The storm over the morning-after pill - what is the discussion about? Episode 48

Monika Rachtan
The debate about the morning-after pill is still going on in the media. Today, I invited Piotr Merks, who is somewhat responsible for the confusion that has appeared in the media, to the programme "Patient First". Hi Piotr, a very warm welcome to you.

Peter Merks
Good morning, I freely admit.

Monika Rachtan
Tell me, as a pharmacist, are you happy that the morning-after pill has been given a bit to pharmacists?

Peter Merks
For years, I have been fighting for pharmacists to have more and more responsibilities and relevant competences, so that when facing new systemic challenges, they become an integral part of the health care system. This has been my mission for 20 years.

Monika Rachtan
You seem to be an ambitious pharmacist who has toured the world to see what pharmaceutical care looks like globally. Did you return to Poland with such a mission to drive change?

Peter Merks
Exactly so. I mainly tried to look for recognised role models and world experts, under whose wings I could and still do create a completely new perception of the profession in Poland.
Monika Rachtan
I am pleased that the morning-after pill has been put into the hands of pharmacists. How has the pharmaceutical community and patients reacted to this news?

Peter Merks
This is a great question, because both the pharmaceutical community and patients have reacted quite specifically. To be honest, I expected such a reaction, because in Poland we often don't know how it works in other countries.

Monika Rachtan
And how does it work in other countries?

Peter Merks
As Poland, a Christian country, we are very conservative. I spent many years in the UK, where sexuality and reproductive health issues are treated very liberally. The same is true in other countries, such as Australia, Canada and Finland, which are liberal on these issues. In Poland, we are only beginning to move in this direction, which I think is absolutely right. The world is changing, which can be seen on platforms such as Netflix, where sexuality is openly treated. We cannot ignore this trend, whether we like it or not.

Peter Merks
Recently someone told me that statistically, every Pole who has started a sexual life has an average of 4.82 partners. So if we count that, it comes out as if there are eighty. So that's what it looks like.
Monika Rachtan
So this tablet is such a seed for a conversation about sex education, about how we should live this sex life so that we are safe. Is that what you think?

Peter Merks
Because, after all, sexuality is not just about getting pregnant. Sexuality is what I feel is completely silenced. Sexually transmitted diseases. This is a very undeveloped topic. You don't talk, you don't talk about chlamydia, you don't talk about gonorrhoea, you don't talk about HIV. How many patients a year in Poland, right? Well, they catch colloquially any of these infections or viral diseases that are terrible in their way, which is HIV. So it's a problem. And now can we afford to? It seems to me that right now is the perfect time to start a debate through exactly the pill, the day after to start the topic of another sex education.

Monika Rachtan
But you also said that we in Poland don't talk about sex, that we are afraid of this subject, that we treat the morning-after pill as something bad. And it seems to me, however, that the women's strike, that we want the right to have a legal abortion, and not when our pregnancy is endangered or when it is a threat to our life and health, but when it is healthy. But simply we want to decide that we want to terminate this pregnancy, how can we not be ready to talk about sex when we want to make such serious decisions? And on the other hand. I don't know if I'm looking at some other reality.

Peter Merks
Everything must be approached sensibly, wisely and practically. Also to sex life, because sex life is one of the indispensable elements of our existence. In my opinion, it's great if someone gets it right, has a wonderful partner, where the sex life really works out. On the other hand, unfortunately, this is not the case. I remember as a thirteen-year-old boy, I used to talk to my mother and say Mum, I wish my first girlfriend was my last. Well, unfortunately. From the original script, right? Also promoted in various lessons, let's say religion. Unfortunately I've developed a little bit in that direction. And I'll be honest, because my mother is a doctor, she's an informed person. Unfortunately it was the case that my parents were divorced in some way, so that projected that I didn't have as much sex education as I would have liked, because it was from a woman's perspective. My mum somehow told me what I should do, how I should behave in this initiation, because, you know, it was a period when girls started to appeal to me, and so on.

Peter Merks
I haven't had a dad in my life, I have a son, so I've been trying since that young age where he's nine. When he's already asking me about what sex is and so on. I try to approach it very wisely, also as in my own way. I have a slightly handicapped childhood because I didn't have this male element, which in my opinion, let's say such a family typically consisting of a man and a woman, this father should have this role of this educator. Well I don't have that, but my mother, it seems to me, managed perfectly well. First of all, she never forbade me, because she knew I would do it anyway. That's the first thing, but the second thing is to do it with your head, so that you are prepared for it.

Monika Rachtan
Do you think a pharmacy could be the kind of place where this conversation could be had just about sex? How to do it safely? How to do it in a healthy way? How to do it with your head?

Peter Merks
Perhaps we should start with what it is like abroad, because many of the accusations which have been levelled at me have to do with where I have come up with such a procedure, that it may in some way violate a certain intimacy. I used models recognised in the world in countries which are a thousand times more liberal than Poland in the context of sexual intercourse, and there something like this functions. But I will talk about the good things and the worse things and the solution, What can we do about it, right? So a question, a question and my answer on that. For me, of course, a very important part of all this is the health and safety of the woman, right? So far, the morning-after pill has not been invented for the man, because that's not how we are physiologically created, unfortunately. Nevertheless.

Monika Rachtan
The day before.

Peter Merks
Well, exactly. Nevertheless, I will say straight away that teenage sexuality has been mapped in the UK. This is something that we in Poland are not doing yet. That or some commercial centres somewhere are trying to do something. Nevertheless, this is not part of a national health strategy. And now what does it mean to map adolescent sexuality? It's looking at where the English have looked, because I'll say I've been so lucky. I've always been lucky in a way in terms of being at the right time and in the right place, meeting the right people. It was exactly the same in England. First of all, I did the first pilot of the morning-after pill, so it's exactly the same situation as in Poland. I worked in a centre in Cambridge. There we piloted all the services we could think of in terms of pharmaceutical care and found that there were places in England where three teenagers were starting. In us, that boundary of starting not seeing.

Monika Rachtan
In general this problem that maybe it is not a problem at all that teenagers can have sex in Poland.

