pharmacists in secure environments - Royal Pharmaceutical Society

Pharmacy
March 2010 | Issue 4
ISSN 2042-4493
Professional
e x c l u s i v e l y f o r m e m b e r s o f t h e R o y a l P h a r m a c e u t i c a l S o c i e t y
Practice guidance
Dealing with dementia
Society updates
The president, CEO and
Country Directors report
Learning &
Development
CPD latest
Board elections
Meet the Chairs
Pharmacists
in secure
environments
What it’s like behind bars
+
politics
finance
travel
food
offers
crossword

e d i t o r ’ s w o r d
Published by
The Royal Pharmaceutical Society of Great Britain
1 Lambeth High Street
London SE1 7JN
Tel: 020 7735 9141
Fax: 020 7735 7629
www.rpsgb.org
Editor
Jeffrey Mills
jeff.mills@rpsgb.org
Contributors
Miranda Green
Matt Guarente
Sue Heady
Sam Lister
Richard Northedge
Liz Rawlins
Alasdair Steven
Philippa Taylor
Art Editor
Nick Atkinson
Editor’s Advisory Panel
Steve Churton
Jeremy Holmes
Mike Keen
Sue Kilby
Colin Morrison
Umesh Patel
Patrick Stubbs
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Cover Image
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Inside story
Healthcare at Her Majesty’s Pleasure
While a spell in prison is probably not top of most
pharmacists’ wish lists, for some the sound of the barred iron
gates slamming shut means little more than the fact you are
on the way to the office, or in many cases the pharmacy.
The Royal Pharmaceutical Society’s hard-fought campaign for the decriminalisation
of dispensing errors may be about to bear fruit, when the
Crown Prosecution Service finally reveals its intentions, meaning few, if
any, pharmacists are likely to wind up in jail for the wrong reasons. But
in the meantime, we take a look this month at one who is “inside” for all
the right reasons.
In our feature on pharmacists working in secure environments we
profile Stella Simpson, Head of Primary Care and Deputy Head of
Healthcare at Her Majesty’s Prison Holloway in London, where she and
her team are responsible for the health of around 500 inmates.
Once again we have an extended News Roundup section this month,
which includes an interview with Dr Berwyn Owen, the Chair of the
Welsh Pharmaceutical Committee, who speaks, amongst other things,
about his role in “challenging the perception of the everyday role of a
pharmacist”.
Sam Lister, Health Editor of The Times, who is newly returned from
the USA, looks at the fate of some of the healthcare promises made by
Barak Obama. And, with the Pharmacy Board elections now complete
we have a few early words from the new Chairmen, Lindsey Gilpin of
the English Pharmacy Board, Sandra Melville of the Scottish Board and
Nuala Brennan of the Welsh Board.
In the latest in our series of Professional Practice features we look at
the latest expert advice on dealing with dementia and, of course, we have
the regular Learning and Development section produced for us by the
Pharmaceutical Journal.
Out travel section this month takes us down to that little bit of Britain
in the Mediterranean, Gibraltar, and to the beautiful Spanish city of
Girona, which has yet to suffer the kind of mass tourism found in other
parts of the country. And in the transport section we have some top tips
on finding the best deals when travelling by rail.
I hope you enjoy reading this, and every, issue of the magazine and I
look forward to your feedback.
Pharmacy Professional ISSN 2042-4493
© The Royal Pharmaceutical Society 2010. While every effort has been made to ensure
that the information is correct, neither the editor nor publisher can be held responsible for
any inadvertent inaccuracies or omissions. Pharmacy Professional is protected by copyright
and nothing may be reprinted without written permission. Manuscripts, transparencies and
illustrations are submitted on the understanding that no liability is incurred for safe custody.
Jeffrey Mills, Editor
March 2010 | Pharmacy Professional
1

Contents
March 2010
26
05 22
43
professionalLIFE
05 News Roundup Latest from the world of pharmacy
11 Media View Sam Lister, Health Editor of The Times
12 Comment The President and CEO speak out
14 A View From... The English, Scottish & Welsh Boards
20 Political Update Charles Willis Reports
21 Business Practice Richard Northedge on Pharmacy
22 Inside story Working in secure environments
26 Professional Practice Care for dementia
learning&development
35 Continuing Professional Development
The Pharmaceutical Journal brings you the latest
lifestyle
43 Travel The sights and
scenes of Gibraltar and
Girona
50 Health Food This month
top chef Philip Howard
52 Transport Less strain the
train
55 The Arts Alasdair Steven
looks at Romeo and Juliet
56 Offers Golfing breaks in
Estepona
56 Prize Crossword Win
leading reference books
48
46
March 20010 | Pharmacy Professional
3

professionallife
n e w s r o u n d u p
Government action needed on
hospital pharmacists shortage
Impact on patient safety
The Society is calling on the
Government to take seriously the
impact on patient safety because of a
shortage of hospital pharmacists. Inaction is
no longer acceptable to our profession or the
patients they care for in hospitals.
Around a quarter of junior pharmacist
positions remain unfilled – up from 22% in
2008. These staff work across all aspects of
hospital pharmacy, including clinical work
on wards, checking the safety and efficacy of
prescriptions and providing information on
medicines.
RPSGB Chief Executive Jeremy Holmes
has written on behalf of the Society to the
Secretary of State to express deep concern as
a professional body at the on-going problem
of recruitment and retention of hospital
pharmacists on band 6 of Agenda for Change.
“The importance of hospital pharmacists
in relation to patient safety cannot be
underestimated, and has been highlighted
yet again by recent studies in relation to
medication errors by prescribers and in
specific areas such as paediatrics,” he says.
“These studies show just how much
hospital pharmacists are relied upon by
prescribers to pick up medication errors and
how they improve prescribing in the first
instance – a vital role in patient safety.
“The recommendations made by the
Department of Health to address the problem
of recruitment and retention on a local
level are welcome, but the independent Pay
Review Body has now twice recommended
specific action to improve the situation,
including payment of a national recruitment
and retention premium. The Department’s
measures are unlikely to be reviewed again
by the Pay Review Body before late 2011,
and patients cannot wait that long.
“All parties involved recognise the
problem of vacancy rates within England,
Scotland and Wales. Our concern is that
unless the Secretary of State addresses
the issue as a matter of urgency, patients
will be left at risk of potential harm for an
unacceptably long time.” n
March 2010 | Pharmacy Professional
5

n e w s r o u n d u p
Driving the Profession Forward
Liz Rawlins talks to Dr Berwyn Owen
Described as a “mover and shaker”
in the pharmaceutical world,
Dr Berwyn Owen is not your
stereotypical pharmacist. In a profession which
struggles to position itself at the forefront in
the NHS, Berwyn seizes every opportunity to
push the profession forward. He compares
pharmacy to the ‘square leg umpire’. For
those of you who don’t follow cricket, this is
an official position standing adjacent to the
batsman but whose role is relatively unknown
and often goes completely unnoticed. The
point Berwyn makes is how this role is
invaluable to the game – that is of course, his
comparison to the world of pharmacy.
I met Berwyn at a conference organised by
the Welsh Directorate of the RPSGB following
his engaging presentation on the benefits of
pharmacist prescribing. The current Chair of
the Welsh Pharmaceutical Committee has
been referred to by colleagues as “Mr Fix It”,
and in his own admission, he always “knows
a man who can”. Despite this, he admits
to being the object of criticism in the past.
“People are always telling me to slow down,”
he says. “I think I can be controversial in my
approach, but there will always be those who
don’t support or like you and don’t agree with
what you say,” he adds. “I aim for about an
80/20 split!”
A man in awe of political heads such as
Nelson Mandela and Barack Obama for
their ability to influence others, I ask, does
he consider himself a leader? “Anybody can
be a leader. I see myself as someone who
empowers and encourages others, enabling
them to share their thoughts and ideas
with others and to speak up,” he says. For
Berwyn, it’s not about the money or power
that inevitably comes with a role such as his.
“It is about challenging the perception of the
everyday role of a pharmacist and influencing
my fellow colleagues so they ask themselves,
what else can I do?” he adds.
Opportunities
Berwyn, Clinical Director for Pharmacy and
Medicines Management within the Betsi
Cadwaladr Health Board is originally from “a
small village”, Llanrug in North Wales. The
extent of his achievements in his career is
impressive, particularly when you consider his
There are big
expectations but
I’m not going to shy
away from anything
initiation into the pharmacy world began only
in 1986 when, at the age of 16, he left school
– and Wales – to work as a researcher with
Beecham Pharmaceuticals in Sussex.
It was here his interest in pharmaceuticals
really developed, leading him to attend night
school and becoming a pharmacy technician,
even being awarded ‘Technician of the Year’
throughout the company in 1988. This is
when the ambition and drive you see within
him today first started to appear, as he
continued with pharmacy; sitting his entry level
exams which gained him a place at Brighton
University school of Pharmacy in 1990.
“I was the first one to go on to university
in my family,” says Berwyn, “My Dad was a
carpenter and my Mum was a housewife and
we never had any real opportunities when
we were growing up,” he says. “This is why
it is fundamental in my drive to fully grasp
whatever opportunities come my way.”
After graduating, Berwyn’s thirst for
academia heightened and in 1995 he
moved to the North East of England and
embarked on a PhD in developing paediatric
formulations for rare and orphan disease
at the University of Sunderland School of
Pharmacy. Berwyn credits his PhD - which
looked at the collaborative research between
academia, the pharmaceutical world and
NHS – with enabling him to develop the skills
he uses today to improve integration and
collaboration across various organisations,
something Berwyn feels very strongly about.
Since December last year, he has been
appointed as lead advisor on National
Medicine Management to the Welsh Assembly
Government. “There are big expectations but
I’m not going to shy away from anything.”
However, with so many high profile work
commitments, there will undoubtedly be
sacrifices to make personally, and he admits
there are times he finds it challenging. “With
a young family there are things you don’t
want to miss. I try not to be away from my
family for more than one night if I can help
it, but considering the current climate I do
feel fortunate that I am able to work in a
profession I am so passionate about.”
Despite leaving Wales for nearly two
decades, Berwyn has settled back in
Caernarfon, North Wales with his wife Cara,
and his two girls, Cêt, 3 and Hanna, 2. He is
glad to see a more united North and South
Wales. “Since I moved in the 80’s, there has
been a definite cultural shift within Wales,” he
says, adding “The growth of confidence since
I left is enormous and this is partly down to
the Welsh Assembly Government ensuring all
those in Wales have a voice”.
He is excited about what the future holds
for pharmacy in Wales. “As a country, I believe
Wales punches well above its weight; we are
diverse and adaptable.” With the anticipated
new Professional Leadership Body, Berwyn
believes there is a big opportunity to reach
the ‘grass roots’ using the newly created
Local Practice Forums. He emphasises how
pharmacists need to use all tools offered from
organisational bodies in order to develop as
a profession. “I see this as an invitation to all
pharmacists,” he tells me. “Just like hosting a
party, it is important that everybody is invited.
I get personally disappointed when people
don’t participate but I have realised over the
years I sometimes have unrealistic or even
unachievable expectations.”
For Berwyn, the NHS of the future will see
full integration within the health professions
for Wales, “I don’t see things as separate
commodities.” With the introduction of a new
five-year strategy plan for Wales promising
to do just that, Berwyn hopes pharmacy will
move forward in terms of integrated working,
professional interaction and improving patient
care. He believes pharmacist prescribing will
play a much bigger role in the future with
the current 100 non-medical prescribing
pharmacists across Wales multiplying to up
to 1000 by 2015. “We will be internationally
looked on as achievers,” Berwyn predicts,
“with our pharmacists on the front line;
available on citizens’ doorsteps, patients can
access professional advice with ease.”
When talking to Berwyn, his ambition
and passion for the pharmacy profession is
more than evident. His achievements to date
provide clear evidence that pharmacists can
move to the forefront in making key decisions
in the NHS. He admits, however, that one
person alone cannot move the profession
forward, and calls for concerted action by
pharmacists at such an important time.
Although it is often in pharmacists’ nature to
become risk assessors, Berwyn is adamant “it
is time to step up and take some risks.” With
a man like Berwyn Owen, with his pace and
drive, taking pharmaceutical issues directly to
the highest strategic levels in Wales, it is only a
matter of time before everyone is listening. n
Society welcomes
Lords’ approval of
Draft Pharmacy Order
Significant step forward
The House of Lords approved the
draft Pharmacy Order in early
February, following the approval
from both the Scottish Parliament last
year and the House of Commons in
January.
“I am delighted that we have taken
this significant step forward on the road
to creating a professional leadership body
for pharmacy. With this legislative hurdle
removed we are aiming for the Society,
as the professional body, to be ready for
launch as soon as regulation is transferred
to the General Pharmaceutical Council,”
says Jeremy Holmes, Chief Executive of
the Royal Pharmaceutical Society.
“The new professional body will have
a clear identity with leadership and
advocacy at its heart, as well as a full suite
of support and development services.
“With the new national Boards now
elected there is a clear groundswell
of support for the process of building
the professional body and a growing
level of confidence that it will be a
first-class organisation to lead and
support pharmacists effectively across
Great Britain. I look forward to keeping
members fully informed as we move
towards launch of the new body.” n
6 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
7

n e w s r o u n d u p
CPD Webinars
A new tool for professional development
New partnership agreement
supports veterinary pharmacists
New and exciting ways of providing
CPD support to its members, who
have a busy schedule working
in their various sectors of the pharmacy
profession, are being prepared by the future
Professional Leadership Body.
The Society has recently run a series
pilot webinars, a new learning tool giving
added flexibility to gain knowledge and
skills without having to travel to training
events. The pilot webinars allowed those
who registered to login remotely and view
the slide presentations while listening to the
talks delivered by the presenters, using their
own PCs at home or at their workplace either
individually or in a learning group.
The CPD specific pilot webinars covered
academic, industrial, community, hospital and
PCT pharmacy sectors and were delivered
between October 2009 and January this year.
The Head of Professional Development and
Education, Dr Carol Evans, guided members
through a PowerPoint presentation explaining
step by step, how to engage in CPD, what
was required, giving a brief overview of the
CPD online recording system, some practical
help and guidance and top tips to make a
CPD entry that would help them with the
pharmacy regulator’s requirements.
This was followed by sector specific
experts, Ruth Edwards, Janet Halliday, Lindsey
Gilpin, Shelagh French and Alpana Mair,
who each presented two case studies in their
relevant fields of practice and shared their
personal experiences in making these CPD
entries.
The presentations were followed by an
extensive Q&A session where participants
typed their questions via the Q&A section
on their PCs giving the panel members an
opportunity to answer them verbally. The CPD
panel consisted of Carol Evans, the pharmacy
sector experts and the Society’s CPD Support
Specialist, Priya Rasanayagam.
“The response we have received from
participants has been very positive. The
feedback from the recent PCT event shows
that 92% who responded found it easy to
logon to the session, with 69% finding the
presentations met most to all of their needs.
81% of the participants expressed a wish to
Webinars are a very convenient way of
learning and are highly compatible with
pharmacists’ busy lifestyles
attend other events in this online format,”
Priya says.
“Webinars are a very convenient way of
learning and are highly compatible with
pharmacists’ busy lifestyles. The participant
numbers and the feedback strongly support
the need for future CPD sessions to be
delivered through webinars.
“We will be organising events in various
specialist topics where the presentation will
be followed by a Q&A and discussion on how
to take that learning forward and apply it
to benefit your practice. There will also be a
brief session on starting an entry about this
learning in your CPD record. We will continue
to offer CPD webinars as a regular feature of
the new PLB CPD offerings.” She adds.
All the webinars conducted so far are
available to download via the RPSGB webex
site. You can view the presentation slides
while listening to the audio recordings by
clicking on the Event Recordings button at
the top right hand side of the screen and
scrolling down to select the relevant CPD
webinar via the link https://rpsgb.webex.com/
mw0306l/mywebex/default.do?siteurl=rpsgb
To attend future webinars all you need
is a computer and earphones (so that you
can listen on stream) or a telephone line (so
that you can dial in at local rate) to hear the
presenters and panelists. Visit our events
webpage at www.rpsgb.org/events to find
out about future events and to register. n
Over 1,500 members have already taken part in
the webinar pilots. The table shows a breakdown
of the various sector pharmacists who took part in
the CPD webinars.
Webinar pharmacy Numbers of attendees
sectors
Academic 29
Industrial 155
Community 193
Hospital 119
PCT Pharmacy 299
The first partnership agreement between the Royal
Pharmaceutical Society and Harper Adams University
College has been signed to provide pharmacy graduates
with specialist courses in veterinary pharmacy and to enable their
continuing professional development.
The agreement will also provide opportunities for closer
collaboration, the sharing of expertise and joint proposals for
research and outreach activities.
“This is an exciting opportunity to provide support for a
special interest group within pharmacy. We are delighted to be
working with Harper Adams University College to raise the profile
of veterinary pharmacy through the provision of high-quality
specialist courses,” says RPSGB Chief Executive Jeremy Holmes.
“The Society, as the new
professional body, will represent a
wide variety of interests and give
members the tools they need to
pursue and extend their chosen
career path. I hope this will be
the first of many such agreements
as we look to build partnerships
across the sector.” n
The RPSGB veterinary pharmacy
education programme has run for
over 25 years but this is the first
time it has been formally accredited
by a Higher Education Institution.
The courses will continue to be
delivered by RPSGB. For further
information on courses please visit
www.vpep.net
8 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
9

