patch pack. Nicopatch 21mg/ 24 hours transdermal patch PL 05630/0038 - ВЈ13.99 for 7-patch pack. PL holder: Pierre Fabre MГ©dicament, 45 place Abel Gance, 92100 Boulogne, France. Supply classification: GSL. Date of preparation: 19 July 2007. Wockhardt UK Limited, Ash Road North, Wrexham Industrial Estate, Wrexham LL13 9UF, UK. Tel: 0800 262 570 Report Adverse Events to licence holder on 0800 262 570. Information on AE reporting: www.yellowcard.gov.uk Nrt01/07 July 2007 Ipf news p8 rev 6/8/07 15:09 Page 8 The Independent Pharmacy Federation Pfizer syndrome Last October, I was privileged (first time in years) to have a visit from a Pfizer Drugs Rep (writes Graham Philips). The poor fellow didnвЂ™t know where to put himself. He left me with the required вЂњPfizer propagandaвЂќ brochure, but could answer none of my questions about future distribution, still less discount structure. What he did acknowledge, however, was that he had worked hard locally to build up relationships with community pharmacists only to have them destroyed overnight by the unexpected distribution announcement. Today, eight months later, and despite monthly requests for a visit, neither the rep nor anyone else from Pfizer has had the courtesy to contact me. So much for the вЂњgetting closer to our customersвЂќ rhetoric. Now, as a UniChem customer, it might be assumed that none of this affects me вЂ” after all, thereвЂ™s only been a small change in the paperwork and I have noticed no change to UniChemвЂ™s usual high service levels. However, a brief calculation of our Pfizer spend shows that we will loose a massive ВЈ8,000 in discount each year as a direct result of the new scheme. I, for one, find it very difficult to believe that the NHS will make up the shortfall, and I donвЂ™t see why the contractors should have to do so. So if the NHS wonвЂ™t pay, and if the contractors (morally at least) should not have to, then the bill should be footed by the arrogant conglomerate which imposed this upon us all. вЂњPfizer syndromeвЂќ affects independent pharmacists and independent wholesalers more than any other sector. IPFвЂ™s recent membersвЂ™ survey showed enormous dissatisfaction with PfizerвЂ™s scheme: 67 per cent said service was worse, 87 per cent said discount was less and 75 per cent said that patients were affected. So, is there a short-term cure for вЂњPfizer syndromeвЂќ? In a word: вЂњYesвЂќ. Now would seem a very good time to review the pharmaceutical price regulation scheme, which featherbeds the industry and allows the PfizerвЂ™s of this world to вЂњget away with itвЂќ. IPF will, of course, be fighting independentsвЂ™ corner. But what of the future? We clearly need a long-term solution that protects us from such vagaries. The obvious answer is to move towards a more clinically-based contract and contractors in England should be grateful to our Scots colleagues for showing us the way. This would be good for patients and good for independents. The IPF will continue to battle for an even playing field. ItвЂ™s your future. Help us to help you. Join the IPF. News and Views from The Independent Pharmacy Federation Join your LPC The IPF says that independent community pharmacy must have a strong voice at a local level, writes Mark Collins. The changes that practice based commissioning (PBC) will bring will mean it is even more important that you get involved with your local pharmaceutical committee (LPC). The LPC is the focus for all community pharmacists and is an independent and representative group. The LPC works locally with primary care organisations such as local primary care trusts and other healthcare professionals to help plan 8 August 2007 ICP healthcare services. The LPC negotiates and discusses pharmacy services with local health bodies and is available to give advice to community pharmacy contractors and others wanting to know more about local pharmacy. The LPC is your representative body, working for you. If independent pharmacists arenвЂ™t on board they wonвЂ™t have an input into such services as smoking cessation, emergency hormonal contraception, and minor ailments and any PBC developments. Contact your LPC secretary now and ask to get involved. The secret war How many pharmacists take for granted the stream of prescriptions that is the lifeblood of the pharmacy, forgetting that they are at the centre of a tiny island, 1.6 kilometres in radius? Their viability relies upon prescriptions from residents in just over 3 square miles, writes Noel Baumber. True, if there are other pharmacies in the vicinity a larger area might be carved out as pharmacy territory, but they will then share that finite prescription volume. Is that a restriction the Office of Fair Trading wants to see lifted? Would it allow pharmacies to flourish, bringing delivery services and dosage systems to patients in rural areas? I doubt it. Given a choice, doctors are more likely to want all the dispensing business there is than to give up dispensing for good. In some counties, local pharmaceutical committees have managed to define вЂњurban areasвЂќ to make more sense of the boundary between dispensing doctors and community pharmacy services. Now there is an increasing threat to our urban areas as dispensing doctors and local medical committees ask their local primary care trusts to change the rurality of civil parishes into controlled areas. What is rational about a parish boundary in this modern world when it comes to providing services? What have flood plains, ducks and bucolic scenery got to do with patient services and your livelihood? If an urban area is redefined and part of it becomes вЂњrural in characterвЂќ pharmacists lose residents to dispensing doctors. There is even a campaign to incite urban doctors to dispense or to start their own pharmacies. LPCs fight a running battle behind the scenes trying to fend off this expansion. The committees that decide such things at PCT level are part of the вЂњcost to consumersвЂќ. They are absolutely minimal costs, yet essential to prevent the erosion and collapse of the professional community pharmacy service. Contacting the IPF The Independent Pharmacy Federation can be reached by e-mail at the [email protected], via its website at www.theipf.co.uk or using the insert in this issue. Opinion p 9 -10 rev 6/8/07 10:57 Page 9 Opinion Taking care of four-legged patients There is a big role for pharmacists in caring for animals but they have to prepare themselves for it. Professor Bob Michell, a vet and a member of the Royal Pharmaceutical SocietyвЂ™s Council, spells out what needs to be done There is still a cadre of veterinary pharmacists represented in the Veterinary Pharmacy Group of the Royal Pharmaceutical Society whose everyday practice is substantially or wholly concerned with veterinary patients. (Unfortunately, its links to the SocietyвЂ™s Council are weaker than they should be, despite efforts to strengthen them.) Mostly, VPC members deal with farm animals and horses rather than pets. The real problem arises not on farms, or in stables, but in the high street where Government policy expects pharmacists to replicate for animals the role that they already fulfil for humans: вЂњThe scientist in the high streetвЂќ. They probably could, but only with suitable transitional strategies, specific training and a sense of urgency. It is essential that veterinary SOLO Plus: Building the future A well designed pharmacy can encourage footfall and improve working practises. The SOLO Plus range is available from Summit Retail Display Limited, who pride themselves on meeting the needs of the smaller pharmacy at an affordable price without a loss of quality. shopfittig W hen I was a young veterinary graduate in the вЂ™60s it was not unusual to find vets writing prescriptions and local pharmacists dispensing them. This was based on mutual goodwill so that pharmacists knew what to stock; and it reduced the range of drugs which veterinary practices needed to keep. Professor Bob Michell: pharmacists need educating for new role The SOLO Plus package includes everything you need for a full refit and covers the pharmacy contract requirements set down by the NHS. SOLO Plus comes to you at a fixed price of ВЈ25,000 plus VAT and is ideal for smaller pharmacies which have up to 50 square meters. A consultation room is included and there is a choice of finishes for the furniture and flooring. It also features a dispensary which has been ergonomically designed to enhance the way you work. NPA Finance & Leasing is available to NPA members, offering competitive interest rates. Throughout the process a dedicated liaison person is on hand to guide you through every step of the way and discuss your plans in detail so that they meet your requirements. For further information about Finance & Leasing and SOLO Plus contact the NPA commercial team on free phone 0800 856 3413 or email [email protected] ICP August 2007 9 Opinion p 9 -10 rev 6/8/07 10:57 Page 10 Opinion pharmacy, especially of companion animals, becomes part of the core pharmacy curriculum. Regrettably, there is as yet no sign of this happening. Training in human medicine and therapeutics is not a sound basis for veterinary clinical advice. A handicap It is a pity that the putative renaissance of veterinary pharmacy is driven by a flawed report from the Office of Fair Trading. It objected, among other things, to the fact that veterinary practices cross-subsidise some of their more expensive services, such as out-ofhours emergency care, from sales of medicines. Yet cross-subsidy is a feature of most businesses; no-one imagines, for example, that the wine at a restaurant really costs anything like the menu price. Futhermore, would pharmacists be happy to be compelled to dispense prescriptions free of charge ? Clearly not, but vets are compelled to write them free of charge for a trial period. What other profession operating in an open market without a government income stream is obliged to provide a free service? And what kind of level playing field obliges vets, unlike doctors, to provide a 24 hour emergency Product update Chapter Pet Health provides a вЂњwideвЂќ range of products to treat both pets and their homes. The range is supported with merchandising materials, patient information leaflets and pharmacy staff training aides. The company says: вЂњFlea populations routinely peak during late summer and early autumn and infestations can make life a misery for both pets and pet owners.вЂќ Chapter Health also comments: вЂњThat successful treatment and prevention of flea infestations requires more than just treating pets directly. 95 per cent of fleas live in the pet environment including carpets, sofas, cushions, pet bedding and even ownersвЂ™ beds. It is essential therefore that any treatment regimen also works to eradicate fleas in the pet environment.вЂќ For more information email [email protected] Chapter Pet Health 01480 436633 10 August 2007 ICP service? This point, ignored by the OFT, is pivotal because the true cost of providing such a service, especially with working time restrictions and increasing risks of drug-driven crime, are enormous and would be prohibitive without cross subsidy. So the opportunity to restore and foster the links between veterinary practices and pharmacists were poisoned from the outset by resentment of unfair impositions and flawed logic. I say this not as a vet but as one who believes that pharmacists could do more for animals if the approach were sound вЂ” even though animal owners, for the most part, appreciate the fact that they receive their advice, and their medicines from vets without the need to take a piece of paper to a separate location, as confirmed by a Quo Vadis survey in 2001. Added value service I suggest the following should be the basis of a pharmacy service: в—Џ Dispensing must add value, ie, add to the effectiveness and safety of the medicine in the bag through sound advice, based on demonstrable, verifiable competence, not casually acquired experience. в—Џ Provision must never be divorced from competence: the fact that a veterinary medicine might be cheaper in a high street pharmacy is irrelevant. All future pharmacists must receive a baseline training in companion animal medicine and species differences in drug handling and responses. Every adult, scientist or not, has a baseline awareness of human health and disease but this is not true of animal health, unless the person has kept pets. The core syllabus is the only place for such training for two reasons: Unlike farm animal or equine pharmacy, which have specialist providers, the idea is to enable the вЂњscientist in the high streetвЂќ to capitalise on the presence of animal owners in the shop and offer advice without the need for appointments. It cannot be left to owners to discover whether or not a particular pharmacy is capable of dealing with their prescription вЂ” imagine if some pharmacies could provide childrenвЂ™s medicines but others could not. It cannot be left to preregistration training to acquire the necessary knowledge and skills because, at present, there are too few pharmacists with companion animal expertise to provide the training. For those who say it does not need much training to sell flea remedies and wormers, there are at least two replies. First, how do you distinguish between flea allergies and other allergies? Second, you could say the same for routine remedies for occasional headaches or stomach upsets. Bridging the gap None of this provides a rapid route to competence, nor will the SocietyвЂ™s veterinary diploma course, simply because, despite its merits, too few undertake it. There is an answer which could also promote a rapid and harmonious growth of collaboration between the worlds of pharmacy and of veterinary practice. Veterinary nurses, many of whom are already responsible for ordering drugs and some for selling them to practices, have the baseline knowledge of companion animal health and disease, and the ability to handle and medicate animals and to show others how to do it. What an animal owner may most want to know about a medicine is how to safely get it into their cat or dog. There is an important opening for veterinary nurses to work alongside pharmacists, and there should be specific courses designed to top up their вЂќ Government policy expects pharmacists to replicate for animals the role that they already fulfil for humans вЂќ knowledge of pharmacy to fulfil this role. Teamwork between pharmacists and veterinary nurses could not only deliver a new and valuable stream of veterinary healthcare, but it could also help to bridge the chasm between veterinary practice and pharmacy. Time is short, because the fulfilment of these opportunities will eventually come under Government scrutiny when the imposed period of free veterinary prescriptions ends. The question will be: what added value did the public gain from receiving prescriptions rather than medicines from their veterinary surgeon? As things stand at the moment, the answer is likely to be вЂњnot very muchвЂќ. Sadly, where the importance and urgency of seizing the opportunities open to the profession is concerned, the Society is asleep at the wheel. But there are encouraging trends; the newest, mould-breaking veterinary school at Nottingham is taking up the challenge of bringing veterinary and pharmacy education together. Let us hope that such trends gain momentum, for the benefit of animal patients. wwisdom AUG p12rev 2/8/07 14:32 Page 12 WitheringвЂ™s Wisdom Colluding or helping? ItвЂ™s funny how a relatively minor incident can lead to a great deal of soul-searching. I was recently presented with a prescription for three monthsвЂ™ supply of temazepam. I canвЂ™t remember the last time I saw a prescription for more than one monthвЂ™s supply. I was so taken aback I went to speak to the patient to inquire whether this was the first time that he had been issued a prescription with this quantity. He told me no; when he had been prescribed fluoxetine to treat symptoms of depression, his sleep had gone from poor to completely intolerable, so his GP had prescribed temazepam. That had been nearly a year