Peter Merks
Sex, but thankfully not. Fortunately. It's hard for me to comment here because I'm not a sexologist. The Polish initiation, on the other hand, is at 18, so as a rule it's eighteen and during eighteen my first time. With a partner. In England it's lowered to thirteen. Is that bad or good? It's hard to say, but the problem wasn't really initiation. The problem was that children were being made out of it and that they were really having children and the state approached it. Firstly, they supposedly supported themselves. I'm trying to show the big, big picture, Also, it's not all zero-one. There is still a middle ground, right? And my impression is that the morning-after pill. As a result of these certain reactions to what we presented as an organisation, we treated it that way. On the other hand, you can't look at it zero-one. 0/1, right? Because as I said, there is also a grey shade in the middle. So now what happened? And it was decided that it was time to map. So it started with educating the boys. What was done? Sex education was started, that actually how?

Peter Merks
The organs are used. It can make a child out of it, can't it? The only issue is whether it will be wanted or not wanted, because as I say, the stimulant comes in, the alcohol comes in, and then we are saddled with the responsibility in.

Monika Rachtan
Age thirteen.

Peter Merks
So let's think to ourselves, let's think about ourselves, about us, what was I generally thinking about when I was thirteen? Well I certainly wasn't thinking about reproduction yet, absolutely not. Nevertheless, I liked the girls and I was aware that I was indeed of a different build than the shorter classmates. So that's important. I was already curious about that. And now this curiosity would have to be channelled in some way. Because as I say, not everyone is lucky enough to have someone at home to tell them. We have a situation. I have a lot of friends whose parents are very conservative and they are really poor in their own way because they talk, they don't talk to their children about it. Obviously I've decided for myself that I'm very liberal with sexuality, and I'll remind you that in 2007 I gave out 29 tablets one day after 29. It's unbelievable. It was generally one of the Bales. At the University of Cambridge. I am sure you are familiar with it. It is one of the very big universities. And there's a pharmacy right in the centre, opposite exactly where this Ball takes place.

Peter Merks
And it was like this, it was from Saturday to Sunday, and on Sunday, of course, these beautiful maids, beautifully dressed up came to me for the day-after pill. I won't forget. The Monday after the whole weekend I get a call from the main boss from this company I worked for. This I hear has broken the English record. You sold 29, Pole sold, Pole sold. I will say this, we have a reputation for being very conservative, whereas, as I said, I maybe represent professionalism a little bit. This is also what I want to talk about today, that I leave my mission, my religion and my beliefs at home. But first and foremost, I help people. Today we are talking about patients. I like that terribly much. Patient first, so I say patient, patient first. In this case, for me, it is a situation.

Monika Rachtan
Not for.

Peter Merks
Her need. So I'll come back to that again. Well, and that pain just ended up being such that these, these young female graduate students came as many as 29, which caused an incredible storm in England, so to speak. But positive ones of course. I remember being nominated for an award in England for a pharmacist who achieves an absolute blockbuster season in context.

Monika Rachtan
You have become a star of the morning-after pill.

Peter Merks
Yes, yes, yes, that's what Blue films wanted to say. Well, almost, but I became the star of the season in general when it came to the morning-after pill. So from that time onwards, the topic really drew me in and I found that I had been waiting very much for this topic to come back in Poland.

Monika Rachtan
Speaking of sex education. I would like to come back to such a topic that is very topical today, which is health education for kids in schools is supposed to come in September. And tell me, in your opinion, should this topic of sexuality, sex education, also be part of this health education subject? Because I remember that, for example, in my time, it was the case that we had upbringing for life in the family, but unfortunately in many such lessons, instead of upbringing for life in the family, condom classes or contraceptive pills, Polish or mathematics took place. So I wonder how this should be solved nowadays.

Peter Merks
And I'm now even looking past, say, my son's peers. Girls mature much quicker and girls actually in his class started as the first to discuss sexuality in general, what organs, who has etc. And he just started coming back to me. Interestingly, not to his mum, but to me. I'm actually glad, because it means that he trusts me as a dad and has started to ask me about these differences. So I would say yes I am very happy that the morning-after pill also touches on reproductive health, because it is. Because it is a topic. I will also talk about it, how it has been wasted in the world. The way out for the morning-after pill is of course to help women in terms of preventing pregnancy. But on the other hand there was also a process in England firstly pointing out a few themes, whether, for example, the situation from mine will also be repeated sometimes, which I have gone through, there are thousands of patients who have been in contact with me and have been given the morning-after pill when a much older partner, a very, very old partner with a young girl comes along.

Peter Merks
I will remind you that in England there is the morning-after pill available under the age of 15 free of charge under what is called the Pension Group Directives scheme. This is the kind of campaign that allows this pill to be free at all, and generally as part of this process a partner much older comes along and says he wants to buy for this girl straight away in England. This interview procedure. Who are you for this girl?

Monika Rachtan
A red light comes on.

Peter Merks
And now see I have been put in the position of a person according to. Legislation that the pharmacist has such a paragraph in the equivalent of the pharmacy law that a lot of things happen in the context of his personal clinical decision and his discretion. And what was very important. I brought it to your attention because who is this person anyway? Because it could have been we know. It could have been classical harassment. So

Monika Rachtan
as the answer you obtained.

Peter Merks
Let me put it this way: firstly, I did not supply the morning-after pill in this case, because I have a clear procedure which says that in such situations I have to report to the relevant authority. It is completely the same situation. Now they laughed for sure. Well they laughed. There are all sorts of products that are used for intimate hygiene for women based on a certain ingredient, which is the bomb ingredient. And now, if I sold more than 12 packs, a lady of a different religion came in wrapped in a handkerchief and says she's going to ask for 12 packs. So at that point I had to report to the police. Seriously, Because that was the procedure.

Monika Rachtan
But you have a procedure, you know what to do, because at the very beginning of the programme I said that it is because of you that this fuss about the morning-after pill has arisen in Poland. Why? Maybe let's also explain to our viewers that you make it clear that of course access is needed, access is very good. The fact that it is the pharmacist who makes the decision is also good, because in many countries in Europe and in the world this is exactly how it looks like, but that it cannot take place in such a way that I come to you, I stand in front of the window and I say good morning, I will ask for the morning-after pill, and you say.

Peter Merks
Please sign.

Monika Rachtan
Signature. Thanks, Spend. Goodbye. Great. Because I, when I first heard that there was going to be access, I was happy. I said whoa, cool. But then I started getting questions and I even did a commentary like this with Martina Pasnik, M.D., who you know. We say hello to Martyna and Martyna. That's how she opened her eyes says Martyna. But you hand out this pill to everyone and she says Well, no? Well, you know, I have to do the interview, I have to go to the consultation room and her. Gee, you have to write a whole procedure to get this pharmacist.

