General practice

General practitioners' views on over the counter sales by community pharmacists

^a Department of General Practice, United Medical and Dental Schools of Guy's and St Thomas's Hospital, London SE11 6SP

Correspondence to: Professor Jones.

More over the counter medications have been made available recently. We carried out a survey of general practitioners' views on various drugs being dispensed by community pharmacists without a prescription to determine whether these views have changed since 1990.¹

Subjects, methods, and results

Details of 1301 general practices were obtained from eight family health service authorities throughout England. All 250 fundholding practices were included in the study together with a random sample of 250 urban and 350 rural non-fundholding practices to permit comparisons between fundholding (mainly rural) and rural non-fundholding general practices and between urban and rural non-fundholding practices. The larger number of rural non-fundholding practices were included so as to increase the statistical power of the study.

In November 1994 a questionnaire was dispatched to one randomly selected doctor from each practice. It sought information on basic characteristics of the practice and the responding general practitioner. The section in Spencer and Edwards' questionnaire which was used to elicit general practitioners' attitudes to the provision of specific drugs by pharmacists in 14 clinical scenarios was reproduced.¹

The overall response rate was 61% (515/850)--69% (172/250) for fundholding practices and 57% (343/600) for non-fundholding practices (²=9.85; df=1; P<0.01). The distribution of practice size, doctors' ages, and average list size did not differ significantly from that recorded in England in 1993.² The table compares our results with those of Spencer and Edwards in 1990.

Table 1--Percentage (number) of general practitioners agreeing and disagreeing that drugs should be dispensed without prescription by community
pharmacists. The 1990 survey1 had 744 respondents; the 1994 survey had 515 respondents. Not all respondents answered each question
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                                                                                              Agree                       Disagree
--------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                    Difference                    Difference
Drug                                      Indication                                 1990      1994     (%)      1990       1994     (%)
--------------------------------------------------------------------------------------------------------------------------------------------
Prescription only at time of 1994 survey
Chloramphenicol drops or ointment         Sticky red eye in children over 2 years  52 (370)  67 (349)    15    39 (278)   22 (116)  -17
Oral broad spectrum antibiotic (5 day     Productive cough in otherwise bealthy
  course)                                   adult                                  15 (106)  26 (133)    11    78 (559)   63 (325)  -15
Topical antibiotic                        Weeping skin infection                   30 (217)  40 (205)    10    59 (415)   46 (239)  -13
Morning after pill                        Unprotected intercourse within previous
                                            72 hours                               27 (195)  53 (275)    26    64 (458)   35 (183)  -29
Trimethoprim (3 day course)               Frequency and dysuria in women           35 (250)  55 (285)    20    54 (382)   33 (171)  -21
Oral nystatin suspension                  Oral candidosis in baby                  63 (452)  80 (412)    17    28 (198)   13 (68)   -15
Co-dydramol (10 tablets)                  Severe toothache at weekend              87 (619)  87 (447)           9 (67)     8 (43)   -1
Penicillin (5 day course)                 Sore red throat in adult                 17 (120)  27 (140)    10    76 (542)   62 (322)  -14
Propranolol (10x10 mg tablets)            Anxiety state in adult                   11 (75)   19 (101)     8    81 (581)   68 (354)  -13
Rectal suppositories containing
  steroids*                               Haemorrhoids                             43 (305)  58 (300)    15    42 (300)   28 (145)  -14
Available over the counter at time of 1994 survey
Cimetidine                                Dyspepsia in adult under 45 years not
                                            responsive to antacids                 11 (80)   54 (280)    43    82 (582)   31 (158)  -51
Nicotine chewing gum                      Smoker wishing to stop                   84 (607)  91 (471)     7     9 (64)     4 (23)   -5
Beclomethasone nasal spray                Allergic rhinitis not responsive to
                                            antihistamines                         46 (328)  67 (347)    21    41 (292)   18 (94)   -23
Antifungal vaginal pessaries              Vaginal "thrush" in women                53 (381)  87 (447)    34    38 (269)    8 (41)   -30
--------------------------------------------------------------------------------------------------------------------------------------------
*Became available over the counter shortly after completion of survey.

Most respondents agreed that pharmacists should issue nicotine gum, oral nystatin, and co-dydramol. This is consistent with Spencer and Edwards' findings. In contrast to the earlier study, over 60% of respondents agreed that chloramphenicol eye drops and beclomethasone nasal spray should be available without prescription for the clinical indications cited. Across all categories the respondents to the 1994 study were more likely than respondents in the earlier study to agree that pharmacists should issue drugs without a doctor's prescription. In both studies, few supported the proposition that pharmacists should issue penicillin for a sore throat or propranolol for anxiety. The differences between the studies were significant at the 5% level (using two tailed Student's t test) for all scenarios except the prescription of co-dydramol for toothache.

Four of the drugs became available over the counter in the period between the two surveys and one became available shortly after completion of the 1994 survey. Between 1990 and 1994 the level of agreement increased significantly (P<0.01) for all five of these drugs.

For each of the 14 clinical scenarios no significant difference in response was found between fundholding and non-fundholding practices or between rural and urban practices. General practitioners from fundholding practices agreed to more scenarios than general practitioners from non-fundholding practices (mean 8.6 v 7.8; P<0.02).

Comment

There has been an overall increase in the level of approval among general practitioners for the provision of a range of medications by community pharmacists. General practitioners from fundholding practices agreed to a slightly wider range of drugs being made available over the counter than practitioners from non-fundholding practices. Fundholding practices have been shown to have achieved significantly greater success in curbing increases in drug costs than non-fundholders.^{3 4} Some caution must be exercised in interpreting the results given the relatively low overall response rate of 60%. However, the more positive attitude of fundholders towards the over the counter availability of a range of drugs is consistent with a concern for containment of prescribing costs.

The increase in the proportion of general practitioners agreeing to drugs becoming available over the counter may reflect greater awareness of the cost of prescriptions to the NHS and the need for cost containment. Given the increasing pressures on their time, general practitioners may be more likely to encourage self-medication for relatively minor problems, more aware of the importance of the community pharmacists as part of a primary health care team⁵ and more supportive of pharmacists' extended role.

We are grateful to all the general practitioners who participated, to Dr Steve Mann and Jerry Cottrell, and to Dr John Spencer and Clive Edwards for permission to reproduce a section of their 1990 study questionnaire.

Funding: This study was supported by a grant from Merck research laboratories.

Conflict of interest: None.

1. Spencer JA, Edwards C. Pharmacy beyond the dispensary: general practitioners' views. BMJ 1992;304:1670-2.
2. Department of Health. Health and personal social services statistics for England 1994 edition. HMSO: London, 1994.
3. Bradlow J, Coulter C. Effect of fundholding and indicative prescribing schemes on general practitioners' prescribing costs. BMJ 1993;307:1186-9.
4. Wilson RPH, Buchan I and Wallet P. Alterations in prescribing by general practitioner fundholders: an observational study. BMJ 1995;311:1347-50. [Abstract/Free Full Text]
5. Ford S, Jones K. Integrating pharmacy fully into the primary care team. BMJ 1995;310:1620-1. [Free Full Text]

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