ago and he was still taking both the fluoxetine and the temazepam, and, because he had to pay the prescription charge вЂ” and because it was more convenient вЂ” his GP was kind enough to prescribe three monthsвЂ™ supply at a time. Had it been explained to him, I asked, that taking medicines like temazepam in the long term could lead to dependence? He asked what business was it of mine? Indeed; what business was it of mine? This was not his usual pharmacy, and, to the patient, my concern appeared to be misplaced. After the patient had left I felt I needed to find out more вЂ” was I wrong to be so concerned? The British National Formulary, of course, says that the use of these medicines should be restricted to a maximum of four weeks and the National Institute for Health and Clinical Excellence (NICE) guidance relating to newer hypnotics reinforces this advice. My interest aroused, I decided to see how many prescriptions for benzodiazepines were for repeats: even if they were for only one monthвЂ™s supply at a time; in principle, there is no real difference between these and a three-month supply. The answer was most of them. This surprised me because my perception was that the use of these medicines had been in decline. So I went to the Prescription Pricing Authority, website where I found that the numbers of prescriptions for these medicines have not changed for the past five years. I asked the primary care trust what services were available to help people come off benzodiazepines and they directed my question to the local drug and alcohol team. It seems to me that this is an entirely inappropriate response: the stigma attached to drug and alcohol services would deter most benzodiazepine users from attending. So where did that leave me? I now have the nagging doubt that dispensing a repeat prescription for a benzodiazepine may not be doing the best for the patient. Nationally, there must be tens of thousands of people taking long-term benzodiazepines. Every time a repeat prescription is dispensed we have to face the question of whether we are really helping or colluding in questionable practice of epic proportions. Mixed messages? In implementing вЂњCare closer to home: convenient quality care for patientsвЂќ, the Department of Health recently issued guidance relating to the provision of more specialised services closer to home with the emphasis on the role of practitioners with special interests, including pharmacists. DonвЂ™t get me wrong, I think this is great: the more services that can be provided at local level, the better, both for patients and for people like us. So what am I worried about? I recently saw a news item about the development of socalled polyclinics that had been established in London. These establishments were essentially super health centres bringing together several GP practices, dentists, and other services, and acting as satellites, where specialists from the hospital service would hold out-patient clinics. On the face of it, this kind of service does appear to be bringing healthcare down to local level, but there are potential problems in concentrating primary care services in this way. WeвЂ™ve all seen how pharmacies have clustered around conventional health centres, reducing the viability of pharmacies that remain genuinely communitybased because they have now become remote from the places where prescriptions are generated. Ultimately, this leads to a reduction in the accessibility that patients have, not only to the provision of medicines but also to all the other services that pharmacies have to offer. Attractive as the idea of the polyclinic may be in some highdeprivation metropolitan areas, I sincerely hope that this model does not become widespread. Care closer to home? ThatвЂ™s not how I see it. Putting the boot in? Boots the Chemists is set to put the status quo in community pharmacy into turmoil with their plan to offer in-store doctors following the success of a pilot scheme in a store in Dorset earlier this year. Boots contends that it is difficult for patients to obtain an appointment with their GP at times that are convenient to them, especially during working hours. In the Boots scheme, a local GP rented space in the store to see patients from their practice who had made an appointment. In parallel with this development, as IвЂ™m sure most of us will have seen from the TV advertising, Boots is putting consulting rooms in its stores so that shoppers can get advice instead of having to see their GPs. Consulting rooms, and advertising I donвЂ™t have a problem with; many, if not most pharmacies now have at least a consulting area. But I view the establishment of instore GPs with deep misgivings. Boots, no doubt, will argue that what they are doing is improving access to primary care services for patients. Others will see it as a cynical use of their prime locations on the high street to create unusually close relationships with local GPs. What is particularly troubling is the prospect that patients will see the presence of their GPs instore as some sort of endorsement of BootsвЂ™s expansion of services in ways that will not be available to the vast majority of independents. Pen name of a practising independent community pharmacist. WitheringвЂ™s views are not necessarily those of ICP 12 August 2007 ICP teva new campaign development 31/5/07 10:59 Page 2 choice You have a choice. So why not choose the best? Buying generics isnвЂ™t easy, but it should be. Price is vital, of course, but so is the assurance that thereвЂ™s customer support if you need it. A wide range from one place saves time, and a livery thatвЂ™s modern and designed to reduce dispensing errors in a busy pharmacy or dispensary. Teva UK Limited offers all those things, and more. For example our Ultimate scheme gives you discounts paid back to your business each month, not quarterly; and on many lines our вЂ�PricewatchвЂ™ offer tracks market prices so you can be sure you wonвЂ™t be out on a limb by the end of the month. Ref: 038/COP/07 Date of preparation: May 2007 We know you have a choice. But we think the obvious choice is Teva. Making generics easier Morley, Leeds LS27 0JG Tel: +44 (0)113 238 0099 Fax: +44 (0)113 201 3937 www.tevauk.com interview p14 -15 rev 2/8/07 15:17 Page 14 The ICP Interview A special career Fiona Cruickshank, managing director of The Specials Laboratory, manages to combine her love of the industry with her qualification in pharmacy and her desire to run her own show. Douglas Simpson talks to her about how she does it F iona graduated in pharmacy from the School of Pharmacy in London University in 1987 with a respectable 2.2. She did a split preregistration year at Charing Cross hospital and the Wellcome Foundation. вЂњI was desperate to work in industry and I managed to secure one of the six industrial places available at the time,вЂќ she says. вЂњ The Wellcome Foundation paved the way for the whole year and I was able to go to a hospital of my choice. I got the best of both worlds.вЂќ What did she enjoy about her preregistration year? вЂњThe six months at Charing Cross came first. It was brilliant. I particularly enjoyed the manufacturing and radiopharmacy. We did a lot of clinical trial work.вЂќ What about the industry bit? вЂњI started in sterile products manufacturing at Dartford. I also experienced WellcomeвЂ™s quality control and development laboratories, tableting and packaging.вЂќ Where next? вЂњAfter the preregistration year I just carried on in industry. There was no question about it. That is what I wanted to do. I did a year on full-time night shift and had my first management experience running a team labelling ampoules and vials on the Dartford site. I learnt about freeze-drying, sterile and aseptic processing. It was an absolutely brilliant way to learn.вЂќ Had she shone at pharmaceutics at the вЂњSquareвЂќ? вЂњI didnвЂ™t really shine at anything. IвЂ™m not like that. What I shine at is people management and getting things done. 14 August 2007 ICP Fiona Cruickshank: spurred on by a spurned buy-out вЂњBut I also like the concept of making stuff. I like the concept of ending up with a good quality widget. I am interested in processes. I love machinery and equipment.вЂќ How long was she with Wellcome? вЂњI stayed with them for three years. But it was a huge site, with 3,000 people and I was worried about becoming specialised in one area of activity. So I left and worked as a pharmacy locum in the community. вЂњAfter a few months I realised that that was not what I wanted to do and I went back into the industry, with Fisons at Holmes Chapel. Again it was shift-work and I had the dubious pleasure of looking after the water system overnight and things like that. But it was the people management and the manufacturing process that was attractive to me.вЂќ So is she a вЂњpeopleвЂќ rather than a вЂњnuts and boltsвЂќ type of person? вЂњYou need to know about the process вЂ” I did pharmaceutical engineering as my specialist subject in my third year at the вЂњSquareвЂќ. From a people perspective, I also learnt how to work in a unionised environment. But you are right. It is dealing with the people that I enjoy.вЂќ How did she get involved in specials? вЂњAfter another spell of locum work, I took a post in a specials laboratory run by wholesalers AAH in rented space at the Royal Victoria Hospital in Newcastle upon Tyne, my home town. There I was in this totally different world doing more real pharmacy than at any time in my career. вЂњWhen I started that job, AAH asked me to do a business plan to look at growing the business. I produced the plan but they decided not to go ahead with it. They had just been acquired by Gehe, which decided that manufacturing did not fit in with their type of business.вЂќ How did she deal with that? вЂњI decided, with the help of some top class advisers, to buy them out.вЂќ What happened next? вЂњThey decided to sell to MartindaleвЂ™s!вЂќ How did she feel about that? вЂњIt was the best thing that ever happened to me. My father, who had been in business all his life, said: вЂ�Why donвЂ™t you just start up yourself?вЂ™ So, with a business partner, I did just that.вЂќ Where? interview p14 -15 rev 6/8/07 15:11 Page 15 The ICP Interview вЂњMartindaleвЂ™s did not want the RVI facilities so I approached the hospital and agreed to rent the space, which we re-equipped. That was in July, 1999. We had to wait three months for a licence and we started trading in the September.вЂќ How did she market the business? вЂњWe bought a mailing list and sent a mailshot to all independent pharmacies from Leeds up to Scotland. The letter went out on a Friday and by the following Monday the telephones started to ring. вЂњWithin a short space of time, we knew we were going to outgrow the premises. I started with three people and by the time we left the RVI in 2001 there were eight of us. We have now moved to a purpose-built facility in Northumberland.вЂќ What was the first order? вЂњFour bottles of calcium carbonate suspension. The husband of one of my staff delivered it. I wish I had kept the payment cheque and framed it.вЂќ Presumably a lot of the products were standard formulae? вЂњA lot were, but others were non-standard formulations. We started from scratch and built up a database.вЂќ What about staff levels in the early days? вЂњI was the pharmacist. I had to check the formulation and sign it off. I had one technician, who is still with me now, and a person in customer services, who is also still with me. вЂњThings are different now. We have a quality control department and a pharmacy department.вЂќ How does she feel about pharmacists passing on this traditional area of activity? вЂњI think it is a real shame. But having been in dispensaries and seen the way that the workload has gone, and the way that the emphasis has changed, I think it is nigh on impossible to dispense these preparations properly. There are few pharmacists who can invest in the equipment, have the calibrations done and all the rest of the things that are needed. Even if there are the facilities, they are used infrequently, so there is a danger of skills getting rusty.вЂќ The skills are still taught in schools of pharmacy, and the calculations section is a вЂњmust passвЂќ section of the pre-registration examination. Is Fiona saying most pharmacists will not make use of these skills? вЂњJudging from the number of extemporaneous preparations ordered from us, there is still a need for them. But having said that, there are few pharmacies experiencing a high volume of them вЂ” maybe one or two a month. It is not really core to what they are doing. If it were it would be reimbursed better. вЂњI still think the skills need to be taught, though, because pharmacists need to understand the concepts behind the service they provide and they must have the ability to calculate. вЂњWe do a lot of student placements in the summer and Easter holidays. The ones that come to us love their pharmaceutics. They love formulation. The place for that, though, is in the industry nowadays.вЂќ Is she happy with pharmacy education becoming more clinical? вЂњI think it is a shame. вЂ�PharmacyвЂ™ should remain a good, all-round science degree. But, speaking to graduates now, they donвЂ™t think of themselves as scientists, which is an absolute shame. They are, in fact, far better equipped to go into the industry than graduates in microbiology and chemistry, who are very specialised. If we do not promote the scientific side, there will be fewer pharmacists going into industry. The talk now among students is: вЂ�I want to look after patientsвЂ™ or вЂ�I want to build a retail empire.вЂ™ The pharmacy schools, in their recruiting literature, emphasise the clinical side.вЂќ What is the full extent of the business? вЂњAs well as the specials side, we manufacture phase one and phase two clinical trials materials for customers. In addition to the specials sites, we have a clinical trial materials manufacturing area, a distribution area and a head office with support services. вЂњWe have grown like that because we donвЂ™t own our buildings. We have acquired leases as we have gone along. We now have to decide whether we want to put everything in one big, new, shiny building or not.вЂќ What about further expansion of activities? вЂњWe are moving into providing over-labelled medicines for the National Health Service.вЂќ What are these? вЂњWe are making over-labelled packs that can be taken off the shelf and given to you if have been patched up at an accident and emergency department. Or the short course of вЂќ Pharmacy graduates are far better equipped to go into the industry than graduates in microbiology and chemistry, who are very specialised вЂќ First order was for four bottles of calcium carbonate suspension Should more students be thinking of a career in industry? вЂњYes, they should. There is a fabulous career path for the qualified person and in other areas, too. There are terrific opportunities for pharmacists in the industry.вЂќ Is she doing anything about this? вЂњWe will be offering preregistration placements in the future. I have to put my money where my mouth is.вЂќ Does she want to see an increase in industrial placements? вЂњDefinitely. We have a relatively short window of opportunity, because there are only a few pharmacists left in the industry.вЂќ How is the Specials Laboratory doing? вЂњExtremely well. We are seeing about 22 per cent year-on-year growth in revenue terms. вЂњWe now have two manufacturing sites for specials in Prudhoe, Northumberland, and a staff of nearly 150. There are 10 pharmacists in the business and about 20 technicians.вЂќ antibiotics that an out-of-hours doctor might give you to tide you over until you can see your GP for a full course.вЂќ The Specials Laboratory remains a private company with Fiona as the main shareholder. She has a business partner, Brian Dougherty, who is a pharmacist and a qualified person. Turnover at the end of 2006 had reached ВЈ8m a year. It is expected to hit ВЈ11m in 2007. Fiona reckons that her company is the second largest in the market, although there is no way of being certain about this. The main focus of her specials business is independents, but some of her business comes from the multiples. вЂњThere are some managers that like to deal with The Specials Laboratory even though their head offices would prefer them to look elsewhere.