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back to article Doctors call for NHS Direct review

The chair of the GP's council Dr Laurence Buckman has called for a proper review of the cost-effectiveness of parts of NHS Direct - we're guessing call centres - and changes to the Summary Care Record scheme. Earlier this week it emerged that NHS Direct is moving to hire call centre managers with no medical experience. Currently …

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Bronze badge
FAIL

NHS Direct = Direct to A&E

At least thats what the triage nurse said to me last time I took a germ factory there (couple of weeks ago). Always end up at A&E because local doctor surgeries, and even a local hospital, can't even put in a couple of stitches any more.

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FAIL

What a cock, a corrupt cock. Look at the real reasons.

Walk in centres were set up for two reasons. I know this, I have to deal with it daily.

Save money. A&E if you walk in, immediatly charge money to the Doctor you are with. Regadless of what you need to do. The charge is a lot of money.

The PCT has to pay the doctor for your treatment, that is then paid to the A&E. You pay more if you go to A&E for non emergency stuff. £65 - £500 each.

So the PCT's then decided to save money, tax payers money by putting in a middle ground. a walk in centre which are PCT employees and therefore avoid the stupid tax that Acute PCT's charge us.

Still with me?

Second is the people using A&E that shouldn't, they go to a walk in centre and THEN get sent to A&E if needed. Or treated if the moron patient goes because of snuffles etc.

The A&E (for my area) then complain because there isn't the footfall through the door to warrant the A&E, or the number of consultants. The walk in centre is removing funds from the PCT despite them complaining all the time.

So now the consultants being sacked or the A&E closing hits the headlines and the walk in centre closes or merges with A&E. And we still pay the acute trust vast sums of money for you turning up with your broken finger, or your bruised knee.

The Doctors are complaining because if you walk into a walk in centre, or use NHS direct you are not walking through the surgery doors. And they are paid for each ten minute visit. It is a tick box exercise. Nothing more. (You ask yourself why your Doctor now does 5 minutes?) They are just complaining because they are not getting as much wage as they used to.

Value for money it isn't, Labours internal market is to blame. Though the tory dems are not making it look much better.

What should be investigated is the hospital to be charged if the person returns within a month. It will mean you are kept in longer than needed, so no beds, more cost to the PCT as a result. If they are paid £500 a day by charging your Dr they want to send you home, if they can keep you in and are now told to keep you in or risk fines, it is 500 more a day per patient. It is now in their interest to keep you in.

And of course the plan to make the Dr's control 98% of their budgets and what they spend come from them. Removing them even further from PCT control. So basically removing the PCT and creating in our area 43 separate PCT's (1 for every Dr.) No central control, no central responsibility. And if they treat the PCT like they do. Expect the NHS to die, very quickly.

Patient care records. One practice (all staff) shut down a window by rebooting the machine. They don't understand the X in the top right hand corner. You trust those people with your critical and sensitive patient information????? Are you mad?

Anon as you know where I work.

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Grenade

A drastic but effective approach potentially.

How about sack every non-medically trained manager in the NHS all at the same time.

Then just see who screams a need for them the next day...week...month.

I'm sure nurses etc. can organise themselves to a large extent.

Like pulling the plug on an old server that gets found at the back of the server room. Unplug and see who shouts.

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WTF?

@jason 7

You do realise that only 4% of NHS staff are managers? That is considerably less than almost every private organisation. They have a thankless yet vital task that we all depend on.

Managing such a large organisation is hard. The NHS has a huge budget and literally life-and-death responsibility. It needs properly trained managers, not doctors and nurses who are doing it as a sideline. The demonisation of NHS managers is lazy politics with very little bearing in reality. Of course there are useless ones, and of course there are problems (such as it being hard to get rid of the useless people), but that's true of doctors and nurses too.

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Anonymous Coward

@DominicT

Yes... BUT...

First of all it depends how you define manager. In my book it's anyone without medical qualifications who's paid more than a nurse.

And even within the narrowest of definitions, how much of the cream do they take off the top of the finances? A hell of a lot in my area where the managers really ARE totally useless (direct experience.)

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You can't sack managers.

You also have to remember payrises in the NHS, and how long term service is rewarded.

It is pay grade based. You start on a grade that has increments, each year you get more guaranteed. So Grade 7 is 30 - 40 grand. However the grade is also a promotion and the term 'Manager' comes with it.