Peter Merks
And pharmacies have consultation rooms. Another question I have just been asked often my dear friends, in Pandemic has become one very good one. A good thing. A good thing has happened. Namely, pharmacies have been vaccinated. I will remind you that pharmacies did a great job of marketing vaccines in the context of vaccinating the population. COVID-19 it was done by pharmacies. So that's millions of really hard work, millions of doses administered by pharmacies to help the population gain immunity to this terrible virus that killed masses of people. And we have had to prepare at this point, so these consultations in general are mostly there, but you also have to be sure of that. It's not like all pharmacies are going to implement the morning-after pill straight away. It's just like with vaccines.

Monika Rachtan
There are some pilots at the beginning.

Peter Merks
But it's like that with everything. In England too, not all pharmacies vaccinate and not all pharmacies do the morning-after pill. Then of course we have the issue, the conscience clause, which I'm also going to touch on today, because it's a topic of professionalism. This is one of my favourite topics, so surely the consultation will not be conducted behind the first table while someone else next to me is still shouting. Is it going to take much longer? Well, because this is the kind of classic pharmacy scenario that looms somewhere in the back of our minds, that someone is already rushing in. It's not, it's not, so to speak, medical advice or anything like that. Here, you have to be quick, because it's like in a shop, because there's a window, because there's another window. No, no, we're moving towards the pharmacy being a place where it's not McDonald's, but in general, right, you have to wait. I always ask my, my, my patients, do you want like McDonald's or do you want in a restaurant? Because at McDonald's it's one, two, three strips and there's no subject.

Peter Merks
And the restaurant is kind of cool. Even when we go on a date it's cool for a restaurant because they'll take care of themselves, etc. I prefer restaurants to have someone come to me, with me, talk to me, ask me about the interview. The interview is generally divided into 3 main sections. Firstly the medical interview, where we look at the patient's predisposition to supply the day after pill. This is what I pay attention to. I gave an example During my last visit to the Ministry of Health, I told about an ectopic pregnancy. A recent ectopic pregnancy disqualifies completely for the dispensing of the morning-after pill. At the pharmacy level, you absolutely have to go to a gynaecologist straight away. That's the way it is, that's the procedure, which makes it clear.

Monika Rachtan
What could happen to a patient who took such a pill, And there was this ectopic pregnancy in her.

Peter Merks
As I said, a great many negative things can happen, the scenarios of which are even probably partly unpredictable for us. A lot of things can happen. In the same way, when I have a patient with epilepsy. If we don't take a history, we don't know what can happen either. She's lowering her excitability threshold, she might get a shock. And now, interestingly, she can do it in the car when she comes out of the pharmacy for example. So I have to have that history, I have to have that baseline. The patient has atrial fibrillation. So also generally one of the contraindications is atrial fibrillation, taking anticoagulants. Herbs, some of which are very popular in Poland, such as St John's wort, are also a contraindication if the patient abuses them, but she should be aware that she has some contraindications in this respect. I also talk about how to take this pill as part of such a consultation, and I know from experience that often patients have a tender love affair, but this can quite easily be remedied when you drink a good glass of water and eat a cookie.

Peter Merks
I always had a biscuit in my pharmacy in England just to eat a good biscuit, didn't I? Before that, the so-called undercoat, right? These consultations of mine really went on in an atmosphere of great friendliness. Even fun, I would say in its own way, but procedure with procedure. I would say yes, if I had been at that stage, if I had known then that this, that service was coming in, I would have done a satisfaction survey on the service I was providing.

Monika Rachtan
I think to convince the ministry.

Peter Merks
I think 10 out of 10, I think the ministry is convinced that this is to come in. And I am also rooting for it, and even at the meeting with the Minister of Health it was clear from my side as the president of the organisation that we are really in favour, because this is the next big step in terms of pharmaceutical care, whether it comes in as a pharmaceutical service, as a benefit. We generally subscribe to the whole action, but medicines are a boon to humanity, but used safely.

Monika Rachtan
What is the argument on social media between pharmacists today?

Peter Merks
I'll say this, it's hard for me to comment very much on it because of the fact that we have this tendency as an environment that we like to argue, but it seems to me that most of the arguments are, as a rule, generated in general also in Poland. Out of ignorance. Because as I said, how many pharmacists are there who have ever done this in Poland? I think that most of the people who address me in a strange way are rude, etc. That it's madness etc. They just don't know how it works. That's why, that's why. I'm terribly happy that thanks to the cooperation with the Silesian Medical Chamber with Mrs Justyna Kazmierczak, the president, we were able to do the first webinar, which is interesting.

Monika Rachtan
Recommended.

Peter Merks
A very interesting webinar really, which was visited by 600+ people and also watched a lot. And there we showed the English model, the American model and the Canadian model. And we showed that, first of all, in these countries, the pharmacist-led day-after pill service gained top patient satisfaction. They were unhappy. Incidentally, if we're talking about a woman and where pharmacy is a woman, pharmacy is a woman in Canada, Canadian women took it a step further. They said that such a great topic the morning-after pill had developed and they liked this professional pharmacy consultation so much that they wanted contraception to be dispensed too. Regular contraception in pharmacies. And that's what happened. Well, yes.

Monika Rachtan
Because it's not something a pharmacist with five years of study behind them can do, but a wealth of knowledge. It's just that the conditions and the procedure have to be there.

Peter Merks
But of course now. You asked me what we ask. We ask, of course, what the period is like, how it is distributed. Generally when there is menstruation, when there is bleeding, this is important in the context that this effectiveness also depends on. At what point in the cycle the patient comes to us, right? We have different situations, for example there was a patient who had casual sex, had casual sex with a partner she met. It happens. It's known, everyone has different temperaments. I always quote such a joke, which was somewhere in one of the universities about philosophical philosophy sold there are such men my lord, professor and women, who do this sex every day, have it. There are those who do it once a fortnight, once a month. And there are those who generally have it once a year. Well there's a sound coming from the end of the room and there's someone laughing What's up there Mr. You can be polite, Professor, it's tomorrow. So. So I'm guessing that here it's going to be spontaneous and things like that can happen, can happen, right?

