The PSI recently finished a consultation on changing the rules around CPD. It is becoming increasing obvious that our assessment is missing a major skill. Our interactions with the PCRS have shown that, in order to be a competent community pharmacist, you need to have psychic powers. In most walks of life, there are business rules. The PCRS has a manual, the Handbook for Pharmacists, that was updated in October 2020. Despite being almost five years old, it is considerably more modern than the previous version, which was released closer to 40 years ago. It has one gaping hole — the almost complete absence of reimbursement limits.

A common question in any pharmacy is, “Will I get reimbursed if I dispense the six adrenalin pens, the 15 tins of baby food or . . . ?”. Searching the handbook for maximum reimbursable quantities tells you a few nuggets. The usual four a month for erectile dysfunction tablets, the premonition of future limits in the form of three Victoza pens a month and, finally, the one that completely passed me by, they will only pay for a maximum of 60 Zyban a month — a fair enough proposition as this reflects the maximum dosage. It has always been a policy that the PCRS will pay for a month’s supply in a month. Now we get to where you need your psychic powers. If you call the PCRS, you will be politely informed of the reimbursement limit. So, for adrenalin pens, the limit is apparently five. This is one less than most allergists prescribe. The logic is typically two at home, two in the car and two at school (or work or wherever). Yet, if you foolishly forgot to ask and claimed for six, you might discover that you were paid. It is like there is a level of flexibility that can only be determined by bounds testing. We have long been told that the reluctance of the PCRS to write down limits is a fear that these amounts would become targets. While understandable, it is unforgiveable that there is no level of consistency. Then again, why would you be surprised when this organisation thinks it is reasonable to have different codes, depending on whether you are a medical card or private patient, for a commonly used palliative treatment, BMX? Recently we got a letter telling us that, depending on the type of migraine you have, they may or may not pay for a new treatment, Vydura. Another complicated rule for a drug many will be unfamiliar with. The rules surrounding State reimbursement are complex, resembling a very unstable Jenga tower. In the absence of certified PSI approved psychic powers, there is a better way. The PCRS could provide a set of business rules, that our software could interrogate at the point of dispensing. This would provide clarity and consistency for all users.

The Ozempic ‘click’ debate is hopefully beginning to recede in the rear-view mirror. It represents another manifestation of the huge frustration, that both pharmacists and the public are facing in the supply of this important medicine. I had a number of diabetic patients stabilised on 0.5mg. Then the screws were turned. The tap went dry and the only formulation of Ozempic available had been the 1mg strength. The choice was stark. Move up to 1mg, move on, or follow social media medical advice. Did I ever think that I would write that sentence? To date, I have been rigidly not engaging with counting clicks. Yet, I type into my search engine and it helpfully advises how many clicks of a 1mg pen for each dose. Some GPs are advising patients to ask the pharmacist to show them what do. This is a medicolegal minefield. More relevantly, there is no indication that issues like these are going to change.

New Orleans recently hosted the Superbowl. One of the half time ads was for a telehealth company called ‘Hims and Hers’. They sell ‘compounded’ semaglutide, which they can legally supply as there is an official shortage of the brand name. Ironically, part of their sales pitch is that their drugs sell for a fraction of the brand originators, but they are still way more expensive than the European equivalents. While the rules around marketing and extemporaneous preparation are vastly different on this side of the pond, there are cross contaminants. While an old concept, more typically associated with LSD, a new type of microdosing regime, for GLP1 agonists, is growing in popularity in the USA. Claims of efficacy for a huge range of health issues are being made. There is currently little or no evidence to substantiate them. Community pharmacy is a busy, complicated profession. It looks like the trajectory is only going one way.