So sacking your Managers actually means sacking the experienced staff. You don't actually have to manage anything, it just means you have been around a long time and the natural pay rise per year grading system automatically calls you a manager.

Speaking from in the NHS, there are tons of crap managers, tons of overworked managers but nearly all those managers are one person teams. We lost two managers and they weren't replaced because of cut backs during labour. Their work went to other managers with no teams, and so on. If you sack them what then? There are no teams to do the work, you would have to downgrade to new staff and begin the whole cycle again, or miss something important, like stopping people smoking, being healthy in communities, coping in A&E, on the wards or helping babies etc.

You need to thin the top of the tree because now we have split PCT's, two boards of directors (and their expenses) in every borough of this land. 152 PCTs + split to form two, provider and commissioner, with rebranding costs and new boards. Only then to realise they can't afford to stand alone and so now they are all merging to other PCTs in neighbouring boroughs. It is a farce of biblical proportions that labour brought in. Don't sack managers, in doing so you have to accept you WILL lose your most experienced staff, and we are not just talking old timers.

And get rid of NHS procurement, six week lead time for a PC, 3 times the cost for basic IT supplies. Just like BECTA for education, NHS supplies and NHS procurement should be scrapped, not the walk in centres.

They should also make it a requirement for foundation PCT's to go public on their accounts. At the moment they don't have to. Why is that? El reg should be asking these questions of the Torydems.

Anon as you know where I work.

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Alert

So it sounds like.....

...you still have a lot of crap managers floating around doing very litte but earning much?

Like I say my approach is to get rid/suspend of all of them, then you'll find which ones are actually needed and then get those ones that are needed back in.

The ones that never get the call after a couple of weeks or so are let go...for good.

Again I'll state its the non-medically trained managers I'm refering to.

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Anonymous Coward

Yes

Because a nurse is going to be lots of use at managing an IT team... Or doing accounts... or HR etc etc... Thats where allot of the non medical managers come from. Stop living in lala land where matrons walk the wards and do what they want and all is well.

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Anonymous Coward

Actually...

...If you brought back the concept of a matron (or gender non-specific equivalent job title for the PC among you), a lot of hopsital wards would be better run, which would result in massive savings for the NHS due to cost savings from proper stocking of drugs and equipment, and saved (wo)man-hours as doctors don't have to chase down a syringe to trreat a patient because the nurses on the ward have been too busy reading Heat magazine to do their job.

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Anonymous Coward

Creep

There's been something of a slip in NHS Direct's function since it was originally announced. We were originally told that we'd be able to call and speak to a medical professional direct. Great idea, but as usual with anything provided by the government the plan and the execution were poles appart.

I've had occasion to phone them once and the "direct" bit was sadly absent. After struggling with my call for some time the operative finally gave in and told me a doctor would call me back. To be fair the call back was relatively quick, within about half an hour. But the delivery of the service falls a long way short of the delivery. The issue at hand was a child drinking some household cleaning product. By the time the doctor phoned back I had managed to get the required answers elsewhere.

If the plan is to take the load off A&E and out of hours doctors services (as we were originally told) then it really doesn't work, not least because after dealing with NHS Direct once you're not going to bother again. So you'll go back to calling your doctor out of hours or visiting A&E. And no matter what we're told by the meeja about A&E departments and long waiting times I've never experienced any problems in that respect.

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Anonymous Coward

Anymore?

"Always end up at A&E because local doctor surgeries, and even a local hospital, can't even put in a couple of stitches any more."

That's certainly not been a function of your local GP for as long as I've been injuring myself. Stitches have been something that's down to A&E since at least 1970 IME.

As for your local hospital, as I said stitches to wounds are a function of A&E, so if a hospital doesn't have an A&E then they don't do that sort of work. It's hardly rocket science.

Why on earth would you consult your GP or a hospital w/o A&E with an injury requiring that sort of attention anyway?

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Happy

Stitches

My Doctor will stich me up - if I go in opening hours - within 1/2 hour or so (depending how much blood I'm leaking) but that doesn't normally extend to local anasthetic while he does it!

And 20 years back, I was on the West coast of Ireland, and needed stitches on a Sunday night. The Doctor couldn't be found, but the local Vet was in the pub. He did a grand job, but insisted on being paid in Guiness up front.

