The Pharmaceutical Journal
Vol 268 No 7200 p781-786
1 June 2002

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Branch Representatives' meeting summary

Untying the rope round pharmacy's neck

Sally Greensmith and Peter Curphey: supervision decision has tied a rope round pharmacy’s neck

The idea of relaxing the Royal Pharmaceutical Society's rules on supervision met no major objections during a discussion forum on professional accountability at the branch representatives' meeting on 16 May. Although some concerns were expressed about practical details, the meeting accepted that, with appropriate safeguards, pharmacists need not oversee every transaction.

The session was led by Council members PETER CURPHEY and SALLY GREENSMITH, who have been holding discussions on the issue with branches and other pharmacy organisations. In an opening presentation they said that the Government's programme to modernise pharmacy services and the new focus on the roles of a modern regulatory body had reopened the debate on professional accountability and supervision. Even though the Society had a lot on its plate in developing as a modern regulator, it had to consider supervision because the same pressures and opportunities were arising in pharmacy practise as in regulation. The Government had given a clear indication that pharmacy practice had to be transparently in the public interest, with no unsafe practices or barriers to progress.

One possible problem was that the Society had insisted on a higher level of supervision than was actually required by the Medicine Act 1968. This level of control could be out of step with what other professions saw as supervision and might be preventing pharmacists extending their role.

Section 52 of the Medicines Act required that the pharmacy sale or supply of medicines other than general sale list medicines should be made only by a pharmacist or by a person acting under a pharmacist's supervision. The Act required supervision of the person, not the transaction — it did not preserve the requirement of the 1933 statute that the pharmacist had to be aware of the sale and in a position to intervene. Similarly, the National Health Service Regulations said that dispensing had to take place under the direct supervision of a pharmacist. But what was meant by supervision had never been tested in the courts. It was the Society that had decided that supervision equalled personal presence.

Although this decision could be said to have tied a rope around pharmacy's own neck, the Code of Ethics had changed its interpretation of the requirements for supervision. It now said that there had to be an identifiable pharmacist accountable for all activities and all relevant staff had to be suitably trained and competent. Work procedures had to be safe, effective and monitored.

If the purpose of supervision was public safety, and if pharmacists were not to oversee every transaction directly, then three essentials had to be in place: a clear system to identify cases where a pharmacist's intervention was needed; an identifiable pharmacist who was professionally responsible, trackable and auditable; and quality assurance measures by which the responsible pharmacist could verify compliance with the systems. It was a move from quality control to quality assurance. The Society's legal department believed that if those three requirements were met there would be no breach of the Medicines Act.

One matter of concern was the public conception of what was currently in place. The patient's inability to collect a prescription while the pharmacist was absent at lunchtime was hard to defend in the case of routine medication. Perhaps there was room for a new way of looking at that sort of temporary absence.

Other health care professions had acceptably delegated activity with the senior health professional retaining accountability. It might be difficult to develop new pharmacy services without taking a different view of personal control and supervision. And if pharmacy did not change, there was a risk of others taking on roles that pharmacists have claimed as their own.

Mr Curphey and Mrs Greensmith concluded with an assurance that the Society had no secret plan to relax supervision. What it was trying to do was to open up the dialogue about how to improve practice, and supervision was just one issue that needed tackling.

BRETT GREEN (Gwent) asked whether the three rules that had been spoken about should be supplemented by a rule limiting each accountable pharmacist to one pharmacy business rather than having one pharmacist flitting between three shops.

Mr CURPHEY said that another possibility might be to have two pharmacists per pharmacy. The Council would like to hear members' views.

MARK KOZIOL (Birmingham) said that one issue that would concern the membership was whether accountability lay with a pharmacist within the pharmacy or with a superintendent pharmacist while technicians ran the show. If the pharmacist was chained in the dispensary, the profession would be unable to develop. The answer lay somewhere between. His personal view was that the closer the individual pharmacist was to the accountability, the safer it was for the patient.

KEN GLEDHILL (Harrogate) said that relaxing the supervision requirements could cause problems for locum pharmacists when supplying the balance of a prescription for which the prescription form was no longer available to check.

Mr CURPHEY said that in a couple of weeks the Society was to launch standard operating procedures (SOPs) that would be required in every pharmacy. There would need to be procedures for how to operate if a balance was to be given out by someone other than the pharmacist who supervised the original dispensing.

STAN WHEATLEY (Dorset) suggested that there was a need to get SOPs into place before addressing the problems of supervision.

Mrs GREENSMITH said that the two went together. If supervision was not considered, technicians trained to work within SOPs would be unable to do so.

PHILIP HUNT (Bristol) expressed concern about prescriptions sent direct from health centres to pharmacies and perhaps not collected for days. There was no opportunity for a sensible intervention before dispensing, and a different pharmacist might be there when the prescription was given out. Whose was the responsibility?

Mr KOZIOL said that when such a case had gone through the Ethics Committee it had been concluded that both pharmacists were professionally responsible.

GUY JEPSON (Northumbrian) said that the debate needed to be extended to cover electronic prescribing and mail order dispensing.

Mr CURPHEY replied that in principle a remote pharmacy had to go through the same professional checks as any pharmacy.

ROGER MILLS (Slough) said that the most important issue in supervision was the pharmacist's absence from the premises. How long was a "temporary" absence? Absence had to be interpreted by the profession before the debate could start.

SAMIXA SHAH (Barnet) said that she favoured relaxing supervision but asked how the accountable pharmacist could be sure that what was dispensed was always right if the skilled technicians were not accountable for their actions at all. If technicians were to be handing out prescriptions, they should be accountable to some extent. It was the same with giving out prescriptions at lunch-time. How could pharmacists perform their function of counselling and advising patients if they were not giving the prescriptions out themselves?

She added that that foremost requirement was to assess the needs of the patient.

Summing up, Mr CURPHEY said that the discussion had given a boost for patient registration, a boost for technician regulation and a boost for individual pharmacists being able to make their own mind up about the process they wanted in their pharmacy. That was where pharmacy should be moving to.