вЂќ And Fiona has enjoyed external recognition of her achievements with the company, which was listed in the Sunday Times Fast Track 100 of BritainвЂ™s fastest growing private companies, and was recently profiled in the Financial Times . She is a former North-East Woman Entrepreneur of the Year. Will she be slowing down soon? вЂњNo chance!вЂќ ICP August 2007 15 business monitor AUG rev P16 2/8/07 14:27 Page 16 Business Monitor Profits as prescribed The ambition of doctors to earn money from dispensing is undiminished. Gerry Green reports T he NHS Fraud Department has once again hit the headlines by taking action against generics manufacturers. And it appears to regularly put under severe scrutiny pharmacy contractors who are accused of such practices as witholding inexpensive вЂњchargedвЂќ item prescriptions. So is it not time that this organisation put under its вЂњmicroscopeвЂќ the whole business of dispensing doctors in this the 21st century? Way back when the health service was founded, GPs in remote country areas where no pharmacy existed were rightly concerned to organise a supply of urgent medication for their patients. In those days, only the better off members of society owned a motor car. In this day and age, as country folk frequently complain, one cannot survive in the country unless one owns a car. Thus the rule allowing GPs to supply medicines to patients living more than one mile from their nearest pharmacy is an anachronism that has survived from those bygone days of 60 years ago. The only reason that GPs have insisted upon maintaining this right to dispense is because they make a profit out of whatever they prescribe. It is also well known that the average value per item and the total ingredient cost per annum is much higher per patient when supplied by a dispensing doctor than if supplied by a pharmacy contractor. And dispensing doctors receive a higher dispensing fee and better discounts from Pfizer, amongst other companies, than does the normal pharmacy contractor, thus giving them an average gross profit in the mid-twenties percentage-wise, while pharmacies typically have one in the upper teens. Many once small villages in the southern half of England and some of those in the Lake District and North Yorkshire have had their populations swollen by вЂњlong distanceвЂќ commuters, city folk with second homes and retirees, so that many now have local populations at or about the 5,000 mark, which is the average population per pharmacy in England. Yet many of these still carry on with their NHS medicines being supplied from the limited inventory of a typical dispensing doctorsвЂ™ practice and without the opportunity for the local population to be able to purchase вЂњpharmacy onlyвЂќ medicines over the counter. And, when a potential pharmacy contractor applies to open in what the вЂњcontrol of entryвЂќ regulations describe as a вЂњcontrolled areaвЂќ, ie, where dispensing doctors supply medication to patients, the process is greatly protracted before the application gets to be considered. 16 August 2007 ICP Even when a pharmacy is allowed, after the due process, to open, the GPs, ever greedy to continue making profit from their prescribing, seek a вЂњgradualisation periodвЂќ before patients are switched to the pharmacy for their NHS medical supplies. Gradualisation used to mean just that; so that, over a six-month period, say, one sixth of the patients affected would move over to the pharmacy each month. This allowed the GPs to adjust their pharmaceutical stocks to accommodate the change. This was another historic practice constructed 30 or 40 years ago when dispensing doctors and pharmacies held the equivalent of around three monthsвЂ™ stock based upon their turnover. Today, most dispensing doctors and pharmacy contractors have average stocks of three weeks or less. Gradualisation In my view, this gradualisation process should be reduced today to one month only and the new pharmacy should be obliged to buy at cost price the dispensing stocks then held by the dispensing doctors, assuming they give up dispensing altogether. In actual fact, most dispensing doctors do go on dispensing for some of their patients who live beyond the one mile limit even though most have to call in at the surgery to see a GP or collect a repeat prescription, which the nearby pharmacy would, almost certainly, be happy to collect, dispense and even deliver where a patient could not wait. So here again, we have rules which modern practice has overtaken and there is no need to continue them in their original form. Many GPs still try to obtain a 12 month gradualisation and some even seek two years. They know that, without the income from dispensing, most new pharmacies will not survive economically and so might be forced to close. Some GPs even organise patient resistance by secretly encouraging village meetings to condemn the primary care trust for allowing a new pharmacy and put forward all kinds of spurious arguments about the quality of the new service, with no mention, of course, of the value of having вЂњan expert in medicinesвЂќ available within the community as a вЂњfirst port of callвЂќ without an appointment (including Saturdays). I am aware in two current client cases involving вЂњdispensing doctorsвЂќ of vigorous attempts to persuade landlords of village retail premises not to let them to a pharmacy. Some doctors have bought up leases or freeholds or bought a restrictive covenant on retail property. Some have actively sought local objections to вЂњchange of useвЂќ of property to a pharmacy. It takes courage on the part of a villager to fall out with their GP because he or she allows a pharmacy to open in their premises! Unless GPs are making a big profit out of dispensing, why else would they battle so hard to prevent a pharmacy contractor from opening on their patch? Some GPs, when forced by other pressures from pharmacy applications, have resorted to applying to open a pharmacy themselves, which might look to be a reasonable answer to my criticism. However, I know of some GPowned pharmacies where a part-time pharmacist is employed and for the rest of the surgery hours the dispensing is claimed to be вЂњsupervisedвЂќ by the GPs! I am also aware of cases where a GP-owned pharmacy is opened and run for a couple of years and then closed down as вЂњuneconomicвЂќ by the GP owners who simply then revert back to the much more profitable doctor dispensing. In 2004, when finalising the new contract for pharmacy in the NHS, the Pharmaceutical Services Negotiating Committee assured all contractors that it had reached an agreement with general practitionersвЂ™ representatives to restrain any further growth in dispensing doctor activities. Why, I wonder, did the PSNC not seek to persuade the Department of Health to remove all dispensing doctor practices on the back of the generous 2004 pay award to GPs? The Daily Mail of July 17, quoting the Information Centre for Health and Social Care, reported that the 2004 contract upped the earnings of a GP by 22.8 per cent to an average ВЈ103,654 per annum in 2004-05, with dispensing doctors average earnings reaching ВЈ119,566. No wonder the doctors are keen to keep dispensing to themselves. Some 15 or so years ago, a Health Minister in the then Conservative government said she believed it was in the taxpayersвЂ™ interest, as well as that of patients, for no prescriber to benefit from the medication he or she prescribes. As a taxpayer I can only agree. specials AUG P17-21 rev-rev 2/8/07 14:46 Page 17 Specials Forging a quality relationship Independents are increasingly trusting specials manufacturers for quality products and good service. Steve Bremer reports D emand for specials continues to increase and the industry remains optimistic about the future, despite some lingering uncertainty about the Department of HealthвЂ™s plans for price regulation. Although no decision has apparently been made following the DHвЂ™s 2005 consultation on adding the top 100 most popular specials to the Drug Tariff, the issue has not gone away. And some specials products, such as menthol and aqueous cream, are now listed in the tariff. Phil Richardson, commercial director at Quantum Specials, believes that potential pricing regulation is still the main issue facing the industry. вЂњIf itвЂ™s not applied fairly by the DH it could have a negative impact on the core manufacturersвЂ™ ability to meet both the needs of community pharmacy and patients,вЂќ he says. The DH is still looking at ways to regulate pricing in the specials industry, says Mr Richardson. Quantum has invested in new facilities that will be opened in the Autumn, but, by carefully managing its costs, Mr Richardson believes that his company will still be able to maintain a quality service even if pricing regulation is applied. But this will only hold true if the regulation is вЂњfair and sensibleвЂќ and allows for manufacturers to maintain the high standards required by the Medicines and Healthcare products Regulatory Agency (MHRA). The Drug Tariff issue has not changed strategy at the Specials Laboratory, says managing director, Fiona Cruickshank. вЂњWe believe we get a fair price for what we do,вЂќ she declares. вЂњWe are well within the BCM Specials has invested ВЈ75,000 in a cream and ointment manufacturing unit framework that the Association of the British Pharmaceutical Industry would expect. WeвЂ™re about providing a whole, end-to-end service.вЂќ A period of change The specials industry is going through a period of significant change, says Dr Andrew Inchley, general manager for BCM Specials. He declares: вЂњThe market is becoming more and more focused on the provision of patient ready (ready-to-use or administer) medicines as illustrated by the dramatic growth BCM Specials has experienced over the past 18 months in demand for liquid medicines,вЂќ he says. Dr Inchley believes this is due, to a large extent, to increased awareness among healthcare professionals of the dangers and increased liability implications of crushing tablets or opening capsules to administer ICP August 2007 17 specials AUG P17-21 rev-rev 2/8/07 14:47 Page 18 Specials Courtesy of the Association of Commercial Specials Manufacturers medicines to patients with swallowing difficulties. As a result, BCM Specials now prepares and delivers over 250,000 bespoke medicines every year. The NHS вЂњPurchasing for SafetyвЂќ initiative is highlighting the need for more ready-to-use medicines. вЂњGoing forward, I expect this to place additional pressure on specials manufacturers to invest further in both product development and the people and facilities required to provide extra capacity,вЂќ says Dr Inchley. BCM Specials remains committed to continued investment in people, facilities and product development to ensure it meets the вЂќ The market is becoming more and more focused on the provision of ready-to-use or administer medicines вЂќ Labelling pre-filled syringes under GMP conditions Concentrating independently focused on your Special needs What makes The Specials Laboratory different? Attitude, approach and people... for the Pharmacy Our Sunday Times Fast Track 100 listed company manufactures unlicensed medicines for the retail pharmaceutical and hospital markets, reliably delivering вЂ�specialsвЂ™ to Pharmacists across the UK. Experienced professionals providing a comprehensive range of high quality products to your Pharmacy within 24 -48 hrs* Our licences allow us to provide a wide range of dosage forms including: вЂў вЂў вЂў вЂў вЂў Oral Liquids Capsules/Sachets Ointments/Creams/Lotions Coal Tar Products Oral Syringes вЂў вЂў вЂў вЂў вЂў Nasal Drops Lollipops Eye Drops Reefers Potent Products вЂў вЂў вЂў вЂў вЂў A Modern Company Providing Pharmaceutical Specials for your Pharmacy To try out this service: FREEPHONE 0800 0439372 FREEFAX 0800 0439378 Suppositories Ear Drops Cytotoxics Imported Products Unit Dose Vials We also make a variety of other toxic products (e.g. hormones) in a range of dosage forms. Orders can be placed by telephone (answer phone service for out of hours calls), fax, or email. Parcels are delivered before 1pm the next day. When even speedier delivery is required, we can offer earlier deliveries or a same day courier service. 97% of orders delivered within 24-48 hours... For further information on how to become Special or to place an order: tel 0800 028 4925 fax 0800 083 4222 email [email protected] www.specialslab.co.uk ...thatвЂ™s what makes The Specials Laboratory different! 18 August 2007 ICP * Imports or unusual items may take longer, check with Customer Care on Freephone 0800 0439372 QuantumвЂ™s range includes, oral solutions and suspensions, pastes, creams and ointments, unit dose powders, capsules, reefers, suppositories, sterile injectables and eye drops. Tel: 0191 262 6800 Fax: 0191 262 6833 specials AUG P17-21 rev-rev 2/8/07 14:47 Page 20 Specials needs of customers, adds Dr Inchley. In the past six months the company has invested ВЈ75,000 in a вЂњstate of the artвЂќ cream and ointment manufacturing unit to produce small batches of product. This facility, in combination with separate investment in product research and development, leads to BCM claiming it can now develop and deliver cream and ointment specials at a significantly reduced price point. The Specials Laboratory has been in business eight years, making it a relative new comer to the market, but was recently named in the Sunday Times Fast Track 100 of BritainвЂ™s fastest growing private companies. The company was listed at number 78 in the 2006 league table, following annual sales growth of nearly 75 per cent over the past five years. Managing director Fiona Cruickshank believes that specials manufacturers have earned their trust from pharmacists over this time. вЂњPharmacists are a lot happier to use manufacturers because the service level is where it should be and it wasnвЂ™t before,вЂќ she says. вЂњPeople are more confident about the service and happier to outsource.вЂќ More players in the market and improved access to product information via the internet have also helped raise awareness. Increased demand for specials is driven by a number of key factors, says Jan Flynn, marketing manager at Rosemont Pharmaceuticals. These include the demands placed on pharmacists by their contract to provide additional services, the British National Formulary for Children and the Disability Discrimination Act. This Act gives patients with swallowing difficulties the legal right to receive their medication in an appropriate way вЂ” which may be a liquid variant. Why should independents choose you? Dr Andrew Inchley, general manager, BCM Specials: вЂњBCM Specials has a 70 year history of being a centre of excellence in the provision of special medicines that meet the individual needs of pharmacists and their patients. We pride ourselves on the outstanding levels of service we offer, from the expert advice we provide during any initial inquiry using the information we have on over 35,000 existing specials formulations, to the way in which our experienced team of formulation scientists develop new one-off products tailored to meet a patientвЂ™s needs. Our delivery performance reinforces this service commitment in that greater than 85 per cent of all products are delivered direct to the pharmacy ordering the product within 48 hours.вЂќ Fiona Cruickshank, managing director at the Specials Laboratory: вЂњWeвЂ™re a totally independent company. WeвЂ™re not owned by a wholesaler. WeвЂ™re independently run by pharmacists and it is the experience, the service level, the work we do and the quality we produce that is so important. We havenвЂ™t got an agenda of shoring up margin from elsewhere in the business because we donвЂ™t do anything else. ThatвЂ™s the reason for coming to us. As a business, our strategy is to sell the right product for the right customer at the right time.