Only anonymous as you never know where insurance companies lurk.

The wife calls me Disaster Area!

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Happy

Re: Stitches

"The Doctor couldn't be found, but the local Vet was in the pub. He did a grand job, but insisted on being paid in Guiness up front."

Did he "bank" his payment "up front" as well?

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Your GP _should_ stitch you up

If you turn up with a non-urgent wound that requires stitching, but you'd have to wait (or book an appointment). I believe sewing up a wound is covered under both the A and the E of Accident and Emergency, and therefore it's not unreasonable to go to an A+E department to get such treatment, particularly if it's serious and / or out of GP hours.

I appreciate that if you're in the middle of nowhere miles from a hospital with an A+E dept then you might expect that this would be a little more difficult. This is why a lot of GPs in rural areas do things like minor surgery more often than GPs working in cities. However, if you live in a rural area, this is one of the risks you should come to accept - you are further from a hospital where you can get emergency treatment, just like you are further from your nearest Tescos or airport.

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Grenade

@AC Friday 11th June 2010 12:12

This is surely where the whole system needs looking at. Putting in stitches is not rocket science - a nurse can do it, particularly these days when real stitches seem to be rarely used, with Steri-strips and/or glue favoured. Taking up space in an A&E waiting room for something like that is a waste of everyone's time - for a relatively minor thing like that, my A&E would usually have you waiting for at least three hours, unless it has changed recently. A&E needs the range of seriousness reducing - it seems you are familiar with the fact that any given shift can run from bruised fingernails to life-threatening incidents. This is a foolish use of resources, but is perhaps a function of the name - Accident and Emergency. People can claim almost anything is an accident and then take up temporary residence in the local A&E waiting room. Perhaps we need to adopt the American term, call them Emergency departments, and encourage GPs or someone else to take on the accidents.

I'm not sure that I agree with you about the length of time that GPs have not been inserting stitches. In the early 1990s I was with an excellent GP surgery that had decided to do minor ops themselves. Their argument - they have been trained to do these things, why not get and give the benefit of it. It made sense to me then, it makes sense now.

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WTF?

Sub title is a bit iffy

I don't think most GPs want an end to consultants (being the upper tier of hospital doctors), they might want an end to management consultants (being the way to waste large amounts of public money in exchange for shiny documents).

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And don't forget...

... the ridiculous amount spent on truly pointless branding consultants. Why does an NHS hospital need a silly logo and corporate font anyway?

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Grenade

NHS Walk-in Centres

They're loved by the public because the public have no medical training. They're hated by doctors, who do.

Example:

Friend of mine suffering vomiting and diarrhoea went to the local NHS drop-in centre, where they duly drugged her up and appeared the fix the problem.

Problem turned out to be gastroenteritus, a potential lethal bacterial illness. The vomiting and diarrhoea was removing the lethal bacteria from her system; the NHS walk-in divs trapped it inside her.

Result: ten days in hospital, considerably more ill than she needed to be, and damn lucky not to die.

Either staff the damn things with people who know what they're doing, or abolish them altogether.

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GP? Easiest job in the world.

As anecdotal as your story, but here goes.

I went to see my GP four times over the course of about six months, complaining about a wheezy cough that I couldn't shake off and sometimes left me struggling for breath. The GP didn't physically examine me, and told me it wasn't something he was prepared to prescribe for. Finally went to a walk in centre near work, where the doctor expressed concern that I had been physically examined, and sent me for an X-ray of my chest. This showed what looked like a severe infection in both lungs, and I was placed on antibiotics and made to provide a sample of saliva. A week later I was hospitalised after coughing up mouthfuls of blood. Turns out the infection was TB, and thanks to the tardiness of my GP I now have permanent lung damage because it was diagnosed at the acute stage.

I'm now contemplating having the GP done for negligence, as all he seems to care about is seeing as many people he can in the ten hours a week he deigns to spend with patients before he toddles off to play golf. Speaking to friends and family who work in various parts of the NHS, as well as the TB team at the hospital, they all have minimum respect for the GPs who they see being paid vast sums to do very little.

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Normally I would defend GPs

But if the facts are as you state them, that does sound like a clear-cut case of clinical negligence*. Don't tar every GP with the same brush though, and remember, if you live in a town or city, you probably have the option of several different GPs (and surgeries) who you can register with, usually by filling out a simple one-side-of-A4 form.

