In this article, a former Secretary and Registrar of the Royal Pharmaceutical Society sets out the reasons behind his belief that registration of pharmacy technicians by the Society would eventually undermine the integrity of the Society as a body representing the interests of pharmacists
As the record clearly shows, I am 100 per cent in favour of pharmacists having well trained support staff in both major sectors of practice. For community pharmacy, I was a prime mover in the initiative to ensure that medicines counter assistants (MCAs) — the staff with whom people usually first have contact when they seek advice or want to buy a medicine in a pharmacy — have the necessary training. I recognised, after analysing the pressures nationally and internationally, that we could say goodbye to pharmacy-only medicines unless people experienced service in a pharmacy that was totally different and much more satisfying than that in GSL outlets. But I was equally certain, for sound reasons, that the Royal Pharmaceutical Society should not register MCAs. The same applies to dispensary or pharmacy technicians.
Members who read the report of the 1999 annual general meeting (PJ, May 22, p729) will know that I asked two questions about reports that the Society’s Council was considering the registration of technicians. Those who were present will recall that the then President did not reply directly to either but said that a group was to be formed to consider all the implications and assured me that I would be given the opportunity of having an input. I have heard nothing since so must assume there are no current discussions. However, three months have passed and I believe the far-reaching implications for the integrity of the Society, as a chartered professional body, of proceeding with any such proposal should be put to members.
I was not surprised to see Dr Appelbe’s article in The Pharmaceutical Journal of November 21, 1998 (p808). He has long sympathised with the idea of technicians being registered by the Society. Indeed, when the second working party on a new Pharmacy Act, of which Dr Appelbe was secretary, decided to make no recommendation on this issue, noting that the Council had rejected the proposal made by the first working party in 1985 that technicians should be registered by the Society, and had twice subsequently confirmed that decision, Dr Appelbe informed me that he was against the working party’s decision.
Dr Appelbe’s article was long on history but lacked, in my view, any single sound argument for registration of technicians by any body. The purpose of registration is normally to protect the public by restricting particular activities to persons holding specific qualifications. In the past, the Council has consistently refused to accept any suggestion that specified tasks in pharmacy practice should be reserved to any person other than a registered pharmacist. Incidentally, the second resolution at the famous Albert Hall meeting in 1965 had nothing to do with registration of technicians. The motion had called for the Society “to take part in negotiations for establishing a scheme for the training and examination of assistants in pharmacy” (PJ, August 7, 1965, p140). So controversial had been the issue of even the Society’s involvement in discussions on the training and examination of pharmacy assistants that the Council considered it necessary to seek prior permission from the membership before becoming involved. After the resolution was carried, the Society participated in meetings of advisory committees of the City and Guilds of London Institute. Dr Appelbe rightly states the Association of Pharmacy Technicians has sought registration within the Society for many years. That is a perfectly legitimate aspiration because it would undoubtedly add enormously to their prestige — but at what cost to the Society’s integrity? He also raised the spectre of some other body registering technicians and asks which is the greater danger to pharmacists, “technicians controlled within the Society” or by some other body. It is far from clear which other body might be interested. The Department of Health has shown no enthusiasm for undertaking the task and when the association sought registration with the Council for Professions Supplementary to Medicine some years ago, the application was rejected because the basic criteria were very far from being met. Quotation of just one criterion will illustrate why: “The applicant organiseation should have an appropriate and acceptable code of conduct regulating relationships with patients and members of other professions or be able to satisfy the council that the members of the profession are willing or need to be governed by such a code.” And I cannot wait to hear the reaction of Parliament if the Society seeks power to register technicians so that their aspirations can be “controlled”. Is not the role of a governing body administering a register to seek to extend the group’s activities and extend their influence? That is certainly what the Society seeks to achieve on behalf of pharmacists.
I am convinced that it would be impossible in the long term for a body with a chartered object “to safeguard and promote the interests of members in the exercise of their profession” also to promote effectively the interests of technicians. New strains would be introduced with the obvious likelihood of conflicts between the interests of the two groups. My experience has demonstrated that this is not a theoretical possibility.
When the distribution of animal medicines was controlled in the mid 1980s, it was decided that, to prevent too great a disruption to existing distribution patterns, there should be a list of medicines which, for a strictly limited period, would be available through agricultural merchants as well as pharmacies but would subsequently be available only through pharmacies. Towards the end of the interim arrangements, senior members of staff in the then Law Department of the Society pressed me to accept that, because the Society registered merchants, it had a responsibility to consider their interests. I declined to accept that argument but undoubtedly the strength of the Society’s case on behalf of community pharmacists was weakened and the “merchants list” became permanent. In the case of merchants, the Society, in practice, registers premises rather than individuals and the role is enforcement of legal requirements and codes of practice. Those employed by merchants do not work in pharmacies alongside pharmacists, which would apply in the case of pharmacy technicians.