вЂќ particular benefit to those pharmacists looking after nursing homes. Included in our pharmacy support package are: a new medicines management DVD and booklet, training materials, a liquid protocol and new guidelines developed for administering medicines to people with swallowing difficulties.вЂќ Jan Flynn, marketing manager at Rosemont Pharmaceuticals: Phil Richardson, commercial director at Quantum Specials: вЂњWe work closely in partnership with pharmacists to ensure that we are meeting their needs. Rosemont supplies a wide range of liquid medicines, with guaranteed quality and delivery within 48 hours for over 99 per cent of orders. When required, we can offer a 24-hour delivery service. We aim for a minimum 3-month shelf-life wherever possible and we manufacture specials to the same standards of good manufacturing practice (GMP) as our licensed products. On-line ordering via our new website is being introduced at www.rosemontpharma.com. We support the pharmacist with a wide range of training materials, which are of вЂњWith rapid service turn around, pharmacists can build strong patient loyalty as part of their overall offering to the community that they operate in. Patients will know (because of confirmed day of delivery) that if the pharmacist promises that their specials medication will be ready for collection the following afternoon, that this statement can be trusted вЂ” therefore, this contributes towards strong patient loyalty. Quantum has always ensured that our customers get a next-day service delivery by 12 noon. This means that patients can very often have their medication by the following afternoon after presenting their prescription to pharmacy the previous day.вЂќ specials AUG P17-21 rev-rev 2/8/07 14:48 Page 21 Specials The future Dr Andrew Inchley, press officer, Association of Commercial Specials Manufacturers, makes some predictions for the future: вЂњFor the majority of independent pharmacists, dealing with a prescription for a special item will be a relatively rare event. Nevertheless, when a patient is prescribed a bespoke medicine the independent pharmacist will have a pivotal role to play as the professional point of contact between the prescriber, the patient and the specials manufacturer. вЂњThe most important point in terms of looking further ahead to the provision of specials in the future is that ACSM members are in this for the long term. Investing in people, facilities and systems in order to achieve an MHRA approved specials manufacturers licence is not something for the short term. In fact, ACSM members have a history of making consistent investment in their businesses to ensure that they are able to react to change and continue to meet the needs of pharmacy customers. They also have to вЂќ In an ageing population a greater proportion of patients are likely to need medicines in a format that is appropriate to their specific needs вЂќ build flexibility into their service and any business plan ACSM members work up in the area of specials needs to include a view on how the market is going to change. вЂњAlthough no-one has a crystal ball, there are changes, or drivers of change, that ACSM members are able anticipate with some confidence. Demographic changes and, just as importantly, the changing attitudes that go along with these demographic changes are among these. вЂњIn an ageing population a greater proportion of patients, generally, are likely to need medicines in a format that is appropriate to their specific needs. Different drugs come on stream every day, but when they do so it is often in a solid dose format, which is inappropriate, for example, for elderly patients with dysphagia. ACSM members are able to use their formulation expertise and skills to translate the solid medicine into a liquid format more appropriate to patients with swallowing difficulties. Increased awareness of the dangers and liabilities from crushing tablets by those who care for patients in care homes has led to an enormous increase in the volume of вЂњready to useвЂќ liquid medicines being ordered from specials manufacturers. We could not have met this need without predicting that we would need to have volume capacity available for the future and investing in our businesses accordingly. вЂњIn addition to changing attitudes and demographic shifts, major health initiatives can also be expected to bring about changes that will impact upon the specials market. The NHS initiative for patient safety, вЂњRight Patient, Right CareвЂќ, which aims to match patients with their care, will significantly increase the growing focus on safety. Within this initiative, NHS hospitals have to have an action-plan to say how they will provide all medicines, including specials, safely. This can be expected to put pressure on NHS pharmacists and compounding units in hospitals and. ACSM members need to plan how to make our specialist expertise and facilities available to provide safe ready to use medicines to meet NHS patientsвЂ™ need. вЂњWhile we cannot always predict what challenges lay ahead we can say with some certainty that ACSM members will continue to build the flexibility and responsiveness into their systems to enable them to deal effectively with todayвЂ™s challenges and plan for tomorrowвЂ™s.вЂќ Mandeville Medicines, a pharmacy specials manufacturer, says: вЂњWhen specials are called for, it is the pharmacist who arguably carries most liability: liability for safety, efficacy and quality. Pharmacists can only mitigate these liabilities if they are able to show that the specials they dispense are clinically justified and that they are of a quality that befits their intended use.вЂќ The company advises that if not extemporaneously prepared in the pharmacy then pharmacists should as a minimum be confident that the specials they buy have been manufactured under strict GMP requirements. Mandeville Medicines supplies specials in accordance with its MHRA Licence No 10410/01 and is able to provide certificates of analysis, GMP compliance and conformity. For more information email [email protected] MANDEVILLE MEDICINES 01296 394142 Product update Oral care AUG p22-25rev 6/8/07 15:13 Page 22 James King-Holmes/Science Photo Library Oral Care Keep on smiling Victoria Goldman discovers a paradox: oral care sales are booming but oral health is declining. More pharmacy input could be the answer T his year saw the 31st National Smile Month run by the British Dental Health Foundation (BDHF), with the aim of encouraging more people to look after their teeth. But despite over 30 years of campaigning, the oral health of the nation is still as bad as ever. In fact, research by the BDHF found that oral health habits in 2007 are actually eight times as bad as in 2006. So why isnвЂ™t the oral care message getting through? вЂњWe donвЂ™t actually know why people arenвЂ™t taking notice,вЂќ says Karen Coates, dental helpline advisor at the BDHF. вЂњBut there is an urgent need for more education on how to brush teeth, how often to brush them and which products to use.вЂќ 22 August 2007 ICP Dental experts are particularly worried, as oral hygiene has such a big impact on peopleвЂ™s overall health, not just on the state of their teeth. Dr Nigel Carter, chief executive of the BDHF, says: вЂњGood oral healthcare is needed to prevent a wide range of conditions and, in particular, tooth decay and gum disease вЂ” which has been linked to heart disease, heart attacks, diabetes, strokes and low birth-weight babies.вЂќ Product usage Oral health may be on the decline, but the oral care market is still booming. According to the February, 2007, GlaxoSmithKline (GSK) Oral Care Category Report, the oral care market is currently worth over ВЈ700m. It makes up over one-tenth of the total toiletries and healthcare category and is up 6 per cent compared with category growth of only 3 per cent. But why is the market still doing well when oral hygiene is so poor? According to Karen Coates, more dental practices are stocking products and there is increased recommendation by the dentist and oral hygienist, so people are still buying products even if they donвЂ™t use them regularly. She says: вЂњPeople are buying on recommendation, especially products like floss, but unfortunately many of them lack the confidence to use the products properly.вЂќ There are so many different oral care products available that it can be difficult for pharmacy customers to know which ones will be suitable for their individual needs. Jon Sandy, GSK oral care category manager, says: вЂњThe oral care fixture can be confusing. In particular, consumers find the brush segment difficult to shop and they are unclear of the technical benefits of different brushes.вЂќ So itвЂ™s not just buying oral care products Oral care AUG p22-25rev 6/8/07 15:17 Page 23 Oral Care Product update Saliva Natura, a spray intended to relieve the symptoms of dry mouth, has been launched by Medac UK. Saliva Natura is said to be the вЂњfirstвЂќ sugar-free mouth spray that has a вЂњpleasantвЂќ lemon and lime taste and is designed to relieve symptoms for up to two hours. Saliva NaturaвЂ™s formulation contains natural extracts of the Yerba Santa plant and is вЂњsuitable for vegetarians and has not been tested on animals.вЂќ Medac UK says that the product вЂњis clinically tested to relieve dry mouth conditions associated with certain therapeutic treatments and prescribed medication, a range of medical disorders and advancing age.вЂќ Saliva Natura is available as a 50ml spray (list price ВЈ3.43, RRP ВЈ4.95, PIP code 325-6302) and a 250ml spray (list price ВЈ9.75, RRP ВЈ14.95). Saliva Natura is available from wholesalers. MEDAC UK 01786 458086. вЂњThe Oral-B Triumph is the most stylish, technologically advanced rechargeable toothbrush ever,вЂќ says manufacturer Procter & Gamble вЂњBuilt-in smart-technologyвЂќ is designed to enable the brush to work together with the brushhead; it recognises each userвЂ™s brushhead as unique and tracks their usage, informing them when itвЂ™s time to change. It also has a new polishing mode for вЂњnatural whitening.вЂќ The product has an RRP of ВЈ164.99. The company says: вЂњThe pioneer of rotateвЂ“oscillate brushhead technology and creator of the most technologically advanced power toothbrush ever in the Oral-B Triumph (ProfessionalCare 9500), Oral-BвЂ™s current power portfolio is second to none. This is shown by Oral-BвЂ™s 82.8 per cent market share and the brand currently being worth ВЈ37m and growing at a rate of 17.4 per cent year-on-year.вЂќ PROCTER & GAMBLE 01932 896 000 GlaxoSmithKline Consumer Healthcare is increasing its focus on oral care for children with the launch of the Aquafresh ChildrenвЂ™s Range. The new range covers вЂњMilk Teeth (0-3 years)вЂќ, вЂњLittle TeethвЂќ (4-6 years) and вЂњBig TeethвЂќ (6+ years) providing a вЂњclearly defined range to help parents make the right choice for their children as they develop and grow,вЂќ says the company. A specially formulated toothpaste and brush is available at each stage and вЂњBig TeethвЂќ also includes a sugar and alcohol-free mouthwash. GlaxoSmithKline plans to support the new range in September with a major ВЈ2m through-the-line marketing package. The range offers different fluoride levels at each stage. GLAXOSMITHKLINE 0845 762 6637 Endekay Disclosing Tablets, вЂњmentioned in The Sunday Times (15th July 2007)вЂќ, are designed to show the user where they need to brush more carefully to remove plaque. Tablets are to be crushed between the teeth, any plaque is then stained red. вЂњIncorporating Endekay disclosing tablets to an oral care regime ensures a consistent good brushing technique, which can help to prevent tartar build-up and decay,вЂќ says manufacturer Manx Healthcare. вЂњPharmacists should approach the oral hygiene opportunity as an extension of their healthcare offering.вЂќ Endekay Disclosing Tablets are part of the Endekay range of products, which follow the вЂњbrushвЂ¦flossвЂ¦rinseвЂќ approach to oral care. In packs of 12 tablets, Endekay disclosing tablets are available from fullline wholesalers; PIP code 032-5282, RSP ВЈ1.95. MANX HEALTHCARE 01926 482511 Snug Denture Cushions, from manufacturer The Mentholatum Company, are designed to offer a temporary solution to the problem of illfitting dentures while the wearer waits for a chance to see a dentist and they are now вЂњsofter and more pliable.вЂќ The product is tasteless and odourless, and the company says, is easy to apply and fit to upper and lower plates to restore a firm fit to loose dentures. SnugвЂ™s soft, plastic liners do not need to be removed for cleaning, and they are intended to give up to three weeks of вЂњcushioned comfort.вЂќ Snug Denture Cushions come in packs of one or two, retailing at a recommended ВЈ3.15 for one and ВЈ4.09 for two. POWERMED HEALTHCARE 0845 222 0555 GlaxoSmithKline has launched the Sensodyne Pronamel toothbrush. The new toothbrush has been specially designed to help protect tooth enamel. It uses вЂњgel padвЂќ technology with вЂњ3D flexibility and micro-fine rounded bristlesвЂќ. вЂњAn easily recognisable and attractive blister case вЂ” which doubles up as a hygienic, re-closable travelling or storage case вЂ” ensures strong shelf stand out,вЂќ says the company. The product is priced at ВЈ2.99 (recommended retail price) and is available in four colours. The Sensodyne Pronamel toothbrush features a small, compact head. The new brush will be supported by TV with a вЂњ10 second tagвЂќ following the existing Sensodyne Pronamel toothpaste advertisement later in the year. GLAXOSMITHKLINE 0845 762 6637 ICP August 2007 23 Oral care AUG p22-25rev 6/8/07 11:16 Page 24 Oral Care that will improve customersвЂ™ oral health, as customers need clear guidance on how to choose the right products and use them effectively. According to the GSK report, pharmacists can help by making the fixture easier to shop, and involving more educational messages at the site of purchase. Effective brushing A correct brushing technique is essential to clean effectively to reduce tooth decay and prevent problems like gum recession. The toothbrush needs to be tilted at a 45-degree angle to the gum-line, and moved in short circular movements several times on the outer and inner surfaces of all the teeth. Customers should also clean the chewing surfaces and their tongue, which is a common site for bacteria. Dr Carter recommends a habit of brushing for two minutes twice a day with a fluoride toothpaste. Yet BDHF research has found that most people brush for a maximum of 45 seconds, while one in five brush less than twice a day. Dr Nigel Carter says: вЂњThe number of people who donвЂ™t even brush once a day is eight times that of last year, while the number of people who canвЂ™t remember when they last changed their toothbrush is up by a similar amount.вЂќ Toothbrushing tools The toothpaste sector shows ВЈ304.2m worth of sales, says the GSK report, but there has been no recent growth. According to the report, trading up to premium pastes (for example, whitening or superior cleaning products) is the way to grow the market. Examples of products with extra benefits include Aquafresh Extreme Clean Tooth & Tongue, Macleans White and Shine, Retardex (for bad breath) and Colgate Total Professional Weekly Clean. However, BDHF research found that there is still confusion among consumers about the benefits of the basic toothpaste ingredients вЂ” for example, 13 per cent believed fluoride is mint flavour, 12 per cent a whitening product and 15 per cent a marketing gimmick. The toothbrush is just as important as the toothpaste, but sales of brushes are not as high (less than ВЈ225m sales). And while toothpaste has 82 per cent penetration, there is only 62 per cent penetration of toothbrushes. Brush heads have become increasingly hitech, with multi-angled bristles, different filament lengths, crossed or waved filaments, rounded bristles, etc. Karen Coates says that consumers should use a medium-textured, small-headed brush with a long neck so that they can reach the back of their mouths. A flat-topped brush is suitable if someone has a good brushing technique, but a brush with mixed length filaments is better if brushing technique is poor, as it will reach more surfaces of their teeth. Another way to ensure that brushing is 24 August 2007 ICP more effective is to use a power brush rather than a manual one. вЂњElectric toothbrushes with an oscillating or pulsating head get into difficult-to reach areas,вЂќ says Karen Coates. вЂњStudies show that electric brushes remove more plaque and debris than the manuals, although technique is also important as the brush needs to be at a 45-degree angle. Many people do think that by using an electric brush, it is doing the work for them, when this is not the case.