n e w s r o u n d u p
m e D I A v i e w
New conference for
new-look Society
Professional support for memebers
Sam Lister, Health Editor, The Times
Under pressure? - Look at the USA
Obama’s healthcare plan in pieces
In step with its changing face as
a professional body, a brand new
conference is being launched by the
Royal Pharmaceutical Society, to be held at
Imperial College in London on Sunday and
Monday September 5 and 6.
Carrying the theme “Supporting Patient
and Professional Decision-Making”, the RPS
Conference 2010 is replacing the British
Pharmaceutical Conference (BPC) and has a
specialised focus on front line pharmacists
and practice.
The RPS Conference 2010 will showcase
how the Society as the new professional
leadership body is supporting its members
to develop their professional, practice and
leadership skills. It will provide an important
opportunity for pharmacists to learn about
the latest practice developments from across
Great Britain, develop their skills and network
with peers and leaders in the profession.
It will also explore how pharmacists
can tackle issues professionally as their
clinical role increases and will provide an
enlightening forum for in-depth and multiprofessional
discussions that will bring
practical solutions to life.
The science element of BPC will now be
run at a separate conference held by the
Academy of Pharmaceutical Sciences (APS)
for pharmaceutical scientists, although the
RPS conference will also maintain a “science
into practice” element.
“I’m delighted to officially announce our
new conference, which is at an excellent
London venue,” says RPSGB Chief Executive
Jeremy Holmes.
“The two-day programme focussing on
professionalism and pharmacy practice has
been developed to reflect the major changes
in the profession and has a real emphasis on
a pharmacist’s role as a public-facing health
professional.”
The programme will be led by Conference
Chair, Professor Marjorie Weiss, Professor
of Pharmacy Practice & Medicine Use at the
University of Bath, together with professional
leads from the Royal Pharmaceutical Society
and its membership.
Thought-provoking
sessions to empower
your professional
and leadership skills
Marjorie says; “This is a not-to-be-missed
event for pharmacists and will showcase
the latest practice research. It will feature
thought-provoking sessions to empower
your professional and leadership skills
through networking and workshops which
will be both inspiring and interactive.”
The Society is now calling on contributions
in any area of pharmacy practice research for
the conference, either as an oral or poster
presentation. Research and development in
clinical pharmacy and education will also be
considered.
Submissions should be either for the
‘’practice development and audit’ or
‘practice research’ category. It should
relate to original, previously unpublished
work contributing to the understanding,
development or evaluation of pharmacy
practice.
Meanwhile, nominations or applications
for the Practice Research Award at the
Society’s Conference 2010 are being invited
for consideration by the conference Practice
Research Panel.
This prestigious award, sponsored by the
Pharmacy Practice Research Trust, recognises
individuals who have made a significant
contribution to the field of pharmacy
practice research and who have the potential
to become a leader in the field.
The 2009 award went to Dr Darren
Ashcroft, Reader in Medicines Usage
and Safety, School of Pharmacy and
Pharmaceutical Science at the University
of Manchester for his work into medicines
usage and in particular quality and safety.
Dr Ashcroft said: “The Practice Research
Award recognised my research and work
over the last 10 years studying drug related
morbidity in the UK and its development
into a wider European context. Winning this
award meant a lot to me.”
Typically, applicants should be at the midpoint
of their career (e.g. Senior Lecturer
or Senior Research Fellow). The winner will
receive a cheque for £1000 and have the
opportunity to deliver a 30-minute lecture at
the Society’s Conference 2010 in September,
based primarily on the applicant’s own
research.
Beth Allen, Acting Director of the
Pharmacy Practice Research Trust said: “The
Trust is pleased to continue its support for
this award. It complements so well our
objective of developing and promoting
academic excellence in pharmacy practice
research. Since we started our support of
this award the two recipients, Dr Margaret
Watson and Dr Darren Ashcroft, have
proved to be worthy winners through their
continuing significant contributions to
pharmacy practice research.” n
The closing date for receiving abstracts for
the conference and/or applications for the
award is 5pm on Tuesday April 13. For full
details visit http://beta.pharmacyplb.com/
events-and-courses/the-royal-pharmaceuticalsociety-conference-2010.asp
The woes and warnings
associated with
healthcare in the UK
may be troubling, but spare a
thought for the Americans.
The United States, the only
industrialised nation that does
not guarantee health coverage
for all its citizens, is fast heading
for the critical list with its
health system ailments. Some
47 million people are without
insurance, medical costs are
rising, doctors’ bills cause most
personal bankruptcies and its
federal programme for the
elderly is unsustainable. For
all its clinical innovation, the
world’s most affluent nation can
be a tough place to get ill.
Barack Obama acknowledged
as much in making healthcare
his top priority on entering the
White House. He promised
change, making healthcare a
fundamental right. Insurance
would be mandatory, either
through a person’s employer or
a government scheme. There
would be tighter regulation
(stopping insurers refusing
to cover people with preexisting
conditions or dropping
them when they get ill). New
mechanisms would control
treatment and drug prices,
while a voluntary insurance
programme would be offered for
long-term care.
Perfect storm
It was a big wish-list, but all
seemed to be going to plan.
By the start of this year, the
Obama administration had
sign-offs from the House of
Representatives and the Senate.
It looked like they could trip
and still stumble over the finish
line. And then, in a perfect
storm of poor politicking, the
Democrats failed to quell rising
anger over the cost and structure
of the programme, added in
some cynical insurance caveats
to please their union backers,
and then contrived to lose
Ted Kennedy’s Massachusetts
Senate seat (and with it their
all-important voting “supermajority”).
A few months on,
and Barack’s grand plan for
healthcare is in pieces.
Think-tanks
argued over
excessive
federal control,
and the
government’s
suitability to
regulate quality
and costs
On a recent trip to
Washington DC, I met with
legislators, pollsters and
commentators from across the
political spectrum who threw
light on this extraordinary turn
of events. It also offered ideas
on ways forward – and a lesson
learnt from the country’s recent
pills and pharmacy legislation.
There was broad agreement
that an overhaul of healthcare
is a must. Tom Daschle, the
Democrat former Senate majority
leader, put it simply: the US does
not have a healthcare system; it
is an amalgam of market forces
which do not prioritise quality.
Republican congressman Charles
Boustany, a cardiothoracic
surgeon, pointed to flaws in the
way hospitals and doctors were
paid – rewarding patient numbers
over best practice. Think-tanks
argued over excessive federal
control, and the government’s
suitability to regulate quality
and costs, while some even
questioned healthcare as a
fundamental right. There is, as
Newsweek columnist Robert
Samuelson observed, an intrinsic
part of the American psyche that
demands autonomy.
An overarching theme was
the sheer size of Obama’s
legislation: it is too unwieldy,
too all consuming, too divisive
and too poorly unpacked and
explained to the public. While
Americans continue to lose their
jobs, sweeping trillion-dollar
healthcare reform is the wrong
priority (a point acknowledged
in its B-league position in the
State of the Union address).
However close things came
to being passed, those on the
political frontline now doubt
any great health overhaul will
be signed with a single stroke of
the legislative pen.
A lunch with Mark McClellan,
a senior fellow of the Brookings
Institution, offered clues
as to what next. McClellan
served both Clinton and Bush
administrations, most recently
running Medicare and Medicaid,
the federal programmes covering
the elderly, disabled and the
poor. In this role, he oversaw the
introduction of a new benefits
scheme for prescription drugs,
designed to ensure patients could
afford the treatments they need
at their pharmacies. The scheme
offered initial coverage of up to
$2,250, with extra allowances
where required. Money that
went unused was reabsorbed into
the patient’s benefits package,
encouraging sensible claims and
spending.
Generic drugs
The legislation was big, but
specific enough to avoid the
reform-stalling divisions that
have scuppered past attempts
to reshape healthcare. It got the
votes needed. McClellan said
that since implementation in
2006, the use of generic drugs
has risen from half to 70%,
while the cost of prescription
claims has dropped by 40%.
Others backed his assertion that
it had improved coverage and
brought some savings.
As President Obama and his
team chew over the healthcare
year ahead, they might look to
this lesson: dump plays at vast
reform and go for incremental
shifts – or risk missing out
entirely on the change so sorely
needed.
Food for thought across the
pond too. For all its monolithic,
multi-layered structures, the
NHS can be a pleasantly simple
place. n
l Sam Lister is Health Editor of
The Times. An award-winning
former health correspondent
and news editor, he has covered
the NHS and medical workforce
through reformation and revolt
and groundbreaking advances
in clinical practice and disease
control.
10 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
11

c o m m e n t
A Strong, Clear Voice
Steve Churton, President
Crossing the Threshold
Jeremy Holmes, CEO
RPSGB President, Steve
Churton speaks to Pharmacy
Professional this month about
the importance of engagement
and of listening to members,
and the changes taking
place to establish the new
professional leadership body
The latest survey of members
resulted in 4,000 responses to issues
surrounding snipping and original
pack dispensing (OPD). The results are
unambiguous and clear. Over 66% consider
snipping packs to be a significant problem,
with nearly 30% considering this to be very
significant.
Such surveys are invaluable for the
profession as a whole, and for the new
professional leadership body. A strong,
clear and collective voice, which can be
expressed on behalf of all sectors on the key
issues facing the profession, and on which
pharmacy must comment, is the key to
effective influence. “But seeking comment
is just the start of what the profession needs.
In the last year we have worked hard to put
the right processes into place, so we act
quickly on the wishes of pharmacists, and
turn these into action” Steve Churton says.
The profession’s view of OPD will be
used to help the national pharmacy boards
develop a campaign strategy to affect the
tangible and influential change required
to improve the lives of members and their
patients.
All the boards are increasingly using the
results of such surveys of representative
samples of the membership to obtain
feedback on issues that challenge pharmacy,
or on which the profession must have a
view.
“I was aware from my first day as
President that I wanted to open the doors
of our offices and let members see and
influence what we do for them,” Steve says.
“My conviction was strengthened when
the Society’s campaign to decriminalise
single dispensing errors was taken up by so
many members. This was a campaign we
had to win. It was a blatant case of injustice
and, through action by pharmacists right
across the country, we affected change at a
startling pace.
“It is important for the professional
leadership body to realise that every single
response from a pharmacist is important.
Our members are busy people, and we
should be grateful to them to have taken the
time to express a view. It is for us to take
them on board and consider how best we
can act upon them, and I’m pleased to say
that, although we can always improve more,
we are getting much better.”
Board Elections
The newly elected boards for England,
Scotland and Wales met for the first time
in February, electing Lindsey Gilpin and
Sultan Sid Dajani as Chair and Vice-Chair
respectively of the English Board;
Sandra Melville and Alistair Jack as
Chair and Vice-Chair of the Scottish Board
and Nuala Brennan and Mair Davies as
Chair and Vice-Chair of the Welsh Board.
In another major step towards having an
organisation that more fully represents their
views, substantially more members than
previous years voted to create the boards
that are now ready to seek, consider and
act upon the views of their members. The
boards have responsibility for driving the
pharmacy agenda in their country, and will
only be able to do this by having a deep
understanding of the needs and wishes of
members in delivering first class healthcare
to their patients.
The inaugural meetings of all three
boards were held in February, with a remit
not only to elect the Chairmen and other
officers but also the representatives to the
underpinning Assembly, which is expected
to meet two or three times a year.
“There has been a lot to do during my
term to prepare for the new organisation
to be established in a way that allows the
current Society to fulfil its professional and
regulatory responsibilities until the very
moment of demerger,” Steve says. “This
has resulted in a high proportion of my time
being spent on working with others to plan
and implement very complex programmes
of activity to ensure the best start in life for
both of the emerging bodies, in addition
to fully representing our profession, and
supporting our people throughout this
period of change”.
He sees his job as that of both leader and
facilitator. The process has been a highly
inclusive and participative one and he points
to the increased role for the boards as a
way to empower members: “Responsibility
and influence is devolved to a more local
level, where boards can truly focus on the
participation of pharmacy in their national
healthcare system, and through effective
Local Practice Forums and technology to
improve two-way communication, the views
of their members will be easier for them to
hear and respond to”.
But not all the changes have been visible
to members. For example, the roles for
all of our people working for the Society
have been reassessed and in many cases
redefined. Directorates and teams have
been streamlined and transformed in order
to improve efficiencies and focus them
on supporting the work of the boards and
members. Some have moved on to pastures
new, and there are a number of fresh faces on
board, and the result of all of this change will
be to significantly increase levels of service
and representation to those who matter most
to us – our members,.
In the recent board elections, board
members were elected on strong manifestos,
particularly those on the English board, and
there is much more for them to do, having
laid the foundations, for the new professional
leadership body to demonstrate relevance
and value.
Steve comments: “The boards have
inherited a new organisation, and one
that is designed to be fit for the future.
Responsibility now rests with those elected
to work with our people and members
alike to make sure that a financially viable
organisation can truly focus on the needs of
those it represents, and the patients who are
dependent upon them for their health and
wellbeing.
“Some see the point of demerger as the
“finishing line” - I don’t. For me it represents
the beginning of something far greater than
members have experienced in the past.
My hope is that in a year’s time members
will appreciate what their new professional
leadership body – the Royal Pharmaceutical
Society – is designed to deliver, and will
come to realise that it provides a valuable
resource for them as individuals and for the
wider profession. I am personally very proud
to have played a part in its creation.” n
As the Deputy First Minister of Scotland
crossed the threshold of our new
Edinburgh office for its official opening on
February 9, I admit I felt a certain pride.
Nicola Sturgeon MSP is also the Cabinet
Secretary for Health and Wellbeing and it’s
a sign of the importance attached to both
pharmacy and the Society that she attended
– as well as the influence of our Director for
Scotland, Lyndon Braddick.
More than 100 leaders in pharmacy
attended the opening of what is truly a “fit
for purpose” new office. It’s very close to
the Scottish Parliament building (pictured),
and I expect that to be reflected in the policy
influence we will continue to have as a
professional body.
Full authority
The last month has seen us cross some other
important thresholds too. The new national
boards for England and Wales as well as
Scotland all met for the first time, and by
the time you read this the first meeting of
the overall “shadow” Assembly will be due
to take place (on March 3). The Assembly
comprises seven representatives from the
English Board, two each from the Scottish
and Welsh Boards, a pharmaceutical scientist,
a pharmacy academic and a lay member.
It will have full authority when we transfer
our regulatory functions to the new General
Pharmaceutical Council and the amended
Royal Charter (as agreed by the membership
last summer) is activated, but it will operate
in shadow form until
then.
The Pharmacy Order
enabling the transfer of
regulation was passed
by both Houses of the
Westminster Parliament
and by the Privy
Council in February.
That was a hugely
important step on the
way to our de-merger.
We received an
excellent report on our
regulatory functions
from the Council for Healthcare Regulatory
Excellence and we can be confident that we’ll
be transferring a first class operation.
In parallel with that, we are well under
way on delivery of our second wave of
actions under the professional leadership
body “Commitments”. Go to www.
pharmacyplb.com to keep up to date on
that. We’ve held more stakeholder meetings,
more Local Practice Forums are emerging,
our Information & Advisory Service is up
and running (tel: 020 7572 2302, email
infopharm@rpsgb.org) and virtual networks,
using simple but smart technology, are
gathering real speed.
We also announced that the Royal
Pharmaceutical Society Conference 2010
– “Supporting patient and professional
decision-making” – will take place at
Imperial College London on Sunday and
Monday September 5 and 6. Imperial is an
impressive venue, with the facilities we need,
accommodation at reasonable rates, and
the opportunity for us to offer a conference
focused on the professional and practice
needs of our members.
Other thresholds? Well, I moved house
in February too. Some would say that
was a simple project in comparison to the
de-merger of the Society. My family might
disagree, but I couldn’t claim it will have quite
such important consequences. Either way,
we’ve entered a new and exciting phase. The
pharmacy family and our patients all deserve
it, and I’m sure you’ll enjoy it. n
Image © ScottISh Parliamentary Corporate Body – 2009
12 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
13

T h e V i e w f r o m e n g l a n d
Challenges ahead for new Board
Howard Duff, Director for England
With the newly elected national
boards firmly in place there
is a general acceptance that
the year ahead will be both challenging and
interesting.
There are quite a few new faces on the
English Pharmacy Board (EPB) and we
had an excellent induction day for them
and the existing members on the day before
the official meeting. It is always difficult
knowing what information to provide for
people but we had a good mix of getting to
know each other, passing on knowledge and
robust discussion.
The board meeting itself had a dramatic
start with the election of Chair, Vice-Chair
and other EPB members to serve on the
Assembly. I am delighted with the election
of Lindsey Gilpin as chair and Sid Dajani
as Vice-Chair, I am sure we will work really
well together.
One of the really nice aspects of the
EPB meetings is the way that observers are
included in discussions and their views are
welcomed. We usually have capacity for
three or four observers, drawn from the LPF
and branch network.
At the mid-February meeting the board
members were pleased to welcome among the
observers two unsuccessful EPB candidates,
Cathy Cooke and Lara Rose, who both
provided good contributions to the debates.
The meeting also received a presentation
from Bill Rial, Associate Director of the
National Clinical Assessment Service. Bill
updated the board on the work of NCAS
in supporting pharmacists in practice. The
board saw a lot of scope for joint work
between NCAS and the professional body
around supporting pharmacists in practice,
mentoring and working through the LPFs.
Pharmacy practice
The new board were in agreement that they
need to align themselves with the newly
emerging LPFs, and paid tribute to the great
work that had been done by the previous
board in helping to map them out. The three
LPF co-ordinators for England were also at
the meeting to make contact with the board
members from their regions.
The progress on creating on-line meeting
spaces was shared with the board and the
commitment to having a virtual or real LPF in
place for April was reported as being on track.
There seem to be a lot of consultations
around at the moment and apart from those
relating to the establishment of the GPhC,
there are three in particular that the EPB are
working on. These are the DH consultations
on Generic Substitution and Pharmaceutical
Needs Assessments and the MHRA
consultation on Strengthening the Medicines
Supply Chain.
Each of these has the potential to
significantly impact pharmacy practice
in England. The board were keen to gain
member input into their responses, so look
out for requests for your views in the coming
weeks.
A recent questionnaire sent out by the
EPB about supply of patient packs and
the current need to “snip” received a huge
response. Over 65% of the nearly 4,000
respondents considered this s significant
or very significant problem (see separate
story). Having this member feedback is great
because it adds a huge weight to the EPB
view, as well as providing a mechanism for
members to drive policy.
The business at the board meeting was
completed on time despite a huge agenda and
a new chair, and without the issue of remote
supervision being raised! n
Pharmacists call for original pack dispensing
The unified voice of almost 4,000
pharmacists has given the Society a
powerful mandate for action when they
gave their views in a survey on dispensing
medicines in original packs.
The English Pharmacy Board kicked off
the national call for original pack dispensing
at the end of last year in a bid to improve
medicines safety for patients and to reduce
medicines waste.
Survey results released to gauge the
feeling amongst the profession show that
pharmacists are strongly behind this initiative
with 65% saying snipping packs to supply
the right amount was a significant problem.
Currently community pharmacists frequently
dispense medicines from manufacturers’
original packs when the pack size does not
correspond to the prescribed quantity.
A massive 91% of survey correspondents
(3,551 pharmacists) said accessing and
providing an additional Patient Information
Leaflet was one of the problems with not
being able to use original packs. Other chosen
survey answers included the increased time
taken to dispense some items (80.3%), mixed
batches and packaging leading to a loss of
patient confidence in medicine effectiveness
(79.1%) and the feeling that snipping tablets
is unprofessional (77.8%).
Clear signal
“We know the impact that cutting up an
original pack can have on a patient’s ability
to take medicine correctly either through
lost instructions or the possibility of mixed
batches,” says Howard Duff, RPSGB Director
for England.
“It is also time-consuming for the
pharmacist and can contribute to medicines
wastage. We’ve now had a clear signal from
the profession that this issue is important to
them and we intend to campaign for change.”
Community
pharmacists in
England should have
the ability to dispense
original packs where
it is appropriate
The majority of pharmacists thought
supplying the most appropriate original pack
and being reimbursed accordingly (86.6%) was
the solution, this was followed by ‘ensuring all
medication is produced in pack sizes equivalent
to an agreed 28 day month’ (72.7%) and third
choice was ‘ensure all prescriptions always
match an original pack for chronic condition
treatment’ (48%).
Professor Nick Barber chaired a meeting
to allow representatives from community
pharmacy, hospital pharmacy, primary care
organisations, and academia to evaluate
survey results and the issues raised. Workshops
included exploring the positive and negative
sides to change, discussing interesting
scenarios if original pack dispensing was in
place along with looking at solutions and
barriers to the problem.
The consensus agreed that community
pharmacists in England should have the
ability to dispense original packs where it
is appropriate for their patients and to be
reimbursed for what they dispense.
The Society’s next step will be to work with
the new English Pharmacy Board members
on how it can use the powerful voice of its
members and other stakeholders to influence
the government to implement original pack
dispensing. n
Lindsey Gilpin
Chair of the English
Pharmacy Board
New Board focuses
on members’ needs
The newly elected English Pharmacy Board
met on February 9, electing Lindsey Gilpin as
Chair, and Sultan ‘Sid’ Dajani as Vice-Chair
ocal Practice Forums were high on
Lthe agenda, and it was agreed each
Board member would be the link for a
number of Local Practice Forums (LPFs) in
their area.
“LPFs will be the eyes and ears of the
Board, so we want to ensure there are
strong communication links between the
two. Every local member will effectively
have a hotline to the Board and be able
to feedback ideas and good practice
from grassroots level. This bottom up
approach is what our new professional
body is all about – listening to the
concerns of members at local level and
addressing their concerns,” EPB Chair
Lindsey Gilpin said.
The Board also examined how health
professionals and providers could
collaborate to improve patient care and
provide a more seamless care pathway.
“The competitive market that currently
exists in healthcare can mean that
professions can work in isolation from
each other, when collaboration would
better use our expertise and improve
the patient experience”, said Lindsey.
“Pharmacists have a huge contribution
to make to this debate and we want to
ensure our voice is heard.
“It’s also vital we bring sectors together
within our profession, so we can benefit
from the cross-fertilisation of ideas and
best practice. Together we are stronger
as a professional body – representing
everyone,” she added.
The Board also elected five members
to the Assembly: Catherine Armstrong,
Martin Astbury, John Gentle, Shilpa Gohil
and Tristan Learoyd. n
l Lindsey went to the London School
of Pharmacy, worked in community
pharmacy as an employee and then
as a community locum. She started an
internet forum for locums, LocumVoice,
in 2006, and was also elected to the first
English Board in 2007.
Historical link
The Society’s Huddersfield Branch used its final
AGM before becoming part of West Yorkshire
Local Practice Forum as the perfect opportunity
for chairman Bob Tomlinson to formally hand
over the chain of office to Margaret Culshaw of
Huddersfield university to be kept and displayed
in the University of Huddersfield School of
Pharmacy. He is pictured (centre wearing the
chain of office) with (from left) Gill Hawksworth
of the University of Huddersfield and WYLPF
lead; Margaret Culshaw and Delia Potts, both of
the University of Huddersfield; Colin Billington,
Philip Crabtree, branch secretary James Wood,
treasurer Neil Roberts and Gemma Wint.
14 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
15

