Dispensing assistants' training was the subject of a community pharmacy session at this year's British Pharmaceutical Conference in Cardiff. Opening the session, the chairman Mr Marshall Davies said that the government's agenda for clinical governance concentrates very much on the quality and services of staff. Speakers during the session discussed not only the training of pharmacy support staff, but also the wider issue of how community pharmacy can deliver quality within the context of the new NHS agenda
The issue of quality and its delivery is at the heart of the transformation and repositioning of pharmacy known as Pharmacy in a New Age, Mr Curphey (chairman of the Royal Pharmaceutical Society's Practice Committee) told the Conference. "And resonating with that is the national imperative of clinical governance," he added.
In community pharmacy, historically, quality in medicines supply had centred on quality assurance of product, speed of assembly, accuracy and assurance of supply to the exact requirements of the prescriber as indicated on the prescription, as well as smoothing out prescribing errors, mainly of a technical nature.
"What I have just described is not dispensing, it is supply," Mr Curphey stated. "If there is one single, simple failure of our profession easily identifiable, it has been our inability to convince paymaster, patient, press and prescriber that there is a cognitive process taking place before, during and after medicines supply," he said.
Mr Curphey went on to describe what pharmacists needed to do to be able to deliver quality in the context of the new NHS. Pharmacists needed to consider workforce issues, guidelines, effective monitoring of clinical care, a code of ethics, audit and a reward system.
Workforce issues Focusing in particular on the supply of and demand for pharmacists, Mr Curphey said "these are of considerable importance if we are to deliver to a high quality agenda". In addition, the workforce had to be properly skilled and trained for the services it provided, and academics and educationalists had responsibilities in providing the underpinning of knowledge and some of the skills required to practise.
Continuing professional development (CPD) was also extremely important. However, the responsibility for pharmacists themselves to participate in the life-long learning process would be very demanding and would put new strains on a stretched workforce. Mr Curphey added that funding was "the big issue" and remained one where the Government was "dragging its feet".
He included skill-mix arguments and support staff skills among workforce issues. "To deliver quality, all the members of the delivery team need to be trained to a minimum defined standard. This includes the counter staff and the dispensing staff."
Mr Curphey hoped that in the future no one would fail to train junior team members because of irrational fears that they would take over the job, because they would become unaffordable, or because the outlay was too high. "Only trained, motivated staff will help us to deliver quality. We should always remember that we can delegate responsibility for an activity, but we can never delegate the accountability," he said.
There was general agreement on extending the pharmacist's role, and central to this was the issue of supervision. Mr Curphey's view was that "the time is fast approaching for the debate [on supervision]; it will be an enormous challenge to square accountability with absence".
Guidelines Pharmacists needed to develop evidence-based practice and, from that, develop and implement clinical guidelines, particularly at the local level. "It is important that we contribute to the consistency of experience which patients should encounter," Mr Curphey said.
Effective monitoring of clinical care As a component of clinical governance, access to relevant patient information and routine recordings of interventions and information were essential. Pharmacists had to find ways of promoting the need for access to relevant parts of patient records, and not just in order to record dispensing information.
A code of ethics A modern, flexible and dynamic code of ethics and standards for consultation would ensure that all pharmacists would have the potential to practise to the very highest professional standards. Pharmacists should be proud of their self-regulatory powers, but should remember that failure to deliver consistently high quality would place a question-mark against that privilege.
Audit Clinical audit has been slow in getting started in community pharmacy, despite the work of the Society's audit fellow. Medicines management programmes would need to incorporate an audit mechanism as audit was designed to produce a permanently improving quality of outcome.
A reward system Any reward system should be based on quality outcomes and should also recognise the unique nature of the private investment involved in community pharmacy.
Mr Curphey listed several potential failings which could prevent community pharmacy from delivering quality:
In addition, there were other factors which might make it more difficult for pharmacists to deliver quality. Mr Curphey spoke of "poky" pharmacies and a lack of solidarity throughout community pharmacy on issues such as resale price maintenance as presenting a poor picture of pharmacy in general. "The way we are regarded stands, to my mind, firmly in the way of enabling us to deliver quality," he said.
Similarly, the way in which pharmacy negotiators were perceived by the Government was important, since this was often how all pharmacists were regarded. Mr Curphey's view was that pharmacists might be regarded more highly if negotiations with the Government centred on quality outcomes and on helping to achieve Government targets.
Lastly, Mr Curphey considered what should be done about those pharmacists who failed to deliver quality. He said it was "cloud-cuckoo-land" to hope that peer pressure and professional pride would solve the problem, and speculated that NHS contracts might in the future contain quality clauses.
Summing up, Mr Curphey said that the challenge was to change community pharmacists from highly skilled, poorly paid, under-motivated, over-worked processors of pieces of paper to full members of the primary care team contributing in a measurable way to high-quality patient outcomes. That required Government commitment to additional payment for the extended activities which flowed from the supply of medicines. "Then we will deliver quality," he said.
Mr John D'Arcy (director, National Pharmaceutical Association) began his presentation by outlining the benefits that staff training brought. "Every successful organisation is characterised by a comprehensive training programme," he said. At a time when quality was so high up the agenda, and when pharmacy as a profession was fighting to prove its worth to paymasters, other health care professionals and consumers, it was essential that the importance of training, and the benefits it brought to service delivery and stakeholder satisfaction were taken on board.