вЂќ According to Steve Davey, Oral B brand manager, power brushes are a key growth area for pharmacists to tap into. Power brushes range from entry-level products like the Oral B Vitality range (including new Vitality Sensitive Clean for sensitive teeth and gums) to premium products like new Philips Sonicare Elite e9500, which is the only angled sonic toothbrush, for better access to hard-to-reach parts of the mouth. вЂќ Oral hygiene has such a big impact on peopleвЂ™s overall health, not just on the state of their teeth вЂќ вЂњWe believe there is huge potential to extend the number of consumers who buy power toothbrushes and increase household penetration,вЂќ says Steve Davey. вЂњAll the brushes within the Oral-B Vitality range provide unique end benefits for consumers and, combined with an entry-level price point, are set to continue to act as a stepping stone to encourage consumers to trade-up from manual brushes, driving the market and reaping profits for retailers.вЂќ Good regime Brushing only cleans 60 per cent of the tooth surface, so the BDHF recommends that people use floss and mouthwash, too. But research on behalf of Oral B has found that less than one in 10 of manual toothbrush users buy interdental products, while, according to the GSK report, floss has only 12 per cent penetration. вЂњFloss and tape are hard to use,вЂќ says Karen Coates. вЂњThe dentist or hygienist will show patients what to do, but many patients donвЂ™t use the products enough to turn it into a habit. There is also a time restraint to a certain degree, as flossing takes longer than just using a brush.вЂќ Pharmacists can encourage customers to buy flossing products like Oral B Hummingbird (power flossing) and Sensodyne Total Care Expanding Gentle Floss and Gentle Tape (for tighter areas), as these make flossing easier and more comfortable. Mouthwash is outperforming the total oral care category and with penetration at just 42.6 per cent, but rising, the sector offers the best potential for category growth. Several new mouthwashes have been introduced to grow the sector. New Listerine Softmint Sensation, a milder flavour than other Listerine mouthwashes, is expected to attract three quarters of a million new users to the mouthwash sector in its first year of launch. New Aquafresh Extreme Clean Purifying Mouthwash cleans the tongue, an important source of bacteria, whilst also promoting healthy gums and protecting against decay. Oral care problems A regular dental check-up reduces the risk of not just tooth decay, but related problems (eg, sensitivity, gum recession and bad breath) as teeth last longer in the ageing population. Yet only just over half of the population is registered with a dentist, and many of these make an appointment only when they have a problem. A survey by Colgate found that 40 per cent of the population are solely motivated to visit the dentistвЂ™s chair because they love the clean feeling they have afterwards вЂ” rather than because they are aware of the importance of regular check-ups. Increasing numbers of people are consuming more fruit, fruit juices and smoothies as part of a healthy lifestyle, but they donвЂ™t realise that they are causing damage to their teeth. Dentists are noticing more acid erosion (wearing down of the tooth enamel) among their patients. In October 2005, 91 per cent of dentists reported seeing cases of acid erosion on a weekly basis, and GSK believes that acid erosion is one of the most important issues since cavities facing dental health. Early signs of acid erosion are sensitivity, discolouration and rounded teeth. In severe cases, teeth become cracked, transparent and severely sensitive. Although a good fluoride toothpaste will remineralise enamel to a certain degree, the use of products like Sensodyne Pronamel and Arm & Hammer Enamel Care can help to protect against acid erosion and reharden tooth enamel. Since overvigorous brushing aggravates acid erosion, sufferers should use a more gentle toothbrush, such as new Sensodyne Pronamel, which is specifically aimed at people with, or at risk of, acid erosion. Pharmacy customers also need to check their eating and drinking habits, if they want their teeth to stay healthy. вЂњPharmacists should tell customers that they shouldnвЂ™t brush their teeth for an hour after eating, as saliva needs to be able to neutralise the acid,вЂќ says Karen Coates. вЂњEating cheese, nuts or seeds after an acidic meal will also help.вЂќ Oral care AUG p22-25rev 6/8/07 11:16 Page 25 Oral Care Product update Aquafresh Extreme Clean Purifying Mouthwash has been launched by GlaxoSmithKline. The new вЂњclearвЂќ mouthwash is intended to clean the tongue and вЂњkill 90 per cent of the bad breath causing bacteria found on the tongue, whilst also promoting healthy gums and protecting against decay,вЂќ says the company. The pack design employs the existing Aquafresh Extreme Clean blue and orange livery for вЂњmaximum shelf stand outвЂќ, with front of pack copy explaining the productвЂ™s key benefits. Support for the Aquafresh Extreme Clean Purifying Mouthwash will include national TV, on-line activity and sampling. The mouthwash is available in a вЂњclear mintвЂќ flavour with a recommended selling price of ВЈ2.49 for 500 ml. GLAXOSMITHKLINE 0845 762 6637 Orajel is a вЂњleading range of products for the rapid relief of mouth pain associated with toothache, mouth ulcers and the discomfort of wearing dentures,вЂќ says manufacturer Accura Health. Orajel is applied directly to the sore area within the mouth and is designed to act within seconds to relieve pain. It is intended for short-term use until the patient can consult a dentist for treatment of the underlying cause of the pain or discomfort. The range includes: Orajel Extra Strength, only available from pharmacies, while Dental Gel, intended to relieve the pain associated with toothache, and Mouth Gel, indicated for the relief of the pain of mouth ulcers and minor mouth irritations, are on the general sale list. ACCURA HEALTH 01294 275800 GlaxoSmithKline is вЂњrevitalisingвЂќ the Macleans brand with a major relaunch based on the proposition вЂњstrong foundations for healthy teethвЂќ. The initiative, which вЂњembracesвЂќ whole tooth health involves new pack designs and the introduction of a new Macleans Total Health franchise. The packs feature an enhanced logo, followed by a вЂњstrong foundationsвЂќ legend, with each product featuring its own new icon to assist variant differentiation. The new packs have recommended selling prices ranging from ВЈ1.89 for Macleans Freshmint to ВЈ2.59 for Macleans White & Shine, with new Macleans Total Health and Macleans Total Health Whitening both priced at ВЈ1.99 for 100 ml sizes. вЂњTravelfriendlyвЂќ 50 ml tubes and 100 ml pumps will also be available on most variants over the coming months. GLAXOSMITHKLINE 0845 762 6637 Wockhardt UKвЂ™s ConfiDent Denture Care range has recently been expanded and now includes: ConfiDent Denture Cleansing Tablets, ConfiDent Denture Fixative Cream designed to hold dentures firmly in place all day long and impart a вЂњfresh and hygienic feelвЂќ, ConfiDent Denture Bath (designed for use with dentures or removable braces), Confident Denture Care Brush (a large multi-tufted brush to remove particles and food stains plus a small angle-trimmed brush to clean hard to reach surfaces), and ConfiDent Trial/Travel Pack (a вЂњhandyвЂќ pouch containing essential denture care items for use when travelling away from home). A free merchandising Unit is available for a limited period in conjunction with an agreed minimum order. WOCKHARDT UK LIMITED 01978 661261 Hygienists recommend interdental brushes more often for interdental cleaning than floss, says manufacturer, Molar Ltd, supplier of TePe interdental brushes. вЂњThe reason is simple: most people find interdental brushes extremely effective and easier to use than floss,вЂќ states the company. TePe is claimed to be the вЂњUKвЂ™s number 1 best selling brandвЂќ and also the вЂњmost recommended and personally used brush amongst UK dentists and hygienistsвЂќ. TePe interdental brushes are available in seven colour-coded sizes вЂњensuring that there is one to fit most interdental spacesвЂќ. They are manufactured in Sweden. Molar has a new pharmacy starter pack. For further information either telephone Molar Ltd or email [email protected] MOLAR LTD 01934 710022 ICP August 2007 25 Automation p26-28 AUG revrev 2/8/07 15:03 Page 26 Automation The robots are coming ItвЂ™s never too early to invest in new technology and pharmacists could benefit from a robot in their dispensary sooner than they think. Steve Bremer reports An ARX Rowa Speedcase at Prestwich Pharmacy W ith prescription numbers rising at 6-7 per cent annually, the prescription fee falling, and the emphasis increasingly on pharmacy services, a dispensing robot is an ideal way for busier pharmacies to free up time. The technology is relatively new and automation is not yet suitable for all pharmacies but it is bound to become increasingly popular. Almost every pharmacy can benefit from some sort of automation, says Dave Harper, retail pharmacy sales manager for ARX in the UK. For example, any pharmacy can benefit from a final checking system to ensure the accuracy of the operation, he says. ARX has over 1,600 robotic dispensing machines installed throughout Europe, around 10 per cent of which are in the UK. About a third of those in the UK are in community pharmacies. ARX says it is the only company that offers systems operating on both main types of automation: в—Џ channel/vending в—Џ robotic, or вЂњchaoticвЂќ solutions. It also provides some lower level softwareonly solutions due to be released shortly. 26 August 2007 ICP In a robotic or вЂњchaoticвЂќ system, a robot arm picks the packs. In a channel system, packs are loaded into channels like a cigarette vending machine and are dispensed one at a time at the bottom. The two types of system should not be confused, warns Mr Harper, and the correct automation solution will vary according to a pharmacyвЂ™s workload and needs. One size does not fit all. Channel systems appeal to lower volume pharmacies with large floor space because the systems tend to be cheaper but take up large amounts of space as they need room both in front and behind for loading and access. And full robots usually attract the larger volume pharmacies and/or those with limited space, as the systems are more space efficient, automate significantly more of the process, are more flexible, but are usually more expensive. For example, a company installed a robot last year in a pharmacy with a total floor space of 5 square metres, which included the shop floor, consultation room and the dispensary area. The pharmacy staff have found the machine to be highly beneficial, describing it as вЂњa much smoother way of doing businessвЂќ. The pharmacist says: вЂњAutomation is certainly very useful if you are struggling for spaceвЂќ. Mr Harper declares:вЂњARX provides the unique service of being able to discuss each possible solution, and, using over a decade of experience, can guide pharmacies through the options available and how these can be justified for each business model.вЂќ With a UK market share in excess of 80 per cent, and well in excess of 1,500 sites across Europe, ARX product development ensures that every aspect and every product is developed well beyond any other system available, adds Mr Harper. ARX has installed over 180 machines in the UK and says it has more service engineers than any other pharmacy automation supplier. Its systems have been tailored to the UK market to allow part (open) pack integration, generic and parallel import inclusion and links to labeling/patient medication record systems. The system integrates with all major patient medication record suppliers including: Cegedim Rx, AAH Link Evolution, Positive Solutions, Systems Solutions, McLearnons and Eclipse. The Healthpoint view Healthpoint Technologies and Willach + Heise (supplier of FAMA, the continental drawer systems for pharmacies) are working together to market the Consis dispensing robot in the UK and Irish markets. вЂњThe synergy between the two companies is obvious as they both seek to give pharmacists the tools, the knowledge, the time and the space to fulfill their new role in this new age of pharmacy,вЂќ says John White, managing director of Healthpoint Technologies. One of the most common preconceptions about dispensing robots is that they are outside the reach of most community pharmacists, costing in excess of ВЈ100,000. The fact that the Consis A and B modules fall substantially beneath this figure and deliver real benefits to the pharmacist was one of the motivating factors in HealthpointвЂ™s decision to take on the Consis franchise, says Mr White. Anyone considering investing in a robotic dispensing system should consider the following questions, suggests Mr White: в—Џ What logistics benefit will I gain both in Automation p26-28 AUG revrev 2/8/07 15:03 Page 27 Automation Case studies George Romanes, proprietor of Romanes Pharmacy in Duns Mr Romanes was introduced to the Consis range by John White, managing director of Healthpoint Technologies. Consis robots work in a similar way to a vending machine and on the premise that 80 per cent of dispensing is from 20 per cent of lines. So a Consis robot is only loaded with the most popular lines that make up the bulk of dispensing. With a price tag of around ВЈ50k this is a more affordable system. вЂњRobots are the way forward to deal with the volumes weвЂ™ve got,вЂќ says Mr Romanes. Willach + Heise, manufacturer of Consis robots, have made pharmacy dispensing drawers for a number of years and Mr Romanes describes its products as вЂњgood German engineeringвЂќ. The robot was installed in February, taking only 48 hours to get up and running. Since then, selecting which lines to put in the machine has required fine tuning and AAH Link has perfected the computer interface. Mr Romanes is please that his robot is the most cost-effective solution for his pharmacy. вЂњIt will do what it says on the tin. YouвЂ™ve got to be doing an awful lot of prescriptions to justify the costs of a chaotic machine.вЂќ The Consis does the work of half a full-time dispenser, says Mr Romanes. This has freed up вЂњuseful chunksвЂќ of his time to carry out extended roles. Fin McCaul, managing director of Prestwich Pharmacy in Manchester and St Peters Pharmacy in Burnley Mr McCaul has recently installed ARX Rowa Speedcases in both his pharmacies, and describes his robotsвЂ™ stock storage capability as вЂњphenomenalвЂќ and their accuracy as вЂњexcellentвЂќ. Mr McCaul chose this model because he believes it is the best supported system and the most sophisticated available in the UK. He was aware of their вЂњgood historyвЂќ in a number of community pharmacies. The robots have a hopper attachment that sorts out and puts away stock. In addition, a Max channel allows the robot to dispense 10-15 items at once. A typical two-item prescription can now be picked in 20 seconds. One robot was installed to facilitate вЂњupstairsвЂќ and вЂњdownstairsвЂќ dispensaries at Mr McCaulвЂ™s Prestwich Pharmacy in Manchester. The robot allows both dispensaries to operate from a single stock holding. It has also created the space for two consulting rooms and three treatment rooms. The robots are more accurate than a human dispenser, with the only potential source of human error being a failure to map bar codes correctly. вЂњItвЂ™s given us an awful lot of flexibility and variability in terms of working practices,вЂќ says Mr McCaul. Dispensing speed has not increased, as Mr McCaul believes he has not yet optimised the robotвЂ™s use, but is confident that he will have a head start when ETP goes live. вЂњWith ETP coming on line we can virtually dispense everything by key strokes.