T h e V i e w f r o m S C o t l a n d
New office and fresh challenges for Scotland
Lyndon Braddick, Director for Scotland
Sandra Melville
Chair of the Scottish
Pharmacy Board
The Royal Pharmaceutical Society’s
move from its York Place premises
to brand new offices close to the
Scottish Parliament is symbolic of the
changes that the Society is going through.
That’s the view of Sandra Melville,
elected as Chairman of the Scottish
Pharmacy Board. Speaking at the official
opening of the new office she said;
“In a year when our new Professional
Leadership Body takes over from the old
Society and with the election of a new
Scottish Pharmacy Board, our move is
symbolic of a time when the profession
must look to a period of continued change.
“The world in 2020 will be very different
from today. Healthcare will adapt to the
changing world and changing technology.
All professions will change how they
care for patients and will increasingly
work in partnership with each other and
with patients and the public. Patients will
want to get the best from medicines and
pharmacy has the skills and expertise that
patients and the public will want.”
Second term
And the fact that the opening was carried
out by Scotland’s Deputy First Minister
and Cabinet Secretary for Health and
Wellbeing, Nicola Sturgeon MSP, gives
a clear indication that the Society and the
Board are developing closer and growing
relationships with the Scottish Government
and Parliament.
Re-elected to serve her second term
Sandra Melville outlined her hopes for
2010 stating: “This is a crucial time for our
profession, with the demerger just around
the corner. The last few months have been
a busy period during which the Board has
illustrated its commitment to the profession
and to the future.
“The newly elected Board now has a
mandate to take forward the work outlined
in the Prospectus and strong leadership will
be crucial as we embark on this exciting
challenge.
“We need to work together to ensure
that members are aware of the importance
of having a strong leadership body that
is truly representative of, and subscribed
to, by the profession, and recognises the
unique arena we have in Scotland. It needs
to support pharmacists in all areas of
practice to achieve their potential and offer
extremely good value for money”.
Sandra will be supported in her role by
Vice-Chairman Alistair Jack. On being reelected
to the position Alistair said;
“I am delighted to have been re-elected
to work with Sandra and the rest of the
Board to take the Society forward at such
a crucial time in the development of our
profession. Pharmacists are the experts in
medicine.
“They work across industry and
academia, playing a vital role in the
discovery, development and delivery
of medicines. They are a vital part of
healthcare delivery, providing high quality
pharmaceutical care to patients, ensuring
they make the best use of their medicines.
Along with my Board colleagues I will be
working to ensure that our profession’s
potential is recognised by policy makers”
Sandra Melville is committed to listening
to what member’s everyday concerns are.
“We are working hard to ensure that the
aspirations of our membership will be met.
Over the next year we will be focussing on
the issues that directly affect our members’
daily lives. We know only too well that
pharmacists are busy people.
“The profession has become an integral
part of the NHS and has shown itself to be
competent in having a positive impact in
managing demand on GP practices. If we
are to take on even greater responsibilities,
then we have to respond to the everyday
challenges faced by hard working
colleagues.”
To help the Society engage with
members on a local basis Natalie Ryce
has been appointed to develop Scotland’s
five local practice forums. Steady progress
is being made and to get involved
or follow progress in your local area
please visit our website at; http://www.
scottishpharmacynetwork.org/.
In the past year the Scottish Pharmacy
Board has cemented its relationship with
the Scottish Government at both political
and civil servant level. The Board was
particularly pleased to be invited to
participate in the Government’s Dementia
Strategy Group and to become involved
in the Government’s scoping exercise that
helped inform the forthcoming Control of
Entry Arrangements formal consultation.
Unnecessary pressure
And just towards the end of 2009 the
Board’s campaigning on the supply of
medicines issue paid off. Speaking at the
Society’s annual Parliamentary Reception,
the Cabinet Secretary announced that
she had asked her officials to explore
“strengthening pharmaceutical regulations
to help ensure that where any delay would
cause clinical problems the pharmacist
and the general practitioner should
work together to ensure patients receive
appropriate treatment”. This is, however,
primarily a GB issue and the Board is
working with colleagues south of the
Border who are lobbying Westminster to
hold an independent inquiry to help resolve
this problem.
The Scottish Pharmacy Board is
concerned that the current situation is
putting pharmacists under unnecessary
pressure at work and could threaten patient
safety if allowed to continue.
In terms of engagement with the
Government and Parliament the Board has
three key priorities for 2010.
*Firstly, it will be providing a forthright
response to the forthcoming Control of
Entry consultation. At a time when there
is a need for pharmacists and GPs to work
together some of the media coverage over
the issue has been misleading. Last summer
the Board actively lobbied MSPs in all
parts of Scotland to make sure they were
fully aware of the pharmacy viewpoint
and to clarify any misconceptions around
the funding of dispensing doctors. The
consultation process is to be used as an
opportunity to highlight the fact that the
services offered by GPs and pharmacists are
complementary, that patients benefit from
having both professions locally, and that
where new pharmacies have opened in rural
Scotland no GP services have been lost.
*Secondly, “A Manifesto for Scottish
Pharmacy” is to be produced for the
2011 Scottish Parliament elections. The
Board’s 2007 Manifesto proved to be a
great campaigning tool and members will
be asked to contribute to the process by
making their own suggestions about potential
policy changes. Amongst the issues being
considered for inclusion will be:
• Pharmaceutical care means patients get
the right medicines at the right time
and at the right dose. The necessary
healthcare records should be made
available to pharmacists regardless of
where the patient contact occurs; in
hospital, accident & emergency, NHS 24,
GP surgery or community pharmacy. The
complete medication history contributes to
patient safety.
• Increased use of pharmacist prescribers in
all settings including out of hours centres.
• Greater clinical involvement of the
profession in care homes and in the
community for patients with dementia.
• Community pharmacists becoming the
gateway to the NHS for everyone with
minor ailments, with referrals not only to
GPs but also directly to other healthcare
professionals.
*Thirdly, over the coming decade the
NHS will face major financial challenges.
The triple threat of reductions in public
expenditure, the demands arising from
Scotland’s rapidly ageing population and
with increased ill health due to rising
trends, for example, in childhood obesity,
requires that those working in the NHS
develop creative solutions which maximise
the use of limited resources.
Significant role
In this context the NHS will need, for
example, to place greater emphasis
on preventative care and self-help and
highlight the need for the public to
recognise the true value of their medicines,
particularly when prescription charges are
being abolished and there is huge pressure
on NHS resources.
Ironically it is at this time when the
NHS faces these major challenges that
the profession can continue to develop its
influence within the NHS. In the last decade
the profession has demonstrated that it has
come a long way from simply dispensing
medicines to playing a significant role in
broader health care issues.
To guide the process of meeting the
continuing aspirations of the profession,
the Scottish Pharmacy Board has agreed to
set up a “virtual” Working Group to feed
in to the UK wide process of developing a
Pharmaceutical care
means patients get
the right medicines
at the right time and
at the right dose
“Vision for Pharmacy”. The “Vision” has
developed out of the” Pharmacy 2020”
strategy. It is hoped that a final Vision for
Pharmacy Document will be agreed by the
summer. n
Minister opens Scottish office
Scotland’s Deputy First Minister and Cabinet Secretary for Health and Wellbeing, Nicola Sturgeon was
on hand to do the honours when the Society officially opened its Scottish Office, next to the Scottish
Parliament building. She is pictured (centre) with Director for Scotland Lyndon Braddick and newly
elected Chair Sandra Melville.
“Pharmacists play a leading role at the front line of health care in Scotland and deliver many services
people rely on in the heart of the community. I congratulate the Society on their move to new offices –
premises fit for a twenty-first century profession which plays a key role in the safe and effective use of
medicines in the NHS in Scotland,” Nicola Sturgeon said.
16 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
17

T h e V i e w f r o m wa l e s
Working on your behalf
Paul Gimson, Director for Wales
Listening to what our members
want and taking action to deliver
improvements for the pharmacy
profession is at the heart of your Society.
Once the regulatory functions are transferred
to the General Pharmaceutical Council this
year, your new leadership body will have
even greater latitude to take on board the
burning issues facing all of our members
and to take action to move the profession
forward accordingly on your behalf.
I have been encouraged by the success of
recent activity by the Welsh Directorate of
the RPsgB and have seen clearly how the
new Professional Leadership Body can and
should be working for you in Wales.
The work we have been taking forward
on pharmacist prescribing over the past year
provides a clear example. We listened to
our prescribers at a non medical prescribing
symposium last April and got to grips with
the real issues and barriers affecting practice.
This was the start of a process which led
us to work in closer collaboration with the
Royal College of Nursing Wales and the
National Leadership and Innovation Agency
for Healthcare to ensure the agenda was
taken forward across Wales.
The successful conference that followed
on 9th February aimed to ‘lift the lid’ on non
medical prescribing and dispel the myths
around the use of the new skill sets of non
The Welsh Directorate hosted a
conference in Cardiff in partnership
with the Royal Collage of Nursing
Wales and the National Leadership
and Innovation Agency for Healthcare
(NLIAH), to ‘Lift the Lid’ on non-medical
prescribing. There were a number of
key speakers including Paul Williams,
Director General for Health and Social
Services and Chief Executive of the NHS,
Dr Berwyn Owen, chairman of the Welsh
Pharmaceutical Committee and member
of the Pharmacy Task and Finish Group
medical prescribers. It attracted prescribers
from all over Wales as well key decision
makers in the NHS in Wales and has now
provided us with a solid platform to help
ensure pharmacist prescribing is considered
in a more planned and informed way across
NHS services in the future.
Recently we have also had success in
influencing the policy direction of the
We now have a new
Welsh Pharmacy
Board in place which
has the drive and
determination to
make a real difference
Welsh Assembly Government in areas
such as rural health and self care. We have
worked hard to capture the attention of the
Minister for Health and Social Services
as well as other Assembly Members and
will continue to ensure pharmacy issues
are at the forefront of the Government’s
health agenda. As a member of the Welsh
Assembly Government’s Pharmacy Task and
Finish Group, I have been voicing concerns
Conference Success
established this year by the Minister for
Health and Social Services and Marc
Donovan (pictured) of the Welsh Pharmacy
Board to name but a few.
At the event, Paul Williams revealed
Welsh Assembly Government plans of a
five year strategy in Wales which aims
to develop well integrated health care
services, fully utilising the skills of all
health professions in a more unified and
efficient health care system. Referring to
the important role of pharmacist prescribers
as one of a number of key resources for
and highlighting solutions to help influence
the future shape of pharmacy in Wales at the
highest strategic level and this is presenting
a range of exciting opportunities for the
profession in Wales.
All aspects of this work are undertaken as
part of the day to day work of the RPsgB
team based in Cardiff and, while it may not
always be obvious to our members, this
activity is crucial for ensuring your interests
are pushed forward on the political stage. I
strongly believe that a result of our recent
work, a swell of momentum is gathering that
will stand the pharmacy profession in good
stead for the future.
We are also on track to develop our LPFs
in Wales and I remain excited about the
possibilities they will provide in shaping
the profession and in enhancing dialogue
between the new Professional Leadership
Body and pharmacists across Wales.
In addition, we now have a new Welsh
Pharmacy Board in place which has the
drive and determination to make a real
difference. I am looking forward to working
with the Board to take a challenging
programme of work forward and am eager
to get to grips with the issues affecting
our members in all sectors and all areas of
Wales. n
Paul Gimson, RPSGB Director for Wales
Contact paul.gimson@rpsgb.org
improving patient care, he said “We [Welsh
Assembly Government] are committed to
developing non medical prescribers in order
to provide service improvements to all
patients across Wales.”
Expert in medicines
Over 100 delegates from a range of
professional and NHS backgrounds signed
up for the conference. The event focused
on the need to utilise the as yet untapped
skills of non-medical prescribers, which are
already available in the NHS with around
100 pharmacists now qualified to prescribe
in Wales.
The Welsh Assembly Government
continues to support and fund the
educational programme to train non-medical
prescribers in Wales and as the experts
in medicines, pharmacists working in all
health care settings have a key role to play
in advising colleagues on medication choice
and undertaking prescribing responsibility
themselves.
Commenting on the conference, Paul
Gimson (pictured), RPSGB Director for
Wales said “I am encouraged that the Welsh
Assembly Government is recognising the
skills of pharmacist prescribers in NHS
care in Wales. We must use this platform
to persuade NHS decision makers of the
benefits of utilising the skills of pharmacist
prescribers more effectively in a more
planned and informed way”. n
For more information please contact:
Ross Gregory, Health Policy Analyst for Wales
Ross.Gregory@Rpsgb.org
029 20 730314
Nuala Brennan
Chair of the Welsh
Pharmacy Board
Welcome to New
Board Chair for Wales
The Welsh Directorate welcomes newly
elected Chair, Nuala Brennan, along
with Mair Davies as Vice-Chair. They were
elected on Thursday 11th February at the
first meeting of the new board.
Commenting on her election to the
position of Chair, Nuala Brennan said:
“I am delighted to take on the Chair of
the Welsh Pharmacy Board and represent
the interests of the pharmacy profession in
Wales at such a crucial and exciting time
for pharmacy. This will be a challenging
role but I have confidence in the wealth of
experience of the newly established Board
which will undoubtedly stand us all in
good stead for the future”. n
LPF Progress in Wales
We have so far hosted three highly
successful Local Practice Forums
engagement events in order to give
pharmacists across Wales an opportunity
to have their say in how the LPF’s should
be run in the future. We have received
a fantastic response from each event,
with high turnouts in North Wales
Pharmacy Practice Forum, Cwm Taf LPF
and Abertawe Bro Morgannwg University
LPF, which alone saw over forty people
attend.
I have always thought
local branch structure
was the ‘jewel in
the crown’ for The
Society and LPFs
should be able to
surpass this
The North Wales Pharmacy Practice
Forum has already made a great start and
has been given the opportunity to pilot
the new Virtual Networking site which
members of LPF’s will be able to use,
giving them a chance to communicate
easily with pharmacists across the whole
of Wales and access information 24/7.
LPF Lead in North Wales, David
Morgan, who has worked closely with
The Society said “The pharmacy network
has huge potential for all members,
if they use it. My priority for the next
few weeks is to persuade members to
register for the pharmacy network (virtual
Networking site).” Although almost 100
members have already registered to the
network, The Society will be looking to
give the network more publicity in order
to persuade members to use it.
“Potentially, LPFs can be very
successful. I have always thought that
the local branch structure was the ‘jewel
in the crown’ for The Society and LPFs
should be able to surpass this.”
The Welsh Directorate will be looking
to really promote the Virtual Networking
Forums within the LPF’s to encourage
members and potential members to get
involved. n
If you require further information on LPFs
in Wales please contact:
Christine Horan, LPF Facilitator for Wales
Christine.Horan@rpsgb.org
029 2073 0315
18 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
19