*IANAL, etc.

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Stop

@TrinityX

Do you seriously think a GP would have done any different initially? They wouldn't. Maybe some antibiotics and "come back if it doesn't get any better".

GPs are unprepared for the unusual, even in the light of campaigns to the public saying "If X, go and see your doctor because you might have Y as a result". Lyme's disease is a case in point - both myself and my wife have been bitten by ticks over the last three or four years, and we have followed the advice to keep the little ba***rd and go to the GP for the appropriate tests. Neither doctor had a clue about Lyme's disease, having to look it up on the computer, and say "Well, I didn't know we had that disease in Britain!"

Doctors are trained to do a "differential diagnosis", which in practice means "Go with the most likely, and if it doesn't get better, try something else". This is fine in most cases, but without the correct information, derived from tests which cost money and time, the most likely may not be what is wrong. A sample of your friend's diarrhoea could have been tested and a more accurate diagnosis given, but there would have been delay, in which case you would still have been complaining.

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Unhappy

My walk-in centre experience

I had an incredible pain in my throat and a sudden loss of my voice, plus at the same time I went nauseous and my colleagues said I looked awful, so off I went to my nearest walk-in centre. Had to wait an hour and a half to be seen, explained (as best as I could with no voice) what had happened, and the doctor examined me. Said he couldn't find anything wrong, but that my blood pressure was giving him "serious cause for concern" and that I should go to see my GP as soon as possible, plus he'd send a fax immediately to them to explain what was wrong (no explanation to me). As for the throat he told me to try Strepsils.

Went to my GP that afternoon in a bit of a panic by now - as you would when a doctor says he is concerned about your blood pressure - and was told by my GP that no fax had arrived so this was news to them, and when they examined me guess what - my blood pressure was perfect. They looked at my throat and said the Strepsils were useless as the problem was laryngeal and the only people who could help me with that were in the ENT and speech therapy departments at my local hospital. This led to a year of speech therapy appointments and numerous laryngoscopy examinations of my vocal cords.

So do I trust walk-in centres anymore? Do I need to answer that?

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Re: My walk-in centre experience

I couldn't disagree more. I had an eye inflammation, which I attempted to make an appointment to see my GP over. The experience was something like:

"The surgery is open from 8am. If this is an emergency dial 999"

*click - redial*

"The surgery is open from 8am. If this is an emergency dial 999"

*click - redial*

(ad infinitum)

*click - redial*

"All our lines are busy. Please call later"

Stuff that, thought I and went to the local Walk-in Centre (at the Hospital I work at!) and was seen within minutes by a nurse, then an eye specialist and given (without having to pay prescription charges) antibiotic ointment.

It had not improved in the 2 days they said to wait, so I re-attended (again with little waiting) and was given oral antibiotics that cleared it up a treat.

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It's the same if you're a hospital doctor

It's impossible to get through to GPs to discuss cases with them.

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FAIL

wasteful GP patient surveys

last went to see my GP over 18 months ago. Every quarter I get a GP patient survey drop on my doormat. what a waste.

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Anonymous Coward

Not to mention GPs...

...whose cost effectiveness is long overdue for a serious investigation. Their salaries seem to be endlessly argued and denied ... but what's undeniable is that earn what the average man in the street would regard as a small fortune. For what, years ago, we could at least expect a level of service beyond office hours and excuses. But no longer.

A couple of years ago, my wife woke my in the middle of the night in severe breathing distress. Took only a glance to see that she was almost certainly in anaphylactic shock. I of course dialled 999, emphasising that this was an extreme emergency. This is a rural area and it took a half hour for the paramedics to reach us. By this time, despite my best efforts she was semi-conscious, but they managed to stabilise her. It was another quarter hour before a doctor arrived. My wife was then rushed the 45 miles to our 'local' general hospital (isn't 'rationalisation of services' wonderful?)

She made a partial recovery, but after a drug mixup by a dyslexic nurse (that lasted days) she developed serious problems she hadn't even gone in with, not to mention that she hadn't been washed in days because she couldn't do it herself. So I discharged, her, brought her home, and spent much of our remaining savings on a private (and competent) nurse.

I wasn't happy about the response times or the subsequent treatment, but all I got when I complained was the usual platitudes. Nor did we ever find out what had caused the attack, even after months of desk-thumping it was clear no-one could be arsed to find out. She was better now - what was my problem?

