Submission to the Pharmacy Council’s 2015 Code of Ethics Consultation

The Pharmacy Council’s Code of Ethics 2011 appears to be a well written document which puts the wellbeing of the patient front and centre. This can be seen throughout the code, and is embodied in the very first clause:

1.1 Take appropriate steps to optimise medicines-related health outcomes for the patient as a fundamental principle of pharmacy practice.

The existing clause 6.9 of the code gives a good level of protection to patients, in that it states that pharmacies should not supply products where there is a lack of evidence of efficacy.

6.9 Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

In the Pharmacy Council’s Consultation Document, the proposed new wording of clause 6.9 of their Code of Ethics splits healthcare products sold in pharmacies into two broad categories:

  • medicine or herbal remedy
  • complementary therapy or other healthcare product

The reason for this split appears to be an effort to relax the code for the second class of products (complementary therapies and other healthcare products). Effectively, this would remove the code’s requirement for there to be “evidence of efficacy” before these products can be supplied by a pharmacist. Instead, the new code only requires that “sufficient information about the product can be provided”. As it stands, the existing code appears to be in place to protect patients – any weakening of the code is going to reduce this protection, and that can only be a bad thing.

The Pharmacy Council’s vision is “Safe Effective Pharmacy Practice”. We believe this proposed change in the Code of Ethics would compromise the “Effective” part of this vision, by making it more likely for individual pharmacies to sell products that do not meet any reasonable standards of credible evidence, and could therefore be reasonably considered to be ineffective.

In the “Background” section of the consultation document, the Pharmacy Council says:

Over a number of years there has been much debate and discussion regarding the  promotion, supply and sale of complementary and/or alternative medicines by pharmacists. This debate has primarily focussed on the efficacy of these therapies.

Given that most pharmacies appear to sell at least some complementary/alternative health products, we presume that this debate and discussion has been around whether pharmacies should stop selling these unproven remedies. The document goes on to say that “Over the past 12-months the level of sector and public interest has notably increased”.  We are glad to hear that the Pharmacy Council is aware of the concerns people have about the sale of alternative health products, but are concerned that their proposed solution, although it is technically a “fix” for the problem, is a step in the wrong direction.

The Pharmacy Council is faced with the issue of pharmacies’ actions conflicting with their Code of Ethics, and changing the code appears to us to be the wrong choice out of the two obvious options the Council has to choose from to help resolve this conflict. Instead of relaxing their Code of Ethics, we think that the Pharmacy Council should instead consider either putting in place an effective program that is able to ensure pharmacies are abiding by their existing Code of Ethics, or delegate this important function to another organisation that is better suited to the task. We think that a code of ethics that carries no incentive for compliance is not a code that is likely to be adhered to. The following paragraphs show that the existing code has not been followed by what appears to be a significant number of pharmacies, and that there is a need for active management of compliance to the code.

We have a concern that the Pharmacy Council’s expectation that “Pharmacists should be able to advise patients about the general use, current state of evidence, associated effectiveness and any safety issues relating to complementary and/or alternative medicines” is unrealistic given the current state of the pharmacy industry, and as such we tasked people around New Zealand with visiting their local pharmacy to ask about homeopathy. We chose homeopathy because there is a strong scientific consensus that homeopathy has no efficacy beyond the placebo effect, and there is no plausible mechanism of action:

“NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective” – Australia’s National Health and Medical Research Council

“Pharmacists should not sell, recommend, or support the use of homeopathic products” – Royal Australian College of General Practitioners

“PSA does not support the sale of homeopathy products in pharmacy” – Pharmaceutical Society of Australia

“The Royal Pharmaceutical Society believes that there is no evidence from randomised controlled trials for the efficacy of homeopathic products beyond a placebo effect, and no scientific basis for homeopathy“ – UK Royal Pharmaceutical Society

“By providing homeopathy on the NHS and allowing MHRA licensing of products which subsequently appear on pharmacy shelves, the Government runs the risk of endorsing homeopathy as an efficacious system of medicine” – House of Commons Evidence Check

“it’s an ineffective treatment. It’s basically giving a glass of water or a sugar pill to patients, and I think you would consider that unethical” – New Zealand Medical Association Chair

We found that around half of the pharmacies visited had staff that were willing to promote or supply homeopathic products without adequately explaining the current lack of evidence. Worrying statements that were reported to us fell into several broad categories. Firstly, there were recommendations from pharmacy staff:

“It brings the body back into homeostasis”

“I have had a number of people tell me it really helped”

“I asked if it was good – she said that it was very good. I asked if it was effective – she said that they were all effective and that the store sold a lot of those products. I asked if it was as good as prescription medication. She said that the sleeping aids would not knock you right out, but otherwise they were all superior to prescription medication. I asked why they were superior, she said because they can never do any harm and that many prescription remedies cause liver damage and / or addiction.”