p o l i t i c a l v i e w
b u s i n e s s p r a c t i c e
The scramble has started
All the latest from the corridors of power, RPSGB
head of public affairs Charles Willis reports
The Parliament is nearly
over and the mad
scramble to complete
parliamentary activity under
this Government is under
way. It’s known as the Washup
and the odds and ends of
legislation already under way
are squeezed into small gaps in
the Parliamentary timetable to
try and maximise output from an
outgoing government.
The squeeze has begun on
poll standings, with the Labour
Party making gains on the
Conservatives who now enjoy a
lead of only single figures. The
tone of conversations are now
subtly different. “If” now means
if rather than when. All bets are
still on a Conservative election
victory, but the debate within
Westminster is whether they will
secure enough new MPs to gain
an overall majority.
A minority government will
leave David Cameron with a real
problem in that he will require
the support of other parties
to push through his spending
plans. It will be very difficult
to find any party to support
swingeing cuts to health and
other government budgets when
it is likely that another general
election could follow relatively
soon after May.
And the issue he will be
thinking about in the wee small
hours of the night is how to make
the cuts of the scale he plans
and still be able to win another
election in the next 10 – 20
months?
Where does this leave
healthcare? The main
Westminster parties have all
accepted that cuts in spending are
inevitable. They dislike using this
word when talking about health
but it is understood that many
associated with local healthcare
The Team have been compiling
examples of cost savings made by
utilising pharmacy more widely
budgets have, for some time,
been planning radical changes.
Conversations are underway
across the country about cuts of
between 10%-20% to certain
aspects of the healthcare budget.
From Global to Local
The future of the global sum,
after it has been devolved and
what PCTs will use it to pay for,
are top priorities at the moment
within the RPSGB. We have
written to the Secretary of State
for Heath, Andy Burnham MP,
explaining our concern and
seeking assurance that pharmacy
will not be allowed to suffer. The
campaign continues.
Andy Burnham must be
getting fed up with pharmacy.
We’ve also written to him telling
him that the current vacancies
at Band 6 level within hospitals
is unacceptable. Again, the
campaign continues.
For years now, the RPSGB has
been engaging with politicians,
explaining the value of pharmacy
from a patient safety, satisfaction
and outcome aspect. For a year
or more we have shifted the
emphasis slightly to include the
glaring fact that, for what we
do and our level of expertise,
we are very cost-effective when
compared to other professions.
The Team have been
compiling examples of cost
savings made by utilising
pharmacy more widely, to offer
as case histories to those in
authority to demonstrate why the
current shift towards pharmacyled
services should be increased.
Pharmacy Order
The major changes within
the RPSGB, to ensure a
smooth transition to a more
representative professional body
have been going on for at least
two years.
Members have consulted, reconsulted
and consulted yet again
so the first offer by the new body
will be exactly what is needed.
The most difficult part of the
process is securing the legislation
to deliver the wishes of members.
A string of pieces of secondary
legislation need to pass through
the two parliaments and
Assembly, flowing through like
eddies in the flow of mainstream
parliamentary business. These
eddies are subject to the surges,
ripples and backwash found on
any river.
Such a backwash was
experienced at the final stage of
the process for the Order to set
up the GPhC. The attention of
a Noble Lord with additional
responsibility to monitor such
pieces of legislation, was drawn
to one particular aspect of
the Pharmacy Order. He was
concerned that there has been a
growth in the powers of entry
for such bodies and he sought
assurances from the Government
that Inspectors would not be able
to enter a premise at will.
The RPSGB Team sought a
meeting with him and tried to
allay his concerns. In the end
both parties could not agree that
the powers of entry for inspectors
is essential. An intense period
of lobbying then took place to
ensure a majority within the
House of Lords. The Order
succeeded in being passed and
now there are only another two
to secure before the GPhC is able
to operate separately from the
RPSGB.
RCGP joint report
The same sense of urgency has
gripped the project team behind
the joint report on closer interprofessional
working between
pharmacists and GPs. Watch this
space for the finished report next
month. n
l charles.willis@rpsgb.org
Bad time for an urgent review
Financially, it must
be hoped these are
not typical times for
pharmacists or for anyone else.
A long recession has eventually
been replaced by below-average
economic growth, inflation
has been negative and the
availability of finance remains
patchy, turning low theoretical
rates into expensive loans if
borrowing is possible at all.
Yet this is the time chosen
for the government to study
pharmacists’ costs to set a new
contract that will determine the
level of future funding.
The current contractual
framework has been in place
since 2005 and was based on
a costs survey conducted two
years before that. But given the
changes that have happened
since then – even before the
recent recession – it is hardly
surprising that the arrangements
are proving increasingly
unsatisfactory and patches have
had to be applied regularly.
Over the past seven years the
nature of dispensing businesses
has changed considerably as
community pharmacists are
increasingly used as both a firststop
entrance to the National
Health Service and a last stop.
High-street outlets are more
and more the frontline of the
government’s campaigns on diet
advice, sexual health, stopping
smoking or health inequalities.
Medicine-use reviews have
joined the list of requirements
since the 2003 survey, along
with repeat prescriptions,
medicine management, the
treatment of minor ailments,
diagnostic and monitoring
services. Yet the Department
Richard Northedge
Funding under the microscope
of Health formula for paying
pharmacies has struggled to
keep up with the workload being
transferred to these outlets.
The new survey is being
conducted during the early
months of 2010 with accountants
PricewaterhouseCoopers
examining the accounts
of a nationwide sample of
pharmacies and questioning
owners. The data collected will
be used by the Pharmaceutical
Services Negotiating Committee
to form the framework of the
future funding agreement.
Financial formula
It is likely that salaries will
continue to account for around
three-quarters of costs, with
premises comprising much of
the remaining typical expense,
but the committee must resolve
whether funding should
continue to be based on the
volume of prescriptions dealt
with when government policies
should be seeking to replace
quantity with quality and when
so much pharmacy work is
no-longer prescription-based.
And with pharmacists under
pressure to invest more in their
clinically-based services, it is
important that the cost of capital
is properly included in the
financial formula.
Ironically, having devised
such a byzantine method of
payments, the Department
of Health feels obliged to
compensate recipients for the
bureaucratic burden of collating
and supplying data but, despite
that workload increasing
annually, the Treasury insists on
reducing payments for assumed
efficiencies.
Lectures on efficiency by
national government to private
businesses might be funny if the
state did not think it its duty to
reduce profit margins every time
the entrepreneurs find a way to
widen them.
But the experience of the 2005
contract is that even if it was
possible to produce a perfect
payments equation, the contract
itself changes the assumptions on
which it is based. The reduction
of discounts from the large drug
companies over the past five
years is a direct consequence of
the guaranteed profit provided by
the contract, for instance. Once
Glaxo, Pfizer and AstraZeneca
could see the profit would come
from the Department of Health
they no longer needed to provide
it to pharmacists through
pricing, and the subsequent state
top-up of the margins guarantee
not only admits its inadequacy
but also acknowledges the
change to supply arrangements
caused by the contract.
Such conflicts will arise where
a monopoly meets a monopsony
– where a limited number of
producers are selling to what is
effectively a single buyer – but
if a pharmacy dispenses more
than the average amount of
branded items it can find itself
operating at a loss. Similarly,
when shortages of supply force
the pharmacy to pay extra to
obtain stock, it can be out of
pocket when a business without
the obligations imposed by the
contract might have preferred
to leave its shelves empty and
customers unsatisfied.
But if the timing of this
review is unfortunate because
of the unusual levels of interest
rates, inflation and economic
activity, it is worrying too
because of the government’s
own pressure to reduce public
spending. However much
ministers might claim to want to
protect the health service they
will enter negotiations seeking to
limit their financial commitment
and squeezing the few privatesector
providers – drug
companies and hospital caterers
as well as pharmacists – will be
easier than cutting the part of the
NHS the state controls directly.
The switch of the global
element of the pharmacy budget
– currently more than £1bn a
year and almost half the total
contractual payment – from the
Department of Health to local
Primary Care Trusts should not
be an excuse for discretionary
decisions that disadvantage
individual pharmacies when
PCT finances are already blamed
for constraints on service.
There have probably been too
many changes in the structure
of the NHS over past years for
a radical rethink of the ways
to remunerate pharmacies,
but while the current contract
unquestionably requires
revision, its replacement needs
to be able to incorporate not
only the changes to pharmacy
practices since the last version
but also the transformation the
profession is likely to see before
the next version. Producing that
based on data sampled during
a recession and negotiated with
a government seeking cuts is
unfortunate timing. n
l Richard Northedge writes
for the Spectator, Wall Street
Journal, Independent on Sunday
and other publications.
20 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
21

f e at u r e s e c u r e e n v i r o n m e n t
You would think that for a person with such a love of
travel as Stella Simpson, going to work each day could be
something of a challenge. Her “office” is, after all, about as
far away from the beaches and cities of exotic foreign climes as it is
possible to get.
You will find it instead deep in the less-than-welcoming heart
of one of the most secure and impenetrable buildings to be found
anywhere in the UK – Her Majesty’s Prison Holloway.
Gaining access to the facility, in something of a wasteland in one
of the grimmer areas of North London, is a challenge in itself, with
the kind of security which makes that found at many airports seem
casual by comparison.
None of this seems to worry Stella Simpson, though, when
I meet her in the inner ante-room of the prison’s reception area
on a dark and dismal winter afternoon, when the persistent rain
does little to alleviate what should, by rights, be a gloomy and
depressing atmosphere.
Far from looking depressed, though, Stella Simpson, the Head
of Primary Care and Deputy Head of Healthcare, is the picture
of enthusiasm as she leads me through door after door, unlocking
and re-locking each as we proceed, up stairs and along seemingly
endless corridors, all smelling faintly of disinfectant, past the prison
pharmacy and into her office which, is has to be said, looks just like
any other office.
Stella has been involved with the Prison Service since about
1989, when she was working as a Locum in a number of
different locations, including Her Majesty’s Prisons Wandsworth,
Wormwood Scrubs and
Pharmacy behind bars
A bunch of keys may be part of everyday equipment but working as a
pharmacist in a secure environment is about much more than ensuring
the doors are locked. Jeff Mills meets HMP Holloway’s pharmacy chief
Role of pharmacists
Pentonville. Between 1993 and 2000 she was a part-time locum
pharmacist at before taking a full-time role as the principal
pharmacist at HMP Holloway on a Locum basis, a role that became
substantive in 2003.
“Back in the early days working as a pharmacist in prisons
was difficult,” she says. “Many of the medical staff didn’t really
understand the role of pharmacists in the clinical care of patients
and resented our intervention.
“A change in the healthcare management in 2000, enabled me to
take forward my vision for development of the pharmacy services,
I was lucky enough to be offered a full-time job in Holloway and
I saw a great opportunity to make changes to update the pharmacy
services and improve the clinical care of prisoners”.
This involved developing the profile of the pharmacy team
within the prison, working with other healthcare and security staff
to implement improved services she says. “One of the results was
that I felt very valued as a professional,” Stella remembers.
And the following years at the prison turned out to be particularly
busy ones for Stella by all accounts, with landmarks including the
publication of a number of articles on prison pharmacy, an award
for innovation from Islington PCT, contribution to guidance on the
safer management of controlled drugs in a secure environments
and developing and implementing an In-Possession medication
system for use in Holloway. She also did a lot of work on Æ
22 Pharmacy Professional | March 2010 March 2010 | Pharmacy Professional 23

f e at u r e s e c u r e e n v i r o n m e n t
Inside story Stella on duty in Holloway Prison
More on-site medical
facilities will mean
fewer prisoners
have to go outside
Holloway for medical
appointments
improving practice in secure environments
and was instrumental in introducing Clinical
Governance to the Holloway healthcare team.
And the pressure shows no signs of letting
up, though it has to be said that Stella seems
to thrive on it, which is just as well, as she
normally has around 500 female inmates in
her care.
“Assessing risk is one of the main
priorities,” says Stella, who oversees
the Primary care team made up of a GP,
pharmacists, technicians and nurses.
“Somewhere between 70% and 80% of the
women in Holloway have substance misuse
and/or mental health issues,” she says. “The
women can be particularly vulnerable and
there is a relatively high incidence of selfharming
in female prisoners. This always
needs to be considered when developing
healthcare services”.
Many of the inmates have been socially
excluded in the past, often because of their
lifestyle, with no real access to healthcare.
For many, a spell in Holloway can come as
something of a respite from their normal
life, though suggestions that some women
deliberately commit crimes in order to be sent
to jail are possibly no more than apocryphal.
Develop new skills
Certainly the healthcare the inmates can
experience is impressive given the obvious
constraints of a secure environment such as
Holloway. Right now plans are well advanced
to create an improved primary care poly
clinic, where all the necessary medical and
associated facilities can be found on one site.
“One of the things I love most about my job
is the variety it offers and the opportunity to
develop new skills. As part of my role I am
the project manager for the new ‘Primary
care poly clinic’ and have designed the layout
and produced, albeit simplistic, technical
drawings for the construction team to work
from and designed a new appointments
system to ensure we can monitor access
and ensure our services are constantly
improving.”
The new polyclinic will enable the
range of healthcare services to expand and
develop and allow better access to services
for the prisoners. It will also allow for
better utilisation and development of the
healthcare staff skills as the Primary care
team who are currently dispersed throughout
the prison come together in a purpose built
facility. “This will make it much easier for
pharmacists and pharmacy technicians to
provide good quality services and work as
key members of the Primary care clinical
team,” says Stella.
Yes another plus of the new centre, expected
to come on stream later this spring, will be that
more on-site medical facilities will mean fewer
prisoners have to go outside Holloway for
medical appointments. Not only is this a more
efficient use of pharmacists’ and other medical
staff members’ time but it also frees up prison
officers, who have to accompany inmates
when they attend hospitals or other medical
facilities ensuring that the regime functions
well and its main purpose of reducing
re-offending by providing psychosocial
interventions is uninterrupted.
Medical records
And when she is not busy with overseeing all
of that, Stella has the job of line managing
the Lead GP, Lead Primary Care Nurse
and the Pharmacy Team Manager; Her
role also involves leading on Clinical Risk
and Medicines Management for Holloway
and she is heavily involved in developing
and improving the Patient Electronic
Medical Records System (EMIS) for use by
Holloway’s clinical staff, including the design
of clinical templates for healthcare screening
during the reception of prisoners.
But important as her work at Holloway
is, there is another life for Stella and that is
her passion for travel and new experiences
overseas, which started back in the years
between 1988 and 1995 when the flexibility
offered by working as a locum allowed her to
indulge her passion.
“I was in Berlin in October 1989, just few
weeks before the Berlin Wall came down and
I have a piece of the wall to prove it,” she
says. She has worked in the United States on
two occasions, not as a pharmacist, though.
“I spent two separate occasions working in
San Francisco waitressing, then I travelled to
Australia and New Zealand.”
Having checked out the USA Stella
turned her attention to South-East Asia with
trips to Thailand between 1990 and 1994
during which she travelled throughout the
country from north to south. “Then in 1994
I spent several months in Sri Lanka and the
Maldives,” she says. This is where she was
able to pursue another of her passions, diving,
a sport which has taken her to many of the
world’s most exotic locations.
“I started diving in the 1990s during a
trip to Catalina Island in the United States.
In 1991 I went diving in Cyprus, then did
my PADI Open Water qualification while
visiting the Great Barrier Reef during a trip
to Australia. I did my advanced PADI Open
Water qualification in Koh Tao in Thailand
about 1992,” and these are just some of the
exotic destinations she has traveled to in
search of the perfect dive site. Others include
Cuba, Egypt and Mexico.
More recently China has been among the
highlights of Stella’s globetrotting. “In 1995, I
spent a month in China and visited my father
in South Korea, then I travelled through
Vietnam for a month,” she says.
She could be forgiven if, from time to time,
she was tempted to gaze out of her office
window across the grim vista of Holloway’s
charmless buildings and dream of her next
excursion. But as pharmacists will already
know, the profession gives little time for such
indulgences. There’s always work to be done,
and that applies to secure environments just
as it does outside the prison walls. n
24 Pharmacy Professional | March 2010 March 2010 | Pharmacy Professional 25

f e at u r e d e m e n t i a
This latest practice guidance from the Society on dementia is part of a mental health
toolkit which is under development. Ziba Rajaei-Dehkordi (lead author) and Denise Taylor
(co-author) provide advice on pharmaceutical care services for dementia in practice. The
RPSGB would like to thank all those who contributed to a mental health toolkit, including
the focus group members, for their advice and expertise
Professional
practice
We bring you an update and the
latest expert advice on dealing with
patients suffering from dementia
Practice Guidance:
Pharmaceutical Care in Dementia
Guidance OBJecTIVES
• To gain an understanding of dementia
and its management
• Identify pharmaceutical issues and meet
patients’ needs
• Explore and implement pharmaceutical
care services for dementia in practice
RPSGB competencies for completing a
CPD entry (see appendix 6 of “Plan and
Record” www.uptodate.org.uk):-
• “making sound decisions and solving
problems in relation to drug therapy”
• “promoting health and healthy
lifestyles”
Background
Dementia is a term for a range of progressive,
terminal organic brain diseases. Symptoms
include decline in memory, reasoning and
communication skills; difficulties in carrying
out daily activities; and loss of control of
basic bodily functions. The emotional impact
on people with dementia and their families
can be enormous, with depression and high
levels of stress common.
Dementia is generally irreversible,
except in a small number of people; termed
‘pseudo-dementias’ (approximately 1% of
all dementias) which are remediable.
Prevalence
It is estimated that 4 to 5% of the population
over 65 years have a dementia, which
rises to 20% over the age of 85 years. The
prevalence is continuously increasing with
the growing aging population. It can also
affect younger people.
Types and causes
Dementia is caused by structural and
chemical changes in the brain
• Alzheimer’s disease – gradual onset and
steady decline. Accounts for approximately
60% of dementias. It is associated with
deposition of neurofibrillary tangles and
amyloid plaque which cause neuronal
death.
• Vascular dementia – sudden onset with
stepwise progression, emotional liability
early in course of illness. It is caused by
cell death due to ischaemic changes in the
brain following a stroke or small blood
vessel disease. Conditions that affect the
circulation of blood to the brain, such as
hypertension, can contribute to vascular
dementia. It accounts for approximately
20% of dementias.
• Dementia with Lewy Bodies –
characteristic fluctuating cognition, Æ
26 Pharmacy Professional | March 2010 March 2010 | Pharmacy Professional 27

f e at u r e d e m e n t i a
visual hallucinations and history of falls
[in addition to Parkinsonian features],
associated with the presence of Lewy
bodies inside nerve cells in the brain
which interrupt its normal functioning.
It accounts for approximately 15% of
dementias. Lewy bodies are also present
in Parkinson’s disease dementia, and
diagnosis is dependent on the time of
dementia symptoms in relation to onset
of parkinsonian symptoms. People
with either form display an increased
sensitivity to antipsychotics which can be
fatal.
• Frontotemporal dementia is a rare form
of dementia, and affects around 5% of
people with dementia. It often affects
the under 65s, with dramatic effects on
behaviour and personality, rather than
memory, in the early stages.
Risk factors
The main risk factor for dementia is age, but
cardiovascular factors are also important,
and people with learning difficulties (e.g.
Down’s Syndrome) may be affected earlier.
Genetic predisposition has also been
associated.
Other risk factors implicated include:
• Environmental toxins causing
neurotoxicity (e.g. excessive alcohol,
pesticides, aluminium levels in water and
diet)
• Head injury
• Gender – The prevalence is higher in men
up to the age of 74 years, but higher in
women thereafter.
• Remedial factors which can be managed
and treated:
o Hypothyroidism
o Vitamin deficiency (e.g. thiamine, B12,
folate, or iron)
o Acute confusional state (delirium)
o Space occupying lesions in the brain or
hydrocephalus
Symptoms
Disease progression varies considerably, but
broadly falls into three phases
Early Stage symptoms, often misattributed
to stress, bereavement or normal ageing
include:
• mood changes;
• loss of short-term memory;
• confusion, poor judgement, unwillingness
to make decisions;
• anxiety, agitation or distress over perceived
changes and inability to manage everyday
tasks.
Middle Stage symptoms include:
• more support required, including reminders
to eat, wash, dress and use the lavatory;
•increasingly forgetful and may fail to
recognise people; distress, aggression and
anger are not uncommon, perhaps due to
frustration;
• risks include wandering and getting lost,
leaving taps running or forgetting to light
the gas;
• may behave inappropriately e.g. dressing
incorrectly, loss of day-night cycle;
• may experience hallucinations.
Late Stage symptoms include:
• inability to recognise familiar objects,
surroundings or people – but there may be
some flashes of recognition;
• increasing physical frailty, may start to
shuffle or walk unsteadily, eventually
becoming confined to bed or a chair;
• difficulty eating and sometimes
swallowing, weight loss, incontinence and
gradual loss of speech.
Consequences of dementia
• People can live with dementia for many
years – the average time from diagnosis to
death is 11-12 years, but diagnosis is often
made late so the course of the illness can
be as long as 20 years
• Most people with dementia have at least
one co-morbidity
• Unpaid carers (mostly female family
members) provide the majority of care in
the community
• Often it is the behavioural changes in
people with dementia that distress the
family and carers the most
• The annual economic burden of lateonset
dementia is estimated to be more
than stroke, heart disease and cancer
combined, of which the majority falls to
families.
• Around one third of people with dementia
currently live in largely private sector
care homes (making up over 60 per cent
of all residents), and the trend is towards
entering care with more severe disease.
Treatments
The National Dementia Strategy (NDS)
in February 2009, outlined key areas for
addressing by healthcare professionals:
1. Ensure better knowledge about dementia
and remove the stigma
2. Ensure early diagnosis, support and
treatment for people with dementia and their
family and carers
3. Develop services to meet changing needs
better.
Pharmacological groups licensed for the
treatment of dementia in Alzheimer’s
Disease are:
• Cholinesterase inhibitors – donepezil,
rivastigmine and galantamine
• NMDA-receptor antagonist – memantine
Æ See Practice Guidance: Supporting
Patients on Medicines for Dementia
(Cognitive Enhancers)
Pharmacological treatment for dementia
should be initiated and supervised only by a
specialist experienced in the management of
dementia
Provide a medication review service to
ensure understanding of dementia
Non-pharmacological: Promoting Good
Mental & Physical Health
Encourage and support patients and their
family/carers to undertake activities and
address lifestyle issues, to promote good
mental and physical health.
Over the Counter Self-treatments –
Gingko biloba has some supporting evidence
in improving memory and concentration.
Note: Theoretical evidence suggests it may
increase the antiplatelet effects of aspirin.
Folic acid, B12 and iron Deficiencies of
these are linked with cognitive dysfunction
(confusion and/or memory problems).
However, if a deficiency has not been proven,
supplementation will generally not have any
clinical effect.
Lemon balm and Lavender Essential
Oils There is emerging evidence for use
in sleeping and agitation either via an
oil diffuser, massage or being placed on
pillowcases or clothing.
Light therapy Evidence from small studies
suggests positive benefits on behavioural
problems from light therapy during winter
months.
Practice Points
for Pharmacists
• Identify people possibly at risk. All
people concerned about memory
impairment; losing objects (keys,
wallets etc) should be signposted to
their GP or specialist memory services
• Offer educational support and
advice and ensure the patient and/
or carer understands how their
medication works and the importance
of continuing to take them. Reassure
them about any concerns such as side
effects and refer as appropriate.
• Signpost to organisations that can
support their educational needs and
prepare them for the future - support
may also be required with advance
directives, wills, finances and the
home environment.
• Poorly compliant patients may
benefit from a once daily preparation
(particularly in polypharmacy) and/or
use of compliance aids with support.
Provide family / carers with advice to
support compliance.
• Swallowing difficulties: consider
alternative formulations for patients
with swallowing difficulties and/or
problems with dose titration.
• Offer a prescription collection and
delivery service
• Encourage self-care in terms of
increasing exercise, taking part in
social activities and doing activities,
which stimulate brain function, such
as crossword puzzles, jigsaw puzzles
or Sudoko.
• Alcohol should be avoided – due to
added effects of drowsiness
• Check for interactions including
OTC remedies. See www.bnf.org for
interactions.
•Gingko biloba: Concomitant use of
aspirin may increase its antiplatelet
effects (avoid combination or use
cautiously). Ensure the patient’s
prescriber is aware if ginkgo biloba
is being taken and any signs of
increased bruising are investigated.
• Establish links with the local
Dementia Advisor for liaison – to
support people in local community
with dementia, to reduce stigma
associated with the illness and to
promote the early recognition of
signs and symptoms with appropriate
referral.
The National Dementia Strategy promotes
the implementation of a local Dementia
Advisor to provide support and information
as and when it is needed. The emphasis
is on proactive engagement of healthcare
professionals rather than a response to a
person who is in distress and no longer
coping. Pharmacists by promoting good
mental and physical health activities can
further help improve the quality of life for
people with dementia and their families.
Levels of pharmaceutical care
services for supporting patients
with dementia
In general pharmacists can:
• Recognise possible symptoms of dementia
especially when responding to symptoms
and refer as appropriate
• Provide lifestyle advice and support
• Signpost to local and/or national support
resources.
Æ See Useful Resources section
Level 1: Pharmacists can:
• Provide a medication review service
to ensure understanding of dementia by
patient and/or their family/carers; provide
treatment support; and address any side
effects and adherence problems. Patients
receiving their dementia medication from
secondary care services for the first time
may not have had access to pharmacist
advice and support .
Level 2: Pharmacists can offer:
• Support for healthy lifestyle interventions
(for patients and/or family/carers),
including:-
Smoking cessation counselling and
provision of nicotine replacement therapy
(NRT)
Advice on use of use of alcohol: NHS
Choices: http://www.nhs.uk/Livewell/
over60s/Pages/Tipsforcuttingdown.aspx
Diet and exercise support and advice -
see Top Tips for eating more fruit and
vegetables at http://www.5aday.nhs.uk/
topTips/default.html
Vascular risk checks and weight
management
• Pharmaceutical care of vulnerable patients
e.g. daily dispensing; compliance charts;
monitored dose systems
• Recognise symptoms of declining
cognitive function: poor functioning in
activities of daily living (e.g. washing,
dressing, self neglect, poor repeat
collection, behavioural and mood changes)
and liaise with the community mental
health team, the GP and/or specialist
services to optimise patient care.
• Support the local Dementia Advisor -
provision of pharmaceutical care education
and information in dementia management.
• Review of inappropriate prescribing of
antipsychotics
Level 3 Specialist Mental Health Level;
Pharmacists role in effective care for
those with dementia
Pharmacist Prescribers; Pharmacists with
Special Interest; or those with appropriate
interest, training and support could develop
an integrated service with colleagues in
secondary care - including prescribing,
diagnosis and support
Other specialist pharmacists e.g. working
in care homes, community or intermediate
care hospitals could also support the earlier
recognition of the illness and appropriate
referral
Pharmacists can:
• Provide early-symptom detection
assessments with referral to a specialist
as appropriate (with appropriate required
training) e.g. Folstein Mini Mental State
Examination.
• Provide medicine education sessions
• Monitor response and side effects
• Suggest therapeutic change if poor
response
• Prescribe (if appropriately trained) in
collaboration with healthcare team and
Community Mental Health Team if
appropriate
• Provide (if appropriately trained) support
on non-pharmacological treatments
• Support commissioners in service redesign
so that medicines management is
integral to care pathways.
Æ
28 Pharmacy Professional | March 2010 March 2010 | Pharmacy Professional 29

