Our undercover health check for pharmacies

by , Senior Health Researcher Consumer Rights 20 May 2013
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When you’re unwell, you need safe, reliable advice to help you buy the right medicine. We sent mystery shoppers into UK pharmacies to give their advice a check up. Can you rely on your local pharmacy?

A pharmacy mystery shopper

Last week, I went to my local independent pharmacy and asked the assistant a question about how I use my asthma inhaler. But the advice didn’t sound right, so I very politely asked if she might check with the pharmacist, and a different answer came back.

That’s just one tiny example of the sort of problem we found in our large, undercover investigation of 122 pharmacies throughout the UK. This is our third pharmacies investigation in a decade and my experience clearly reflects some of our findings.

Our trained mystery shoppers visited the large chain pharmacies – Boots, Superdrug, the Co-operative, Lloyds, Rowlands and four major supermarkets (Asda, Morrisons, Sainsbury’s and Tesco). The shoppers also visited smaller chains and independents, which still make up over half of the market.

Uncovering ailing advice

Their visits were rated by a panel of three experienced pharmacists, and more than four in 10 visits were found to be unsatisfactory.

In one scenario, our mystery shoppers asked to buy Pantoloc Control for heartburn, but seven out of 10 pharmacy staff failed to ask vital questions before selling this strong drug. If the questions had been asked, the staff members would have found that the mystery shopper is on warfarin to prevent blood clots. Pantoloc can interfere with warfarin levels, leading to potentially serious problems.

Independent pharmacies and smaller chains gave worse advice overall than leading chains and supermarkets (58% vs 34% giving unsatisfactory advice). The counter assistants who dealt with our mystery shoppers without consulting the pharmacist were significantly more likely to give poor advice than pharmacists (67% compared to 27%).

We did find some green shoots of hope, however. We saw some improvement for two scenarios that we also used in our 2008 investigation – one asking for medicine to treat traveller’s diarrhoea and another for migraine medication.

Helping pharmacies get better

The next step is to ask why we’re seeing trends across the years – our last investigations in 2004 and 2008 saw similar issues with assistants not involving pharmacists and important questions being missed, as well as independent stores under performing when compared to chains.

But we’re pleased that the new regulator, the General Pharmaceutical Council, and the professional body for pharmacies, the Royal Pharmaceutical Society, are taking our findings seriously. They are planning a joint event in the summer to discuss these issues with companies, training providers and medicine manufacturers.

I think your neighbourhood pharmacy – whether it’s a small independent or part of a big chain – is a place you should be able to get safe and reliable advice. Our investigation has found worrying variations in the quality of this advice.

This all leads to me wonder if my experience at my local pharmacy was just a one-off. Have you received bad advice, or are you receiving the good advice and service we saw in some pharmacies?

36 comments

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Malcolm R

It doesn’t occur to me to ask a pharmacy for medical advice – I’d use my GP or practice nurse – they know your history. Isn’t that what they are meant to be there for?

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Stuart

If you’re after medical advice then fair enough. If you’re after advice on medicines though, then you’re better off with a pharmacist. They are more accessible and you don’t need an appointment. They’ve even easier to phone than your doctor/practice nurse. Most pharmacists will be able to answer any medicines related query from the information you can provide, but if there is doubt due to not knowing your history then they can refer to your GP. This saves you’re GP time and will also probably make your life easier.

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darrenp-uk

It would help if people also volunteered any information about their medical history. Then there would be a “belts & braces” approach to patient safety, with the patient playing an important role in it too.

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Figgerty

Counter assistants in pharmacies are not trained to give advise on medicines and it would be foolhardy to ask and rely on that advise. Many over the counter products are sold in our supermarkets and you would not expect the supermarket staff to advise you on their use.

I have in the past asked a pharmacist for advise and was asked about medical conditions and what medication I was taking. I would expect that advise to be sound and if s/he had any doubts they should tell me to contact my GP.

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Paul

Any vounter staff with a responsibility for selling medicines in a pharmacy MUST undertake a nationally recognised Medicines Counter Assistants course. This is in stark contrast to a supermarket for example where only staff working in the defined pharmacy area are required to do this.

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Figgerty

Paul: How long is the course and how detailed.

I see customers asking counter staff for advise all the time and the staff just seem to read out details from the packaging.

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Karen

The medicine counter assistant course takes around 2 years to complete and covers majority of common problems treated with over the counter medicines. It also sets out a range of questions which MUST be asked when selling any over the counter medication, such as what other medication is being taken etc. If anyone is not doing this then they are not doing what they should be and this should possibly be mentioned to the Pharmacist in charge.

Hi Figgerty
Thanks for your input.
Just to say that two of our scenarios (used by our mystery-shoppers) were for medicines where pharmacists are required as a condition of sale to oversee the sale. So if a counter assistant is – understandably – not sure – they should surely be asking the pharmacist to advise?

