Ethnographic account of multicompartment compliance aids (MCCA)/dosette preparation in Willow Pharmacy

Willow Pharmacy is the ‘dosette hub’ for the Woodland Independent Pharmacy group. The work of preparing dosettes is called ‘being on production’ and is a technology-supported routine involving a full-time dosette robot and its human co-workers, typically three pharmacy technicians, also working full-time to ensure supply keeps up with demand. The robot cannot work unsupervised and needs constant attention. Demand for dosettes is increasing every month, as displayed on a handwritten poster on the wall in the ‘production area’ where a running tally is kept. The pharmacy technicians are engaged in a constant, well-coordinated round of stocktaking, ‘de-blistering’ drugs, ‘replenishing’ the robot and running each production session. Deblistering is the process by which the staff prepare the medicines for the robot, as it cannot process medicines from their original packs. Pills are ‘popped’ out, one by one, from their blister packaging into containers which slide into the robot. Some staff use a deblistering machine for this, pulling a large metal lever to press the pills out of their packets into interim containers for checking by the pharmacist prior to replenishment. Others do it manually. Technicians work at speed and use a wide range of technologies including: computer programmes; Excel spreadsheets, often printed out; written log books; printed cards; scribbled post-it notes. All contribute to maintaining the smooth flow of routines and a sense of predictability as they generate dosettes in 4-weekly batches ready to stack on the shelves awaiting final checking. Medicines are referred to as ‘fast lines’ (ie, there is a lot of demand for them by the pharmacy’s clients) or ‘slow lines’ (ie, less demand). This categorisation is an important component of decision-making regarding whether a particular medicine warrants inclusion in the robot. ‘Slow lines’ may be designated ‘externals’ (meaning that the medicine is added to a dosette box by hand once the robot has done its job). The integrity of medicines may be at risk if they are left out of their packaging for too long. Expensive lines are also dealt with as ‘externals’ so that the pharmacy can remain agile in its response to market price fluctuations. Despite everyone’s best efforts to rationalise production, there are inevitably plenty of exceptions and contingencies to deal with. We often see filled dosettes recovered again from the shelves as staff attend to unanticipated changes in patients’ prescriptions. This entails a painstaking process of using tweezers as a tool to isolate, break off and remove the backing from relevant cells of the dosette, then carefully removing and/or adding the relevant medicines, sealing the cell up again and attending to all the associated paperwork and electronic documentation. If the technician in the ‘dosette corner’ receives too many requests for changes of this kind to the contents of dosettes in quick succession, the job quickly becomes very stressful.

Vignette of Marco

Marco is a retired chef. His narrative begins over 10 years ago at age 60 when he was diagnosed with diabetes and then with a ‘cardiac problem’ which led to him having major surgery. He lives in an owner-occupied flat on the top floor of a low rise block in a deprived inner city area. We usually sit outside on his covered balcony when I visit; he smokes cigarettes and sips ‘real’ coffee (‘life’s little luxuries’) as he talks.

He tells me about his blackouts, painful joints, lack of youthful energy and strength, fingers which get sore from finger prick tests (which he tactfully avoids except in the week before his diabetes check-up), and his warfarin levels which ‘go up and down like a bloody yo-yo’. He has no upper teeth and his dentures don’t fit as he is awaiting dental treatment, so despite his fondness for cooking, eating is difficult.

Marco displays a sense of resignation about his ill health (‘I don’t bother the doctor with everything—what can they do?’). He is prescribed 15 items of medication but has not seen his GP for three years, although he attends the surgery regularly for nurse-led diabetes checks and warfarin monitoring blood tests (‘a nuisance’). His medicines mean ‘survival…I have to take them for life to keep me alive’ but at the same time they ‘get on my nerves’ and ‘I wouldn’t take any of them by choice…but I don’t have any choice.’