вЂќ A robot may not be suitable for every pharmacy, but Mr McCaul believes that the concept has huge potential. вЂњItвЂ™s just getting your head round using it and adapting how you work. The public are very impressed with it.вЂќ Mr McCaul recommends this model to other independents. It works well in both his pharmacies, achieving slightly different objectives. The St Peters Pharmacy in Burnley is an extended hour pharmacy so staff there do not need as much help putting away stock but it is effectively stored for access at any time. Software and an interface from Positive Solutions software work well with the robot, says Mr McCaul. ICPвЂў Summer 2007 A R X Automation Independant Community Pharmacist 2 Bespoke Choices, 1 Absolute Decision 'Automation is certainly very useful if you are struggling for space' - Shiv Bagga, Robot-Owner, Manor Park Pharmacy, London 'I can now spend the time talking to my customers whilst the requested packs are being dispensed' - Tim Dobbin, Robot-Owner, Herrington Pharmacy, Durham The Rapid and Economical вЂ�AutoMaxвЂ™ The Efficient and Flexible вЂ�Rowa SpeedcaseвЂ™ Automating your pharmacy is a big decision as it is, never mind choosing what type! Thats why automating with ARX is simple. We supply both the rapid, economical Channel-based systems and the more complete, efficient Robotic dispensing machines. With a product range including both, ARX are able to help you decide which technology will benefit your Pharmacy. вЂ�Script volume has increased, which has increased turnover. We couldn't cope with current volumes without automationвЂ™ - Martin Bennet, Robot-Owner, Associated Chemists, Sheffield The UKвЂ™s Number 1 Provider of Pharmacy Robotics For any information regarding ARX systems please contact us on (+44)01727 893360 alternatively email on [email protected] ARX Ltd вЂў Tel: +44(0)1727 893360 вЂў Fax: +44(0)1727 893361 вЂў Email: [email protected] вЂў Web: www.ARXinter.net ICP August 2007 27 Automation p26-28 AUG revrev 2/8/07 15:04 Page 28 Automation Figure 1: The benefits of robotics terms of staff savings as well as stock efficiency? в—Џ Will there be a tangible increase in dispensing accuracy? в—Џ How much will I improve my service to my customers? в—Џ Are there space saving efficiencies I will gain that I can utilise? в—Џ Will my customersвЂ™ waiting times be cut? вЂњThese questions, coupled with the challenges of the new contract, really will help focus your mind as to whether the robotic pathway is the right way for your pharmacy,вЂќ says Mr White. Another important factor to be considered is shown in Figure 1. The UK pharmacy market operates on the 80/20 rule, where 80 per cent of the prescriptions dispensed are from 20 per cent of the lines in the dispensary. As the graph illustrates, any real economic or service benefit from going beyond 90 per cent tails off dramatically. вЂњIn other words, a combination of a fast moving system and a Consis robot will deliver all the benefits of automation at the most realistic price.вЂќ The first Consis robot in the UK was installed at George RomanesвЂ™s pharmacy in Duns in the Borders. The dispensing load on Mr RomanesвЂ™s pharmacy and the fact that the Consis system is modular helped him to choose a Consis A2 module. This type of system can grow with a business and be extended without major disruption to the existing set-up. Mr White predicts that robotic dispensers will become increasingly common in pharmacies: вЂњOne thing is certain вЂ” more change will follow and the introduction of a robotic dispensing system will put the community pharmacist in pole position to meet those challenges.вЂќ Product update вЂњWith over 2,500 units in use around the world, the Baxa Repeater Pump is the most widely used hospital pharmacy pump and fills the need for accurate fluid handling in the pharmacy through the automation of routine filling procedures,вЂќ says manufacturer, Baxa (UK) Ltd. The repeater pump is also used in community pharmacies for methadone dispensing for patients on community-based drug detoxification programmes; the pump is designed to save time and resources in the pharmacy. The repeater pump features motor strength powerful enough to pump viscous fluids, and is the вЂњpharmacyвЂ™s most reliable friend for fluid transfer and filling applications,вЂќ says the company. The pump delivers volumes of between 0.2 ml to 9.9L with accuracy of +/- 1per cent above 2 mL. BAXA UK LTD 01344 392902 The Methasoft Treatment Management System (TMS), from Methsoft UK Ltd is a computerised system that is designed to help pharmacies and substance misuse clinics better to manage the care provided to service users. Covering the вЂњcomplete flowвЂќ, from triage and initial assessment, through to care planning and dispensing of therapeutic drugs such as methadone, the Methasoft TMS is intended to save staff time, improve clinical governance and allow facilities to provide a higher level of care to more clients. The dispensing system keeps full records of medication provided to a client, and allows staff to dispense liquid drugs via the system using an electronic pump. An audit trail is kept, including detailed inventory records of drug stocks, and an electronic controlled drugs register is kept automatically. A вЂњfully comprehensiveвЂќ security module ensures that the вЂњright service client gets the correct doseвЂќ. The Methasoft TMS has been вЂњinstrumental in preventing double dosing of service usersвЂќ. The Methasoft TMS is currently in use across both community pharmacy, the Prison Service and Drug and Alcohol Action Teams across the UK. For further information or to request a product demonstration contact Methasoft UK Ltd at [email protected] METHASOFT UK LTD 0845 300 5243 28 August 2007 ICP The MTS Medication Technologies PlusPak is a patient concordance-support system, now supported by automated filling technology, the OnDemand Multi-Med. Interfaced to the pharmacy software system, the multi-med fills MTS multidose cards, seals them and prints and affixes labelling, providing a finished product ready вЂњjust in timeвЂќ for the patient. вЂњThe multi-med maximises workflow, while allowing easy checking and is equipped with sophisticated software to maximise accurate dispensing and efficient inventory management,вЂќ says the company. Multimed is intended for use with a wide variety of MTS mutidose card designs, including tear-off cards which allow the patient to be given medications in a single blister, or perhaps a set of blisters for the day. Further information can be found at www.mts-mt.co.uk. MTS MEDICATION TECHNOLOGIES 0870 7661462 Clinicalfocus AUG P29-31 V2rev 6/8/07 11:21 Page 29 Clinical Focus Improving compliance in community pharmacy Mark Greener examines an age-old problem and calls for more research into the ways that people use (or donвЂ™t use) medicines A common problem Poor compliance is common with almost every treatment in almost every disease, as the following examples illustrate all too clearly: в—Џ Between 31 per cent and 44 per cent of patients taking monotherapy for raised blood pressure did not use their antihypertensive for at least two months during the first year of therapy.1 Up to half of patients discontinue antihypertensive drugs during follow-up lasting between 6 months and four years.2 в—Џ Up to 30 per cent of patients stop within 6 to 12 months of starting osteoporosis treatments taken daily or weekly.3 In another study, 19 per cent of patients discontinued within a year of starting treatment for osteoporosis.4 в—Џ Estimates of compliance with antidepressants range from 30 per cent to 97 per cent, with a median of 63 per cent.5 Not surprisingly, poor compliance undermines outcomes, as the following examples illustrate: в—Џ Fifty-three per cent of patients taking statins discontinued treatment during a twoyear study. The patients who persisted with treatment were, depending on the dose, between 20 per cent and 40 per cent less likely to require hospitalisation for an acute Mauro Fermarello/Science Photo Library N o matter how efficacious and welltolerated modern pharmacology manages to make a medicine, itвЂ™s useless if it remains in the blister pack rather than in the patient. Yet many, in some conditions most, patients donвЂ™t adhere to their doctorsвЂ™ and pharmacistsвЂ™ recommendations. They miss doses. They delay taking the drug. Sometimes they drop out of treatment entirely. And it doesnвЂ™t seem to matter whether the disease is relatively trivial or potentially life threatening вЂ” poor adherence is pervasive. Yet the factors that influence adherence and the most effective means to improve compliance remain poorly investigated. Nevertheless, community pharmacists can, by going back to first principles, address factors that contribute to poor adherence. myocardial infarction compared with their less adherent counterparts.6 в—Џ Patients who complied with antihypertensives were 19 per cent less likely to suffer a first cardiovascular event, 32 per cent less likely to die from a cardiovascular event and 42 per cent less likely to develop heart failure than those who did not comply. 7 в—Џ During an average follow up of 2.2 years, 13 per cent of patients with HIV or AIDS who filled less than 50 per cent of their prescriptions for therapy based on nonnucleoside reverse transcriptase inhibitors showed a sustained suppression of viral load (less than 400 copies per ml). This compared with 25 per cent and 73 per cent for those that вЂњfilledвЂќ 50-60 per cent and 90-100 per cent of their prescriptions, respectively. 8 в—Џ Each 25 per cent increase in the proportion of time without inhaled corticosteroid doubles risk of being hospitalised for asthma. 9 Futhermore, a confidential enquiry into asthma deaths reported that just 20 per cent of fatal attacks were sudden. Therefore, 80 per cent of deaths from asthma were probably potentially preventable. Behavioural and psychosocial factors, such as poor compliance, smoking, denial, depression and alcohol abuse, contributed to 81 per cent of the deaths. Some deaths had several contributory factors. Nevertheless, poor compliance probably contributed to 61 per cent of deaths.10 Enhancing adherence Clearly, improving compliance is an imperative for community pharmacists and other healthcare professionals. Unfortunately, the evidence base suggesting ways in which health care professionals can enhance adherence is relatively weak. For example, a review of 32 studies assessing compliance with antidepressants found no вЂњconsistentвЂќ indication of which interventions would improve adherence most effectively. 5 Furthermore, many methods work in some studies but not others. Moreover, most studies rely on patient self-report or pill counting, which do not necessarily accurately reflect compliance.11 Lindenmeyer et al examined the literature surrounding the role of pharmacists in improving adherence in people with type 2 diabetes. They found that reminders and specialised packaging, but not pill counts, improved compliance. Integrated management and education programmes led by pharmacists and aimed at вЂњunder-servedвЂќ patient populations lowered HbA1c by between 0.8 per cent and 2.2 per cent. 12 In the UK Prospective Diabetes Study (UKPDS), a 1 per cent decrease in HbA1c reduced the risk of developing microvascular endpoints and myocardial infarctions by 37 per cent and 14 per cent, respectively.13 Nevertheless, while pharmacists can improve outcomes in people with type 2 diabetes, the authors conclude that it is вЂњunclear whether this resulted from improved patient adherenceвЂќ.12 Against this background, pharmacists can go back to first principles and address factors that could undermine compliance in some patients. For example: ICP August 2007 29 Clinicalfocus AUG P29-31 V2rev 6/8/07 11:51 Page 30 Clinical Focus в—Џ Simplify complex regimens, such as those with multiple doses and polypharmacy.11 Simplifying antihypertensive dosing regimens increased adherence (by 8 per cent to 20 per cent) in seven of the nine studies assessed in a Cochrane review. The reviewers suggest that reducing the number of daily doses should be the вЂњfirst line strategyвЂќ to enhance adherence with antihypertensives. 14 в—Џ Address side effects.11 Patients who experience problems with their medication (including adverse reactions) are 3.5 times more likely to reduce the dose or discontinue than those who do not.2 в—Џ Address patient concerns about the appropriateness of medicine.11 Adherence is highest when patients regard the necessity of the medication as exceeding their concerns, for example about toxicity. Conversely, compliance is lowest when their concerns exceed their perception of the medicineвЂ™s necessity. One study looked at four characteristics that could influence compliance: scepticism, ambivalence, indifference and acceptance. Patients who are highly sceptical about medicines are around 40 per cent less compliant than the mean. Those who accept the diagnosis and treatment are around 50 per cent more compliant than average. The other traits fell between these extremes. Pharmacists could tailor treatment in line with these characteristics. For example, indifferent patients may be more likely to adhere to a regimen that is easy to administer and drugs that produce the full benefits rapidly. Those patients who are ambivalent about treatment may benefit from a regimen that minimises adverse reactions and by healthcare professionals proactively addressing any concerns. Those who are sceptical may need considerable counselling and education before they accept the need for Product update Tabtime Ltd is a вЂњleading supplier of medication management products,вЂќ pill and tablet timers, reminders, dispensers and organisers and pill splitters, cutters and crushers for those who find medication difficult to take. The latest addition to the product range is Tabtime 5 an вЂњelectronic pillboxвЂќ with five daily alarms, five corresponding tablet compartments and a countdown timer for regular doses. Tabtime 5 is designed for Parkinson, AlzheimerвЂ™s, multiple sclerosis and epilepsy patients. All alarms on Tabtime products are вЂњset it and forget itвЂќ. The products in the вЂњpill splitters, cutters and crushersвЂќ range are all designed to provide a storage space for whole or cut pills. More details at www.tabtime.com. TABTIME 01270 767207 30 August 2007 ICP treatment.15 Uncovering and addressing these concerns depends on taking a nonjudgemental, non-confrontational approach. Indeed, this attitude should underpin all conversations about compliance. в—Џ Address denial and other psychological issues.11 In patients with asthma, concurrent panic and anxiety is associated with greater use (which is another form of non-compliance) of corticosteroids and bronchodilators as well more frequent hospitalisations.16 As mentioned in the June issue of ICP (post-traumatic stress disorder article, p32) detecting anxietyspectrum disorders in community practice is relatively straightforward. в—Џ Address any confusion and physical difficulties, especially among elderly people . For example, offering patients clear instructions in large type, using ordinary, rather than childresistant, caps and linking medications to events, such as meals when not contraindicated, may help.11 в—Џ Question patients. Simply asking patients вЂњDid you ever forget to take your medicationвЂќ identifies many non-adherent subjects with hypertension who are prone to a cardiovascular event. Patients who answered вЂњyesвЂќ to this question were, for instance, 28 per cent more likely to experience a cardiovascular event or death and 35 per cent more likely to experience their first non-fatal event. Other studies suggest that patient interviews identify between a third and half of those with poor adherence. However, pharmacists should be aware that patients, usually unintentionally, tend to over-estimate adherence and underestimate poor compliance. 