Any member who is unconvinced by the merchants example should reread the report in The Pharmaceutical Journal of May 1 of the National Conference of Pharmacy Technicians (p608). The meeting overwhelmingly carried a resolution that technicians should “support representatives of the profession [presumably representatives of the profession of pharmacy technicians] in seeking registration at the earliest opportunity” and agreed that the Society was the appropriate organisation with which to seek registration. This confirmed the understandable aspiration of technicians. The conference went on to debate “extended roles” for technicians “with appropriate qualifications”. There were then contributions about technicians being trained in one hospital to check medicines and counsel patients on the wards and a statement, according to the Journal’s report, that in the hospital concerned “dispensing now had hardly any pharmacist involvement”. In another hospital, “technicians had also assumed ward-based duties”, at first alongside a pharmacist but later alone, “and a clinical technician trial on a neurology ward in 1998 had been highly successful and might be extended to other wards”.
Achieving these extended roles — accompanied by a Level 4 NVQ or an advanced diploma — are no doubt legitimate aspirations. But how could the Society promote these aspirations and at the same time discharge its chartered object to members in the community as well as the hospital sector. And would we confuse the definition of member? The current situation is that, as a result of the perseverance and successful efforts of successive leaders of the Society, registration of an individual is synonymous with membership — a position that is the envy of virtually every other pharmaceutical society in the world. We should be very careful not to take any action that would threaten that position. Has the Council in mind that the qualification “registered with the Royal Pharmaceutical Society as a pharmacy technician” could only be used when the person’s sole employment is in a pharmacy? Could that be enforced? Or would be have another “Pharmacy” restaurant situation, only this time in respect of a GSL outlet?
The hospital sector has on several occasions expressed support for the registration of pharmacy technicians, not least when recruitment and retention of pharmacists in that sector has been difficult. The community pharmacy sector has consistently been strongly opposed to registration of technicians with the Society and one can see why when the implications are considered. The National Pharmaceutical Association, which has in membership virtually all pharmacy owners apart from Boots the Chemists Ltd, has recently confirmed that opposition (PJ May 8, p645). The NPA understandably asks why, if there is a need to list technicians who have recognised qualifications, the model followed for medicines counter assistants cannot be used. As I pointed out at the annual general meeting, the report in The Pharmaceutical Journal of March 13 (p351), “Professional standards and training for dispensary staff from January, 2005”, stated that “after cost, the second biggest issue raised during the consultation period was whether the Society has a role in setting up a register of qualified pharmacy technicians”. That puzzled me because the subject was not even mentioned in the consultation document on which individuals and organisations had been invited to comment. The logical conclusion would appear to be that those in favour of registration were more likely to raise the issue than those who responded only to the questions raised in the consultation paper. It was hardly surprising therefore to read in the March 13 report that “the balance of opinion was that the Society does have a role in this area”.
My first question at the AGM was whether, in line with its declared policy of transparency, the Council would publish, or make available to interested parties, who had said what on this subject. I made the point that equal weighting could not properly be given to comments from individuals or bodies like the Association of Pharmacy Technicians and organisations like the NPA, representing virtually the whole of our profession’s community pharmacy owners. No answer was given. The Council must disclose that information and details of the responses to the later consultation to members, if there is any intention to proceed. I was also surprised at the statement in the PJ article of March 13 that “from January 1, 2005, all staff involved in the assembly of a prescription, including the generation of labels, will need to be trained to a minimum standard or be undertaking such a course of training. In addition, pharmacists will be obliged to ensure that all dispensing staff are kept up to date.”
The current Code of Ethics (obligation 1.14) requires pharmacists to comply with the Standards of Good Professional Practice which is an Annex to the Code. Paragraph 5.2(2) of the standards document makes it clear that a pharmacist responsible for supervising dispensing bears the associated legal liability and professional responsibility, and 5.2(3) adds that the pharmacist must be able to delegate “to suitably trained staff, those tasks that he is confident can be undertaken by them”. Paragraph 7.1 states that “members of staff engaged in the dispensing process must be adequately trained for the purpose” and also that “support staff must receive continuing education and training to enable them to provide competently the professional services being offered”. In the community sector, the onus is thus on the pharmacist-owner, or the owner and superintendent pharmacist if the owner is a company, to ensure that staff are fully equipped for any task they are expected to undertake.
Under clinical governance in the National Health Service community pharmacy sector, again the onus will be on the provider, in this case the pharmacy contractor, to ensure that all staff involved in providing NHS pharmaceutical services — pharmacists and support staff alike — are competent. And, of course, every pharmacist has personal responsibilities under the Code of Ethics to maintain competence.
Surely the obligation to delegate tasks only to competent staff and to ensure they maintain competence already exists.
The second question I asked at the AGM was whether the Council considered the Society had power under the Charter or the Pharmacy Act 1954 to register pharmacy technicians. Again no direct answer to the question was given. I expected the President to say that no power currently existed but the situation might change when the Health Bill, then before Parliament, became law. The situation now is that under Schedule 3 of the Health Act 1999, and Section 54, an Order may be made covering “the regulation of activities carried on by persons who are not members of the profession but which are carried out in connection with the practice of the profession”.