But my biggest complaint - dismissed out of hand - was about my GPs - 3 of them in a joint practice. At the time they were all slumbering within a mile of my house. Why hadn't one of them been called out? They could have been there in 10 minutes. Simple ... they "weren't on duty" !

Sorry to shout and swear, BUT....

My wife was DYING, and THEY weren't on f...ing DUTY?????? What the hell has medicine descended to in this country?

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FAIL

Why is this a GP issue?

GPs are paid to see people with non life-threatening health problems. This is what they are trained to do. If you spent five years at medical school (which costs tens fo thousands of pounds, out of your own pocket, not from txation) and then had to do a crappy hospital junior job for two years before having to train for a further five years to qualify as a GP, then I don't think it would be unreasonable for you to expect a salary commensurate with your skills and experience. not to mention the risk of liability which you would have to pay thousands of pounds a year to insure yourself against.

GPs work longer hours than the 'man in the street' and have to deal with numerous whining idiots with colds demanding antibiotics.

That said, the situation you describne above with your wife was quite clearly an emergency situation. Hospitals have these places called 'Accident and Emergency' departments where they have the trained staff and equipment to deal with emergenceis that GPs do not. Why should a GP (who has probably just worked twice the hours you do in a week) be called out of bed in order to tell you that your wife has gone into anaphylaxis and requires emergency treatment at a hospital? A GP cannot just turn up and administer drugs you know - they have to be prescribed and issued from a pharmacy by law. Hospitals have such pharmacies, and also have nurses trained to administer those drugs.

Whilst I am sympathetic to your experience of the NHS, I feel too many people unfairly blame thier GPs. Most GPs are incredibly hard working caring professionals. Sure, there is the occasional incompetent example, but you will find this in every profession.

You admit yourself that you live in a rural area - do you seriously expect there to be a hospital with an A+E department on your doorstep? If so, then feel free to pay the taxes to support this yourself, as I don't think others would be so keen to pay for largely unused hospitals in the middle of nowhere.

Yes, the NHS isn't perfect but it really pisses me off when people blame the doctors, many of whom still work above 80 hours a week, often with no breaks during their shifts for such niceties as lunch, despite the fact that it is illegal for the hospitals to expect them to do so. Ironically, people seem to be more sypathetic towards nurses, who are seen as harder working despite the fact that they have a good union, which gets them protected breaks and much shorter hours than doctors.

It used to be that medical professionals got a modicum of respect from their patients, with the recognition that they had trained hard and work long hours in a stressful job where they take the risk on a daily basis of making one mistake which will ruin a patient's life. People who do nothing but complain like yourself seem to think that they have some sort of right to treat doctors like servants because their salaries originate from taxation. Why don't you start trying to treat others with the same respect you would expect yourself?

Disclaimer: I am not a doctor, however my mother was a GP and my father a hospital consultant. I have good friends who are doctors working in the NHS now and they frequently work long hours, rotating shifts, 24h on-calls (where you DO get called out several times a night), etc. For not much more money than I earn doing a 9-5:30 office job.

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Silver badge

At the risk of over-generalising...

... there is no sense of duty instilled in the people who become doctors or nurses any longer. It is a job in which a sense of vocation is regarded as a failing. I stopped working for the NHS several years ago partly because of this.

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Anonymous Coward

Strewth

'Nick Chapman, chief executive of NHS Direct, defended the service which he claimed pays for itself in stopping people from using other NHS resources'

Where the fuck do they find these people? Close it down.

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Flame

Stop talking B*ll*cks about GPs

Declaration of interest, I'm married to one.

My wife leaves the house at 7.15 am and gets back at 7pm. We live 15 mintues from the surgery.

She goes in 2 nights a week to make sure the paperwork's all completed so her patients get good service.

She's getting increasing hacked off with dealing with people who've been lied to by the government about what they can expect from the NHS.

Her practice been told by the PCT to reduce the number of people they send to hospital by 10%. When someone dies as a result of a (for example) cancer misdiagnosis becasue of this target, who will lose their livelihood?

They've been told only to prescribe the cheapest generic drugs regardless of any difference in side effects.

Numpty who said they're paid by the number of consultations they do: tosh.

Numpty who claimed GPs only cared about fitting in the golf: tosh. Have you seen the crap letters hospitals send back with poor documentation and wafty arrogant letters from consultants?