f e at u r e d e m e n t i a
Practice Guidance: SuPPOrting PatienTS on Medicines for
Dementia (cOGnitive Enhancers)
Guidance OBJecTIVES
To understand, identify and meet the
pharmaceutical care needs of patients:-
• initiating medicines for dementia
• on maintenance therapy and
• withdrawing from cognitive enhancers
RPSGB competencies for completing a
CPD entry (see appendix 6 of “Plan and
Record” www.uptodate.org.uk):-
• “making sound decisions and solving
problems in relation to drug therapy”
• “promoting health and healthy lifestyles”
Background
The dementias are neurodegenerative
disorders that result in progressive mental
decline with other chronic conditions and
behavioural problems being a common part
of the illness. There are two pharmacological
groups licensed for the treatment of the
symptoms of Alzheimer’s disease (AD):-
• Cholinesterase Inhibitors
(donepezil, rivastigmine and galantamine)
These agents are licensed for the
symptomatic treatment of mild to moderate
AD (rivastigmine also licensed for
symptomatic treatment of Parkinson’s
disease dementia).
• NMDA-receptor antagonist – memantine
is the first NMDA-receptor antagonist to
be licensed in the United Kingdom for the
treatment of moderate to severe AD.
1. Pharmaceutical Care at Initiation
Pharmacological treatment is normally
initiated by specialists but can be continued
by general practitioners under a shared-care
protocol.
Patients and their family/carers need to
be aware at the start of treatment with a
cholinesterase inhibitor that improvement
from pre-treatment function occurs in
some, but not all cases. It may be possible
to at least slow the progression of the
disease. However, it is likely that as the
disease progresses individual patient
performance will decline, eventually to a
stage where the agent may seem to have
little clinical effect.
Advice to patients at initiation
Patients and their family/carers should be
made are aware of the following:
• Possible side effects and how to manage
them (see table)
• Symptomatic treatment, not curative
• Dose titration - after initiation patient
tolerability and dose will be reviewed after
2 to 4 weeks [depending on the product].
• Take at a regular time each day
• Carer role in monitoring medication - to
ensure the medicines are taken each day.
• Avoid alcohol - Alcohol is a CNS
depressant; and should be avoided if
possible.
• Provide information and sign-post:-
o Leaflets on dementia / depression and
medication
o Local memory clinics
o Support resources and services e.g.
audiotapes, peer support groups,
including diet and lifestyle
There is widespread
concern about the
over-prescription
of antipsychotics in
dementia
Side Effects: Advice on Management
People need to be informed about the most
common side effects to self manage and to
identify when to seek medical advice.
For a detailed list of side effects and
interactions see BNF www.bnf.org
• See table opposite
2. Pharmaceutical Care for
Maintenance Therapy
• Pharmacological treatment benefit is
assessed by repeating the cognitive
assessment at around 3 months from
diagnosis and every 6 months thereafter.
• The evidence to support the use of these
medicines relates to their cognitive
enhancement and improvements in
behaviour and daily activities.
• Such assessment cannot demonstrate how
the disease may have progressed in the
absence of treatment but it can give a good
guide to response.
• Up to half the patients given these drugs
will show a slower rate of cognitive decline.
• If a cholinesterase inhibitor causes
intolerable side effects or if the patient
is thought not to be responsive then an
alternative agent can be tried. When
withdrawing cholinesterase inhibitor
therapy, monitor for signs of decline and
reinstate if appropriate.
• Many specialists repeat cognitive
assessment 2 weeks after discontinuation
to assess deterioration; if significant
deterioration occurs during this short
period, consideration should be given to
restarting therapy.
• Care should be taken with use of
antipsychotics in older people with
dementia, as such medicines may hasten
cognitive decline and may be linked
to an increased risk of fatal stroke and
cardiovascular disease. There is widespread
concern about the over-prescription
of antipsychotics in dementia. Several
studies have shown that interventions led
by pharmacists can successfully reduce
antipsychotic use in care homes (see
Westbury 2009 ). There is increasing
evidence that citalopram, memantine
and non-pharmacological approaches to
managing behavioural disturbances may be
effective. (see Ballard et al 2009)
Mild to moderate stage
• Cholinesterase inhibitors are licensed
for use in the treatment of Alzheimer’s
disease, specifically for mild to moderate
disease.
• Rivastigmine is also licensed for mild
to moderate dementia associated with
Parkinson’s disease.
• Rivastigmine should be prescribed with
caution in patients with renal impairment
or mild to moderate hepatic impairment.
• Cholinesterase inhibitors delay disease
progression by about six months, but
evidence from clinical practice suggests
that some patients may benefit for four
years or longer.
• Although cholinesterase inhibitors belong
to the same group they all produce their
pharmacological effect differently, so if a
response to one agent is not seen, then it is
justifiable to try another.
Moderate to severe stage
• Memantine is licensed in the United
Kingdom for the treatment of moderate to
severe dementia in Alzheimer’s disease.
• NICE does not recommend memantine for
moderately severe to severe Alzheimer’s
disease except as part of well designed
clinical studies; patients already receiving
memantine can continue treatment until
they, their carers, or their specialist
consider it appropriate to stop.
• The Scottish Medicines Consortium has
advised (January 2004) that memantine
is not recommended for the treatment of
Alzheimer’s disease.
3. Pharmaceutical Care in the Later
Stages of Dementia
Of key importance at this stage of the
illness is to support patients and their
family/carers in assessing the medicines
that are of necessity. Care becomes more
complex as the physical, as well as, the
neurodegenerative signs and symptoms
manifest.
The National Dementia Strategy is
proposing that a palliative care approach
is adopted and that services are timely,
integrated and individualised to the patient.
At this stage there may be difficulty
in swallowing and eating so advice on
medicine administration and dietary
information may be necessary. For some
patients this may mean medicines need to be
administered as a liquid, topical or parenteral
form and may need to be added to food, if
appropriate and necessary.
There is guidance on the covert
administration of medicines (Ref:
RPSGB Law and Ethics Bulletin: Covert
administration of medicines. Pharmaceutical
Journal 2003:270:32 (Jan 4) www.pharmj.
com/editorial/20030104/society/ethics.html)
Consider also the possible pharmaceutical
implications of this. Æ
Anticholinergics: concomitant use of
these in people with dementia needs
careful consideration to minimise
potential side effects. The following
medicines with anticholinergic side
effects will interfere with memory and
exacerbate or cause confusion:
• Hyoscine • Antipsychotics
• Oxybutinin • Procyclidine
• Tricyclic antidepressants
Furosemide and cimetidine have been
associated with acute confusional
state. Digoxin also very rarely causes
confusion; the main problem with
digoxin [and beta blockers] is possible
synergistic increased risk of bradycardia
with cholinesterase inhibitors.
Side Effects: Advice on Magagement
Cholinesterase Inhibitors donepezil, rivastigmine & galantamine
Common
Less commonly/rarely
NMDA-receptor antagonist memantine
Common
Less commonly
very rarely
Presenting signs and symptoms
Considerations & Advice
All cholinesterase inhibitors can cause
side effects such as:-
• Headache
• Diarrhoea
• Muscle cramps
• Fatigue
• Nausea, vomiting, abdominal pain,
dyspepsia
• Insomnia
• Dizziness
Side effects are generally mild and
transient, and often disappear within
a few days of continued treatment.
However, in some patients these effects
may be severe and result in significant
weight loss.
To reduce effects: take after food and
dose titrations should be over 4-week
periods (as unwanted cholinergic effects
are dose-related) and a non-sedating
anti-emetic may be required/prescribed.
Arrhythmias, palpitation, myocardial
infarction, cerebrovascular disease,
paraesthesia, tinnitus, and leg cramps,
gastrointestinal bleeding, dysphagia,
hypotension, exacerbation of Parkinson’s
disease, and sweating.
USE WITH CAUTION in patients with
• sick sinus syndrome or other
supraventricular cardiac conduction
conditions;
• patients with concomitant asthma,
obstructive pulmonary disease
• at risk from peptic ulcer disease.
• rivastigmine and galantamine should
be prescribed with caution in patients
with renal or mild to moderate hepatic
impairment; both are contraindicated
in severe hepatic impairment. Use
donepezil with caution in hepatic
impairment.
Constipation, hypertension, headache,
dizziness, drowsiness.
vomiting, thrombosis, confusion, fatigue,
hallucinations, and abnormal gait
Seizures, pancreatitis, psychosis,
depression, and suicidal ideation also
reported
NOTE: Concomitant prescribing of other NMDA antagonists should be avoided, for
example amantadine, ketamine, and dextromethorphan
30 Pharmacy Professional | February 2010
March 2010 | Pharmacy Professional
31

f e at u r e d e m e n t i a
Useful Resources for
people with dementia
and their families
• The Alzheimer’s Society : www.
alzheimers.org.uk
The Alzheimer’s Society provides
a useful support including respite
care (even for a few hours a day) so
that the family continue to have a
semblance of a life of their own. The
Alzheimer’s Society has branches in
most locations.
• Alzheimer Scotland: www.alzscot.org
• Mental Health Foundation: www.
mentalhealth.org.uk
• Choice and Medication: www.
choiceandmedication.org.uk
• PharmacyHealthLink have a
number of lifestyle resources
(“resource cards”, leaflets, posters):
www.pharmacyhealthlink.org.
uk/?q=leaflets-and-factsheets
• Patient UK: www.patient.co.uk/
selfhelp.asp (weight loss, alcohol,
smoking, sleep, mental health etc.)
http://www.nhs.uk/conditions/
Dementia/Pages/Introduction.aspx
(includes a video – dementia the real
story ( a carer’s view)
• Mental Health Foundation: talking
therapies: http://www.mentalhealth.
org.uk/information/mental-healtha-z/talking-therapies/
• Dementia Management – Family
Practice Notebook http://www.
fpnotebook.com/Neuro/Cognitive/
DmntMngmnt.htm
• ‘Coping with Dementia: A
practical guide for carers’
www.healthscotland.com/
documents/1469.aspx
• ‘Facing Dementia: How to
live well with your diagnosis’
www.healthscotland.com/
uploads/documents/9365-
FacingDementia2008.pdf
• ‘Worried about your memory?
www.healthscotland.com/
documents/3250.aspx
Useful Resources for Pharmacists
• Taylor D. A. Medicines Use
Reviews in Dementia. CPD
Module. Pharmacy Magazine
May 2007
• Worsley, A; Husband, A.
Understanding Alzheimer’s
disease. Pharmaceutical Journal
2006:277:643-646 www.
pjonline.com
• DH. National Dementia
Strategy, February 2009 http://
www.dh.gov.uk/en/SocialCare/
Deliveringadultsocialcare/
Olderpeople/
NationalDementiaStrategy/
DH_083362
• DH. The Use of antipsychotic
medication in people with
dementia. Time for Action
(2009)
• All-Party Parliamentary Group
Report. Always a last resort.
Inquiry into the prescription of
antipsychotic drugs to people
living with dementia in care
homes (2008)
• Westbury, J. How community
pharmacists can help reduce
antipsychotic use in care
homes. Pharmaceutical Journal
2009:283:653-654 www.
pjonline.com
• Ballard, C G et al Management
of agitation and aggression
associated with Alzheimer’s
disease. Nat Rev Neurol
2009;5:245-255
• Maidment, I. et al. Efficacy of
memantine on behavioural
and psychological symptoms
related to dementia: A
systematic meta-analysis. Ann
Pharmacother 2008;42:32-8
• SIGN CG 86 February 2006.
‘Management of patients with
dementia: A national clinical
guideline’ www.sign.ac.uk/pdf/
sign86.pdf
• NICE guidance: Memory
assessment service: www.
nice.org.uk/usingguidance/
commissioningguides/
memoryassessmentservice/
memoryassessmenthome.jsp
• NICE Alzheimer’s disease
– donepezil, galantamine,
rivastigmine (review) and
memantine: guidance
(amended August 2009)
www.nice.org.uk/search/
guidancesearchresults.jsp?key
words=donepezil&searchType=
guidance
• Dementia: Supporting people
with dementia and their carers
in health and social care (NICE
& SCIE, November 2006): www.
nice.org.uk/cg42
• The Care Commission,
Scotland, May 2009.‘Remember
I’m Still Me’ www.
carecommission.com/images/
stories/documents/publications/
reviewsofqualitycare/
remember_im_still_me_-_
may_09.pdf
• The Care Commission,
Scotland, April 2009.‘Better
Care Every Step of the
Way’www.carecommission.
com/images/stories/
documents/publications/
reviewsofqualitycare/better_
care_every_step_of_the_way_-_
april_2009.pdf
• Bazire S. Psychotropic Drug
Directory 2009. Aberdeen:
HealthComm UK Ltd; 2009.
• Taylor D, Paton C, Shitij K. The
Maudsley Prescribing Guidelines
10th Edition. London:Informa
Healthcare;2009.
• The United Kingdom Psychiatric
Pharmacy Group www.ukppg.
org.uk
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ATMs are owned and operated by Bank of Ireland
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learning&development
Produced by The Pharmaceutical Journal
■ R E S O U R C E S
Focus on renal medicine
RENAL medicine is the latest topic to
receive the Centre for Pharmacy
Postgraduate Education’s Focal
point treatment. Focal point is an interactive
problem-based approach, which facilitates
learning in small groups (PJ, 28 February
2009, p225).
“This topic was chosen to support the
ongoing progress to demonstrate a clinical
future to community pharmacy, and to
highlight the extended role [it] can play to
support patients with renal problems. We
were delighted when the national clinical
director for renal care, Donal O’Donoghue,
endorsed and praised the programme,” said
Christopher Cutts, CPPE director.
Tutor-led workshops on renal medicines
will run until late March (visit www.cppe.
manchester.ac.uk
for details) but
the materials are
also available for
those in England
who have
developed their
own learning
communities.
CPPE learning
materials on renal
medicine designed for use by hospital
pharmacy teams (Learning@lunch) have
been available since October 2009.
NHS Education for Scotland offers
education on renal medicine through direct
learning courses. Further details can be
obtained from pharmacy@nes. scot.nhs.
uk. The Welsh Centre for Professional
Pharmacy Education does not
currently offer materials on renal medicine
but is in the process of reviewing its
portfolio.
OTC tamsulosin
Numark, in collaboration with Flomax
Relief manufacturer Boehringer
Ingelheim, is running a series of evening
workshops on tamsulosin as a new overthe-counter
category. Workshops will run
across the UK until 11 May 2010. They are
free to Numark members. There is a £50
fee for non members. Contact Betty Avill
for details on 01827 841205.
■ N E W S R O U N D U P
Cardiovascular drugs
Patients treated with calcium
channel blockers for mild to
moderate hypertension are at
greater risk of developing atrial
fibrillation than those treated with
angiotensin-converting enzyme
inhibitors, angiotensin-II receptor
blockers or beta-blockers. A UK
study, published in Annals of
Internal Medicine, looked at
4,661 patients who were
diagnosed with atrial fibrillation
while receiving long-term
antihypertensive therapy.
● Selective blockade of
angiotensin II receptors may offer
important health benefits to
patients with cognitive decline.
Data from over 800,000 patients
indicate that treatment with
angiotensin receptor blockers is
associated with a smaller risk of
developing dementia compared
with other cardiovascular drugs.
Patients with existing dementia
and taking angiotensin receptor
blockers experienced slower
disease progression and had lower
risk of nursing home admission.
Depression
Researchers point out that
prescribers and patients should be
aware that antidepressant efficacy
is based on studies that only
include patients with more severe
levels of depression. This follows a
data analysis suggesting that
patients with mild or moderate
Yasemin Sumer/Dreamstime.com
depression may not benefit from
antidepressants (JAMA).
Paracetamol
Further evidence of a serious
interaction between paracetamol
and warfarin — presenting as
fatal bleeds — has been published
in the European Journal of Clinical
Pharmacology. In practice,
paracetamol is considered a safer
option than non-steroidal antiinflammatory
drugs but it may be
advisable to advocate small,
occasional doses only.
Phenytoin
Thai and Han Chinese may be at
greater risk of Stevens-Johnson
syndrome as a result of
phenytoin use compared with
Caucasians. A study in Drug
Safety Update points to a
significant association between
the HLA-B*502 allele, present in
up to 9 per cent of Thais and Han
Chinese, and this side effect but
the Medicines and Healthcare
products Regulatory Agency has
stopped short of recommending
screening for the allele, unlike its
advice on carbamazepine.
Correction Last month’s news
round up on myocardial infarction
should have read “vitamin K
antagonist”, not “vitamin K”.
learning&development
These Learning & Development
pages are produced by The
Pharmaceutical Journal as an
exclusive benefit for members of
the Royal Pharmaceutical Society
Editor Lin-Nam Wang, MRPharmS
● tel 020 7572 2413
● e-mail LandD@pharmj.org.uk
March 2010 | Pharmacy Professional 35