Peter Merks
Second subject There was a party. The patient was taking regular pills, birth control pills, a combined birth control pill. Unfortunately it was the case that she drank too much wine, she vomited it then, but in between she vomited etc. Unfortunately there was sexual contact with a regular partner. So they came to me, well they say to me I won't forget this. Well you know says Peter Pharmacy orally. They say to me You know, we do what a woman does with a man. And listen, help. I say no problem, listen, we're going, we're doing, we're doing the interview and so on. What happened? Of course I mark, I document it in the electronic paper documentation system. We have. We have two documents paper and electronic. We leave a trail after the visit we describe what happened, we recreate the relevant situation, that the patient vomited a tablet. Then we give her the tablet, the day after tablet. In England it's even better because there are two preparations, actually three. The first one is this, this. This is the equivalent of the Polish Escapelle 1500. And the second one is just

Peter Merks
This is the second one. We can. One works it's 72 hours, the other it's 120. And we move in this big therapeutic window where we can help either this or that. And now It's still an issue that for some women one is suitable, for other women the other issue is suitable, e.g. weight. Here too, this is not discussed in the media.

Monika Rachtan
Because in Poland there is currently a plan for one in 1 type.

Peter Merks
But, of course, I am also in favour of expanding. Already, I will say frankly, we have started, today we have started a very large European study to see what this subject looks like in other countries. I am very pleased. All the pharmacists in general globally are helping me to show another cool data. I will say yes there are two countries that are very liberal, but not really with the consent of the pharmacists. There, apparently the pharmaceutical lobby was too weak to emphasise patient safety to the decision-makers because, as I said, I am always afraid of this situation where politicians have their certain nonchalance and often don't analyse certain things and don't observe scientific trends, just something happens, political will, it happens.

Monika Rachtan
Acts. This was the case here. Likewise the truth.

Peter Merks
That is what is happening. But as I say, well it's nice that I think Poland should be grateful that it has people who are able to lead this subject as it should be. So. Let's go back for a moment more to what has been controversial this oversight. We have two options. I will tell you the situation from this week. Immediately after all the storms, I contacted colleagues of others, other, so to speak, of the same identity organisations in other parts of the European Union. Beyond i. A very interesting situation. I don't know if you know, but in England when going into, for example, a consultation for the morning-after pill, we have the option of taking a witness with us.

Monika Rachtan
A possibility, but.

Peter Merks
Not necessarily, but not a necessity. And now there was a situation where the pharmacist would not want this witness. And what did it turn out to be? The patient who came in with him, She was a 43 year old, mature woman who says please I'll have the tablet you had for documentation, and now she says If you don't give me the box, the diazepan, generally I'm going to jump out, pull down my bra, and say you raped me. And of course it happened. She runs out naked flying around the pharmacy. That's how a colleague described it. And it ended with the pharmacist being suspended. He was 8 months out of work because there was an investigation into whether or not there was actually a problem. She turned out to be a drug addict, of course. She turned out to be a patient in general, who does this on a regular basis, extorts in this way. We are only getting to that stage.

Monika Rachtan
Yes, because I think the people who want to do away with this procedure, who say it's unnecessary, they don't really think about what might happen from the side of the patients towards the pharmacists, that it's already gone through, that you've already experienced it, because also there was a statement somewhere on social media about what this Merks is saying about these procedures, how he doesn't know Polish society, because he sat so many years in England and there people are different and Poles are not ready for it. How do you comment on that?

Peter Merks
Great process. As a Pole, I think I rather know my, my country and as a person who has 232 cross-sectional studies on pharmaceutical practices, which makes me absolutely a leader in Poland and not only abroad. I'm hired by the whole world because what we show in Poland with what success we implement and this research really wears, they are cited several hundred times a year, and I guess Merks has to be judged from the perspective of his scientific research and global success, right? Because the word expert is not 220 here and there a day on social media, it's scientific output, right? It's a question of course of how to approach this, what I mean by expert. The word expert in Poland is often misused.

Monika Rachtan
Do you think pharmacists in Poland are ready for me to come to them in the consultation room? For me to talk about why I need the morning-after pill? Because I will probably get asked about that too. Asked and are they ready to think of me not.

Peter Merks
In a bad way. Listen, great question I would ask you. It's always answered by my survey, and I knew straight away it was coming. I did a survey of pharmacists and I have to tell you it's pretty good. 85% says it's going to be ok with it, and I did a survey like that for vaccinations as well. The most interesting option 5% said that for religious reasons they will not vaccinate. That's not how I got into it. I thought it would be worse. I thought it would be worse, but I try to treat these things in a way that is, shall we say, quite funny sometimes, don't I? Whereas here it's not bad. 85%. In the group the study is going on all the time, she wants to and has said she will do it respectfully etc. This is a good result. It really is a really good result. I for one am very pleased that pharmacists are so open about this. The second topic yes in the context of this supply of supervised weight is also not a necessity. It is so straightforward. You can, but you don't have to. But the issue is what happens if you are given something.

Peter Merks
I have the impression that sometimes we are lacking as in the case of driving. We lack imagination about what can happen. Because just because you have a driving licence doesn't mean you know how to drive. That's the way it is, isn't it?

Monika Rachtan
But I also think you have to have some information at all about what might happen, because we substantively.

Peter Merks
Risk assessment unfortunately we are not.

Monika Rachtan
Ready, we are not ready for this situation. That's what I think we think, we will come to the pharmacy. I say we patients and we will take a candy, but never something that is dispensed in a pharmacy. Even that dietary supplement is not a candy. It is something that affects our body, our health. And here the interests of both sides have to be reconciled, because both the patient has to stay safe and the pharmacist has to stay safe.

Peter Merks
I have been teaching pharmacology, pharmacokinetics, that is, anything generally related to the drug, that is my area for very many years. I directly talk about, explain about, discuss how a drug behaves in the body, how it penetrates into specific components, where their density gets, how deep they can go, how long they take to eliminate. All this matters. The second topic of importance is that advice all round. The third what happens, say, when you get one patient pregnant? After all, I'm just waiting for a lawsuit from you that you will hold a grudge against me or the pharmacy owner. Any pharmacy that gets such a lawsuit will be suspended from operating probably for the duration of the investigation. So that's also the consequences of this situation. And now in my purpose is that you should take. How safer for you to produce.

Peter Merks
And if I generally see that the procedure is repeated. You know, there was this situation. I had a person not far away on the estate where I live who was very educated, but she liked to generally enjoy life and she was taking up to 4 times a month and she was feeling very bad. She felt very unwell, but there was this element of education missing here, to go and just use normal contraception.

