The Pharmaceutical Journal Vol 267 No 7164 p320
8 September 2001

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Comment

More pharmacists, not delegation, is the key to the future of pharmacy

By Richard J. Schmidt

I was a little bemused by the article by Anthony Harrison (PDF 55K) regarding supervision and delegation (PJ, 21 July, p89). In the second paragraph he acknowledges that would-be pharmacists have to pass through a preregistration training year, but promptly dismisses this as a separate issue not requiring any further contemplation. He then goes on to discuss the preregistration training of optometrists and hospital doctors while singling out the training of anaesthetists for special consideration. Although different models of supervision and delegation operated by the various health care professions are explored, no attempt is made to relate the different models to the context in which the individual professions operate. Ophthalmic opticians do not delegate their eye-testing functions; medical practitioners do not delegate their diagnostic or surgical functions; anaesthetists presumably do not delegate their anaesthetist functions. But all professionals acknowledge the limitations of their skills and experience and “delegate” upwards or sideways to those in or outside their profession with specialist knowledge. The implicit if not explicit conclusion reached, however, is that the pharmacy profession will not be able to develop until effective delegation, under indirect supervision, of routine tasks to properly trained and therefore competent technicians is carried out.

First, there is the legal framework to consider. This was dealt with by John Ferguson (PJ, 28 July, p122). Delegation of duties in pharmacy has to take due regard of the various laws governing the sale or supply of pharmacy and prescription-only medicines. It really does not matter how much or how little training a dispensing technician or counter assistant has received, nor indeed how competent he or she may be. The fact remains that both dispensing technicians and counter assistants are prohibited by law from supplying P and POM medicines except under the direct supervision of a pharmacist.

Secondly, we need to take due regard of the nature of the medicines supply process. Let me use as an example the dispensing of a prescription in a community pharmacy:

(1) A prescription is presented for dispensing. No special supervision of trained technicians or counter assistants is required.

(2) The required medicine is found on the dispensary shelf. No special supervision of trained technicians is required here.

(3) The patient’s medication record is found on the dispensary computer. This is a point at which the pharmacist’s input is required. Without intending to cast aspersions on the abilities of dispensary support staff, the person best placed to interpret a patient’s medication history and to decide how the current prescription fits into the patient’s ongoing medication, if any, has to be the pharmacist. This is, after all, one of the key reasons for implementing patient medication record keeping in pharmacies. Although it is true that many patients will present the same prescription month after month and that protocols can be implemented for trained technicians to deal with these, there will also be many other patients presenting prescriptions that do require the assessment of a pharmacist. The problem that faces all community pharmacies is that there is no way of knowing whether a prescription presented for dispensing will be a routine case or a case requiring the pharmacist’s direct intervention.

(4) The medicine label is generated and affixed to the medicine. No special supervision of trained technicians is required here.

(5) The medicine and label is checked against the prescription before being packed ready for handing to the patient or his or her representative. Competent technicians are probably as capable as pharmacists as regards checking that the dispensing process has been carried out faithfully in accordance with the prescription. However, there is more to dispensing that the mechanical or robotic compliance with the wishes of a prescriber. This is the final opportunity for the pharmacist to contemplate the appropriateness of the prescriber’s wishes. It is not appropriate to delegate this task to dispensing technicians or counter staff even though most prescriptions most of the time could in practice be dispensed accurately and handed out by competent technicians. The role of the pharmacist is to identify and deal with potential problems, and to accept legal responsibility for his or her actions or omissions. This cannot be delegated.

(6) The medicine is handed to the patient or his or her representative. No special supervision of trained technicians or counter assistants is required here. However, this is again a point at which a pharmacist’s input may be required if there is a need to explain how a medicine is to be used or if some matter relating to the prescribed medicine needs to be clarified.

Every community pharmacist will be familiar with the above schedule of activities, but the opportunity is taken here to describe the dispensing process in outline for the benefit of those readers who are not pharmacists or have no experience of the dispensing environment inside a community pharmacy.

The point being I would make is that the professional activities of a community pharmacist are entwined in such a way with activities that can be delegated to competent support staff that it is difficult to imagine how the development of the community pharmacy can be stimulated through changes in the model of supervision/delegation.

The clinical pharmacist in a hospital environment is likely to be aware of a patient’s medical condition and will be closely involved in the prescribing process. Prescriptions so generated can reasonably be passed to competent dispensing technicians in the hospital dispensary. Community pharmacists are not made aware of the patient’s medical condition and have to rely instead on an intelligent assessment of a patient’s medication record. This is why a pharmacist’s direct input is required for each and every prescription presented for dispensing in a community pharmacy.

If, or when, community pharmacists are provided with direct access to a patient’s full medical history, if, or when, they become directly involved in prescribing decisions with GPs and prescribing nurses, if, or when, electronic transfer of prescriptions is made to robotic dispensing machines and if, or when, the activities of prescribers are so closely controlled by intelligent systems that they are no longer able to make life-threatening mistakes, perhaps then it will be possible to delegate the task of dispensing to a pharmacy equivalent of a dispensing optician or a dental therapist. But that still leaves the question of when and how patient concordance and medicines management functions of pharmacists are to be delivered.

The future of pharmacy lies not so much in finding ways of off-loading routine tasks to competent technicians (we already do this), but in installing additional pharmacists in community and health centre pharmacies. Perhaps the new primary care trusts can at last recognise this and help the profession of pharmacy to develop enhanced services.

Dr Schmidt is a pharmacist from Barnoldswick, Lancashire