The Pharmaceutical Journal
Vol 268 No 7191 p430
30 March 2002

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Is the hierarchy losing the plot over supervision and skill mix?

By Graham Phillips

The combined pressures of the pharmacy manpower crisis, the failed global sum system and our enthusiasm for new roles leaves the community branch of the profession at risk of oblivion.

Before I am branded a Luddite, let me make clear that I strongly support the use of dispensing technicians: I have no wish to see pharmacists wasting their time licking, sticking, pouring and counting. My own company policy is to employ technicians wherever possible to carry out the mechanical aspects of dispensing, thereby freeing the pharmacist to spend as much time as possible at the medicines counter. I do, however, insist on a pharmaceutical assessment of every prescription.

I am actively involved in medicines management, having spent the past three years as a primary care group/trust prescribing lead, and I currently sit on the local PCT executive committee and board. I would submit, therefore, that I am as committed to "Pharmacy in the future" as anyone in this profession. Nevertheless I believe passionately that a community pharmacist's fundamental place is in the pharmacy and that our prime function is to add value to medicines — all medicines — whether sold or dispensed.

Consider the following two scenarios:

(1) The husband of one of our regular patients requested symptomatic relief on behalf of his wife. My qualified medicines counter assistant determined that a pharmacist's intervention was required. A brief oral history revealed that the patient had upper gastrointestinal symptoms, felt bloated and was unable to eat. Inspection of her patient medication record revealed poly-pharmacy for rheumatoid arthritis (fenoprofen plus methotrexate with only ranitidine 150mg bd as a mucosal protectant). Of course the patient's symptoms could be the symptoms of uncomplicated upper GI dysmotility, but the medication history and inadequate mucosal protection (a proton pump inhibitor was indicated) meant that the patient was at risk of gastric erosion, duodenal ulcer or worse. I opted to recommend a pro-kinetic agent (domperidone) plus a liquid food supplement (Build Up) with advice to see the GP within 48 hours if symptoms persisted or worsened.

(2) We received an apparently straightforward request for a product advertised on television. The parents described a pyrexic six-year-old with a history of asthma and febrile convulsion. Paracetamol was not adequately controlling the temperature. The advertised product is a pad which adheres to the forehead, releasing a cooling vapour, thereby inducing a cooling effect. Clearly it was important to control the temperature but the obvious option of adding ibuprofen suspension was contra-indicated. I gave appropriate advice regarding optimal dosage and use of paracetamol suspension together with cooling techniques (tepid flannel, increased ventilation) which should control the situation.

Any community pharmacist reading this will find both these scenarios entirely unremarkable. They are typical of the interventions we make (but do not yet record) every day, many times a day. However, I describe them because the truth is that the policy-makers at Lambeth and elsewhere are so far removed from the daily practice of pharmacy — especially community pharmacy — that they need to be reminded what it is like.

We must never forget that it is the wonderful combination of accessibility and availability that makes community pharmacists uniquely valuable, and often the most serious and significant interventions flow from apparently trivial initial enquiries. The work flow in community practice is entirely unpredictable and it is impossible to know in advance which queries will be sufficiently significant as to require a pharmacist's intervention and which will not.

The use of dispensing technicians undoubtedly frees community pharmacists' time, but it is generally accepted that only 90 minutes are freed each day, and that the free time is not made available in usable chunks. Certainly there is not enough free time to allow the pharmacist to absent himself from the pharmacy to conduct a clinic at the local GP surgery or to perform a medication review of a patient at home.

The public hugely values the prompt, professional advice that community pharmacists give. To propose that either of the patients in the two scenarios above could reasonably be expected to wait an hour while the pharmacist returned from, say, a prescription review at the surgery is flying in the face of reason — and worst of all it is most certainly not patient focussed.

It is a fact that most care is self care. Pharmacists have unique skills here. For reasons that I fail to understand, supporting self-care seems to have lost its profile and is at risk of being trivialised. This makes no sense because self-care is high up on the Government's agenda. The Royal Pharmaceutical Society has just published an ambitious set of proposals for "pharmacy only" or "pharmacist prescribed" medicines. Under the heading of minor ailments, the proposals include switching proton pump inhibitors, topical antibiotics and topical metronidazole. Appropriate recommendation for use will inevitably require the input of a pharmacist.

Any suggestion that all of the above could be handled by well-trained dispensing technicians is clinically unsafe. Technicians are excellent dispensers (I am quite certain that the best of them could check one another), but there will always remain the need for a pharmaceutical assessment of each prescription. Even the best technician cannot replace a pharmacist, a health professional present in the pharmacy, with a remit to add value to all the medicines available there.

For some, the answer to the manpower crisis is effectively to abandon supervision. There is a massive political risk in this. If we are prepared to accept that a pharmacy can run perfectly satisfactorily for an hour in the absence of a pharmacist, then why not for a day? If for a day, then why not for a week? In fact, why do we need pharmacists in community pharmacies at all? It then follows perfectly logically that the dispensing fee will be cut because there is no longer the justification to fund a professional salary.

There is, rightly, a huge debate within the profession about the balance of skill mix and supervision. Certainly practice must change, and of course we must embrace the modernisation agenda, but that does not mean that clinical supervision or pharmaceutical assessment can be abandoned. A naive extrapolation of changing practice in the secondary care setting, where there is generally no self-care consideration and patients may wait hours for a prescription, simply does not work in the community.

There are those within the profession, especially within the hierarchy at Lambeth, who have entirely lost the plot. In my view, they have a level of access to Government ministers which is frankly frightening when one realises just how distant they are from daily practice.

Now is the time for those of us in the real world to stand up and tell it like it really is before it is too late. If we do not, we will be courting political suicide and walking into professional oblivion. And who would be the greatest losers? The public.

Graham Phillips a pharmacist from St Albans, Hertfordshire