Monika Rachtan
Are you, by looking at these documents, by looking at the medical records, able to verify this? Well, I think you are. And if I go to different pharmacies, today, I will come to you.

Peter Merks
You raise a very important topic. Pharmacist It's about time they got access to patient's medical records. We need to see a situation where I'm sorry and it's already got one doctor I can't give you. This is already the moment. Here you are ringing the alarm bells, so to speak, for this issue to be regulated as soon as possible. Pharmacists have a system in England that shows that somewhere a patient has already benefited. But I will also mention some more. We have a procedure laid out, something that will happen. I will say such an interesting story I worked. I don't know if I should brag about what, but as I say, I am trying. I'm also trying to tell you that Polish pharmacists who go to England or somewhere in the West in general, it's not like we immediately land in a centre in Cambridge, which is prestigious and most of the patients we serve have a professor's degree. It's elite. Yes, sometimes you end up in afen where a big problem is father-daughter or mother-son cohabitation, for example. You end up in Norfolk, where there is generally a very high incidence of pregnancy or teenage girls or teenagers.

Peter Merks
It's also a problem. You get to places where sexually transmitted diseases are a really big, gigantic problem. Well, and you have to find a solution to that in some way. So here this statistic clearly shows what to do. Sex education. Well I ended up in one county where there was no doctor, no clinic. The only obok health centre was the pharmacy where Peter worked. Unfortunately it was like that. It was a public house. Literally vis a vis 100 metres. Staff full, cars would come and pick up the ladies. Interesting location. Another record. Really. Another record of spending, spending. And I have to tell you, I'm trying to say it so you can hear it out loud. And this patient comes to me Once, right? Then she comes a second time and she comes a third time. I say Listen, do you know what this is already? You know, we're already over the limit. And listen, we have a big problem because you should. You should generally do something about yourself. You should go to the Family Planning Centre. I'm giving you here the number that we have through the pharmacy.

Peter Merks
There are some very nice girls there that we worked with as well, because you know we all know each other. Please, take, take, take care, take care of yourself, because it's really dangerous. He says to me like this Listen, I drink, I smoke. I'm so destroyed. My life is not happy at all. I'm doing this because this is the kind of life I have. You just don't know what it is. Let's make ourselves. Let's think about what we can do about it. And of course I'll do it. Yeah, yeah, yeah. So a bit of psychology, well because that's my job, that's what it's all about, communicating with people, talking to patients. It's just that the patient comes first. As a result, we sort of decided that we were referring her to the Family Planning Centre. She went. They put on a copper coil, of course, because that was the solution, because after all, no one had ever said that from a Polish pharmacist from a conservative Christian country 86% Catholics had learned that there was such a thing as an HIV coil in England, which is a developed country and sexuality is normal, so to speak.

Peter Merks
Do you know what was the biggest turnaround for me in this situation? And it came back to me after a week, just as Piter brought me British biscuits. And so thank you for not judging me, just for helping me. And I will tell you honestly it made a difference. It was a game changer in my life. Yes, me from a conservative country. Yes, he's in an English church every Sunday. Yes, the bishop is my mate. Now we have been friends for years in general. But I didn't judge my patients and listen, it was a game changer. As I sometimes hear about certain organisations that are very conservatively religious, to counter, not to introduce, to block. Generally I can't listen to that for a very simple reason, because the alternative to this banning is that we will use it on the Dark Market on the black market. And now do I really as a Catholic with an ethical, moral backbone want that. That clandestinely, just like drugs people get drugs of unknown origin?

Monika Rachtan
All the more so because they can get it at the pharmacy. It is safe and we are using the potential of pharmacists, which is huge. I here Twitter again and again and again to this. But I wrote such a Twitter recently that I am very happy that pharmaceutical care is being extended because I think pharmacists who study very hard for 5 years. Someone corrected me that the 5.5 are reduced to being a salesman in a drug shop, soap, bath salts and so on. It's a great topic and I was lynched there that pharmacists in general don't feel at all hopeless as they sell that bath salt and that what am I even talking about? That why am I writing such things, that we are exploiting the potential of pharmacists in Poland? And as I sat here. We were talking to the pharmacist. As she started talking to me, I thought to myself. The girl knows so much. All in all, we would be able to not go to primary care doctors in 80% cases if we used the potential of pharmacists and their knowledge that they have gained in their studies. And you know.

Peter Merks
What I have been pointing out for a very long time now is that the decision-makers do not fully understand what we are for. Note that millions of coins are paid for our education. A large proportion of us flee to the West. Those are the ones who are actually burning through that money. We mindlessly do. But that is how we are. I wanted to make a clear point here my dear friends, how are the British planning the process? I work with the British all the time, I do new services for them as an expert. In a little while, I will also be a Canadian expert, so another country is asking me to cooperate. I hope that Poland will finally come knocking on my door one day and take advantage of it. We don't value our own, we have such a national trait. But the protest is planned 25 years ahead. So what are the English looking at in terms of these courses? Why was pharmaceutical care introduced in 2005 in the first place? There was a complete paradigm shift they said God dear, we are paying so much money, thousands of pounds to educate these pharmacists and they are actually just serving drugs off the shelves. After all, they could be doing other things. And now the second problem. That was the problem.

Peter Merks
There is a shortage of nurses, a shortage of doctors. But as you say, there are a very large number of minor ailments and problems that at the pharmacy level we can deal with. The pandemic showed that. We do a study before the pandemic and after the pandemic the increase in the number of disease entities was from 30 to 60, so to speak. A number of problems that at 100% level we dealt with at the pharmacy level without the slightest hassle with over-the-counter medicines available. So the potential is there. It's just that, as I say, everyone is talking about it, but no one is making it a systemic solution. And now what else are the English planning? The English are looking at how the medical workforce is developing in the country and looking at who will be too few and who will be too many, What will happen. We don't have these things at all, we just say there is a tragedy and so on. But on the other hand it's like I asked my colleagues who were setting up, who are setting up pharmaceutical care, services in the UK. I say listen, how did you guys in general, how did we get on with doctors in general. And he says Listen, the doctors were so loaded, they were happy, they were even happy.