Marco’s pharmacist offered to package his medicines into a MCCA and deliver them direct to his flat, but he declined:

‘Sometimes you’re offered a service but it doesn’t mean you really need that service, you know what I mean? I can do it myself, it gives me a little exercise…it can wait a little while before I need the service…I can do it myself now.’

He continues:

‘There’s a couple of people in this block I noticed they have it [their medicines] delivered; they have this delivered, that delivered, when they’re capable and it would be good for them to go around there and get it, you know?’ He goes on: ‘sometimes it’s just laziness.’

I soon learn that Marco’s friend Vicky helps him organise his medicines, though he tells me repeatedly that he could easily manage himself. Vicky is in her 40’s and visits every day; she sometimes answers the phone when I call. She prepares his Do-It-Yourself [DIY] cassette-type MCCA on Sundays at a frequency that depends on the results of Marco’s warfarin monitoring [International Normalised Ratio or INR]. If his INR is stable she may prepare four weeks at once. After all, Marco says ‘you don’t want to be undoing it all again do you? It would be nuisance’. Vicky also prompts him to order his medication from his GP using an online service when supplies are low. Marco says he knows ‘roughly’ what his tablets are, although a video-recording of one of his clinical consultations with his GP casts some doubt on how well he knows them by either name or purpose. Warfarin and insulin are the only medications he ever refers to by name—the others he knows by condition (diabetes, blood pressure), shape and size (the ‘big one’), time of day (the ‘night one’, or organ (‘heart’). This knowledge is adequate for his organisational purposes.

Marco explains that the DIY MCCA he uses currently is bigger than previous models he has tried—his medicines outgrew the smaller versions. The cassette consists of a stack of seven rectangular boxes labelled by day of the week. He takes the ‘Monday’ box from the bottom, causing the others to slide downwards within the supporting rack. There are 12 pills distributed across the four cells but each day he shifts the ‘midday’ ones that Vicky has prepared into the ‘morning’ cell (any time from 10 am until 1pm, it turns out) and shifts the ‘teatime’ ones into the ‘evening’ cell; two rounds of medicine-taking is easier than four. It seems that Vicky feels obliged to organise them as the prescription dictates, leaving Marco free to take responsibility for his personal re-organisation. He tries to take his evening medicines 20 minutes before eating but if he forgets—which he admits he sometimes does—he takes them two hours after eating ‘or thereabouts’. He finds it ‘very, very annoying’ that his medicines change in shape and colour so often, especially as he is colour blind and colours are confusing at best of times. His insulin pen sits on the coffee table, with extra supplies in the fridge. He keeps three inhalers in a ‘Man Tin’. There is a glyceryl trinitrate (GTN) spray by the bed ‘just in case my heart starts messing around’ and he adds ‘it comes out with me all the time’. In addition, he keeps a basket in the bathroom where:

‘I do accumulate a little surplus, but I try not to, not so much, you know, just a little bit so it gives me an extra three or four days, besides what they give me, you know?… But I don’t have a massive supply, because what happens is if she [the GP] changes one of them in strength and they won’t take the tablets back or anything back… only a few, not stocking up, you know.’

He retrieves his warfarin paperwork which is tucked behind an ornament on the mantelpiece. He points to the date of his next appointment in 1 weeks’ time. He explains he has to take his ‘yellow book’ to the surgery every time he needs a prescription for warfarin; this requirement doesn’t align well with the electronic routines now in place for ordering medicines online and transferring prescriptions between his GP and pharmacist.

On a later visit, Marco shares a poignant story about Vicky. When he met her a few years ago she was unable to manage her money, was overspending and not caring for herself. Marco bought her a tin, with two compartments—one for ‘this week’s’ money and one for ‘next week’s’ money—a kind of ‘financial compliance aid’ and has helped her ‘get on her feet’ financially. Marco told me that he had advised Vicky that ‘it is easy to live a life in which you just don’t care about anything. It is harder to live a life in which you care.’