There were several benefits to pharmacists of training pharmacy support staff:
For support staff themselves, benefits included an increased level of empowerment and job satisfaction, and greater motivation.
Mr D'Arcy referred to pharmacy protocols as one of the initiatives introduced to attempt to differentiate the pharmacy experience from that in any other retail outlet, and to ensure that consumers were supplied with the medicines most appropriate to their needs. However, the effectiveness of protocols in practice varied widely — some were never reviewed to reflect changing practice, others were applied over-zealously which might drive customers away rather than add to pharmaceutical care.
"It is essential that as a profession we take on board the importance of protocols as a means of adding value to the pharmacist's role in self-medication. . . . Unless we can convince manufacturers of the value inherent in pharmacy exclusivity, they are likely to focus on the commercial attractions associated with deregulating products to GSL status," Mr D'Arcy warned.
A key feature of pharmacy protocols was the training of medicine counter assistants. Mr D'Arcy stressed that the profession had to make certain that the combination of staff training and pharmacy protocols was put to best effect in the pharmacy.
"There is no quick fix to staff training and development," he said. "It requires time and effort, and above all, a high level of commitment from the supervising pharmacist, who has a duty to ensure that pharmacy assistants apply the knowledge and skills acquired from training to their everyday work."
Mr D'Arcy moved on to discuss the Royal Pharmaceutical Society's Council's decision that from 2005, all pharmacy staff involved in dispensing activities, ie, prescription assembly, including the generation of labels, would need to be trained to a minimum standard (which had yet to be defined).
This decision to introduce mandatory training for dispensary staff came with the Society's skill mix report, "Making best use of pharmacists and their support staff". Sorting the "skill mix conundrum" was fundamental to taking community pharmacy forward, said Mr D'Arcy. But while the problem was relatively straightforward — how could pharmacists take on a range of additional roles on top of their current full-time role? — the solution was not. The Society's document suggested that mandatory training of dispensary staff would solve the problem. The NPA, however, had reservations about this approach, although Mr D'Arcy stressed that the NPA was not in any way opposed to the training of dispensary staff.
Mr D'Arcy referred to research which had shown that while the use of trained technicians would free some pharmacist time, this would not be contiguous and, therefore, would not help in freeing pharmacists for non-interruptible pharmacy-based tasks or tasks away from the pharmacy.
"Against this background, it does seem that the overall objective of the report will not be achieved," he said.
The NPA was, however, pleased that the Society was commissioning new research in this area.
Mr D'Arcy drew attention to the fact that, since publication of the Society's skill mix document, clinical governance had emerged. A key feature of any quality assurance process, such as clinical governance, was the use of standard operating procedures (SOPs), which were proposed in the Society's skill mix document. According to Mr D'Arcy, since SOPs would reflect the actual practice in the pharmacy and would be the ideal way of identifying the actual training needs of dispensary staff, they should be implemented before deciding on a required minimum standard for training.
Mr D'Arcy suggested that if all dispensary staff were to be trained to, for example, NVQ level 2, this would carry course costs of around £1,000 per student even before costs associated with study leave and pharmacist supervision were considered. Given the current precarious financial status of community pharmacy and that enhanced training of dispensary staff would add value to NHS pharmaceutical services, Mr D'Arcy suggested that it would not be unreasonable to hope that assistance with training costs could be provided by the Department of Health.
Consideration had also to be given to the large number of experienced, yet unqualified staff and occasional staff working in community pharmacies, and how they would be dealt with under the proposals. The NPA was working with the Society to ensure that practical and financial difficulties associated with the day-to-day running of a community pharmacy business were taken into account.
The skill mix document had emphasised that no relaxation of the current pharmacist supervisory requirements was intended; this fitted with the NPA's view which was one of total opposition to any relaxation. Against this background, there were some pharmacists who did suggest that the only way truly to free pharmacists' time was to link the requirement for mandatory training of dispensary staff with a relaxation of supervision, and that this was the way forward for community pharmacy. Mr D'Arcy questioned whether this was what community pharmacy really wanted. He asked if community pharmacists were prepared to take "a huge leap of faith into an area of uncharted territory in the search for new roles", and speculated as to where pharmacists would be left if the new roles were not sustainable or plentiful enough to be viable.
Furthermore, the bigger issue was that of public interest, Mr D'Arcy said. "Patients' best interests are served where there is direct pharmacist involvement in the dispensing process."
Mr D'Arcy ended by saying that there was a need to create a learning culture of which training was a key component, but where an individual's current skills and need for development of new skills were also taken into account. "This is a labour intensive process," he admitted, "but the benefits are enormous."
The session opened for questions. A member of the audience expressed concern about the costs associated with training staff and the likelihood that once trained they would move out of community pharmacy and into hospital pharmacy posts. In response, Mr Curphey said: "We have to be committed to the principle of training to the minimum standard. You have no choice if you believe in the quality agenda and pharmacist contribution to health care."
Answering this, Mr D'Arcy said that it was not possible to implement training at any cost since, in the extreme, this could mean pharmacies going out of business. It would be necessary first to work out who was going to do what; then costs could be assessed. However, that could not be done until the minimum standard for training was known, he suggested.