11 в—Џ Inquire about swallowing problems. Age-related changes in swallowing physiology and dysphagia arising from disease are relatively common among elderly people and can cause The Medidos tablet dispenser, from Dudley Hunt, вЂњis still the market leading tablet dispenser,вЂќ says the company. Medidos has seven marked boxes. Each box contains four adjustable compartments labelled вЂњbreakfastвЂќ, вЂњlunchвЂќ, вЂњdinnerвЂќ and вЂњbedtimeвЂќ. To secure the box there is a Velcro strap. Dudley Hunt also supplies Medimax, which has nearly four times the capacity of Medidos, with eight individual boxes. A patient record card and a sleeve to house a single day box are included and both models are available in clear covers as well as in a blue wallet. Dudley Hunt says: вЂњThe Medidos and Medimax range of tablet dispensers helps ensure the right pills are taken at the right time.вЂќ For further details on the full range of medication management products go to www.dudleyhunt.co.uk. DUDLEY HUNT 01796 482 105 problems when patients try to take capsules or tablets. For example, a study conducted in community pharmacies reported that 62 per cent of patients over the age of 65 years had experienced difficulties swallowing solid medications. In 46 per cent of cases, a community pharmacy study revealed, swallowing difficulties sometimes prevented patients from taking their medicines.17 Against this background, a recent consensus guidelines stress the importance of asking whether the patient experiences problems swallowing medicines.17 However, the community pharmacy study found that only 11 per cent of patients or their carers reported that the doctor or nurse asked about swallowing difficulties.17 While prone to recollection bias, the low rate suggests that healthcare professionals rarely ask about swallowing problems. For those patients who experience problems, the guidelines suggests considering alternative formulations, including liquids. Clearly, future studies need to characterise evidence-based techniques that enhance compliance.13 In the meantime, by going back to basics pharmacists can address many of the issues that appear to be linked to poor compliance. As a profession, pharmacists could lobby drug companies and other organisations that fund research for further research into the ways in which community health professionals can enhance adherence. Pharmaceutical companies bemoan the cost of developing new medicines. Politicians and providers lament the increasing costs of medical care. Yet better compliance could improve outcome. But this means investing more to investigates ways to address the many a slip twixt pack and mouth. The PlusPak is a вЂњsimple, high quality and cost effective patient concordancesupport system widely used in the UK,вЂќ says manufacturer MTS-Medication Technologies. The 7-day pack with 28 blisters is available in heatseal or cold-seal, and in standard and tear off forms. Now as part of MTS Medication Technologies Ltd вЂњconstant innovation programвЂќ the PlusPak, and the full range of MTS care home blister cards are available manufactured from biodegradable materials. The packaging is designed to biodegrade harmlessly back into the earth and is eco-friendly вЂњas the process does not require external energyвЂќ. For more information go to www.mtsmt.co.uk. MTS MEDICATION TECHNOLOGIES 0870 7661462 11:21 References 1. Elliott W, Plauschinat CA, Skrepnek GH, Gause D. Persistence, adherence, and risk of discontinuation associated with commonly prescribed antihypertensive drug monotherapies. J Am Board Fam Med 2007;20:72-80 2.Anon. After the diagnosis: Adherence and persistence with hypertension therapy. Am J Managed Care 2005;11:S395-99 3. Papaioannou A, Kennedy CC, Dolovich L, Lau E, Adachi JD Patient adherence to osteoporosis medications: problems, consequences and management strategies. Drugs Aging 2007;24:37-55 4. Rossini M, Bianchi G, Di Munno O, Giannini S, Minisola S, Sinigaglia L, Adami S. Treatment of Osteoporosis in clinical. Practice (TOP) Study Group Determinants of adherence to osteoporosis treatment in clinical practice. Osteoporos Int 2006;17:914-21 5. Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C. Patient adherence in the treatment of depression. Br J Psychiatry 2002;180:104-9 6. Penning-van Beest FJ, Termorshuizen F, Goettsch WG, Klungel OH, Kastelein JJ, Herings RM. Adherence to evidence-based statin guidelines reduces the risk of hospitalisations for acute myocardial infarction by 40 per cent: a cohort study. Eur Heart J 2007;28:154-9 7.Nelson MR, Reid CM, Ryan P, Willson K, Yelland L. Self-reported adherence with medication and cardiovascular disease outcomes in the second Australian National Blood Pressure Study (ANBP2). MJA 2006;185:487-9 8. Nachega JB, Hislop M, Dowdy DW, Chaisson RE, Regensberg L, Maartens G. Adherence to nonnucleoside reverse transcriptase inhibitor-based HIV therapy and virologic outcomes. Ann Intern Med 2007;146:564-73 9. Rau JL. Determinants of patient adherence to an aerosol regimen. Respir Care 2005;50:1346-56 10. Harrison B, Stephenson P, Mohan G, Nasser S. An ongoing confidential enquiry into asthma deaths in the Eastern Region of the UK, 2001-2003. Prim Care Respir J 2005;14:303-13 11. Hill J. Adherence with drug therapy in the rheumatic diseases part two: measuring and improving adherence. Musculoskeletal Care 2005;3:143-156 12. Lindenmeyer A, Hearnshaw H, Vermeire E, Van Royen P, Wens J, Biot Y. Interventions to improve adherence to medication in people with type 2 diabetes mellitus: a review of the literature on the role of pharmacists. J Clin Pharm Ther 2006;31:409-19 13. Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:405-12 14. Schroeder K, FaheyT, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database of Systematic Reviews 2004, Issue 3. Art No: CD004804. DOI: 10.1002/14651858.CD004804. 15. Aikens JE, Nease DE, Nau DP, Klinkman MS, Schwenk TL. Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication. Ann Fam Med 2005;3:23-30 16. Strek ME. Difficult asthma. Proc Am Thorac Soc 2006;3:116-23 17. Strachan I, Greener M. Medication-related swallowing difficulties may be more common than we realise. Pharmacy in Practice 2005;15:411-4. 18.Wright D, Chapman N, Foundling-Miah M et al. Consensus guideline on the medication management of adults with swallowing difficulties. In Foord-Kelcey G, editor. Guidelines вЂ”summarising clinical guidelines for primary care. 30th ed. Berkhamsted: Medendium Group Publishing Ltd, October, 2006, pp 373-6 Page 31 Health Watch MOVING TOWARDS RECOVERY A five-year study of long-term recovery after strokes has started at Southampton University. Lack of knowledge about how stroke survivorsвЂ™ mobility changes over time makes it harder for therapists to discuss long-term goals with patients and to predict the benefits of rehabilitation therapy. Specialists at the universityвЂ™s Rehabilitation Research Centre are working with local hospitals to measure long-term recovery of mobility and to assess how improvements will enhance quality of life. EXTRA POUNDS OF RISK Weight is confirmed as an important risk in endometrial cancer by a study of 223,000 women in 10 European countries. The risk to the womb lining was doubled in women with waists of more than 34in, those who have piled on more than 44lb since the age of 20, and obese women. The womb cancer tendency was seen as particularly strong in post-menopausal women and those who had never had the contraceptive pill or hormone replacement therapy. A 2004 survey put British womenвЂ™s average waist measurement at 34in, compared with 27.5in during the 1950s, when people had wartime diets and exercised more. The study, part-funded by Cancer Research UK and BritainвЂ™s Medical Research Council, was published by the European Prospective Investigation into Cancer and Nutrition. ASPIRIN STANDS GUARD Aspirin seemed to prevent asthma from starting in an American study involving more than 22,000 doctors. All the doctors appeared asthma-free when the study began. After five years, asthma had developed in 40 per cent more of those who did not take aspirin. This is thought to be because aspirin stops the airway inflammation symptomatic of asthma. However, the researchers warned that aspirin does not necessarily help already diagnosed asthmatics. The research вЂ” the PhysicianвЂ™s Health Study вЂ” also suggested that asthma incidence has soared in Britain, the United States and Australia because children now usually take paracetamol for pain relief instead of aspirin. GO FAR ON MOTHERвЂ™S MILK Breast-fed people appear to succeed socially more than those fed by bottle. Bristol University researchers found they were 41 per cent more likely to climb the social ladder, possibly because breast-feeding aids brain development, producing better academic results, job prospects and earning potential. The findings showed the advantages were greater the longer breast-feeding continued. In addition, the researchers thought long-term health was improved and that other social and economic benefits could eventually be discovered. They had investigated 3,000 people in their sixties and seventies as part of a study of diet and health in pre-war Britain. TOOTH TOP-UPS Surface damage to teeth could eventually be repaired with an enamel substance created in the laboratory. Scientists at Tokyo University first prepared enamel from pigletsвЂ™ teeth on a collagen base. Then they placed it in the stomachs of young mice, where the cells developed into tissue similar to tooth enamel. BRAIN-DAMAGED SMOKERS Cigarette nicotine has finally been shown to damage the brain and create dependence. Researchers who conducted a study supported by the American National Institute on Drug Abuse reported that smoking changed cerebral tissue just like cocaine, heroin and other narcotics. UNHEALTHY NOTE FOR SINGERS Even opera singers face an occupational health hazard. Researchers at the Catholic University of Rome have found that all professional singers are at risk of developing oesophageal reflux. Opera singers, however, were shown to be at twice the risk because they put more stress on the diaphragm. The danger is that reflux can inflame and damage the vocal cords and lead to laryngitis. IstockPhoto 6/8/07 IstockPhoto Clinicalfocus AUG P29-31 V2rev ICP August 2007 31 business focus p32 rev 6/8/07 15:18 Page 32 Business Focus 100 hour contracts: threat or opportunity Are 100-hour contracts a business threat or an opportunity? David Parker sets the issue in context T he changes to the control of entry regulations in 2005 were precipitated by an Office of Fair Trading investigation that was highly critical of the lack of competition that resulted from the regulatory framework in place at that time. Indeed, the OFT was so critical that it proposed complete deregulation of entry to the pharmaceutical list. The Department of Health significantly watered down this advice by making a limited number of changes to the regulations with the aim of encouraging competition and thus improve services available to patients. These changes included four exemptions to the вЂњnecessary or desirableвЂќ test for entry to the list. The jury is currently out on whether these changes have in any way met their objective. What is certainly clear is that the threat posed to existing pharmacy owners is significantly less than would have been experienced had the OFT had their way. In fact, apart from the odd, very rare, example the only exemption that has put real fear into preexisting contractors is the 100-hour exemption. It is easy to understand that an owner who has paid a good deal of money for the goodwill of a business, or has spent many years building a solid customer base, would be unhappy about the prospect of somebody joining the party for free. On the other hand, it is very hard to find a member of the public that considers a pharmacy that is open to serve them from 7am to 11pm to be a bad idea. Whichever side of the fence you sit on, the plain facts of the matter are that the regulations are as they are, which for existing owners represents a threat and for aspiring owners an opportunity. Substantial applications But just how much of an opportunity or threat does the 100-hour contract represent? The number of applications for 100-hour contracts has been substantial for obvious reasons. The exemption is very straightforward: you simply find premises, promise to open for 100 hours per week, buy some stock and, as if by magic, you are the proud owner of your very own pharmacy. (Although 100-hour applications can be rejected in exceptional circumstances) The 100-hour opportunity has also coincided with two other market conditions that have increased the propensity for non-owners to chance their arm in business. 32 August 2007 ICP First, the locum market has changed quite significantly over recent years. Where the balance of power in the market was previously held by the locum, with a ready supply of work at healthy rates of pay, this balance has shifted somewhat recently. Secondly, there is buoyancy currently in goodwill values for pharmacy contracts. The values at which pharmacies change hands simultaneously serves to both exclude many independent first-time buyers and emphasise the apparent opportunity of a вЂњfree businessвЂќ offered by the 100-hour route. However, existing and aspiring owners should take the threat or opportunity of the 100-hours contract with a significant pinch of salt. For, while there are certainly some opportunities to create a profitable business by trading for 100 hours per week, such opportunities are remarkably few and far between. As any existing owner will be aware, by far the greatest cost line on his or her profit and loss account are staff-costs. In fact, good management of staff costs and opening hours can mean the difference between healthy profits and regular loss. As most pharmacies only open for around 45 hours per week, it does not take too much imagination to recognise that staffing a pharmacy for 100 hours per week, many of them unsocial hours, can cost at least twice as much. The unavoidable fact that a pharmacist is required to be present for 100 hours per week means that a turnover of close to ВЈ500,000 is required to fund his or her salary alone. Add to this the other staff costs, rent, rates, heat, light, etc, and a turnover of close to ВЈ1m could be necessary just to break out of loss. Of course, some operators of 100-hour pharmacies will work many of the hours themselves, and thus see some of the costs are absorbable. However, this will only be palatable in the short term if you are convinced that you are ultimately going to earn more money than you did as a locum or an employee. The idea of a вЂњfree businessвЂќ with nothing to pay and little risk is also somewhat inaccurate. Although the вЂњbarrier to entryвЂќ is lower than that for an existing contract, there are still some significant costs to bear and the commercial outcomes are somewhat less predictable. The costs of entry into the 100-hour market will include at least the following: в—Џ Purchase of a property or entry into a lease вЂ” a typical nine year lease can amount to a tidy sum в—Џ Fit out of a property вЂ” ВЈ50,000 is easily spent on a modest fit-out в—Џ Stock вЂ” this is particularly tricky for a new-start pharmacy as it is impossible to know what stock to hold (Hold too little or the wrong products and you will either have a reputation for poor service or a lot of redundant stock on your hands) в—Џ Accumulated losses вЂ” this is the biggest investment of all (Until the business reaches its break-even point it will be running at a loss. Under average operating conditions, break-even could mean around 6,000 prescription items per month or almost ВЈ1m turnover per year, no mean feat) The losses to be made in the early stages of the business are substantial and only when the break-even point is passed will these even begin to be offset. As many existing 100-hour operators will recognise, break-even may be a long time coming