It is not clear whether the “regulation of activities” would necessarily cover registration of technicians. What is clear is that before a draft Order is laid before Parliament, the Secretary of State must first publish the draft and consult widely. After three months he may lay the draft or an amended draft before Parliament “together with a report about the consultation”. The health professions were happily successful in ensuring that this type of Order will require a positive resolution of both Houses of Parliament, so there will always be an opportunity for debate if there is objection to any proposed provision within an Order.
When professions seek primary legislation that is not a Government’s programme, parliamentary time is seldom available. If there is a window of opportunity, Ministers are always concerned to be assured that the legislation will not be controversial within the profession or from another source which has a legitimate interest. Ministers are likely to adopt the same policy in relation to Orders which require a positive vote in each House.
The Society urgently needs major reform of its disciplinary machinery, reform which has the support of the whole profession as well as the Statutory Committee. So the necessary assurances about the non- controversial nature of that legislation could probably be given. The same assurances could not, however, be given on any proposal to include power in the Order for the Society to register technicians, especially if the National Pharmaceutical Association maintains its firm opposition to the proposal, leaving aside the individuals who have written to the PJ. Pharmacy is likely to have only one bite at the required Order and the debates in Parliament on the Health Bill made clear that pharmacy will be behind the Council for the Professions Supplementary to Medicine (CPSM), for which there has been a major report on reorganisation, and the UK Central Council for Nursing, Midwifery and Health Visiting (UKCC) in the competition for parliamentary time. The Minister (John Denham) indicated that during the present Parliament, the Government aimed “to put in place successor bodies for the UKCC and the CPSM”. If the Society wishes to get its well-prepared proposals for reform of the disciplinary machinery through with reasonable dispatch, it will be well advised to exclude any proposal for the Society to register technicians, which is bound to be controversial.
Dr Appelbe is a proponent of breaking up the Society, stripping it of powers of registration which means its rights to accredit degrees, administer the preregistration training programme, conduct the registration examination, enforce the Code of Ethics and administer the disciplinary machinery. These powers would be given to a new General Pharmacy Council and the Society left as a body with voluntary membership, effectively stripping it of real influence. He has usually been in a tiny minority on this approach within the Council, often a minority of one. He may see registration of technicians as a step in that direction — and he may be right.
I have no doubt, because Dr Appelbe mentioned them in his article of November 21, 1998 (p808), that dental nurses and veterinary nurses will be raised in any future discussions. Dental nurses serve to illustrate my point about the potential for break up of the Society. Dental nurses are registered by the General Dental Council. As the Secretary and Registrar knows, a recent proposal by that Council to extend registration to other categories of support staff was very controversial within the professional body representing dentists, the British Dental Association. There is no register of veterinary nurses. The Royal College of Veterinary Surgeons (RCVS) keeps a list of people who have passed an appropriate course of education and training (currently somewhere between NVQ Levels 2 and 3). Those on the list are entitled to carry out specific acts of veterinary surgery under Schedule 3 of the legislation relating to veterinary surgeons. The RCVS has presumably kept this list under its Charter powers for there is no statutory power to do so and no disciplinary process. The first degree course in veterinary nursing started this year and the second is likely to follow next year. So the veterinary profession faces difficult questions in the near future. Should the RCVS seek legislation giving it power to establish a register of veterinary nurses with all the attendant machinery, and if so will this mean representation of veterinary nurses on the RCVS council and a change in the nature of the organisation? Should the British Veterinary Nursing Association become the regulatory body or should it be the equivalent for nurses of the British Veterinary Association? Again there is the prospect of strains within the RCVS as the inevitable conflicts of interest arise. The Society can avoid these by opting out of any involvement in registration, or even listing of technicians. The Society’s Council is to be congratulated on its decision that standard operating procedures should be in place in all pharmacies. That will more clearltidentify the role of trained support staff in the technical aspects of the dispensing process and the Society can properly indicate the necessary content of training courses for these tasks. But this does not require registration of technicians, far less registration by the Society.
The Council, if it intends to proceed, must:
I was asked before I retired whether I intended to stand for election to the Council. I replied that I did not but repeated what I had said at the 1997 annual general meeting that I would be active should there be any proposal which I perceived to threaten the integrity of the Society as the professional and registration body for pharmacists, the combination of which gives the Society its strength and status to present views on behalf of the whole profession of pharmacy — and no one else. As I have sought to explain in this article, I consider that registration of technicians by the Society would, in time, impose intolerable strains within the Society’s structure and thus eventually undermine its integrity as the body representing the interests of pharmacists in the exercise of their profession. If the Council starts along that road, members might in time conclude that the aphorism “whom the gods wish to destroy they first make mad” is apposite.