L E A R N I N G & D E V E L O P M E N T
CPD
Understanding essential tremor
Most readers will probably think of Parkinson’s disease if tremor is
mentioned but essential tremor should be a more likely association.
Navjot Nannar looks at this condition, treatment options and advice
ATREMOR is an involuntary
rhythmic movement
characteristically affecting
projecting parts of the body, including the
hands, head, lips and tongue. Even the
eyelids can be involved.
A fine degree of tremor is normal in
healthy people; this physiological
tremor is rarely visible, does not interfere
with activities and is not thought to be
related to disease. It occurs in all voluntary
muscle groups and can be detected if a
person is asked to extend his or her arms
and a piece of paper is placed on top of the
hands. Physiological tremor can become
more pronounced as a result of fear, anxiety
or exhaustion. Tremor can also be caused
by conditions such as hypoglycaemia, as
well as by diseases such as
hyperthyroidism.
Tremors can be described in many ways
but can generally be divided into those
occurring at rest (when the muscle is
relaxed; resting tremor), those
demonstrated on posture (eg, when sitting),
and those occurring on movement
(intention or action tremor). A resting
tremor is often distal. It can be seen in
Parkinson’s disease and can affect the left
or right side of the body only, with motion
being asymmetrical in one or more planes.
It is differentiated from the other forms of
tremor in that it is slow and its effect is
diminished or eliminated by movement.
Intention tremor is predominantly
peripheral with its motion being along one
Oscar Burriel/Science Photo Library
Evaluate
Reflect
Act
Plan
Reflect on knowledge gaps
1. You conduct a medicines use review with a
man in his 30s with asthma. He mentions
that he is embarrassed because he
cannot lift a pint in the pub without his
hands shaking. What questions do you
ask and what advice do you give?
2. What treatments are used for essential
tremor?
3. What practical advice can you give to
people suffering with tremor?
Before reading on, think about how this
article may help you to do your job better.
plane. It is faster than resting tremor and is
evident throughout the range of movements
a patient is asked to make when tremor is
investigated. Intention tremor is sometimes
seen in people with cerebellar disease (the
cerebellum is involved in movement and its
co-ordination). However, in these patients,
the tremor is irregular, both proximal and
distal, in different planes, and slow and
exaggerated on activity.
The onset of a tremor can arouse concern
of a central nervous system lesion, such as
a tumour, or other serious disease process
and investigation is needed. Initial
investigations can include a physical
examination (which will include observing
tremor symmetry, and checking for any
sensory loss, muscle weakness and
problems with reflexes), taking a family
history and blood or urine tests. The patient
may also be asked to perform tasks so that
difficulty performing everyday functions
can be assessed.
Tremor — resting, postural or intention
— can be induced by drugs. For example,
pharmacists will know that antipsychotics
can cause extrapyramidal side effects,
including tremor. Other examples are given
in Panel 1.
Essential tremor symptoms
Aside from enhanced physiological tremor
(ie, natural tremor that is observed during a
stressful encounter) essential tremor is the
most common type of tremor. However,
pharmacists will probably be more familiar
with the tremor of Parkinson’s disease and
the differences between this and essential
tremor are summarised in the Panel 2. (It
should be noted that it is possible for
essential tremor to co-exist with other
conditions causing tremor.)
Essential tremor is a neurological
condition that most recognisably causes the
hands, head, legs and trunk to shake on
voluntary movement. The voice can also be
affected. The condition can be progressive.
The general pattern is of a tremor starting
in the arms and then progressing to other
parts of the body. Some patients develop
problems with their gait and balance that
are beyond those caused by normal ageing.
The overall prevalence of essential tremor
is thought to be 300 to 400 per 100,000.
Although incidence increases with age,
essential tremor is not a condition confined
to the elderly. If present in childhood,
symptoms can be worse around puberty.
Although the mechanism is not clearly
understood, essential tremor is believed to
be generated within the central nervous
system by way of olivo-cerebellar
oscillation.
Essential tremor, which is sometimes
called familial tremor, can be described in
genetic terms as having an autosomal
dominant trait with variable penetrance,
mapping to chromosome 2p 2-25. Essential
tremor is also sometimes called benign
tremor and for those with mild symptoms,
psychological measures, such as
biofeedback and relaxation techniques,
may be helpful. However, the condition
can be challenging, affecting daily
Panel 1: Drugs associated with tremor
activities such as writing, typing, dressing,
personal grooming and eating. Such
problems can lead to frustration, cause
stress and temporarily worsen symptoms,
and sufferers describe their experiences as
ranging from trivial to disabling. Some
patients are afraid that people assume they
have drug or alcohol problems. For people
with more severe symptoms or those
unresolved by psychological measures,
pharmacological approaches may be
needed.
Pharmacological treatment
At present there is no medicine created
specifically to treat essential tremor — all
Produced by The Pharmaceutical Journal
A common example of a drug associated with tremor is salbutamol (and other bronchodilators),
which stimulates beta 2 adrenoceptors on skeletal muscle to cause a fine tremor, especially in the
hands. (Hence beta-blockers can be used for symptom control [see main text]).
Dopamine receptor blocking drugs, such as metoclopramide, can also induce tremor, and it is
noted that tremor emerges in patients with Alzheimer’s disease who are treated with
cholinesterase inhibitors, (reinforcing that anticholinergics are effective in the treatment of
Parkinson’s disease tremor).
Amiodarone is structurally similar to thyroxine so its binding to the nuclear thyroid receptors
could be linked to its side effects of hypo- or hyperthyroidism, the latter being a state in which
tremor may manifest.
Fine tremor can also be a side effect of lithium therapy but a coarse tremor is a sign of toxic
doses, as pointed out in information for patients, recently published by the National Patient
Safety Agency. The mechanism of action remains somewhat unclear, but lithium appears to
substitute sodium and potassium in cellular transport processes. It also has an effect on the
release of monoamine neurotransmitters, by way of altering ion concentrations and flux across
cell membranes. Lithium also plays a role in the regulation of second messenger systems relating
to beta adrenoceptors and muscarinic receptors.
Examples of other drugs that induce tremor include pseudoephedrine, theophylline, tricyclic
antidepressants, selective serotonin reuptake inhibitors, nifedipine and valproate.
Withdrawal of some drugs, such as benzodiazepines, can induce tremor. Alcohol withdrawal
can also bring about tremor. Conversely, small amounts of alcohol may help to decrease essential
tremor (see main text) but the mechanism behind this remains unclear.
Panel 2: Main differences between essential tremor and
Parkinson’s disease tremor
Essential tremor
Noticed on action
Generally not associated with other
symptoms or conditions, although
anxiety can co-exist
Does not usually respond to anti-
Parkinsonian drugs
Parkinson’s disease tremor
Noticed at rest (also known as “pill-rolling
tremor”)
Associated with bradykinesia (slow movement),
rigidity, akinesia (absence of movement) and
depression
Does not usually respond to treatments for
essential tremor
those used have other indications — but
some prove beneficial for sufferers. These
drugs can either be used alone or in
combination. It is worth reminding patients
that although a medicine may work well
for one person it might not for another.
Deciding on the best treatment is a trialand-error
process that requires time and
patience.
Medicines prescribed for essential
tremor mainly include propranolol,
primidone and other antiepileptic drugs,
and benzodiazepines.
Propranolol Propranolol is generally the
drug of choice because it has been
36
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March 2010 | Pharmacy Professional 37

L E A R N I N G & D E V E L O P M E N T
CPD
Produced by The Pharmaceutical Journal
used extensively for essential tremor, as
well as for tremors associated with anxiety
or thyrotoxicosis, at a dose of 40mg two or
three times daily, increased as necessary to
a daily maintenance dose of 80–160mg.
Caution is advised in those with heart
failure, diabetes or asthma.
Although propranolol is most effective
for tremors of the hand, it may also benefit
those with head or voice tremor. However,
a complete suppression of symptoms is
rare. Side effects, although uncommon,
include fatigue, depression, impotence,
nausea, weight gain, rash and diarrhoea.
Patients can generally expect some
resolution of their symptoms in one to two
hours after a single 10–40mg dose and the
effect can last up to four hours. A longacting,
once-daily preparation can be used
for ease of administration but some patients
(eg, those whose tremor worsens at social
events) may wish to take propranolol on an
as-required basis. (A tip for those
embarrassed by tremor at social events is to
rest hands on furniture to minimise
symptoms.)
Other beta-blockers, such as atenolol,
metoprolol and nadolol, may also be
beneficial in essential tremor, but the
greatest evidence is with propranolol.
Antiepileptics Primidone can be an
effective option for the treatment of
essential tremor. It is metabolised to
phenobarbital and phenylethylmalonamide.
The latter has little if any
effect on tremor. (Phenobarbital has
previously been used for tremor, but doses
in excess of those obtained with primidone
were needed to be beneficial — it is
primidone in its premetabolised state that is
responsible for tremor reduction.)
Side effects of primidone include nausea,
visual disturbances, fatigue and influenzalike
symptoms. Although these might only
be experienced in the initial stages of
treatment, they can prevent patients from
continuing with the therapy.
Primidone can be started at 62.5mg daily
and gradually increased over two to three
weeks according to response, to a
maximum daily dosage of 750mg.
Primidone can be a good option for patients
who experience side effects with or become
tolerant to beta-blockers, or for whom betablockers
do not produced the desired effect.
Gabapentin and topiramate are emerging
as treatment options for essential tremor.
Gabapentin has been evaluated in several
randomised controlled trials for its efficacy
and safety. 1,2 Its mechanism of action
remains unclear but it is believed to work
by enhancing central gamma-amino butyric
acid (GABA) agonist activity and hence
ion channel tone. These trials suggest that
short-term treatment at doses of
1,200–1,800mg/day is tolerated well,
serving as a viable option as monotherapy
for essential hand tremor. Gabapentin is
generally well tolerated in both young and
old, despite possible side effects of ataxia,
irritability, sedation and weight gain. With
its comparably safe profile and relative
ease of use, gabapentin serves as a useful
alternative as a second-line agent and also
as an adjunct when symptom relief is
insufficient.
Essential tremor can
be disabling and
those affected often
suffer in silence
Topiramate works by blocking sodium
channels. Its reduction of essential tremor
has been observed at doses lower than
those required in the management of
epilepsy. Most of its side effects are
usually minimal and reversible, but can
include cognitive slowing, anhydrosis,
acute glaucoma and renal stones. Literature
suggests starting at 25 or 50mg at night for
the first week and increasing by 25mg or
50mg each week, with titration based on
side effects and tolerance, to a maximum
daily dose of 400mg daily. Although
topiramate is seen as a possible option for
the treatment of essential tremor, especially
where other therapies prove ineffective,
further research is needed.
Benzodiazepines Benzodiazepines,
such as clonazepam, diazepam, lorazepam
and alprazolam, may be useful in patients
who do not respond to propranolol or
primidone, or in those who have associated
anxiety. The mechanism of action is
unknown but may be related to GABA
agonist augmentation by its action at the
benzodiazepine receptor-GABA receptor
channel complex for passage of chloride
ions. 3
Side effects of drowsiness, depression,
fatigue, loss of co-ordination, memory loss
and confusion, mean caution should be
exercised, particularly in the elderly.
Moreover, these drugs must be prescribed
judiciously because of their potential to
cause dependence.
Benzodiazepines are generally less
effective than primidone and propranolol
and have a more concerning side effect
profile. Lorazepam may be preferred
because of its milder sedative profile at
doses of 0.25–0.5mg but no dose is
specifically advised in the British National
Formulary. Caution is needed in not
exceeding the maximum daily dose of 4mg
in adults. (In the elderly or debilitated half
this maximum dose would be wise.)
Other therapies Other pharmacological
therapies that have been used for essential
tremor include mirtazepine and botulinum
toxin.
Mirtazepine Mirtazepine is a presynaptic
alpha 2 adrenoceptor antagonist, which
increases central noradrenergic and
seretonergic transmission. Although it is
indicated as an antidepressant, it is
sometimes used for essential tremor.
However, due to its lack of reported
effectiveness for many patients and its
significant side effects, it is not routinely
recommended for this condition. Some
of its adverse effects include dry mouth,
confusion, urinary frequency, weight gain,
disorder of gait, nausea and blurred
vision. No recognised doses have been
recorded but the lowest tolerable dose,
within its limits of the maximum daily
dose used for mood disorders, would be
sensible.
Botulinum toxin Botulinum toxin has been
used in some hyperkinetic movement
disorders. Botulinum toxins are derived
from Clostridium botulinum and seven
serologically distinct neuroparalytic
subtypes — A to G — have been isolated,
each differing in their mechanism of
action. Type A botulinum toxin, which
exists in the form of two chains, heavy and
Panel 3: Non-pharmacological strategies
● Use travel mugs or other cups with lids,
especially when on the move.
● Avoid caffeine and products containing
sympathomimetics, such as over-thecounter
decongestants, that can increase
heart rate and tremor.
● Keeping elbows close to the body when
performing tasks can help control hand
tremor.
● Use a signature stamp and carry selfadhesive
address labels for forms.
● Have food pre-cut into manageable bite
sized pieces.
● Drink from a glass or mug filled half-way
and use a straw where necessary.
● Use a rubber mat to avoid plates sliding.
light, connected via a disulphide bond, is
used in the management of essential
tremor. Treatment involves multiple point
injections into the affected muscle groups,
repeated every three to four months.
The mechanism of action can be described
in three steps. The first step involves the
binding of the heavy chain to a specific
membrane acceptor situated on the
presynaptic cholinergic terminal of the
neuromuscular junction. The light chain of
the toxin is then endocytosed and targets and
cleaves the synaptosome-associated protein
involved in the fusion of acetylcholine
vesicles at the presynaptic membrane. When
this protein is cleaved, acetylcholine release
is prevented, bringing about paralysis.
(Affected nerve terminals develop neuronal
sprouts and eventually motor neuron
function is re-established with reinnervation
of parent terminals and regression of these
auxiliary neuronal sprouts.)
The most common adverse effect
expected is the unwanted diffusion of the
toxin beyond the target muscles, producing
focal weakness.
Alcohol The effects of alcohol in reducing
tremor have long been recognised, with up
to two thirds of patients reporting
temporary (one to two hours) relief. 4
Positron emission tomography studies have
revealed that cerebellar hyperactivity is
notably reduced by the effects of alcohol. 5
The mechanism of action has not been
clearly described, but, like
benzodiazepines, the effect of alcohol is
mediated through gabaminergic
mechanisms. Nevertheless, routine
consumption of alcohol for symptom
alleviation should not be widely
recommended.
People with essential tremor and seeking
medical help will often already rely on
alcohol to attenuate their symptoms. For
example, sufferers may describe having
one or two drinks in preparation for
attending a social event. There have been
suggestions that those who adopt this form
of “self-medication” are at an increased
risk of alcoholism, but their pattern of
consumption is much the same as that of
the general population. 6
Future treatments According to the
International Essential Tremor Foundation
(IETF), drugs being investigated for
essential tremor include: 1-octanol (an
alcohol that naturally occurs in citrus oils),
Author Navjot Nannar will be
available to answer questions
online on the topic of this CPD
article until 15 March 2010
Galka/Dreamstime.com
sodium oxybate (a central nervous system
depressant used for cataplexy but with
abuse potential), T2000 (a barbiturate) and
carisbamate (a new anticonvulsant).
Non-pharmacological strategies
The medicines available can effectively
treat only about half of affected individuals
with disabling tremor. In addition, with
long-term propranolol and primidone
treatment, tolerance can develop. The
advent of new surgical techniques, such as
thalamotomy and thalamic deep brain
stimulation, has, therefore, proved a
valuable option for those with a disabling
tremor who have not had adequate control
from pharmacotherapy.
Surgery Surgery for tremor disorders was
first attempted some 100 years ago. It
involved the destruction of large parts of
the brain so weakness and paralysis were
possible complications. In 1947, surgical
advances allowed for selective destruction,
sparing surrounding areas of the brain, and
the ventralis intermedius (VIM) nucleus of
the thalamus became recognised as the
most effective target. The thalamus is a
collection of cells deep in the brain
involved in relaying motor and sensory
signals. The VIM is a collection of neurons
and it is now understood that creating a
lesion here disrupts the cerebellar-thalamic
circuit from generating a tremor.
Thalamotomy Thalamotomies are
generally unilateral and performed on the
side of the brain contralateral to the
dominant or most affected limb. Bilateral
procedures are generally avoided due to the
increased risk of severe permanent
dysarthria or even mutism. The procedure
is carried out under local anaesthesia
because the brain is devoid of pain
sensation and also allows the subject to
participate in physiological tests to ensure
a satisfactory result. It is reported that more
than 80 per cent of patients who have had
this procedure experience long-lasting and
complete (or near complete) resolution of
their disabling tremor. 7 Concomitant
midline head and voice tremors can
respond to this surgical intervention. In
some circumstances the procedure may be
repeated should there be incomplete
resolution or if the tremor re-emerges.
38
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Produced by The Pharmaceutical Journal
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Deep brain stimulation Deep brain
stimulation (DBS) of the thalamus is
another option for patients with disabling
tremor that has not been adequately
treated with pharmacotherapy. Surgery is
used to place a wire in the VIM nucleus
of the thalamus and this is connected,
under the skin, to a device that provides
electrical currents to control symptoms.
DBS is non-ablative and adjustable (it is
reversible and impulse settings can be
changed to minimise side effects and
ensure optimum efficacy). Bilateral DBS
has a reduced risk of permanent
morbidity compared with bilateral
thalamotomy. The mechanism of action
remains unknown but current lines of
thought describe the device as providing a
chronic artificial “neural noise” that
disrupts the cyclical activity within the
motor circuits. 8 The efficacy of DBS is at
minimum on a par with thalamotomy 9 but
it is a relatively expensive option with
respect to the cost of the device and
maintenance required.
Lifestyle Although essential tremor does
not alter mortality, it can be progressive
and disabling. Many sufferers will have
altered their lifestyles and avoided events
they previously enjoyed and some even
feel they cannot leave their homes.
Patients affected by tremor may suffer in
silence and seek independent means, such
as increased alcohol consumption, for
managing the condition. The IETF has
prepared a list of suggestions to help those
with tremor continue with activities of
daily life (see Panel 3, p39). It also gives
advice covering situations such as visiting
the dentist (especially for those who suffer
with head tremor), eating in restaurants
and going through airport security and
other events that can worsen tremor.
Other lifestyle adjustments involve
using suitable devices and equipment,
such as voice-activated equipment or
large button telephones. The key to
successful management centres on being
prepared.
Support in the pharmacy
Pharmacists can help people with
essential tremor in a number of ways.
They can be aware of the condition and
the options available to help attenuate it
Check your learning...
available online
until 29 March
2010
so they can provide advice where needed.
They can also spot other types of tremor.
For example, those with tremor associated
with hyperthyroidism might experience
weight loss, hyperactivity and sweating.
Furthermore, medicines use reviews can
be used to rule out tremor as a side effect
of medicines. Pharmacists can also help
sufferers by providing medicines in easyto-use
dosage systems.
A full assessment by a GP is a sensible
starting point for people presenting with a
tremor and pharmacists are ideally placed
to point patients in the right direction. They
can also signpost to organisations such as
the National Tremor Foundation (see
Signposting).
Signposting
■ The International Essential Tremor Foundation
also offers excellent advice and suggestions for
the management of essential tremor
(www.essentialtremor.org).
■ The National Tremor Foundation is a UK-based
charity providing help, support and advice to
those living with all forms of tremor irrespective
of age. It also assists healthcare professionals
(www.tremor.org.uk).
References
1.Pahwa R, Lyons K, Hubble JP, Busenbark K, Rienerth
JD, Pahwa A et al. Double-blind controlled trial of
gabapentin in essential tremor. Movement
Disorders 1998; 13:465–7.
2.Gironel A, Kulisevsky J, Barbanoj M, López-Villegas
D, Hernández G, Pascual-Sedano B.A randomized
placebo-controlled comparative trial of gabapentin
and propranolol in essential tremor.Archives of
Neurology 1999;56:475–80.
3.Guan XM, Peroutka SJ. Basic mechanisms of action
of drugs used in the treatment of essential tremor.
Clinical Neuropharmacology 1990; 13:210–23.
4.Lou JS, Jankovic J. Essential tremor: clinical
correlates in 350 patients. Neurology 1991;
41:234-8.
5.Boecker H,Wills AJ, Ceballos-Baumann A, Samuel
M,Thompson PD, Findley LJ et al.The effect of
ethanol on alcohol-responsive essential tremor: a
positron emission tomography study.Annals of
Neurology 1996;39:650-8.
6. Rautakorpi I, Marttila J, Rinne UK.Alcohol
consumption in patients with essential tremor.Acta
Neurol Scand 1983;68:177–9.
7. Schuurman PR, Bosch DA, Bossuyt PMM, Bonsel GJ,
van Someren EJW, de Bieet RMA et al.A
comparison of continuous thalamic stimulation and
thalamotomy for suppression of severe tremor. New
England Journal of Medicine 2000;342:461–8.
8. Benazzouz A, Hallet M. Mechanism of action of
deep brain stimulation. Neurology 2000; 55(suppl
6):S13–16.
9. Hariz GM, Lindberg M, Bergenheim AT. Impact of
thalamic deep brain stimulation on disability and
health-related quality of life in patients with
essential tremor. Journal of Neurology,
Neurosurgery, and Psychiatry 2002; 72:47–52.
● Navjot Nannar, MBChB, MRPharmS, is
senior house officer (FY2, neurology,
gerontology and general practice) at
University Hospitals Coventry and
Warwickshire NHS Trust.
CPD articles are commissioned by The
Pharmaceutical Journal and are not peer
reviewed.
Act: practice points
Reading is only one way to undertake CPD
and the Society will expect to see various
approaches in a pharmacist’s CPD portfolio.
1. Visit the www.essentialtremor.org and
read patients’ accounts of having
essential tremor.
2. Look out for tremor when talking to
patients or conducting MURs.
3. Investigate the range of devices that
may help people with tremor.
Evaluate
For your work to be presented as CPD, you
need to evaluate your reading and any
other activities. What have you learnt?
How has it added value to your practice?
(Have you applied this learning or had any
feedback?) What will you do now and how
will this be achieved?
Record
Consider making this activity one of your
nine CPD entries this year.
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lifestyle
contents
43 Travel
The Rock, plus Girona and Dali
48 Fashion
Suits you madam
49 Personal finance
Where to stash your cash
50 Health Food
Chef Philip Howard
52 Transport
Less strain on the train
55 The Arts
Romeo and Juliet
56 Offers
For members only
56 Prize crossword
Clues just for Pharmacists
Gibraltar rocks
It has been a fortress and a sactuary, now it’s a
facinating tourist attraction. Jeff Mills discovers why
You would have to be a real romantic
to call Gibraltar a beautiful place, though
I am sure in the eyes of British sailors
heading into the Mediterranean from some
long and tedious patrol in far-off waters it
must have been a sight for sore eyes and beerstarved
lips.
The Rock, for it really is little more than
that, doesn’t simply sit in the sea just off
the coast of southern Spain, to which it
is attached by a narrow isthmus, it very
thoroughly dominates the immediate vicinity.
As though John Bull’s bulldog was standing
guard with his arms folded, daring any
foreigners to proceed beyond the border.
Gib has been British since 1704 when the
Treaty of Utrect ceded the Rock to the British
crown “in perpetuity” Mind you that did not
stop the Spanish trying a number of times to
take it back. And they have not given up yet,
even though today it is politicians rather than
the military who engage in the skirmishes. Æ
March 2010 | Pharmacy Professional
43