or may never be reached. In fact, some are not even a quarter of the way to this target and face either a long time under water, or a tricky exit strategy. Aspiring entrepreneurs should also recognise that the value of a 100-hour pharmacy is, like all other businesses, based on its ability to make a profit for a buyer. A 100-hour pharmacy that has a turnover of ВЈ500,000 will certainly be making a loss and can therefore be viewed as a liability rather than an asset. Only when a business starts to make profit will it have a value to anyone. Thus, the classical turnover ratios that are heard in the market do not apply in any way to 100-hour contracts. Based on its lower profitability, the additional headache and greater vulnerability, a 100-hour pharmacy with anything less than a ВЈ1m turnover will have little or no resale value. Above this the value will climb with turnover but less steeply than for a standard contract. Wherever your opinions lie with regard to the value of a 100-hour pharmacy service, what is certain is that the threat or opportunity that 100-hours presents is of a limited nature and, whether exploiting or defending against the 100 hour exemption, the key considerations are the same: в—Џ Can a 100-hour business in the particular location ever achieve the level of turnover required to make profit? в—Џ Can the entrepreneur fund the cash-flow shortfall until then? в—Џ If yes to the above then what level of profit might ultimately be made and will this offset the losses, and investments made? в—Џ Can the aspiring business owner afford to take the risk? David Parker is a specialist in pharmacy business transfer and business development. He can be contacted by e-mail at [email protected] (tel 0789 423 4873) market update p33-34 AUG rev 6/8/07 11:09 Page 33 Market Update New wording for Decapeptyl The Decapeptyl licence wording has been changed to state that the product is indicated for the treatment of patients with locally advanced, non-metastatic prostate cancer, as an alternative to surgical castration, and for the treatment of metastatic prostate cancer. Decapeptyl is also indicated for the treatment of endometriosis (3mg and 11.25mg), uterine fibroids (3mg only) and central precocious puberty, where onset is before eight years in girls and nine years in boys (11.25mg only). IPSEN 01753 627777 Apotex launches perindopril Apotex UK Ltd has announced that it has won a patent dispute, allowing the company to launch its generic version of the ACE inhibitor perindopril to the NHS. Generic perindopril was first launched by Apotex in the UK in August last year, but was withdrawn because of the dispute. Colin Darroch, UK managing director of Apotex, says: вЂњIt has been a long legal process in dealing with the patent situation and we are delighted that at last perindopril can be made available to patients in the UK at a reduced cost to the NHS.вЂќ He adds that it is clinically equivalent to the branded version. APOTEX UK 01525 243550 WaspBane to take sting out of summer WaspBane is a вЂњnovel patented unique high efficiency wasp trap that, unlike other wasp traps, does not cause swarming,вЂќ says manufacturer WaspBane. The product is used by вЂњmajorвЂќ theme parks, zoos and visitor attractions. The company says that the WaspBane trap has reduced sting rates by over 97 per cent when compared to low efficiency traps. WaspBane is pesticide, toxin and pheromone free, and has a disposable self sealing bait chamber that is designed to only need to be replaced annually. Some 300,000 people are said to seek medical attention each year for wasp stings. The Waspbane product is available for retail sale. There is more information at www.waspbane.com. WASPBANE 01480 414644 Panda pack redesign вЂњSoft eatingвЂќ liquorice brand Panda has been given a new look with redesigned packaging across the entire bag range. вЂњClearвЂќ on-pack tick boxes now feature on all bags with вЂњfree fromвЂќ and вЂњsuitabilityвЂќ information designed to make it easier for consumers to select products from the fixture. Lisa Gawthorne, marketing manager for Panda, says: вЂњIngredients integrity is the core to PandaвЂ™s continued success. There are so many great things to shout about with the Panda brand.вЂќ BIO STAT 0161 419 6307 ICP August 2007 33 market update p33-34 AUG rev 6/8/07 15:21 Page 34 Market Update вЂњLavish LooвЂќ Optrex ointment from POM to P Boehringer Ingelheim Consumer Healthcare has launched a new consumer marketing campaign with the introduction of the вЂњLavish LooвЂќ. The DulcoEase вЂњLavish LooвЂќ will tour outdoor festivals. The facility is intended for women only and is decorated in bright pink and blue and вЂњoffers a luxurious alternative to standard outdoor toilet facilities,вЂќ says the company. Kate Evans, senior brand manager, Boehringer Ingelheim Consumer Healthcare, makers of DulcoEase says: вЂњWe believe we will be one of the first manufacturers to create a luxury loo of this kind for outdoor events.вЂќ New Optrex Infected Eyes Eye Ointment is available over the counter from pharmacies without a prescription. The antibiotic chloramphenicol 1.0 per cent w/v eye ointment has been reclassified from POM to P status. Optrex now has a range of treatments for acute bacterial conjunctivitis. Optrex Infected Eyes Eye Drops were launched two years ago. Manufacturer Reckitt Benckiser says the benefits of the new ointment include: no need for storage in a fridge and preservative-free. The launch will be supported by a вЂњcomprehensive, accreditedвЂќ training package and the brand will be on TV with a campaign from October. RECKITT BENCKISER HEALTHCARE 0500 455 456 POWERMED HEALTHCARE 0845 222 0555 New Actavis packaging Actavis is launching new packaging across its range of generics. It is designed to make it as easy as possible for patients to take medicines correctly and to minimise dispensing errors. Jonathan Wilson, marketing director, Actavis, says: вЂњWe have worked closely with our customers to ensure that the packaging meets the latest guidelines to maximise safety and compliance.вЂќ The new livery includes вЂњvibrant, contrasting and distinctive coloursвЂќ designed to improve product recognition and highlight essential information. Sara Vincent, UK country manager, adds: вЂњBeing the champions of first class generics is our primary focus, but we are also boosting our OTC offering through POM to P switches.вЂќ Pharmacy prizes To celebrate 30 years of Sudocrem in the UK, manufacturer Forest Laboratories is offering independent pharmacy customers the chance to enter a prize draw to win one of six HamleyвЂ™s teddy bears (worth ВЈ59.99 each). Sudocrem Antiseptic Healing Cream is claimed to be the вЂњUKвЂ™s number one sellingвЂќ treatment for nappy rashвЂќ. Forest Laboratories is also running a competition in association with Infacol Probiotic Drops. It is offering pharmacists and pharmacy assistants the opportunity to win one of six sets of ВЈ50 Marks & Spencer vouchers by answering five questions. Infacol Probiotic Drops are a food supplement designed to help maintain a healthy balance of good bacteria in a childвЂ™s digestive system. FOREST LABORATORIES 01322 550 550 ACTAVIS 0800 373 573 Ricola marketing campaign As part of its winter marketing campaign, Cedar Health, UK distributors of herb-based confectionery Ricola, is investing ВЈ100,000 in a 30 day вЂњguerrillaвЂќ sampling program. Ricola sampling will visit вЂњmajor UK towns and cities to boost the profile of the brand with consumersвЂќ. During September, 250,000 free samples will be given away that carry money off coupons and offer the chance to win a trip to Switzerland for two people. The sampling campaign will be supported by a national radio competition which will see more Ricola products given away. CEDAR HEALTH 0161 419 6307. New Oilatum shampoo Oilatum Scalp Intensive Shampoo is a new addition to the Oilatum range of dermatological products. Manufacturer Steifel Laboratories says: вЂњ The product comes with all the gentle qualities of Oilatum Scalp Treatment, but, used twice a week, its maximum strength formulation helps soothe and clear more serious scalp conditions.вЂќ Oilatum Scalp Intensive contains ciclopirox olamine, an anti-fungal agent, salicylic acid, to help with the removal of вЂњstubborn flakesвЂќ, panthenol to nourish and condition, and menthol, to soothe вЂњsoreness and rednessвЂќ. STEIFEL LABORATORIES 01628 411500 New counter unit Cegedim Rx is offering pharmacists a service for recycling old computer equipment. The company says: вЂњThis is especially important at the moment with many pharmacies upgrading their equipment to take advantage of the N3 connection within the EPS programme.вЂќ The company will collect the equipment directly from the pharmacy and then dispose of it in a way that is вЂњenvironmentally and ecologically friendlyвЂќ вЂ” further information from a Cegedim Rx account manager by telephone or at [email protected] GlaxoSmithKline Consumer Healthcare, in partnership with Ceuta Healthcare, is вЂњrenewing its focusвЂќ on EarCalm Spray and Joy-Rides tablets with a new counter display unit designed to raise awareness and вЂњdrive salesвЂќ of these pharmacy only brands this Summer. EarCalm Spray is the вЂњfirst and onlyвЂќ branded OTC treatment for mild outer ear infections. Joy-Rides tablets can help prevent motion sickness in adults and children aged three years and over. The вЂњcolourfulвЂќ counter unit features a consumer leaflet with advice about ear infections but pharmacy advice is also encouraged to ensure appropriate recommendation. The units can be obtained by calling Ceuta Healthcare Customer Services. CEGEDIM RX 0870 8411233 CEUTA HEALTHCARE 01202 780558 Cegedim Rx recycling service 34 August 2007 ICP bishopstoke AUG p35 2/8/07 15:21 Page 35 Bishopstoke Chronicles In the wars Battling proprietor Sid Dajani ends up a local hero S ometimes I feel that вЂњdisorganisedвЂќ and вЂњincompetentвЂќ are tattooed onto my conscience like вЂњloveвЂќ and вЂњhateвЂќ are on the fists of thugs. The increased workload and pressures mean that multi-tasking in doing all my different jobs results in me forgetting the odd thing like updating a standard operating procedure. My вЂњto doвЂќ list goes into pages and there are not enough hours in the day to tackle even half of the jobs on it. Sometimes it seems I never get off the starting blocks! I am trying to reach my quota of patient survey forms, complete my tax returns, carry out medicines use reviews, train staff, help my patients, undertake smoking cessation clinics and so on. If anyone can tell me if pharmacists, especially contractors, are allowed the luxury of вЂњlife and where to find itвЂќ I would be most grateful. Like a mermaid When work is going well, time glides by like a mermaid on a millpond, but when it is bad it is like swimming against a tide of treacle. And just when things are going well, things can turn sour. But something must be going right вЂ” my staff and I achieved record-breaking prescription figures last month and the patient survey forms we have had back are by and large highly complimentary. The smoking cessation service for which we have now been accredited is a roaring success. We have recruited over 50 clients to date and, though that may be a small number for some, it makes a big difference to an individual proprietor like me. Out of all those who have reached the fourweek period, 80 per cent have successfully quit and carbon monoxide monitor rates prove this. One person had an initial reading of 33 and this fell to 2 in just two weeks; his breathing had improved so much that his wheeze was markedly less pronounced. His reaction adds to the immense job satisfaction that drives my motivation and feeds my enthusiasm. The great success of my smoking cessation service when there are many pre-existing non-smoking cessation clinics run by pharmacists and others proves there were at least 50 potential quitters who couldnвЂ™t be helped anywhere else; we have made all the difference to them. The smoking cessation clients have also filled in patient survey forms as part of the deal! Did it really need to take two years for the PCT to get us accredited for this? How many more people could we have helped in the meantime? Why were we the last to get accredited? Will it take another two years before we get accredited to provide emergency hormonal contraception and weight management clinics? Does the PCT benefit by not allowing people more access to such services? вЂќ Why were we last to be accredited for smoking cessation ? Will it take another two years before we get accredited to provide emergency hormonal contraception and weight management clinics? вЂќ Generics set-back To dampen my spirits, new local GPs have decided to go down the branded generics route, which means I cannot at present source many of the items. And to open an account with another wholesaler will mean losing discounts with my existing wholesalers as I will purchase less. To add to my misery, the GPs implemented the formulary changes within two days of me being informed. This is one nightmare I didnвЂ™t need and I can only wonder what or where the next blow is going to be. I was so ecstatic with my aforesaid end of month figures that I invited my staff to a meal. As I parked my car to meet my hungry staff in the restaurant an hour after we closed, I heard a commotion right next to me. A big, bald, burly man was protesting his innocence to a newsagent owner who had accused him of putting items into his pocket without paying for them. I didnвЂ™t want to interfere, but I thought it would be a sensible thing to do to call the police. At my mere suggestion of this, the big man elbowed the owner in the chest, knocking him to the ground, and, before I knew it, I got a punch in the mouth. Someone came out of nowhere and grabbed the assailant from behind, by which time I gathered my senses. Without wishing to incriminate myself in this age of human rights legislation вЂ” where victims of crime end up as defendants in court proceedings вЂ” my next move gave вЂњbig boyвЂќ reason to reconsider his position. It certainly brought tears to his eyes and stopped him in his tracks. Altercation resolved and threat removed I straightened my jacket and spent an enjoyable evening with my staff, although my lip was beginning to swell and the pain got worse as the evening wore on. Sore lip The next day, my lip was so sore I couldnвЂ™t even smile and the bruise didnвЂ™t look good in front of the customers. It looked as if I had been in a drunken brawl! I was relatively lucky though; the newsagent turned out to have a broken sternum, which was only discovered after his second visit to hospital in as many days, and another passer by ended up with stitches, which meant there were people worse off then me. It seemed churlish to seek to milk the situation for sympathy. I was grateful for the 11 or so new prescriptions that people brought in when they thanked me for helping out in the street. As news got round, my cover as the mystery saviour was exposed and I ended up on a local radio news broadcast. However, I wouldnвЂ™t recommend tackling local thugs as a new contractual pharmacy service or as a way of getting new business or prescriptions. After all crime doesnвЂ™t normally pay! No part of this publication may be reproduced without the written permission of the publishers. Published by CIG Ltd В© CIG Ltd. Colour Repro by Willows Focus. Printed by Grange Press, Brighton. ICP is available on subscription to individuals working within the community pharmacy sector. Unbranded pictures copyright Photodisc/Digital Stock. Some of the editorial photographs in this issue are courtesy of the companies whose products they feature. The publishers accept no responsibility for any statements made in signed contributions or in those reproduced from any other source, nor for claims made in any advertisements. 28120 Ind Com Phar 297x210 23/7/07 17:36 Page 1 THE EASY WAY TO BOOST YOUR SALES FIGURES You wonвЂ™t have to do very much as a Western Union Agent. You wonвЂ™t have to invest in anything. 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