Peter Merks
And where did it actually start? It started with lawsuits. There were so many lawsuits against doctors that one day they pressed Know what? Get those pharmacists to keep an eye on us already because we're tired. Was that really the case? Second topic. After all, if you look at the effective number of visits per year, most of these visits are not really effective. This is also what the NFZ u report showed in the Ministry of Health's 2021 study, where I also created this. There it is shown clearly that we mainly come for repeat prescriptions. In England this subject is solved 88% patients are chronic, established diseases. Just go and the pharmacy can dispense for six months. Once every six months a visit is necessary. Now what do we do in Poland? We generally make a prescription for 12 months, which is nowhere near the clinical, international guidelines. Well, and we create our own reality, which is not, so to speak, unrealised in scientific publications or some standards. Yes, it is exactly the same here. So it has been stated listen to the doctors, dear ones, we need you for serious things, because you have more diagnostic skills, and the pharmacist can handle everything around him, then he can tell you that a patient has interrupted your treatment and you do not know about it, because later on maybe you can burden the system.

Peter Merks
The pharmacist may tell you generally that, for example, she goes for the day after pill too often and it is dangerous because she may have a liver problem. He might tell you, for example, that he needs support to stop smoking, because smoking now is the biggest problem. I don't know if you know, in England now there is a complete ban, like a restriction on the sale of tobacco products. Teenagers are the biggest problem.

Monika Rachtan
This is also a very big problem in Poland

Peter Merks
There is a big problem with tobacco products, but here it is quick action, action, action, reaction. Well, we wait until something is politically sexy in the context that it is profitable for a politician or politicians to introduce something nice, then forget it, because vaccination is not some great success. I always repeat one of the anecdotes of a warm friend of mine from Canada Listen, if they hadn't made those vaccines for those pharmacies, they would have been carted off in wheelbarrows. Well that's what it would look like.

Monika Rachtan
That's how it is. But I always have this feeling that it's at the last moment when they're already on fire that they reach out to the pharmacists, that it would have been possible, as you said, to plan, to think about this knowledge, to use it, to put together a plan of action and then everyone would have been happy and it wouldn't have come to the situation as it is now. In March we found out that.

Peter Merks
He is due to enter in 12 days, this 13 in a fortnight and all.

Monika Rachtan
They are afraid. Why should they be? After all, you could have sat down calmly, planned it and done it in such a way that both the pharmacists would feel safe and that it would actually be two birds with one stone and that the politicians could also prove themselves here and fulfil their promises. But listen, you said professionalism. What kind of professional is a pharmacist who dispenses the morning-after pill safely for himself and the patient?

Peter Merks
Above all, the most important thing in professionalism is a certain professional ethic. For me, the key to everything is not to judge. As I sometimes hear that someone won't give it out because there is some kind of conscience clause. Look, well I chose the medical profession to help. Yes, I have seen loads of things. For me, it's not just the community pharmacy where I've worked. I have also worked in hospitals and seen a lot of things. Based on what I have seen, I could say that sometimes I have had a lot of contact with a certain pathology, but I am not here to judge. I always follow this principle. I treat each of my patients like a member of my family, which is how I would want my mother on the other side to go to the pharmacy and be served That's how I would want to serve everyone. That is my priority. The second important thing I need to be educated, that is, not on the basis that I think they live in Antarctica because something shines there, etc. I just ask the question why and whether there is scientific evidence that says I should do that. This is very important.

Peter Merks
Yes, the third one, of course, is also, as I say, the relevant studies, because that is also. That's professionalism. Now in these studies, to be great, we have to be up to date with new trends, right? We're going to do this kind of work in 2020, the second or third or 21st where we've submitted, we've submitted to the British Board of Pharmacy exam. We wanted to subject the last 12 pharmacy graduates and we wanted to see how they were doing with these clinical questions. Because what we're talking about today, which is a patient comes to you, the patient has a weight such she had unprotected sex then and there and now. Whether she qualifies or doesn't qualify, that's clinical knowledge. Well, and unfortunately these clinical questions were somehow subject to discussion by me. And now not the principle of criticism, just that we should change, we should change. Never. My role as an expert was not to criticise anything, because any, any reform is years away. Pharmaceutical care was not introduced overnight in England either. I won't forget. Listen, in 2005, when I arrived 2004/2005 in three months all the pharmacies that were supposed to contract pharmaceutical care were ordered to build after consultation under the threat of losing their licence.

Monika Rachtan
They also made the same mistakes as the Poles.

Peter Merks
There are no situations where people don't make mistakes like a pharmacist. Listen, you're not going to ask is how many lawsuits have you had? I've had two. Yes, Oh Jesus, terrible. Does that mean I'm bad? No, ladies and gentlemen, when you work, you have lawsuits. Well, yes, that's the rule. He who doesn't work is not wrong. That's the way it is. And now I'm talking about this completely lightly, because this is part of my practice. I get paid properly for my responsibility, for my responsibility in England, because I shoulder your health, your life. I'm happy to take that, because I'm happy that you guys are happy. Pandemic was also a great, great, great time. I would say yes to so many good thank yous I wanted to say on air, but so much of the good alcohol my patients brought me was thanks for helping them. It really is such a thank you. Being able to give of yourself to someone is really one of the main characteristics of professionalism for me. What else? I don't know if you know, but, for example, in many countries where pharmacists have to go through special aptitude tests to be a pharmacist, just like a doctor.

Monika Rachtan
Able to.

Peter Merks
To talk to and like people. Because listen.

Monika Rachtan
There is probably nothing worse than a pharmacist who is offended at people. Just like a doctor.

Peter Merks
Working with people, working with people. You either love it or you're not suited to it. So I love people. I love. I'm a social animal, a social animal. Generally my wife often says to me God dear, what do you keep coming up with? People you want to save and they don't want to save themselves. So maybe she's actually right, but can you imagine not having Merks in a while? Well it's a bit like that.

Monika Rachtan
I am very similar in that I really like talking to people, I like talking about patients. I think that with such open conversation, with dialogue, we can really change a lot in this system. But one more question about safety. Because like you said you worked in the area, around the brothel, in the pharmacy and I can imagine such a situation you say you didn't have access to medical records, so that's a problem. Well that's the thing, we have to realise that when it comes to this safety, there can be sexual offences too. And the morning-after pill can be such a white glove that someone puts on after such an incident, which is kind of their way of avoiding responsibility for what they do. So we, too, here pharmacists first of all have to take responsibility for this whole situation and for all the other consequences that might happen. What experiences have you had with the deceased?