t r av e l G I b R A LTA R
If you want to see
some 17th century
graffiti you will find
it in the Great Siege
Tunnels
Neighbours Spain viewed from the Rock
Gibraltar has seen more than its fair share
of bloodshed over the centuries. In 1782
the British were forced to build the famous
Great Siege Tunnels in one of their many
battles with Spain. You can visit them to this
day.
Nelson fought the Battle of Trafalgar
from the deck of his flagship, HMS Victory,
close to the Rock in 1805 and never lived
A part of britain,
which just happens
to lie bathed in the
sunshine off the
Spanish coast
to tell the tale but it was in the 19th century
that Gib really came into its own, as a vital
staging post for ships trading with India.
It saw plenty of action during the
Second World War, too, when it was the
headquarters of naval fleet Force H, from
where General Eisenhower planned and
executed the North Africa landings in 1942.
Visit the Rock today and you simply
cannot escape its history, there is evidence
everywhere you look – roads hewn out of
the rock by teams of British Army engineers,
enormous iron rings once used to haul
cannon up to vantage points at the peak,
buildings once used as barracks for the very
large garrison once based here.
Even now you are left in no doubt that
Gibraltar is an active British military base,
as well as a thriving tourist town. The naval
dockyard is still there, though there are
fewer ships in port now, and it is not unusual
to come across the odd military parade, led
by a band from the Royal Marines.
Even away from the military installations
you are left in no doubt at all that Gibraltar
really is a part of Britain, which just happens
to lie bathed in the sunshine off the Spanish
coast.
Take a walk down the main street and
familiar names will spring out at you at
every step. Marks &
Spencer heads the
list of UK stores; the
police are dressed
exactly the same as
their colleagues at
home and the Britishstyle
pubs serve pub-style food, much of it
of the chips with everything variety, in spite
of the often soaring temperatures outside.
The warm weather and the ever-present
towering rock above you aside, you could
easily be forgiven for thinking you had
never flown anywhere at all and were still in
some UK country town, admittedly during
the height of summer.
Go inside some of these shops, however,
and stand by for a very pleasant surprise.
Almost everything you will find on sale
here, most of it exactly the same as you
find at home, is much cheaper. Not only is
Gibraltar one of Britain’s last remaining
colonies, it must be one of the best-value
places on earth to buy your booze, perfume
and dozens of other luxury goods and it
makes very little difference whether you buy
at the so-called duty-free shops at the airport
or not, the whole place is virtually duty free.
Small wonder that the battalions of expat
Brits who spend
their time sunning
themselves at their
villas just over the
border in Spain make
the weekly trip to do
their shopping here.
And small wonder that at times the queue to
cross the border with a car looks more like
a major UK city at the height of the evening
rush hour.
But it is not only the fact that Gibraltar is
a tax-free home from home that encourages
holidaymakers to visit, there is plenty
more to do than simply go shopping. The
sightseeing may not be that extensive
(but let’s not forget this is after all a small
rock) what there is makes for quite a few
interesting day trips.
Love them or hate them, you simply have
to take a tour to the Upper Rock to see the
famous Barbary Apes, which live in a semiwild
state. Do not get too close, though, they
may look cute but they have been known to
bite.
There is plenty of bird life up here, too,
with frequent sightings of Griffon vultures,
countless songbirds and even the odd stork
as it migrates between Europe and Africa
across the Strait of Gibraltar.
The Gibraltar Botanic Gardens, known
locally as the Alameda Gardens, are worth
a visit to see the large variety of plants and
trees, some indigenous, some imported.
St Michael’s Cave, a dramatic natural
grotto, is a must see. If you are very lucky
you may even be able to get hold of some
tickets for one of the concerts or other live
performances staged here.
For a snapshot of the Rock’s history make
time for a visit to The Gibraltar Museum.
Look out for what many believe to be the
best example of a Moorish bath house, in the
basement. And if you want to see some 17th
century graffiti you will find it in the Great
Siege Tunnels, which run for more than 30
miles through the Rock.
For all its hustle and bustle, though, and in
spite of what the tourist board may hope to
achieve, the reality is that many people you
will see shopping in the streets, following
the tourist trail and snapping pictures of
the apes are day trippers who pile off the
coaches from the popular Spanish resorts
both up and down the coast, where the
beaches are much better and there is a far
wider choice of hotels.
An increasing number of people do
Britain abroad The Marina, bobby on the beat and top of the Rock
choose to stay in Gib itself, though. There
is a fairly limited selection of hotels, though
one or two do stand out for the quality they
offer.
Best known of the top establishments is
probably the Rock Hotel, which has been
playing host to visiting dignitaries and
mainly business travellers for as long as
anyone can remember. Or there is the Eliott
Hotel near the centre of town. The problem,
at least if you are visiting Gibraltar on
holiday, is that neither has a beach. There
are, quite simply, very few of them around
on the rock.
For a proper feeling that you are staying
in a holiday resort rather than on the edge of
some UK shopping centre, you are better off
choosing the Caleta Hotel, which sports not
only an outdoor swimming pool but direct
access to its own, albeit small, sandy beach.
Refurbished in 2000 and with its own
health centre, the Caleta is said to be one of
the best hotels in Gibraltar and it is difficult
to argue with that.
Just do not expect the kind of five-star
accommodation and service you can find
just over the border in Spain. The Caleta,
just like Gibraltar itself, is homely rather
than luxurious. But there’s little wrong with
that for a few days. n
For more information you can contact the
Gibraltar Tourist Office www.gibraltar.gov.uk
44 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
45

t r av e l g i r o n a
The jewel that is
Girona
Far from Spain’s mass tourism areas, this city is just
waiting to be discovered, Philippa Taylor finds out why
Think of Spain and what comes to mind? The
beaches of the costas, perhaps; the nightlife and
24-hour club scene of the Balearic island of Ibiza,
much loved by those who thrive on too much alcohol and
little or no sleep; the cool of Barcelona with its designer
hotels, chic shopping and fashionable restaurants or the
bustle of the capital, Madrid, still a long time favourite for
a weekend break – then there’s Girona!
Never heard of it? Or perhaps you have come across
it but know precious little about it. Then this is a good
time to change all that. Girona (or Gerona if you prefer
the alternative spelling), tucked away slightly inland from
Spain’s eastern coast and roughly north-east of Barcelona,
is a city well worth getting to know.
This is not the Spain of mass tourism, inflated prices
and fish and chips for supper, visit Girona and you will see
the country not only as it really is but as it quite probably
was hundreds of years ago, long before Spain became best
known for its beaches and visitors from the colder climes
of Northern Europe toured at a much slower pace, taking
time to explore, admire and experience a culture very
different from their own.
Girona was already well on the map in Roman
times and there is plenty of evidence of their presence
even today. The ramparts they built are largely intact,
though now they form part of the Passeig Arqueologic
(Archaeological Walk) which runs right round the city and
provides a very pleasant trip through history.
Start your exploration on the north side of the town,
near the oddly-named church, Esglesia de Sant Pere de
Galligants (St Peter of the Cock Crows), take the narrow
street leading into the old part of the town and admire the
huge Roman foundation stones, marking the original route
of the Via Augusta, the road which once lead all the way
from Tarragona to Rome.
Of course no Spanish city would be complete without
its cathedral, usually the bigger the better and Girona’s
is no exception. The west face may be Catalan baroque
but the rest of the building is pure Gothic on a very grand
scale. Indeed the single nave, built in 1416, is said to be the
widest Gothic span anywhere.
Make time, too, for a visit to the cathedral’s museum,
with its fine collection of Romanesque paintings and
statues. The collection’s most famous work is a tapestry,
“The Creation”, parts of which date from the 11th Century.
You will not be alone in your amazement at the richness of
the colours after all these years.
Another world A shrine to Salvador Dali
But there is much more than simply history and art
to this attractive city. To see it at its best and most lively
make a beeline for the river, the Riu Onyar, where tall
pastel-coloured buildings rise above the water and form
the backdrop for a lively area of thriving shops, street cafes
and bars which, this being Spain, do not really come into
their own until well into the evening.
This is the Rambla de la Llibertat, known as the old
town, although in reality many of the buildings were
constructed as recently as the 19th Century to replace
sections of the city wall damaged during a seven-month
siege by the French in 1809.
A visit here is much more
than simply a trip to a
museum or gallery, it is a
delight, it is confusing, it is
hilarious and it is tragic
Take an early evening stroll, stop off for a drink at one
of the traditional tapas bars, then choose from any of the
remarkably cheap, often family-run, restaurants in the area
and you will be doing exactly the same as the locals and
their forebears have been doing for centuries, long before
tourists came on the scene.
And in the morning head for another of the unmissable
attractions of this part of Spain, Figueres and the Teatro-
Museo Dali, founded by perhaps the town’s most famous
son, Salvador Dali, in 1974 and said to be the second most
visited museum in Spain after the Prado in Madrid.
A visit here is much more than simply a trip to a
museum or gallery, it is a delight, it is confusing, it is
hilarious and it is tragic – do not be surprised if you end
your tour feeling mentally, if not physically, exhausted by
it all.
The building itself, with its eye-catching glass-domed
roof and glass-embedded walls, is extraordinary in its own
right but step inside and you really do find yourself in
another world, all of it orchestrated by Dali himself, who
incidentally died in Figueres in 1989 and is buried right in
the museum.
By no means all of Dali’s best-known works are here
but the way in which those which are housed here are
displayed will almost certainly amaze you. Look out
for “Rainy Taxi”, a black Cadillac being sprayed by a
fountain, the “Mae West Room” with its furnishings
designed to look like a huge face and the ceiling fresco
in the “Wind Palace Room”, not to mention the amazing
display cases of mechanically-powered jewellery.
And after all that sit at a pavement café with a glass of
wine and congratulate yourself on finding a part of Spain
still successfully off the beaten track. n
For more information contact the Girona tourist office, tel:
0034 972 226575, www.ajuntament.gi/turisme.
46 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
47

p h a r m a c y f a s h i o n
p e r s o n a l f i n a n c e
Ready to wear fashion for work
Many busy professionals find knowing what to wear to work a
challenge they can do without. Sue Heady has some suggestions
Everyone needs this £7,200 bag
Miranda Green on why all savers should have one thing on their
shopping list before they do anything else – a nice, tax-free isa
These days, knowing what to wear
to work is more of a minefield than
ever, there is such a fine line to be trod
between looking smart and looking stylish
(creative types might feel at ease in jeans and
cute floral tops for work, but it simply doesn’t
cut the mustard for professionals).
According to Amanda Slader, Chief Fashion
Advisor for John Lewis (www.johnlewis.
com), “The good news for spring/summer
2010 is that the suit (with softer lines and
more muted tones) is making something of
a comeback.” This is music to my ears, as a
suit seems so much simpler to throw on in
the morning than separates, which have to be
matched in colour, shape and form.
Though most tailored suits are black,
grey or navy, Amanda points out that it is
also possible to find a colourful, smart and
sassy suit. Take L K Bennett’s chic take on
a 40s-style suit or one of Hobbs’ red or royal
blue suits (both in-store at John Lewis) as
stylish examples.
Quality clothes
This is where personal shoppers (John Lewis
calls them fashion advisors) really come into
their own. They know their stock so well,
they can make instant suggestions that reflect
your shape, colouring and lifestyle, thereby
helping to save money, time and angst. Says
Amanda, “I would say 98% of my customers
buy something that they would never have
dreamed of trying on, it’s either a different
colour to what they’re used to wearing or it’s
got a different shaped neckline etc. We’re all
guilty of buying what we’ve always bought
– and probably what our mothers always
bought too!”
Concern that a personal shopper is going
to pressurise customers into spending
huge amounts of money may put off many
people, but in-store shoppers don’t work
on commissions and they don’t work for
any particular brand. They simply provide
impartial and objective advice for anything
between 90 minutes and three hours, on
a complimentary basis courtesy of the
department store or shopping outlet, such as
Bicester Village (www.bicestervillage.com),
where they are based.
At the outlets, you won’t get this season’s
fashions, but you can make considerable
savings on quality clothes – always useful in
a recession – and the expert advice of Fiona
Huntingford, the personal shopper at Bicester
Village, comes as a bonus.
“One thing I notice with almost all my
female clients is that they wear their clothes
at the wrong length, says Fiona. “We don’t
all have the same length legs, so take up the
hem of a skirt or dress so that it falls at the
narrowest point of the leg, just below the knee,
and legs look longer and thinner. Anything
lower and it immediately looks frumpy.”
Sometimes just one
purchase can make
all the difference
Other obvious mistakes to avoid are tight
trousers revealing underwear lines, skirts
so fitted that it’s impossible to sit down
comfortably, jackets too small to be buttoned
up and shirts that gape – men, put away those
tummies! Vice versa, clothes shouldn’t be too
big; jackets should hang off shoulders, not half
way down arms, and belts are there to ensure a
snug fit, not to pull in inches of excess material.
Style is as essential as fit. As Amanda points
out, “Men with short legs should avoid turnups
on their trousers and too long a jacket, as
both will eat into their leg length and make
them appear even more diminutive.”
As menswear is not particularly seasonal,
a suit can last man years, so it’s important to
buy the right one. Visit Bicester Village and
an Armani suit, pinned and altered by the
store, can look like it has been made for you,
at a fraction of the price you would normally
expect to pay for a bespoke outfit.
For women’s work wear, both Fiona
and Amanda recommend high street stores
Hobbs and L K Bennett, as well as Reiss for
something a little different. If you’re willing
to spend a bit more, Jaeger and Nicole Farhi
come highly recommended, while Warehouse
and French Connection are the winners at the
lower end of the range.
Remember, a work wear wardrobe doesn’t
have to be huge. Amanda believes the
essential components of any working woman’s
wardrobe are a jacket, a pair of trousers, a
skirt, perhaps a dress and about six tops,
plus a host of different accessories (scarves,
jewellery, belts etc). As a general rule of
thumb, she suggests buying three tops for
every pair of trousers or skirt.
Feel a million dollars
Sometimes just one purchase can make all
the difference. About 15 years’ ago, I used a
personal shopper to help me select a black and
white trouser suit for an interview with a head
hunter. Unlike anything else in my wardrobe,
it made me feel a million dollars and when
I arrived at the interview, the first thing the
recruiter said was, “I can see you’re a woman
who wouldn’t settle for less than £60,000 per
year, Miss Heady.” As I was used to earning
about a third of that sum, I decided there and
then that personal shoppers were indispensible
to a working wardrobe. n
IT’S a question that financial journalists
dread at this time of year: “What ISA
should I buy?” It’s a simple question that
has many difficult answers. First of all, it’s a
very positive sign that the person is asking at
all – millions of people who can, don’t.
An ISA – an individual savings account – is
a tax-free savings plan that allows you to put
up to £7,200 a year into an investment – or
£10,200 if you are over 50. As of April 6, when
the new tax year starts, all of us will have that
new limit too. Effectively, it’s a wrapper – think
of it as a bag – and you stuff the bag full of the
investments you like. It can be up to £3,600 in
cash, effectively the same as a savings account,
and the rest can be in a range of financial assets.
Or, it can all be in assets – you choose.
But the choice is the problem. As an ISA
is just a kind of financial bag, asking what to
put in it is alike asking, “I’m going shopping.
What should I buy?”
The first bit of advice is, make sure you use
the annual allowance – if you have savings,
and do not have an ISA, you are paying tax on
the gains from those investments needlessly.
You don’t have to come up with seven grand
either – you can invest smaller amounts, and
even save monthly, with some providers taking
as little as £100 a month.
And so on to what you put into it. The range
of options is staggering. Even with cash, there
is a wide choice of accounts that are ISAapproved.
Like normal savings accounts the
rates differ, the charges differ, and the tie-ins
differ too. Some, which require notice periods
before you withdraw money, pay more interest
than instant-access, for example.
But the really tricky bit is deciding which
investments you want. You can put in UK
or foreign stocks, and even corporate bonds.
You can choose a managed fund which offers
investment into a massive range of assets, with
differing styles, risk profiles and objectives.
You can put hedge funds in. You can choose an
exchange-traded fund, which is, as the name
suggests, a fund which is listed on the stock
exchange and its shares are quoted, just like
Marks & Spencer.
However, ETFs are made up of a very wide
range of assets – from those that represent
an index, like the FTSE100, to those that
represent a commodity, like gold, or a theme,
like oil exploration.
You can choose a self-select ISA into which,
for example with Interactive Investor (www.iii.
co.uk), you can put stocks and other assets into
the ‘bag’ and take them out again at will, for a
flat trading fee of £10.
Basically, you need
to think about risk
and reward. How
risky do you want the
investment to be?
Now you get an idea of why anyone in
finance dreads the question.
Basically, you need to think about risk and
reward. How risky do you want the investment
to be? Because if you are truly risk-averse,
then something as close to cash as possible, for
example a government bond, or gilt, might be
for you. Or, if even that makes you nervous, a
managed fund of government bonds, where the
manager seeks to maximise gains and iron out
risk by spreading his investments.
Lots of people go for a tracker, which seeks
to replicate the UK, or another, market. But the
massive volatility – the amount of price swings
– in recent months has made people think twice
about this supposedly ‘safe’ choice. In reality,
even emerging market funds – which seek out
companies in growing economies – are less
volatile over the long-term than the Footsie.
This year, which ends on April 5, lots of
investors bought into theme funds, for example
infrastructure, which will benefit from longterm
government spending on major projects
and opportunities like airport expansion.
Another popular choice is eco-funds – not
funds which are ecologically sound, but which
seek out opportunity in renewable energy
or water. There are even funds specifically
based on water, a key theme for our ever more
populated planet.
You can carve up the investable universe
in other ways too. You might think the US is
going to roar back to economic well-being,
or be convinced that Brazil, Russia, India and
China are going to be the driving force of the
global economy for the next 20 years – if so,
buy a BRIC fund.
One of the newest assets you can place in
an ISA are the corporate bonds listed on the
London Stock Exchange. While these are
mostly immune from capital gains tax anyway,
income paid from the interest is taxable.
Throw them in an ISA, which most brokers
should be happy to do for you, and you could
pick up around 6% tax free. There is a risk
– that the companies go bust – but you have
more chance of getting your money back than
if you buy shares. Either way, if you use an
ISA, any gains you do make won’t be taxed,
which is a comforting idea all by itself. n
48 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
49