“When asked if they were as effective, she said that it has to do with your belief system.”

“When asked how the homeopathic remedy that she could order in for me works she said that it would help my body to heal itself”

“The staff member told me that these products worked, and that science was starting to show this. She dismissed the idea that they only work as well as placebo, and insisted that they have a real effect.”

“I was told by a staff member from behind the prescription counter that homeopathy works, and that its extensive historical use was evidence of this. I was also told that the number of customers they have buying homeopathic products was testament to its efficacy.”

“different to normal medicine but with a mix of ingredients that would help”

“I asked about homeopathic sleep drops on the shelf below and was told they definitely work.”

“The pharmacist told me that the Weleda Cold & Flu remedy would absolutely help with a cold, and with flu symptoms as well. He said that I should take a large initial dose that would help me recover quicker.”

“he has no problem with recommending the Weleda products to customers”

“She said that Arnica was an absolute must-have, and then proceeded to take me to a section and offer me several bottles of different concoctions, all of which ad 9c or 10c after them, which I recognised as the symbol for incredible amounts of dilution”

“The pharmacist confirmed this was a homeopathic product and then started out by saying they had several mothers that swear by this product”

“was recommended a homeopathic sleep remedy”

“I was told that homeopathy would help with a cold, and that it works “holistically”. I was also recommended vitamin C, echinacea and aged garlic to treat the symptoms.”

“Three products were recommended for a cold. I was told it worked for the staff member’s son, better than any other medicine. I was told that echinacea would definitely treat my cold”

“I was told that homeopathic Weleda Echinacea would help lessen the length of a cold, and that homeopathy helps by boosting the immune system. The staff member also tried to sell me high dose vitamin C and a Go-Vir supplement.”

Next were staff members who weren’t sure what homeopathy was (In fairness, some of these pharmacies didn’t stock homeopathy):

“he was almost totally ignorant of the subject and thought it had active ingredients”

“the assistant had little knowledge or awareness about homeopathy thinking this was instead ‘natural’ or ‘herbal’ and directed me to these products instead”

“the younger ones simply had no idea what any of these things were”

“the staff member didn’t really seem to know what I was talking about”

“She said because they were natural, I asked her if she knew what was in them or how they worked. She said she would get her manager”

“the assistant had to ask the Pharmacist as she didn’t know what homeopathy was”

“She said she wasn’t sure, but she thought homeopathic was probably different to natural”

“I was told that there’s no chemicals, and instead it’s plant extracts.”

Several pharmacies were happy to recommend visiting somewhere that would give a more positive outlook on homeopathy and/or a greater range:

“they didn’t stock that product, but I could find it at Health 2000”

“suggested I come back tomorrow when the expert on homoeopathy would be in the shop”

“the assistant had little knowledge about homeopathy and referred me to a natural health food shop”

“if a customer wanted homeopathy products she would refer them to a local homeopathy dispenser”

“She recommended “Health 2000” for a greater selection”

“Suggested Simillimum [a local homeopathic dispensary] if I was after homeopathy”

“I was redirected to a local spiritual/natural health store for more range, and told that I would get good advice there.”

The full text of the reports we received accompanies this submission.

It seems that some pharmacies did not stock homeopathy, but a significant number of others did have homeopathic products on their shelves and in most of these pharmacies staff were willing to offer homeopathy as a viable treatment, with no information offered about a lack of efficacy. It was only on further probing that a subset of these staff members were then willing to share their thoughts that homeopathy isn’t generally understood to be effective.

In the main, the reports we received painted a picture that many pharmacies are selling ineffective health products, and that staff are either reluctant to speak their mind about their lack of efficacy or have a mistaken belief that it works. This is echoed by a recent statement attributed to the Pharmacy Council’s chairman:

Pharmacy Council chairman Dr Andrew Bary said the rules as they stood were “unworkable” and many pharmacists, including himself, were already selling complementary medicines, even if they didn’t believe their claims.

This statement concerns us as it suggests that even the head of the Pharmacy Council does not take the Council’s Code of Ethics seriously. With the code being an important patient protection mechanism, we’re disappointed to see it so readily disregarded.