Out-of-hours: There's some serious misunderstandings about this. GPs were given finally given the right to go home to their families of an evening. But they pay for this privilege. Literally, they have to fund it themselves. Which, having worked 12 hour days where they're not allowed to make a mistake or a patient may try and destroy their life, funnily enough, most do. Or worse still a vindictive patient who doesn't like the medical opinion that's been given about them will try and damage their career. (Man above with anaphylactic wife/TB person as well, I'm not saying you're vindictive patients, some are though). Some doctors disagree though and want to out of hours back. So the answer is: It's a bit more complicated than that.

How about patients not bothering to turn up for appointments? Wife had a surgery for 2 hours the other day. Saw 2 patients. 12 were booked. Not a common occurrence, but makes the point.

But when they practice defensive medicine, the PCT will penalise them for looking after their patients properly (see targets mentioned above).

The NHS has problems, but don't go pointing fingers at one part of it. Instead of listening to some of the nonsense here, try this blog to see it from the other side:

http://thejobbingdoctor.blogspot.com/

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Anonymous Coward

Oh deary, deary me!

Hardly worth turning in then, for a measly quarter million p.a.?

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Silver badge

Please point me in the direction

of all these clinical staff earning a quarter of a million pounds p.a. working for the NHS.

Or did you just pluck that figure from your arse?

Admitted, some doctors can earn silly money doing private work, but that's beyond the scope of the NHS somewhat, and if people are prepared to pay for it from their own pockets, let them.

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Stop

Hang on a second....

"NHS Direct ... serves five million people who phone its call centres, ... five million who use its website. ... another five million calls in response to other services ..."

Five million .... Five Million .... Five Million.

That's a little symmetrical. Am I the only one who smells completely made up statistics here????

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"completely made up statistics"

Is there any other kind?

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Unhappy

0845 rates: typical British stealth tax

It's high time that NHS Direct stopped using its rip-off 0845 number that can be prohibitively expensive (40p / minute) when called from mobiles or payphones.

Students and others away from home may not have access to a landline, and few people would want to use a phone in an open-plan office to discuss their medical conditions. And even from landlines, the best rates and discounts are seldom available on 0845 calls.

It should be an 080 number because the NHS is supposed to be free at the point of use, but if that's unrealistic then it should at least be a surcharge-free 03 number.

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Pint

who needs the PCT's?

Having recently joined the world of general practice, I have started to learn about an organization called the primary care trust...hmmm

Their job appears to be to try and renegotiate the contract they did a few years ago.

I suspect they are about to get cut to pieces.

What I want is:

1. open source software which can grow with the NHS

2. some measured risk taking with patient confidentiality.

We make confidential phone calls, send confidential letters and faxes - yet confidential emails are not the main method of communication within the NHS?

I could go on, but I already have!

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Happy

I like NHS Direct

Being able to speak to a doctor in the middle of the night can be helpful when you harbour several Germ Factories.

That's part of what I pay my stamp for. Happy to pay it to the NHS rather than greedy bankers.

As usual the leeches of society are bleeding the Country dry.

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Grenade

"Time to bin Consultants" -Contextual mistake-you foolish boys!

"Time to bin Consultants"

Chaps - it means a different thing in the NHS, these are the top dog professional medics

not the time wasting overpaid, under-skilled IT types.

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Much bollux about GPs here

I'm one.

We don't mostly get salaries - partnerships distribute profits as drawings.

We don't have a cotnract to provide night time services, these are let to other orgnaisations, in some of which some of us work under separate arrangements. We don't pay the PCT to take this off our hands, we were offered 6k a few years ago to provide an "improved" more managed service to what at the time was costing us around 9k per Principal to provide - the NHS admins and gov. of the time wanted to take it over and promised to do it better, cheaper. It isn't cheaper, either. There is a big difference between not accepting an invitation to bid for a service for a fee, and paying someone else to do it, regrettably even some of my colleagues misconstrue it.

If an actual ambulance turns up at an emergency, the crew don't cand wait for a doctor, and especially not a GP. One of the posters may have been attended by a non-technical crew who then waited for a paramedic, or may simply be telling a story tenuously connecte to reality.

And we carry a few drugs around, and can perfectly well give them without having to write prescriptions and have a pharmacist dispense them to the patient.

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