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acquaintances, friends), in deliberating their healthcare. Somerespondents reported having views of their health that differedfrom their doctors; many were resistant to medications. However,they infrequently communicated their views to doctors or pharma-cists. In reference to a variety of health conditions that they couldor could not explain, respondents resisted (not always success-fully) the ‘sick role’, and focused their health-seeking activities onmaintaining coveted social roles in retirement, leisure and family.All study participants reported the negotiation of medicines – cau-tious use or refusal and resistance towards medicines – particu-larly those whose purpose or effect was unclear. Access to ‘free’drugs enhanced some respondents’ willingness to try them.

Our stories of the negotiation of medicines, as depicted inelderly Chinese respondents’ health and illness narratives,reflect the conceptual idea of the ‘pharmaceutical person’. Indepicting a particular (self-directed) type of patient, these nar-ratives suggest specific implications for the healthcare profes-sional. Rather than assuming or expecting elderly patients tobe obedient or compliant – an unspoken assumption, accord-ing to our participants – the clinician needs to consider how touse their consultation and examination moments with elderlypatients to help them reach medication-taking decisions thatare optimal in the broader context of their lives.

1 Ballantyne PJ, Clarke PJ, Marshman JA, Victor JC, FisherJE. Use of prescribed and non-prescribed medicines bythe elderly: implications for who chooses, who pays andwho monitors the risks of medicines. Int J Pharm Pract2000;13:133–40.

2 Lumme-Sandt K, Virtanen P. Older people in the field ofmedication. Sociol Health Illness 2000;24:285–304.

3 Horne R, Graupner L, Frost S, Weinman J, Wright SM,Hankins M. Medicine in a multi-cultural society: theeffect of cultural background on beliefs about medica-tions. Soc Sci Med 2004;59:1307–13.

4 Martin E. The pharmaceutical person. Biosocieties2006;1:273–87.

Ethics: Professional, Practice and Research

22 Misconduct: the pitfall of pharmacy practice

B Chaar and J Penm

Faculty of Pharmacy, The University of Sydney, Sydney, Australia. E-mail: [email protected]

The public in general has great trust in healthcare profession-als to act in their best interests at all times. In Australia, doc-tors, nurses and pharmacists are considered the mosttrustworthy professions. This trust is upheld by professionalethics and is of crucial importance to healthcare professionalsand the broader society that supports them. Professional mis-conduct can jeopardise this trust and should be minimised toensure that patient health and well-being is not compromised.This research seeks to identify the issues surrounding profes-sional misconduct in pharmacy. The aim of this study was toidentify parameters of professional misconduct in pharmacyin Australia, and analyse the most common types of miscon-duct in Australia, with particular focus on characteristics ofpharmacists who transgressed and their justifications forcommitting misconduct.

Definitions of misconduct were identified from all PharmacyActs in Australia and compared. Disciplinary hearingsbrought before the Pharmacy Boards in Australia from1990–2002 were collected. Demographics of the pharmacistsinvolved and details of the cases were entered into a database.The reasons given for committing professional misconductwere subjected to qualitative analysis using the groundedtheory method, with the assistance of NVivo 7 software.

Professional misconduct was defined using general terms: lackof skill, experience, knowledge, care and judgement, but varia-tions were detected between states. Cases of misconduct in Aus-tralia from 1990 to 2002 were collected; 195 of them wereadjudged guilty of misconduct. Of the cases that provided ade-quate detail, the majority of pharmacists were male (89%) and aproprietor (68%), and the misconduct occurred in the commu-nity setting (97%). The most common type of misconduct wasinappropriate supply of medications, followed by inadequatewritten records. Reasons cited for committing misconduct werehuman error, lack of pharmacy practice knowledge, manage-ment skills, personal issues and intentional transgression.

Pharmacy Boards have considerable powers in defining pro-fessional misconduct according to Pharmacy Acts in each ofthe states and territories of Australia. A number of variationsin the definition of professional misconduct were detected.These variations impact on the interpretation and understand-ing of professional misconduct in pharmacy. More specificand unified definitions may be required to ensure that all phar-macists are consistently aware of the definition and understandthe implications of professional misconduct in pharmacy

Discussion

References

Introduction

Methods

Results

Discussion

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across the board. It appears that the majority of misconductoccurred unintentionally. Punishing individuals who do notintentionally transgress generally promotes defensive changesand hinders the reporting of future mistakes. Instead, a sys-tems approach that includes support programmes for impair-ment of any type could be adopted to minimise misconductfrom occurring in the future and maintain the public’s trust. Asthe roles of pharmacists continue to expand, it is increasinglyimportant that pharmacy takes measure of the ethics and regu-lation of the healthcare services it provides. Professional mis-conduct, one of the major pitfalls of pharmacy practice, maybe minimised by adopting recommendations such as unifica-tion of the definition of misconduct in legislations, and asystems approach to reporting and handling of misconduct.

23 Good governance for medicines in Thailand: situation assessment and policy implications

N Kiatying-Angsulee and W Sripateth

Social Pharmacy Research Unit, Chulalongkorn University, Bangkok, Thailand. E-mail: [email protected]

The World Health Organization (WHO) has launched the GoodGovernance for Medicines project, with three phases to be imple-mented between 2005 and 2009. Thailand was invited to partici-pate from the first phase together with three other countries.

This study aims to provide a comprehensive picture of the levelof transparency and potential vulnerability to corruption of threepharmaceutical functions in Thailand; namely, registration,selection and procurement, using the WHO scoring system. Theresults are intended to guide improvements in the system.