Given the evidence we collected of pharmacies offering not just homeopathy, but also other unproven treatments, we wonder if it would be wise for the Pharmacy Council to consider running their own “secret shopper” visits to New Zealand pharmacies to ensure a consistent high standard of service.

As well as these pharmacy visits, a quick search of New Zealand pharmacies online showed a worrying number of pharmacies outright promoting homeopathy for sale. Examples of homeopathy being promoted by these pharmacies online are:

“A popular service we provide are concise acute homeopathic consultations”

“a range of homeopathic medicines to treat a wide range of illnesses and concerns”

“Homeopathic remedies offer gentle solutions to common complaints without the nasty side effects of many drugs”

“an all-natural allergen-free homoeopathic formula that provides soothing support for wind, colic, upset stomach, bloating and hiccups”

“[Homeopathic] tablets help the body cope with tobacco cravings and are a useful substitute for cigarettes”

“Weleda ARNICA 30C… Used to treat bruising and sprains”

“Treatments such as homeopathy… may be great avenues to consider if you’re suffering from chronic illness.”

More information about these websites accompanies this submission.

Pharmacies are in a privileged position in today’s healthcare industry, where the advice of pharmacy staff is trusted by patients. This position has been well earned, with a long history of highly trained professional pharmacists and other pharmacy staff giving valuable advice to patients. The Pharmacy Council’s Code of Ethics says as much in the introduction to Principle 6:

Patients, colleagues and the public place their trust in you as a pharmacy professional.

This trust will inevitably extend to the products on a pharmacy’s shelves – many people will believe that if a pharmacy is selling a product, there must be good evidence of efficacy. People will assume that because pharmacists are known to have the best interests of their patients at heart, they would not be willing to supply anything lacking in clinical evidence of efficacy.

The Pharmacy Council consultation document clearly states that:

In instances where there is credible evidence to suggest a specific complementary and/or alternative medicine/product lacks efficacy, pharmacists should not promote or recommend its use.

We agree with this, and think that it would make a valuable addition to the code if “supply” is added. This paragraph regarding products where there is evidence of a lack of efficacy would make a good counterpoint to the existing clause, which talks of products with a lack of evidence of efficacy.

Additionally, as a part of this new clause, we would like to see provision for either the Pharmacy Council or another related body to maintain a list of classes of products where it is deemed that there is credible evidence of a lack of efficacy. This list would both help pharmacies to avoid unintentionally breaching the Council’s code of ethics, and would save individual pharmacists having to do their own time consuming research into these products. It is much more efficient, and would be a much more robust solution, if this research was performed once by a group of experts under the care of the Pharmacy Council, and that information was then shared with all pharmacies.

The document says that “It is not Council’s intention to endorse or prohibit the supply of any particular complementary and/or alternative medicine or product”. Whereas we understand that not endorsing a product is a wise stance, prohibiting the supply of products or classes of products that are ineffective, or even just recommending that pharmacies refrain from supplying them, would seem like a good way to ensure that pharmacies can easily abide by their Code of Ethics without having to try to figure out the Pharmacy Council’s intention. We support any measures the Pharmacy Council take that will make it easier for pharmacies to interpret the Council’s various codes, and it seems obvious that there is a need for clarity regarding clause 6.9 of the Code of Ethics.

Finally, the Council’s consultation document says that “Pharmacists must also respect patients’ rights to freedom of choice or autonomy in relation to their treatment options”. We hope that the Council understands that people’s freedom of choice would not be removed if pharmacies stopped selling unproven treatments. There are many other avenues in New Zealand where patients would continue to be able to purchase these products. As an example, pharmacies generally don’t sell therapeutic magnetic bracelets, as these are considered not to be efficacious, but they are still available for New Zealanders to buy at alternative health stores and online sites.

In conclusion, we do not support the Council’s wording of the proposed supplementary clause to section 6.9 of the Pharmacy Council Code of Ethics 2011. We are concerned with the Council’s motivation for making this change, and would prefer to see the current wording both kept and enforced. We would also like to see a different supplementary clause (6.9b) to the Council’s suggested clause added:

6.9a Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

6.9b Do not purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is credible evidence to suggest it lacks efficacy. A current list of these categories of products can be found <on the Pharmacy Council website / at / in Appendix X>.

This submission has been prepared by the NZ Skeptics, and is approved by its Committee:

  • Mark Honeychurch
  • Barry Lennox
  • Keith Garratt
  • Matt Beavan
  • Daniel Ryan
  • Michael Edmonds
  • Lisa Taylor
  • Robert Woolf
  • David Riddell
  • Brad MacClure
  • Vicki Hyde
  • Craig Shearer

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