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Anne

Surely the common sense thing to do is to ask to speak to the pharmacist, particularly if you know you are taking a drug such as warfarin, which is well know for its potential for drug interactions.

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Karen

It’s a shame this research gives Pharmacies such a bad name when there are many who work very hard to give their customers the best service possible. ALL of our staff are highly trained and they also know to only work within their own competancies, for example any customer wanting to buy over the counter medicines who was taking Warfarin would always be referred to the Pharmacist.
It is also very difficult to approach some customers reguarding their medicies as they tend to see Counter Assistants as ‘shop girls’ and refuse to take any advice given. It is very rare you get a good response when refusing to sell something to someone!
Customers wanting to ensure they get excellant advice and services should ensure they use a ‘Healthy Living Pharmacy’ accredited Pharmacy (which can be found on NHS website).

Hi Karen
Thanks for your input and for the useful tip.
I’m always a little surprised though when our research is seen as giving a profession a bad name rather than as using a research methodology (in this case, mystery-shopping) to give practitioners a fair test of skill, presenting a picture overall of where practice needs to improve.
We did see some excellent practice – I take your point on this – but such a high level of poor practice (43% overall) is surely not good enough. Why might this be?

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Karen

I completely agree that the figures are not good enough and the point I meant to put across was that it’s a shame some Pharmacies are letting the rest of us down!

I wouldn’t like to make excuses for those Pharmacies who are not performing as they should, however I can understand how it can be easy to forget what an important role our Counter Staff play and concentrate all our energy on other services such as dispening.
We need to remember that it is the Counter Staff who spend the most time with our patients and as such should be subjected to the same scrutiny as our Pharmacists and Technicians.
Employers should be ensuring that Counter Staff are regularly reading around the subject and brushing up on their basic skills.

Pharmacies are highly regulated by the NHS and the RPSGB and are regularly inspected, however these inspections concentrate on the Dispensing process and paperwork. Perhaps an annual mystery shopper should be included in these inspections?

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Figgerty

Customers are aware of how highly trained pharmacists have to be before they are licenced to dispense drugs. How are we to know if the counter assistant has just started work in the pharmacy or has had weeks of training in whatever. How are we to know their competencies.

Yes, I agree. As above, I’d expect the counter assistant who’s not sure to consult the pharmacist as these medicines are sold under the supervision of the pharmacist. It’s not up to the patient to work out who is who…

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wavechange

For years I have used the pharmacy in my local branch of Tesco. Their stocks are better than other local pharmacies and they collect prescriptions that I order online.

I have rarely asked for advice but have raised various issues with the pharmacist on duty. Some years ago, I had occasional problems with one brand of generic inhalers due to a manufacturing defect. Twice I was given a replacement and the third time I was told that this would be the last time, because of the cost involved. I gave a robust but polite response, wrote down my contact details and suggested that he should pass on my concerns to their head office. Since then, they have changed to supplying inhalers made by other manufacturers.

On one occasion, a pharmacist warned me that an antibiotic was not compatible with one of my regular prescription items. This was flagged up thanks to the computer system used to record my medications. Unfortunately, it missed another incompatibility, which I discovered on reading the leaflet provided with the pills.

Although I am very much in favour of pharmacists providing generic products to save the NHS money, I object to the fact that some come with leaflets that are in tiny print or are in other ways inferior to the information provided by the market-leading brand and other generics. On behalf of those with poor sight and the elderly I make a point of reporting inadequacies to the pharmacist. I have rarely had very positive feedback but I believe that Tesco is making some effort. I have been told by a pharmacist that their buying power often lets them buy the market leading brand at a competitive price.

In the last year I was asked to participate in a survey when I visited the pharmacy. I have no idea who funds this, but I was asked useful questions and given the opportunity to provide feedback on their service.

While waiting in a queue to be served I have not been impressed by the fact that staff often fail to ask customers about what other medication they are using before suggesting a purchase. I also dislike the fact that expensive brands are displayed and recommended when there are cheaper alternatives. I expect that it is Tesco’s policy to promote products with the highest profit margin.

Thanks, Wavechange. Some important themes here about good, clear info and communication needed, plus the value feedback from customers.

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Stuart

Very interesting results. I’m surprised to find that independent pharmacies performed worse than supermarket pharmacies. I guess pharmacy owners have a business to run, so I wonder if the additional pressure takes away from time available to train and remain up to date, or the amount of time available to spend with patients. I’m not surprised to see Boots performing poorly, for various reasons.

I think the limitations of the study should be highlighted though. The author states that this is a ‘large’ study but personally I wouldn’t consider 122 pharmacies to be large at all. This shows in the results where only one Co-op Pharmacy was rated as ‘good’ and this amounted to 8% of the total. It would also be interesting to know whether the number of each type of pharmacies visited was equal across the survey, as this could massively skew comparative results.