Peter Merks
What did you say? Of course pharmacists have to take responsibility, but there has to be a systemic solution for them to do that. Because at the moment it's that he's going to say to himself, oh, I see this gentleman is taking advantage of a teenage girl, we're not able to. Then where do I call? Do I have a procedure that will tell me where to call? Well I don't even know what to do, I'll tell you honestly no, I don't know where in Poland what number 112 Surely not. Or the fire brigade to extinguish the urge. Nevertheless, there is no such procedure. So I'm fully willing to take responsibility, but I have to have a process put together And actually like on the other side, like they're going to do a Family Planning Centre or a centre for reporting, so to speak, difficult situations, I have to have that number to answer and not just until 4pm, but after that.

Monika Rachtan
You also talk about the fact that in England it is the case that a patient who. Takes the morning-after pill. Takes it in the surgery in your presence.

Peter Merks
There is a witness, there is a witness. I just always took one of my friendly technicians to observe the whole process. So then why? I don't know if I was talking about this situation. I have not spoken before. Today about how the pharmacist didn't sign this witness. And she was the one who was accusing him of harassing her, and she wanted to enforce a strict drug not working. So these are cases. I'll say this, I'm not going to spoil the mood today, but we were really talking to each other this week with policy makers from other countries. There are 200 of these tests, the typical ones that didn't make the headlines. But the consequence of the morning-after pill was reproductive health, the introduction of various safety procedures for women. And I would like us today to understand the morning-after pill as a tribute to you, dear ladies, that I really want to do well and I want you to be safe. And as I say, I love sex itself, so in large quantities and any quantity, as he says, I am mega liberal in this context. On the other hand, the health of female patients and Polish women is incredibly important to me.

Peter Merks
Why did I come back? Because I met a wonderful Polish woman with whom I have a child and it couldn't have been any other way, so it was all the more reason for me to come back to carry a certain torch and answer questions that seem difficult, crazy to some. Believe me, I don't do crazy things. I always have scientific documentation to back up my sometimes even strange theses.

Monika Rachtan
There is ongoing work by the Ministry of Health to get this morning-after pill into pharmacies on the first, first of May and to get this pilot going. I know that I sit on expert groups advising the Minister, along with other experts, on how this should look. Can you give a hint, tell us what's going on there on the backstage and is there a chance that this procedure will be introduced with a head and will have arms and legs?

Peter Merks
As an organisation, we received a draft pilot regulation for our opinion. We pointed out several important elements there. Firstly, we showed, we sent the results of the survey to the Minister. We wasted the willingness of the pharmacists, as I do with atrial fibrillation and the services I also provide for them. I stated that I would take a professional approach, as is done in England. We have talked to pharmacists, there is a willingness. That is very important. Now the second element is to find pharmacies that are willing to do it. I will say this from the experience of very many projects I do, it's not that everyone will immediately move their hands and it will happen. There is a part that is fully prepared, a part of the pharmacies that wants very much, but as it used to happen, because they had, they didn't download, that is, they wanted very much, but they didn't get to the end. This also happens, and in the end, even from the examples, there may be a thousand pharmacies that apply, and in the end, by the end of the project to 77. It is also this drop, And this drop out is also often a big problem that can happen. This is an important topic. The Ministry is meeting with various pharmacies in Poland to encourage them to enter the pilot.

Peter Merks
The third thing we sent out I would say yes there is no political will without satisfaction, without patient satisfaction. So too, as an organisation, we created a crazy survey to assess satisfaction with the pharmacy service in order to build even more political will for more and more appetite for new things.

Monika Rachtan
So you haven't already made the mistake you made?

Peter Merks
And so I will ask myself. I'm certainly already with the topic I'll be the first to stand up and do. As I say, I always come out as a scientist, and we're often cross, because when I'm in science I say I'm not a practitioner, so I try to be like that frog in the wildfire. And intelligent, and pretty in the middle standing.

Monika Rachtan
Are you planning to get employed in a pharmacy?

Peter Merks
I do pharmacy all the time. So colloquially I work in a pharmacy, in a small pharmacy outside of Warsaw. Why outside of Warsaw? Because there are very nice people there, but also a different experience. You collect differently though. It is difficult.

Monika Rachtan
It is difficult. In Warsaw, we often talk about Warsaw.

Peter Merks
In Warsaw, it's random. And above all, what's cool is the relationships with patients and patients. Like I said, the pandemic has also brought a lot of cool things, because the vaccination has caused people to start exposing themselves to the pharmacist, which is also amazing. I also always emphasise I have to tell you that when I was working in Cambridge, Cambridge is an academic centre, to my wife I always say listen, so many young breasts I have seen, What happens is we vaccinate somewhere. Whereas so many oncological lesions that I found and showed and reset to local dermatologists, it's really hundreds. And these patients were coming back again. As I say, it was overtime, because it's not paid to me, it was overtime. The patients, on the other hand, were grateful. Now think about that. The solution within. As part of that, I should observe moles and I should make a project out of it. But I on this subject.

Monika Rachtan
I also once spoke to primary care doctors and, of course, the doctors who are aware of this agreed with me. On the other hand, I asked a few primary care doctors, the kind who work in some county hospital. Listen, when a patient comes to you with a cold and you examine him, you look at his moles, like you paint some moles or something. Well if there's one then yes if there's 20 then no, if there's 50 then definitely not. And I say sometimes like something is a liability. I would stand there and everything. But professional burnout I understand everything. Whereas again as you say, that pharmacist can fulfil so many wonderful roles and help that patient so much that we should just be getting handfuls from those pharmacists for the benefit of our patients. But listen.

Peter Merks
You've touched a lot on this, because I'm still going to get into your words at the beginning of this. Today I'm talking about attitude, about business in general, so it's important that there is some balance in patient care between being able to fulfil the ethical attitudes of the pharmacist versus versus the business commitments that are there as well. I would remind you that if the pharmacy wasn't really a place where the main revenue is, unfortunately, the margin, but there would be surcharges for services, then we could at some point, as in other countries, compensate with these health services, yes Hawke Services or Pharmacy Compliance Services. All this to make the pharmacy a real health facility. However, here we are at the beginning of the road, so the morning-after pill is a nice gesture towards pharmacists and also really creating the political will is to satisfy patients and patients. In this case, if the patients show that they are happy, then I think that is the way forward for the next things.

Monika Rachtan
Finally, I would like us to summarise what this pharmacy procedure is likely to look like. If all these things that we have proposed to the Ministry of Health are put in place so that our Vicki, Vicki, our audiences too, so that you know what it will be like.

