The Pharmaceutical Journal Vol 267 No 7161 p226
18 August 2001

This article
Reprint
Photocopy

Comment

Only radical change can tackle community pharmacist workload and shortages

By Robert Gartside

The job of community pharmacist has become too hard for most people. There have always been exceptional pharmacists who could handle vast workloads, but they have been a minority: the tail, if you will, of a normal distribution curve. Other things being equal, the average workload should be just comfortably within the capacity of average people. The present community pharmacy problem is that more work is being presented to the average pharmacy than can be handled by the average pharmacist.

Slowly, slowly, the workload in the average pharmacy has crept up until it is now much heavier than that of exceptional pharmacies only a few years ago. Remuneration has not kept pace with the workload. Twenty years ago an average pharmacy dispensed just under 3,000 prescriptions per month and an exceptional pharmacy, perhaps double that. Only in the centre of large cities would you find higher numbers and these were recognised as being exceptional pharmacies which needed exceptional pharmacists.

Now, however, the average Welsh community pharmacy dispenses 4,500 prescriptions per month and double that number is not particularly unusual. Every health authority area has a number of pharmacies which dispense three or even four times the average number of prescriptions; 12,000 prescriptions per month is a high figure, but it is attained by a significant number of pharmacies.

Compare this with the United States where the American Pharmaceutical Association has recently warned that more than 2,500 prescriptions per month can constitute a dangerous workload for one pharmacist. Compare, indeed, hospital practice here in the UK, where a normal outpatient prescription workload is around 1,000 prescriptions per month for a single pharmacist. There may be differences in the work, but they are not that great.

Nor is this all. Many surgeries have developed a laissez-faire attitude to prescription writing, in the confident knowledge that the pharmacist will sort it all out.

Recently I received a prescription that called for one month’s supply of catheters of unspecified make, type or size. “Doctor said you would sort out the quantity and everything else and any aggro will you phone him,” the patient said. All very professionally gratifying no doubt, except that it came at a time when the prescriptions were coming in at the rate of one every one and a quarter minutes; and it was a trivial difficulty compared with the problems caused by the many incomplete or inadequate prescriptions I receive.

How about the prescriptions that just read “dressings for one week”, or even (from a locum doctor) “give what they had before”? If there is time available, these incomplete, inept, or inaccurate prescriptions can provide great professional satisfaction, but when dealing with one means that 10 other patients have to wait, they are just an added burden in an already burdensome job.

Some time ago there was a survey which showed that few GPs spend more than 10 hours a week in actual contact with patients, and none spend more than 20 hours per week in patient contact. The reason, of course, is that theirs is an exceptionally emotionally demanding job and mere human flesh and blood can take no more than this. The doctors have reached their physiological and psychological work limit.

Is it possible that the same kind of thing is true of community pharmacy? Is there an upper limit to what is psychologically or physically possible as a day’s work in a pharmacy? Have we now reached that upper limit?

I venture to suggest that we have indeed run up against the buffers, that we are now asking more of the average community pharmacist than he or she can provide. The present difficulties of recruitment and retention are well known. At some times it is almost impossible to obtain pharmacists for community work, no matter what persuasion is applied or what financial incentives are offered.

In North Wales we have three to eight community pharmacies closed every Saturday for lack of pharmacists. The supermarkets long ago gave up all hope of meeting the extravagantly lengthy opening hours for which they are contracted. In one North Wales town recently, two of the four pharmacies were closed all day Friday and one was closed all day Saturday. There are supermarket pharmacies which have not adhered to their contract hours for weeks at a time. There have been formal complaints to the health authority of pharmacies closed for whole days in the middle of the week. Double working, where a pharmacist opens one pharmacy in the morning, dispenses the urgent and methadone prescriptions, closes it, and then moves to run another one in the afternoon to keep some semblance of service running has become relatively common. At least one local health group (primary care group in England) has approached the local pharmaceutical committee with a serious proposal for a Saturday closure rota. This was refused, but it is not going too far to say that we have drifted into a position where the service is on the point of collapse.

We need to consider whether the present and worsening shortage of community pharmacists is not simply a question of money but is more a reflection of working conditions and a workload, which are simply too onerous to be borne. Few, if any, other professions work more than a 35-hour week as a routine (some exceptional high earners in all professions, of course, do much more). Very few indeed work for more than 35 hours a week standing up and, in the health professions, no one else spends this amount of time in patient contact. Yet the pages of The Pharmaceutical Journal have carried letters from young pharmacists detailing the 12- and 13-hour days they are working without proper breaks. A few, a very few, are doing this for five and six days a week. No one has come forward to defend this practice and declare it safe, but there has been no professional condemnation either.

There has been a feeling in the past that the apparent shortage of pharmacists was simply caused by insufficient money. After all, there are 40,000 pharmacists on the register and only 12,000 community pharmacies. Even allowing for hospital and industry there should be no shortage of pharmacists. But we now have locum rates which are almost as high as GP locum rates, and the locums become ever more scarce. Permanent pharmacy managers are an endangered species. Despite all the advantages of continuity which permanent staff bring, every month there are more pharmacies which are manned entirely by day-to-day locums. The conclusion must be that it is not the money alone: the only possible explanation must be that the job itself has become so unappealing that workers to do it cannot be found whatever reward is offered. There is, after all, no problem whatsoever in finding prescribing advisers, and little real problem, despite all the shouting, in finding hospital pharmacists, and both at lower wage rates than in the community. Pace my hospital colleagues, when I qualified 40 years ago there was no one employed in the bottom two grades in hospital work and much the same is true today. The real shortage, the shortage which is causing the pharmacies to close, is in the community.

All of this leads me to the conclusion that radical change in community pharmacy is not only desirable but has now become essential. The direction of that change, however, needs a debate in depth which has not yet even begun, even though time is fast running out.

The author is secretary to a local pharmaceutical committee in Wales and is a member of the Welsh Executive of the Royal Pharmaceutical Society. This article is his personal view