I would also be interested to know how the ratings were actually derived and what constitutes ‘good’ advice. Also exactly which questions were asked. It seems that something of an outlier has been used as a standard example of performance – requests for Pantoloc are virtually non-existent! Whilst not excusable I’m not surprised if unsatisfactory advice was given, particularly by counter assistants not familiar with the drug. This doesn’t really reflect the advice that could be expected in 99% of occasions.

It’s also a little irritating to see the sensationalisation of these results by Which? The interaction between pantoprazole and warfarin is certainly not confirmed, and moderate at best. Whilst additional INR monitoring is probably advisable to be on the safe side, any link to ‘hospitalisation’ is not supported by the evidence.

So whilst these snapshot results do give some cause for concern and should not be ignored, I think the public can be reassured that pharmacies are probably not giving out bad advice 43% of the time as Which? claims. I’d like to see these investigations beefed up in future to show greater statistical power to and to take account of the huge variety of services offered by pharmacies and the multitude of ways in which pharmacists/pharmacies interact with their patients.

I’d just like to point out that whilst I am a pharmacist, I have no vested interest. I don’t work for any community pharmacy.

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Karen

In addition to Stuarts note about the interaction between Warfarin and Pantaloc, It is not even listed in the OTC medicines reference guide due to it not being confirmed.
I was also surprised to see independants and small chains performing so badly, I myself work for a small chain and I think that one of the reasons our Pharmacy is always so sucessful (as shown in our annual customer questionnaire not just my opinion!) is because we are a small, close knit team and it is therefore easier to carry out accurate appraisals on my team. I can also always hear what my counter staff are saying to customers and it is very rare that I have to intervene.

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wavechange

With plenty of well established drug interactions, choosing warfarin and pantoprazole (the active component of Pantoloc Control) was not the best choice. The British National Formulary refers only to possible enhancement of the anticoagulant effect of warfarin. I agree with Stuart, though the fact that a drug is not well established as a pharmacy product is no excuse for failure to consider drug interactions. As Stuart says, we really need to know the questions that the undercover customers were asked.

I do not, however, see a problem with sample size. It is sufficient to show that there may be a general problem, even if differences between pharmacy chains are only an estimate.

In view of the wide range of known drug interactions for warfarin, the GP prescribing it should recommend patients declare their medication to avoid possible problems.

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pmjh

The warfarin scenario is an excellent example of a medication where pharmacy staff must be vigilant when selling otc products, and it highlights the importance of asking the appropriate questions. However in reality every patient on warfarin KNOWS to inform pharmacy staff when looking to purchase medication. The real issue with this scenario is that pantoloc was asked for by name and being a P med should have been referred straight to the pharmacist. It is not only the training these assistants failed to follow but also the company SOPs. There are obvious failings on the counter assistants part and pharmacists have to trust their staff will only advise within their competence. It is impossible for pharmacists to directly supervise every sale as they now spend more time in the consultation room providing pharmacy services such as medicine use reviews and healthy living checks. In my experience patient safety is priority number 1 in a pharmacy so hopefully a result of this report those minority within pharmacy will aim to improve this to catch up with the majority of pharmacies who provide excellent patient care.

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pmjh

The ”problem” of getting different advice from a counter assistant and pharmacist on inhaler use is not a problem at all as counter assistants are not trained to counsel patients on this. Patient’s requiring advice of this nature will nearly always ask for the pharmacist. I have never had a member of my staff attempt to advise on any matter outside their competence. I wonder what type of questioning did the mystery shoppers use that seemed to compel these counter assistants to try to answer their queries without referring to the pharmacist.

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John Ward

I have always been very satisfied with the service I have receieved from pharmacists and their assistants, and I am somewhat surprised and disappointed by the general resumé of conclusions deduced from the survey. I tend to share some of the concerns over the veracity of the survey. I suppose busy practices should really have more than one pharmacist on duty at all times in order to oversee the sale of other medications and the answers given to any questions raised by customers. Other issues [like the crisis over A&E performance] demonstrate that GP capacity in the UK is falling well short of necessity; consequently pharmacies are under greater pressure from patients who want “quick” attention for what they might suppose are “simple” ailments and the pharmacist’s time is increasingly taken up with dispensing and consultation thus placing ever more reliance on counter staff [who are also trying to answer questions on vitamin supplements and anti-wrinkle creams]. The miracle is how well pharmacies perform despite these impediments.

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wavechange

The investigation is reported in the June issue of Which? magazine.

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John Ward

Thanks Wavechange. It would be helpful if these Conversation intro’s told us when an investigation was fully reported in a recent or upcoming Which? magazine. I shall look out forthis when the magazine arrives.

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wavechange

I agree. My magazine has not arrived, but I read the article online.