Peter Merks
It looked like, play out a scene. Super, I like that. He comes to me and you say good morning, good morning.

Monika Rachtan
MSc.

Peter Merks
And good morning.

Monika Rachtan
Ms Magister. I come with such an embarrassing situation for me, but I need this morning-after pill and I know that some kind of prescription has to be written for me by your magistrate. This we can do.

Peter Merks
It's not a problem, though listen, we'll go to the consultation room. There, in the quiet and in a safe place, away from the hustle and bustle, we will have a certain conversation. I hope this is not a problem for you. Don't follow me. I will take you to the consultation room on the way. If we had a procedure to take a witness, I might say Come on some pretty or come and have a look because I have a patient. I will gently let her know in a very discreet way to come with me. Please sit back and make yourself comfortable. We need to fill in a bit of paperwork so you feel safe.

Monika Rachtan
But what kind of documents will they be? Are you going to ask me something, What could it be? What he doesn't want to reveal to you.

Peter Merks
My dear? Do you mind? I'm Peter, I'm a pharmacist, and I'm going to hold a consultation with you today. I'm going to do this consultation. I need to take some information as to why they are important. First of all, because I am looking at the morning-after pill and your request in terms of safety, right? As you know, all medicines are a boon to mankind, but worth taking properly. So I'm going to ask you some questions. I'll give you a brief medical history, because I'd like to know.

Monika Rachtan
I don't have much time.

Peter Merks
So it will be very quick, 10 minutes maximum, so I will ask you a question quickly. In terms of what point in the cycle are you at, When was the situation? Is what was the reason you approached me? Was the contraceptive pill not working, was it a random situation etc? So that we make the best decision on how to give it to you and then you answer these questions for me. I also ask, for example, have you had an ectopic pregnancy in the past? Are you taking any other medications that are typically pharmacological? I ask you about e.g. dioxins. I ask you about their tin, I ask you about antibiotics, I ask you generally about the different herbs, supplements that you take or whatever, whether you have chronic diseases, because that is also very important and that gives me and tells me that you are fully in good health.

Monika Rachtan
I don't measure, I don't take anything.

Peter Merks
So I just need you to give me a quick signature. You sign and at that point I have a question for you. I'm going to ask the question do you want to take the tablet with you or do you want it to be taken safely under supervision? Keep in mind that if anything, because you might feel a bit worse, But. But don't worry yet in the case of this other tablet available weight. We told the patient to take a tampon with her. Or either a pad. Immediately, because there could be bleeding, so we also warned her not to be surprised. And that's the next stage. See, you go on your own, you start bleeding, you're in the middle of work or you're driving. The pharmacist remembers you. Listen, buy a pad yet, because you might have a problem. Something might happen. So I warn her. And now listen. It's important that you drink a glass of water. I'll get you one. I'll give you a tablet, take one. And when she says, have you eaten anything, I ask Well you know what, I haven't eaten anything on an empty stomach since this morning then I say That's not good. You know what, I'm the one with the super doughnuts.

Peter Merks
I always buy for my patients. Here, She doesn't get that doughnut, so she eats it, sips it, etc. And at that point she takes herself not on an empty stomach, but.

Monika Rachtan
So nothing terrible, terrible.

Peter Merks
And at that moment, at that moment the patient comes and says yes God, but it was extra. I've never had anyone do anything to me like that hahaha. So generally, yes, that's more or less how it is. It looks like. Is there an option to take it home? I've had that happen sometimes too. Whereas, as I say, we were always more in the direction of making the lady feel safe, well, because if she talks, someone has to tell her about it. These potential side effects, they are always there. And now it's about us wanting to engage the patient, the therapeutic process, so that she's fully aware of what she's taking and what might happen, so that you're not surprised. So So it's the same with methadone u, which is used in patients in the pharmacy, also supervised patients who are addicted to heroin or hard drugs. It's the same with tuberculosis, where patients were also taking pills out. So it's all about safety, right? We look out for things that might scare you in some way. I wouldn't want you to be frightened at home later.

Peter Merks
God dear, the bleeding at home has started. God dear, what did he basically do to me? Or gave me pills that you can God pee blood and so on until he called what was going on and what was happening. No, no, calm down. Those pills stain it brown. It's not blood. So that's my job.

Monika Rachtan
I am watching the revolution that is currently happening in pharmaceutical care. It is happening right before our eyes. And I am very pleased. For me, this conversation with you and conversations with pharmacists who are aware, who want to help patients, are a great pleasure. Well, because as we wrote here.

Peter Merks
We observe difficult topics for you.

Monika Rachtan
We are trying difficult subjects. I for one hope that all this work with the Ministry of Health goes smoothly, so that on the first of May we will actually enter a pharmacy that will be ready for it, or at least a section of pharmacies that will be ready to dispense this morning-after pill. What is your wish for the first of May? First of all.

Peter Merks
For this to take off at all. Secondly, at least a few dozen pharmacies in various regions of Poland should sign up to the project, so that more or less quite a few patients can take advantage of it. In general, I do not expect it to be a big revolution at the beginning, because it is not going to be that all patients will be flying in now, just buying the morning-after pill, is it? This is also a process. That's why, my dears, as he was coming in after the consultation and we were moving from a typical retail model, a sales model, into a medical model and a medical pharmacy model, nobody wanted to follow me to the consultation. Listen, and as I was leaving I had to go to.

Peter Merks
Work, I have to show you something. Yes?

Peter Merks
So it is. It's a process. Do you remember? Well with us the progression is very fast. In Poland, the dynamics of change are terribly fast and I feel that sometimes we can't keep up with how quickly certain things are being introduced. Patient medical records and KP one of the best inventions globally. A really excellent project, that it only goes further and that these powers continue to develop. So it's not bad in our country. The issue is just that even things that are unbelievable to us are impossible. Let's take a cold approach, because it's really not all that bad if it's done and implemented properly. The word pilotage, the key is pilotage. The English didn't introduce certain elements at the beginning at all either, because there was no situation like that either. It was commercial, available 100 1000 PLN. Also, a short piece of paper is filled in once, twice, three times, but the English soon realised that this is not safe for British women. Generally I remind there is relaxation, there is generally sexual themes, there is very let's say, there is consent for many things.

Peter Merks
So they were also learning and they were getting more and more restrictive about certain things in the pilot. There were several studies on the morning-after pill. Eventually a model was developed that still works today, which we are trying to implement.