Vignette of Jackie

Jackie was diagnosed with a lifelong neurological condition as a teenager when she spent a year in hospital unable to walk. Her complex biography includes a stillbirth, a prolonged episode of severe loss of vision from which she recovered, numerous operations, diabetes, domestic abuse, two marriages. Now in her 70s she has ongoing chronic pain.

Jackie lives in social housing with her son and is prescribed 11 items of regular medication. She begins our interview by dropping her medicines accidentally on the floor. It is not unusual for us to find pills on the carpets when we visit our research participants; they are often clearly beyond their reach. With some difficulty Jackie manages to retrieve them and explains ‘I take a metformin and something that goes with the metformin beginning with an ‘A’—it’s on my list somewhere—they go together in the morning’. She refers to the ‘thing that goes with the metformin’ four times during our interview and I conclude this is how she ‘knows’ and remembers it, though I later learn it is also ‘the orange thing’. She tells me ‘I like to get them down my throat as quick as I can, because some of them have got some horrible taste to them…powdery, at the back of your throat, they lay there’. She explains that the bad taste stays for about an hour. She goes on: ‘In the evening, I take a metformin after a meal, on its own, and then—about no later than 10 o’clock—I take a co-codamol and carbamazepine and something beginning with ‘E’ which is a cholesterol tablet. And then just before I go to bed I take my diazepam to stop me shaking in the night’. Through the day, she is also guided by her pain, adjusting her medications ‘according to how the pain is’ and she has other medicines which she takes to reduce the ‘acid’—a symptom she attributes to ‘taking so many of them [medicines]’. And then, there are the ‘terrible’ eye drops which she cannot manage independently because of the effects of her neurological condition on her hands:

‘I can hardly get them into my eyes. It’s terrible. My son has to do it, because whenever anyone comes near my eye I shut it. And I said ‘how long’s that for? and she [the GP] said ‘for life’.

She thinks she is supposed to have her eye drops four times a day but as her son goes out to work at 06:45 there is no one to help with them during the day. A neighbour has offered but Jackie doesn’t want to ‘keep bothering people’.

Jackie has a faded, well-used, Do-It-Yourself MCCA—one compartment per day, the days of the week now barely visible on the lid. David, her son, fills it every Sunday. She explains that she has got it out for me to see, but usually it’s kept ‘out of the way’ in the kitchen. Each compartment contains eight tablets (five separate items of medication). Jackie selects her tablets from each single compartment four times per day, choosing them by shape and colour. She is unsure of some of their names but, like Marco, she recognises them by their material properties. She is more than capable of filling this box herself, but David takes pride in helping with this crucial technical aspect of Jackie’s care and she is grateful that ‘I’ve got somebody keeping an eye on me’. His role in helping her with her medicines management affirms his responsibility towards her as her official carer, alongside the more personal, hands-on aspects of her care, such as turning her most nights when she calls for him as she gets stiffness and spasms in her legs.

Although it is fiddly, Jackie manages to empty her ‘as required’ medicines (she calls them ‘her spare ones’) from their blister packaging herself, and puts them together in a separate small ‘spare tin’: co-codamol for pain, prochlorperazine for dizziness and omeprazole for indigestion (a pill which degrades outside its original packing). Like her regular medication in her DIY MCCA the different ‘spares’ are mixed together. When we visit, this tin is in the kitchen, but it accompanies her to bed at night and fits neatly in her handbag for trips outdoors.

In addition, Jackie has a basket under her bed where she keeps tablets in their original packs. This is where she places medicines when they are delivered to her house by the pharmacy, and she tries to anticipate her needs by staying about month ahead. She monitors her basket daily when she gets up and when she goes to bed, and calls the pharmacist on her mobile phone direct from her bed when she recognises her supplies are low. By keeping them under her bed and checking them daily she knows she won’t ‘get to a stage, I’d think Oh My God, I’ve got no tablets’. She tries to strike a compromise between running out of medication and falling foul of the rather stark warning on the repeat prescription list she has from her doctor’s surgery which reads: ‘Don’t stock-pile medicine at home—only order what you need’. Like her MCCA, she keeps these medicines ‘out of my way all day because they are upstairs’. She prefers her medicines to be out of sight when she is not dealing directly with them.