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Candy

PHARMACIST NOT PRESENT

I was refused my made up prescription, at a supermarket, as the pharmacist was not present.
I had to wait until the pharmacist returned. I am told this is the law.

Scenario 1 –
a – pharmacist makes up prescription.
b – pharmacist hands prescription to courier.
c – courier delivers to patient (pharmacist not present)
I understand this is fully compliant with the law.

Scenario 2 –
a – pharmacist makes up prescription.
b – pharmacist hands prescription to assistant.
c – assistant places made up prescription on shelf.
d – customer arrives.
e – pharmacist is in back of pharmacy (has no idea what assistant is doing).
f – assistant retrieves made up prescription from shelf and hands to patient.
I understand this is fully compliant with the law.

Scenario 3 –
a- b – c – d – as scenario 2
e – pharmacist is at lunch.
f – assistant refuses to hand over the already made up prescription to the patient.
This has to be a ludicrous interpretation of the law.

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Harnek

Correct, this is a ludicrous law and not an interpretation. Just an example of the things we pharmacists are up against with legislation and governance within the profession. This report is quite rightly damning in some respects. This is not an excuse but there is so much wrong with how the Department of Health and regulators are dealing with community pharmacy at the moment, most good ethical independent pharmacists are just trying to keep their business afloat and continue to provide a good, personal service to their loyal patients. I can’t speak for the bad ones!

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ambrose

I too am concerned that the Which survey may unwittingly give an erroneous picture of pharmacy service. Customers are patients, and as such they should perhaps assume a little bit more responsibility for their health by engaging in a better dialogue with the pharmacist and/or counter assistant. They could also use a Medication Passport which would provide the pharmacist with an instant display of what meds. the patient is taking and of additional medical information. It is too easy to criticize a busy pharmacist for not devoting 100 per cent attention to a patient who is 100 per cent passive.

You may be interested in our latest Conversation on our pharmacists investigation – this time on some pharmacists failing to explain that there’s no scientific evidence that homeopathy works: http://conversation.which.co.uk/consumer-rights/homeopathy-homeopathic-remedy-pharmacists-advice-investigation/

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Figgerty

Patrick, this is a little in-house for the normal consumer.

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Ivan

You say in your report that ”…the advice given in one scenario had the potential to lead to a serious drug interaction, leading to bleeding problems and even hospitalization.” You also say “…Pantoloc can interfere with warfarin levels in the blood, leading to potentially serious problems.” Really? What evidence can you quote for this claim? The reality is that if you look at the evidence for a warfarin/Pantoloc Control (pantoprazole) interaction, it is tenuous at best and seems to be confined to some unexplained isolated and rare cases reported in the maker’s literature. Without knowing the full details we really have no idea whether they were valid interactions or not, or how serious they were, or whether there might have been some other explanation. So this is a very questionable drug interaction indeed to ‘test’ the pharmacies with. You criticize many pharmacies for not doing very well in your survey, but your mystery shoppers did pretty badly as well when they posed this drug interaction question, and it certainly weakens the results of your test investigation. I’m not surprised that some pharmacy staff failed to “…spot a potentially serious interaction.”

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Concerned Professional

The saddest and most frustrating incident of poor advice I have come across was when a socially vulnerable new mother I was working with, in my capacity as a Health Visitor, visited the local pharmacy. She was breastfeeding her 2nd baby, having breast fed her first child for several months, but was in pain from stitches from the birth. She went to the pharmacy to ask what she could take to help the pain and was told by the pharmacy assistant, who did not consult with the pharmacist, that there was nothing she could take for pain if she was breast feeding. She gave up breastfeeding that weekend. This damaging advice has such ongoing consequences for both mother and child, it is difficult to think them all through without feeling anger and disappointment that someone who clearly had no knowledge or understanding of either medication or breast feeding did not realise the effects of their authoritative pronouncement. In the context of this particular issue there is scope for considering the education process of both pharmacists and staff around breast feeding in the community and understanding of the principles of supporting breast feeding.

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southeast

I have every faith in my local chemist, pharmacy, assistants and all members of staff, as I know they have up to the minuet training and would check on the computer to see if anything suggested was incompatible with my numerous medications I feel that this survey is casting doubt on smaller groups of chemists, who cannot defend themselves, I am jumping to there defense, as surely if a person was taking medication of a stronger kind they would as I do, carry a script with them, I do feel strongly about this

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farce

“would check on the computer to see if anything suggested was incompatible with my numerous medication”
All information that’s is available to pharmacists should also be made available to the public directly.

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GT

Interesting headline and selected figures. But…
Where is the full report and detailed information about the scenarios and qualifications of the mystery shoppers. The devil is always in the detail and not the headline. I would like to see the complete report not selected elements from it.

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Steve

May I ask, in what percentage of cases was the pharmacist involved in the sale rather than only the counter assistant?

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