The Pharmaceutical Journal
Vol 268 No 7180 p14
5/12 January 2002

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Implications for continuity of service when pharmacy is run by a succession of locums

By John Wilson

As a locum pharmacist, I work for occasional days in a variety of pharmacies. Most are excellent, with good supporting staff, mostly women (I have only once worked with a male dispenser) and usually the first bit of dispensing done is a cup of coffee for the pharmacist! The pharmacies themselves vary greatly from the smart, modern shop in a fairly new shopping mall to a large mid-Victorian building that had once been a family-owned pharmacy. The family had lived over the shop and some of the store rooms still had the original gaslight fittings. On a shelf in the mahogany-fitted dispensary there were some medicine bottles, complete with corks, that bore labels in the previous owner's fine copperplate hand.

Each pharmacy I work in is memorable for one reason or other. However, most of them seem to have one feature in common — they have no permanent pharmacist.

Not long ago, I spent a couple of days in a truly delightful "health centre pharmacy" — just a room in the surgery premises, opposite the reception and within sight of the doctors' rooms. The work was all professional: there were no toiletries or cosmetics to sell. While there, I was able to talk to all but one of the partners in the practice, sorting out potential problems with the medication of several patients. One of the doctors lamented the lack of a permanent pharmacist there (the pharmacy had existed on locums for well over a year) because they had lost the excellent rapport that they had experienced with the previous pharmacist.

One would have thought that such a pharmacy would have had no difficulty in attracting a permanent pharmacist. The problem seems to be that a role as a permanent locum may be more attractive to many pharmacists than the role of pharmacy manager.

Sometimes, it seems, good managers are "lost" and go freelance because of the attitudes they encounter within large multiples. This is often particularly evident when a small chain of pharmacies is taken over and the pharmacist managers feel the nasty cold wind of new "management techniques" and other pressures to perform. This is to say nothing of the ageist attitudes that more than one pharmacist of my acquaintance has experienced. For others, the sheer freedom of being self-employed and not tied to any one pharmacy is the attraction.

Then there are others like myself, technically retired but anxious to keep their hand in, without whom many more pharmacies would be unable to remain open. This appears to be an increasing problem in some parts of the country.

I expect that the role of self-employed, freelance locum is likely to be the career choice in the future of an increasing number of pharmacists. The burgeoning numbers of locum agencies is just one piece of evidence of this shift in working pattern. I have received letters from several such agencies, inviting me to join their list of locums, and promising a variety of "goodies" including loyalty bonuses if I do so. One, indeed, stated that the agency concerned had secured a "major contract" with a large multiple to provide locum cover.

It would seem that the traditional place for the locum, in covering the holidays of a proprietor or manager, and perhaps the odd day when the pharmacist was not well or had urgent business to attend to, has largely gone. Many pharmacies, or so it seems, operate entirely on locums for prolonged periods. In some cases, the shop staff appear to have despaired entirely of ever having a permanent pharmacist. This state of affairs causes a number of problems which I believe that the profession has, so far, ignored. One of these is the need for continuity.

If the pharmacist is truly to be regarded as a member of the health care team, which seems to be an aspiration of the profession, then continuity is essential. How would we feel if, on going to the GP surgery, we saw a different doctor each time? By that I do not mean a different partner in the practice, but someone who came for only a few days before moving on and being replaced by another short-term locum?

Now this may not matter too much to the person who visits the doctor only every few years. However, the situation is different for a patient with long-standing, chronic illness. One has only to think of diabetes, cardiovascular disease, asthma (probably the most common group of medical conditions in Britain) to realise that it would not be conducive to good medical care if a different locum doctor was behind the desk every time the patient attended the surgery or required a home visit.

Again, how about an elderly patient who requires regular visits from a nurse? Would having a different (locum or agency) nurse each time really help? A major part of health care is the professional getting to know the patient as a person, and this is not possible if there is a different professional each time. Why should it be any different for pharmacy? As one woman said to me: "Every time I come in here there is a different chemist."

The concept of pharmaceutical care, howsoever we choose to define it, has one essential component, and that is continuity. I believe that this may already be causing problems. As an example, let us consider the supply of emergency hormonal contraception (EHC). Some areas now have arrangements whereby EHC is supplied free of charge at certain pharmacies under a patient group direction (PGD). To take part in these schemes, the pharmacist is accredited to the health authority, but only after taking part in a formal training programme. What happens when the pharmacist manager leaves, is not replaced, and a succession of locums runs the pharmacy? The PGD system will break down completely, unless all the locums likely to work at that pharmacy are accredited to the health authority as having undertaken the necessary training. This goes much further than the new disciplinary and control powers for health authorities that are being mooted (see PJ, 1 December, p774).

I believe that the Royal Pharmaceutical Society has not yet begun to consider the effect on the profession of a significant part of the pharmacist workforce operating permanently on a locum basis. This will have far-reaching effects on our plans for new roles for pharmacists. How can we undertake anything new, when we seem unable to offer a permanent pharmacist, who can develop the pharmacist's role as a member of the health care team, in many pharmacies? I propose that we should address this issue urgently.

There is little point in having a wish list for the future if we are unable to offer continuity in that most basic of pharmaceutical services — dispensing. Perhaps the Society should commission a survey of the number of pharmacies that operate permanently on locums. At least we would then have some idea of the extent of the problem. Solving it is another matter.

John Wilson is a semi-retired pharmacist based in Arnold, Nottinghamshire, who works part-time as a writer and locum pharmacist