h e a lt h f o o d
The science of top cuisine
Continuing our series of Pharmacy Professional features in which we
ask top chefs to come up with healthy yet easy to prepare recipes
Aquiet culinary professional,
Philip Howard has been Head Chef
(and co-owner with Nigel Platts-
Martin) of The Square since it’s opening
in December 1991, and saw the restaurant
move in February 1997 to its current address
in London’s Mayfair from it’s previous St
James’s site. Before joining The Square,
Howard worked with Marco Pierre White at
Harvey’s, Simon Hopkinson at Bibendum
and with Roux Restaurants Ltd.
Howard’s distinctive modern French food
has enjoyed great critical and consumer
success. A first Michelin star was awarded
to The Square in 1994, followed by a second
in 1998. Numerous other “Chef of the Year”
accolades followed.
A degree in Bio-Chemistry
from Kent University gives
Howard a unique understanding
of cooking and ingredients from
a scientific perspective and he is
an avid runner (he regularly runs
the New York and London marathons).
He opened his second restaurant, The
Ledbury, in London’s Notting Hill area
in November of 2005
showcasing his protégé
Brett Graham. It received
its first Michelin star
within a year of opening
and continues to go from
strength to strength.
In October 2009,
Philip partnered with
restaurateur, Rebecca
Mascarenhas to open
Kitchen W8, an informal
London neighbourhood
restaurant. n
Herb Crusted Saddle of Lamb with Shallot Purée and Rosemary
Serves 6 People.
1 Saddle of lamb, off the bone.
50 ml reduced lamb stock.
For the herb crust:
100g fresh bread crumbs
100g butter, melted
1 small egg
1 tbspn ground parmesan
1 tbspn finely chopped parsley, rosemary
and thyme
1 clove of minced garlic
Pinch of salt and ground black pepper
12 Small waxy potatoes
20 shallots, thinly sliced.
100 ml double cream
3 cooked artichoke hearts cut into four
12 cloves of garlic in the skin
250g fresh spinach
150g butter
1 sprig of thyme
1 sprig of rosemary
50 ml olive oil
2 tomatoes, blanched, peeled de-seeded
and diced
Here’s how…
The day before
Combine the dry ingredients of the herb crust
in a food processor and blend for 30 seconds.
Gradually add the melted butter and finally,
the egg.
Roll this paste out between two sheets of
greaseproof paper with a rolling pin until 2mm
thick and place in the fridge to chill and set.
Get the butcher to take the saddle of lamb
off the bone (reserving the two small fillets)
and to remove the outer husk of skin. Lay the
whole saddle out on a chopping board in front
of you with the two loins of meat running
parallel away from you. Trim off all the fatty
meat either side of the two loins leaving you
a rectangular piece about 8” X 6”; insert the
two fillets between the two loins. Leave the
meat to sit in this form overnight.
On the day
• Pre-heat the oven to 220 C.
• To make the shallot purée, sweat the shallots
in 50g of the butter with a good pinch of salt
and pepper. Once softened, add the cream,
bring to the boil and purée in a blender. Pass
through a fine sieve and keep warm. Place
the garlic with 25g of butter and the thyme
in the oven until soft, about 15-20 mins.
• To cook the potatoes, trim the ends off each
potato and cut in half. Season and cook
slowly in butter until golden each side.
• About an hour before you wish to eat,
season the lamb on both the fat and meat
sides and slowly brown the fat sides in a
heavy- based pan. Baste the meat with the
rendered fat and roast in the oven for about
15-20 mins – 15 mins for rare and 20 mins
for medium. Remove from the oven and turn
on the grill.
• Take the herb crust out of the fridge, cut out
a rectangle to fit the lamb. Peel off one layer
of greaseproof paper and place the crust
over the lamb. Peel off the second layer of
greaseproof and leave to melt into the lamb.
Place under the grill and brown.
• Leave the lamb to rest for 20 mins. During
this time cook the spinach in the remaining
butter with pepper and salt and drain well.
Sauté the artichokes in half of the olive oil.
•Just prior to serving make the sauce. Bring
the lamb stock to the boil, add rosemary and
the remaining olive oil and the diced tomato
• Serve one thick slice of lamb to each guest;
garnish each plate with the spinach, roasted
garlic, sautéed artichokes and shallot Purée.
Any roasted/sautéed potato would suit
this dish.
50 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
51

t r a n s p o r t t r a i n s
Fully trained
Matt Guarente gets on the right side of the tracks to enjoy
rail travel again – and not a curly cheese sandwich in sight
IT sounds like a challenge for Top Gear. Clarkson, the
Hamster, and Captain Slow will each be given a method of
transport to get them a couple of hundred miles from A to
B; points are also awarded for the level of comfort and the least
expensive route.
Jeremy Clarkson would probably get a supercar. And Richard
Hammond a backpack and a low-cost airline ticket. James May, as
befits his tortoise-like approach, would probably be handed a train
ticket and a copy of Puzzler. But – my money would be on him to
win the challenge.
Train travel is changing. Even for those of us who commute on
them, on a growing number of routes investment has helped push
comfort up, and travelling times down.
But what has really changed is the realisation that fast, efficient
train links are necessary for the economy, for the environment,
and the overburdened roads.
Could we be on the cusp of a new golden age of rail travel?
Well, we might have to wait more than a decade for full,
Continental-style high speed links to spread beyond the track
from St Pancras to the Chunnel, but the argument is certainly
stacking up in favour of letting the train take the strain.
It is a more compelling idea than it has been for decades when
compared to road or air travel – less hassle, time-efficient, and Æ
52 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
53

t r a n s p o r t t r a i n s
t h e a r t s t h e at r e
Romeo and Juliet in all its forms
Alasdair Steven explores the drama of the play, ballet, opera and film
Grand designs The main concorse at London’s St. Pancras station and the romance of steam locomotion
increasingly cost-efficient too. Train operating
companies are making an effort to offer good
incentives as well as differentiated and products
and services. And – frankly – it’s about time.
One of the most traditional ‘grand voyages’
is between Cornwall and London. Driving this
route can be a painful experience, as anyone
who has tried during peak holiday times can
attest, but the fast service between Plymouth
and London covers the distance in a little over
three hours.
First Great Western, the operator of the
high-speed services to the west, two years ago
‘refreshed’ the interiors of the trains and is
testing out a new seat-back, on-demand video
system called Volo that will be on all its highspeed
trains by November.
Families heading to Cornwall this summer
(which my family will be) can book connecting
twin-berth sleeper cabins with the Volo
video system already installed. Suddenly, the
previous ‘best’ option of a flight to Newquay
from Gatwick looks both expensive and,
with the long check-in times and security
procedures, time-consuming.
It has to be said that walk-up prices for trains
remain eye-wateringly high, so for leisure
travellers the mantra has to be: book early.
For example, a family of four travelling in
two months’ time would pay £182 for a return
Cardiff-London ticket if they bought it the day
before travel, but booking ahead would cut that
price to as little as £69 for all four. Next, invest
£26 in a Friends & Family Railcard, which
would cut that price to £39. You get a year of
cut-price tickets when at least one adult travels
with one child.
But it’s not just families. Over-55s get a
slew of bargains, for example travel anywhere
in Scotland for £15 with Scotrail, while the
under-26s, or qualifying students of any age,
receive 1/3 off fares with a £26 card. Lots of
operators, including Chiltern, London Midland,
SouthWest Trains and some First companies,
and soon Virgin Trains too, offer group
discounts when as few as three people travel
together, giving one free ticket when two others
pay the normal fare. Already on Virgin, groups
of 10 or more can save up to 70%.
It has to be said that
walk-up prices for
trains remain eyewateringly
high, so
for leisure travellers
the mantra has to be:
book early
Check the websites of the operators for other
offers too. For example, FirstGreatWestern is
offering two-for-one admissions to attractions
in London, Bath, Bristol and beyond when you
buy a train ticket, from the London Dungeons
to the grandstand at Ascot. You don’t get that
when you drive yourself, and extra perks are
the last thing travellers expect when they travel
by air.
Three top tips
The rail network is surprisingly dense and
if your chosen trip looks a bit tortuous, seek
alternatives. For example, travellers from
Birmingham or the North East who want to
get to Gatwick can avoid a stressful trip across
central London – change at Milton Keynes
for services through west London to Clapham
Junction and beyond.
During weekends and public holidays, most
operators offer a cheap upgrade service – for
example, £15 on Virgin services from Glasgow
to Birmingham. More space, better seats, free
refreshments and snacks come with the price.
Canny travellers with standard-class tickets can
spend most, if not all, of their time in a firstclass
seat if they are dining on trains that offer a
restaurant service.
Some passengers can’t travel ‘backwards’,
others really want a table – but unlike airlines,
train companies can change ‘equipment’ and
therefore layouts, making seat selection a bit of
a lottery. Book your seat anyway, arrive early,
and if it’s not right make a dash to get what
you want in the carriages that are often left
unreserved.
Top Tracks
• London-Paris Capital to capital in a shade
over two hours – magnifique. Bring a book
though, the scenery is dull
• Settle-Carlisle Thank Michael Portillo for
saving this route, with its stunning views, 14
tunnels and 24 viaducts – and grisly history
• Newcastle-Edinburgh Hugs the majestic east
coast, and once you cross the Tweed at Berwick
the border is only a few miles away
• London-Penzance sleeper Wake to the sun
glowing in the mist over the Tamar, the lovely
coastline and St Michael’s Mount
• London-Fort William sleeper Or, wake to
see deer at dawn as this long-distance rolling
hotel glides through the Western Highlands
• Welsh Highland Railway This revived steam
route winds through 20 miles of park from
Caernarfon Castle and past Snowdon
• Manchester-Sheffield Across the Peak
District with a view of 2,000-foot Kinder
Scout, and the Hope Valley countryside is
lovely. n
RSC/Ellie Kurttz
ShakesPEARE’s Romeo
and Juliet is amongst the
great romantic-tragedies
of the world’s stage. It combines
the intensity of young love with
two feuding houses in medieval
Verona; thus setting up a bloody
and dramatic final confrontation.
Such is that drama the play
has been refashioned in many
other forms, most notably as a
great ballet by Prokofiev, two
operas (by Gounod and Bellini)
and the brilliantly updating to
the backstreets of New York by
Leonard Bernstein in his musical
West Side Story.
Unlike many of the other
tragedies by The Bard, Romeo
and Juliet does not have an evil
villain. Instead people who
manifest good intentions and
qualities are turned to poison by
the world in which they live.
And strangely it is Friar
Lawrence who supplies the
poison. At his first appearance, in
Act 2 (Shakespeare makes a point
with his stage direction: ‘Enters
with a basket’ suggesting that the
Friar has been gathering herbs, he
comments, “O, mickle (abundant)
is the powerful grace that lies/In
herbs, plants, stones, and their true
qualities/For naught so vile that on
the earth doth live/ But to the earth
some special good doth give.”
He speaks of medicinal
plants and claims that, though
everything in nature has a useful
The Royal Shakespeare Company’s new production of Romeo and Juliet,
directed by Rupert Goold and with Mariah Gale and Sam Troughton in the title
roles, runs from March 12 at the Courtyard Theatre in Stratford-Upon-Avon
purpose, it can also lead to
misfortune if used improperly.
He gives Juliet the drug that will
put her into a death-like coma
for “two and forty hours” thus
setting up his involvement in the
enveloping tragedy.
Poison – or the prescribing of it -
the Friar argues is not intrinsically
evil, but it is a natural substance
made lethal by human misuse. It
is almost as if he is justifying his
giving, near the end of the play,
the sleeping potent to Juliet that
will then result in Romeo also
taking a draught of poison.
The Friar tries to put his
medicinal theories to use when he
agrees to marry Romeo and Juliet;
with best intentions he hopes that
the rare goodness of their love will
reverse the hatred between the
two feuding families.
Atropa belladonna is the herb
that scholars maintain Juliet
takes to fake her death. It is a
herbaceous plant with extremely
toxic foliage and berries which
contain scopolamine. It can cause
both hallucinations and delirium
and has a long history of use as a
medicine, cosmetic, and poison.
It was often used in medieval
times as an anaesthetic. When
Romeo hears of Juliet’s ‘death’
he visits an apothecary. When he
drinks the potent he exclaims, “O
true apothecary! Thy drugs are
quick. Thus with a kiss I die.”
On stage the play has been
much performed. There was
a classic production by John
Gielgud in 1935 in which he
alternated the role of Romeo and
Mercutio with Laurence Olivier.
In 1960 at the Old Vic in London
the title roles in Franco Zeffirelli’s
production were played by John
Stride and Judi Dench.
Several films have been made
notably in George Cukor’s Oscar
winning movie of 1936 (with
Moira Shearer and Leslie Howard)
and Zeffirelli’s 1968 version with
the very young Leonard Whiting
and Olivia Hussey. That raised
eyebrows as the wedding scene
was shot nude when Hussey was
aged only 15. Then in 1998 there
was a delightful twist to the Romeo
story in Shakespeare in Love (with
Gwyneth Paltrow and Joseph
Fiennes) detailing The Bard’s
problems when writing the play
and setting it against the backdrop
of his own doomed love affair.
The play is an all-embracing
and powerful romantic tragedy
of “two star-cross’d lovers”. The
final poignant lines, as the curtain
descends the audience is told:
“For never was a story of more
woe / Than this of Juliet and her
Romeo.” n
l Alasdair Steven is a freelance
writer on the arts. He has covered
opera and ballet in the UK as well
as writing television scripts.
54 Pharmacy Professional | March 2010
March 2010 | Pharmacy Professional
55

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Clues Across
4 Inoculation cutting excess weight around
June 2nd and July 1st (3,3)
5 Smallness, oddly, of customers’ purchases... (5)
7 ...decrease of same for some Optrex? (4)
9 Medical threat to the King when out of
bed (5-2)
10 Inventory on the cattle ranch? (5)
12 Bill is at home with Whitney (7)
14 Another term for: ‘reachin’ for the stars’ (7)
15 Useless source of vitamin C? (5)
17 Joint connected to... (7)
18 ...the skull, fool! (4)
19 On the street I agree they’re eyesores (5)
20 Prescription marked ‘once’ on the box? (6)
Clues Down
1 Andrews’ product originally brought up
rudely, perhaps? (4)
2 Unfinished medical journal dealing with
boils (5)
3 Column will give support to thiamine (8)
4 Life preserver displaying the sign of the
Cross (5,3,3)
The prize this month is a copy of each of
Stockley’s Drug Interactions Pocket
Companion 2010, extensively updated to
reflect the latest findings, and the Clinical
Pharmacy Pocket Companion, an A-Z
handbook containing concise and practical
pharmaceutical information for clinical
pharmacists and other healthcare professionals.
Both are published by Pharmaceutical Press.
6 Look forward to love, yelling for medication
(11)
7 The Princess is returning for some laxative (5)
11 Clue: ‘Passover pills’ (8)
13 What’s heard, as time passes, about causes
of Lyme Disease (5)
16 Fahrenheit always used for high
temperature (5)
18 Part of a wheelchair that may be cracked (4)
WCONGRATULATIONS to Ms Angela Goodwin of Harwich, Essex who wins copies of Drugs in Use and The Obesity Epidemic and Its Management.
Feb Answers Across; 5. Prescriptions; 7. Enzymes; 8. Hurry; 9. Corns; 10. Cold; 13. DEET; 14. Short; 16. Hives; 17. Cerumen; 18. Sleeping pills
Answers Down; 1. Seizure; 2. Nits; 3. Liquid; 4. Snore; 5. Pierce; 6. Combs; 10. Cut; 11. Formula; 12. Stings; 13. Dieter; 14. Syrup; 15. Vials; 17. Cane. Prize Word: INSULIN
56 Pharmacy Professional | March 2010

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