Jackie speaks fondly of her local pharmacy and says they ‘know me, because they call me Jackie, so they know me really well’. But she complains that ‘they [the medicines] never all run out together. It’s a nightmare. I feel as though I am permanently ringing up the chemist for my tablets’. We ask Jackie if there is one thing she could change about her medicines what would this be. Without hesitation she replies ‘Not take any of them!’

Vignette of Zac

Zac, who is almost 90 is a retired secondary school teacher. He has lots of friends, is active in his church and serves his local community by running errands and cooking for people frailer than he. He tells me he derives great satisfaction from helping others. He adopts a dutiful, independent approach to his medicines and often talks about being a ‘good’ patient—‘my doctor tells me that I’m one of her best patients because I seem to do the right things, eat the right things and take the medication’. He tells me that people cannot believe he is the age he is: ‘It is my education and my faith that have got me through…and I look after myself’.

He keeps a three-month supply of medicines in a carrier bag by his armchair in his living room. Every Saturday, without fail, he organises his medicines for the following week. He lines up his morning and evening tablets, and puts them into 14 separate small plastic bags, wrapped inside tissue paper. He then puts them into his trouser pockets: left pocket for morning tablets and right pocket for evening tablets. He keeps a whole week’s supply here, taking a packet from each pocket every morning and evening. The system works well for Zac. His medicines are high priority, kept close to his person and his busy lifestyle need not interrupt his medicines taking—nor vice versa; he can keep religiously to his schedule wherever he happens to be.

Like Marco, Zac has been offered a pharmacy-prepared MCCA and has resisted (‘as long as I have my faculties’). He heard on the news that people make mistakes with the doses of medication in these boxes; he doesn’t want anyone ‘mixing things up’ and his ‘brain is turning over well’.

A few months later, Zac is admitted to hospital. Some of his diabetes pills are stopped, he is advised to start insulin injections and he now receives a weekly MCCA. No one discussed the MCCA with him and he is unhappy about it, protesting ‘while I am capable I want to do it myself’. He now feels ‘on edge’ every Wednesday and stays in his flat waiting for his medicines to drop through the letterbox. On one occasion they did not arrive until after 7 pm, after his pharmacy’s advertised closing time and he became extremely worried. On another, he noticed the ‘cholesterol medicine’ was missing. In our cultural probe activity (‘wishful thinking’) he explains that he wishes he could have a conversation with his GP about going back to his old system, adding ‘I want to be in control of my own destiny’. He wants to be free to go out and dislikes the weekly round of anxiety that he may run out of pills. He walked to the surgery several times hoping to secure an appointment to discuss this, only to be told there were no appointments.

Several months passed, before we observed a clinical consultation between Zac and his GP. Zac explained ‘I’m not very happy with the dosette box… they restrict me in my work and my movement.’ The GP explained that Zac could have more than one box delivered at a time and promptly arranged this with the practice administrator responsible for MCCAs. Zac continued cautiously: ‘I’m not particularly keen on dosette boxes. I’m quite careful about medicines’ but the GP did not get to the bottom of Zac’s concern.

In a conversation after the appointment, Zac explained to us that pharmacists can make mistakes with the medicines ‘so you still have to check that they’ve done it properly’, suggesting that he did not feel relieved of the organisational burden but had lost the sense of control and freedom that he enjoyed before. He complained that sometimes he can’t recognise the tablets now because the brands change and went on to say that people who like dosettes are ‘taking the easy route’.

We realise his diligence is being undermined and he speculates ‘maybe they thought now I’m over 80 I can’t manage?’ He tells us he will try out the ‘four weekly dosettes’ then go back to the GP again and ask ‘why I even need to be on them [the dosettes]’. Several months later in our final discussion with Zac, before the end of our data collection period, he had yet to have this conversation with his GP.