Three assessment tools were developed using a participatoryapproach coordinated by the WHO, and were used by all fourcountries including Thailand. The quantitative instrument withthree questionnaires was used by two independent nationalassessors for each country during November 2004. Keyinformants were persons who had a stake or interest in pharma-ceutical systems and who were involved in the drug registra-tion, selection and procurement process. Altogether 36 personswere interviewed. Documentation was collected and analysedqualitatively as supportive evidence. Calculation of rating

scores was performed using WHO-developed scales. A work-shop was held afterwards to report the assessment and providefeedback for preparation of a national ethical framework.

The overall score for Thailand was 7.4, which meant marginallyvulnerable to corruption. According to the WHO’s proposal, arange of scoring between 6.1 and 8.0 represented marginallyvulnerable. The decision area corresponding to drug registrationreceived an average indicator score of 7.0, also indicating mar-ginally vulnerable. Essential drug selection obtained the highestrating of all three areas, earning 8.0, indicating marginally vul-nerable with a higher level of transparency. The score of 7.1 inthe area of procurement indicated marginally vulnerable. Threecase studies performed supported the rating score.

The Essential Drug List (EDL) selection in Thailand showsthe highest score for ethical practice, with recent changes inthe EDL process an attempt to make the process transparent.Some relevant factors involved in the pharmaceutical systemincluded political power, technocratic and bureaucraticpower, and medical professional power. Registration andselection in Thailand are centralised processes but procure-ment is not centralised. Each health facility, after an allocatedbudget by the Ministry of Public Health, has the authority topurchase medical products. Different practices make it diffi-cult to average the score. It was thus suggested that law andregulation should be revisited and updated continuously.Registration needs attention on the conflict-of-interest decla-ration. Monitoring and enforcement are two critical processesthat need to be strengthened in all areas and levels. Informa-tion to all stakeholders is a necessary process for successfulimplementation.

24 Dispensing to the elderly in a New Zealand town: too much or too little?

S Horsburgh1, P Norris1, G Becket2, B Arroll3, J Cumming4 and P Herbison5

1School of Pharmacy, University of Otago, Dunedin, New Zealand, 2School of Pharmacy and Pharmaceutical Sciences, University of Central Lancashire, Preston, UK, 3General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand, 4Health Services Research Centre, Victoria, University of Wellington, Wellington, New Zealand and 5Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. E-mail: [email protected]

Introduction

Aims

Methods

Results

Discussion

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Pharmacy dispensing databases are a rich source of dispens-ing information. In New Zealand they provide the only practi-cable means for obtaining data on all dispensings regardlessof state subsidisation.1 Unpublished data in New Zealand(from the Best Practice Advisory Committee) indicate thatthe number of medicines taken by older adults is on averagegreater than the number taken by adults at other ages. Thiscarries important health implications, as the risk of adverseeffects increases with the number of medicines taken. Thereis also international evidence to suggest that older adults areover-dispensed some medicines and under-dispensed othersrelative to actual need.2,3

This report uses data collected from pharmacy dispensing data-bases with the objectives of identifying whether (1) older adultsare dispensed more medicines on average and (2) the dispensingof specific medicines reflects need in the older adult population.

A moderate-sized New Zealand town (population 32 000)with good variation in ethnicity and socioeconomic statuswas selected. The town was also chosen because it was morethan an hour’s drive to the nearest other town with a phar-macy, making it likely that nearly all of the residents’ pre-scription medicines would have been dispensed bypharmacies in that town. Dispensings to patients in the sur-rounding rural areas (population 12 000) were also likely tobe captured due to the distance to the nearest other town witha pharmacy. All of the town’s community pharmacies and thehospital pharmacy were approached and agreed to supplydata from their dispensing computers for the period 1 October2005–30 October 2006. Data from these pharmacies weredownloaded and imported into a database for cleaning andanalysis. Records from the dispensing databases includedinformation on patient demographics (name, age, date ofbirth, address, National Health Index number) and the typeand dosages of medicines dispensed. Age stratum-specificpopulation counts from the 2006 Census were obtained fromthe Statistics New Zealand website.

A total of 654 743 dispensing records were obtained. Ofthese, 16 540 (3%) were dispensings for Practitioner SupplyOrders and veterinarians. Removing these left 638 203 dis-pensing records. Of these dispensing records, 589 417 (92%)had a valid age. The following table summarises the numberof dispensing by age stratum, as well as the unadjustednumber of dispensings per area resident.

The analyses support previous unpublished findingsthat older adults do receive more medicines on average,with the number of medicines dispensed increasingsharply with age. They are preliminary analyses, however,and will be refined further to adjust for confounding bysuch factors as gender and to assess concurrent medicinedispensing in older adults. The results from analysesof the types of medicines dispensed will also bepresented.

1 Ryan K, Norris P, Becket G. Capturing data on medicinesusage: the potential of community pharmacy databases. NZ Med J 2005;118:223.

2 DeWilde S, Carey IM, Bremner SA, Richards N, HiltonSR, Cook DG. Evolution of statin prescribing1994-2001: a case of ageism but not sexism? Heart2003;89:417–21.

3 Gaw A. The care gap: under use of statin therapy in theelderly. Int J Clin Pract 2004;58:777–85.

Medicines: Cost, Quality and Access (ii)

25 Are generic medicines in Europe too expensive?

S Simoens

Katholieke Universiteit Leuven, Leuven, Belgium. E-mail: [email protected]

Little is currently known about how prices of generic medi-cines are set and how these vary between European countries.The aim of this study is two-fold. First, to carry out an

Introduction

Aims

Methods

Results

Age stratum Number of dispensings

Percentage of overall dispensings

Dispensings per area resident

0–14 53 573 9% 5 15–29 36 784 6% 5 30–44 59 342 10% 7 45–59 111 106 19% 13 60–74 160 342 27% 33 75+ 168 270 29% 69 Total 589 417 100% 13

Discussion

References

Introduction

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ethics: professional, practice and research

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