The Pharmaceutical Journal
Vol 268 No 7204 p927-930
29 June 2002

June Council meeting

All pharmacists should be potential prescribers, Society tells Government

Every pharmacist on the British register should be seen as a potential supplementary prescriber, the Royal Pharmaceutical Society has told the Government in its response to consultation on prescribing by nurses and pharmacists and the necessary changes to prescription only medicines legislation (PJ, 20 April, p521). The response was approved by the Society's Council at its meeting in London on 11 and 12 June.

However, while making that point as a matter of principles, the response recognises that the priority for public funding of prescribing training would be determined by the needs of patients and of clinical services.

The Society says that core training for prescribing should in future be incorporated into the pharmacy undergraduate curriculum, with registration as a prescriber achieved after successfully completing a period of competency-based supervised practice. The Society would be responsible for defining and accrediting the training for pharmacist prescribers and accrediting those pharmacists who have demonstrated their supplementary prescribing competency.

Commenting on a list of proposed principles of supplementary prescribing, the Society does not consider that, in this context, prescribing and dispensing responsibilities need to be separate, provided that all pharmacist prescribers participate in an approved programme of clinical governance that establishes sound systems for patient safety.

On a proposed principle referring to access to patients' records, the Society suggests clarifying and strengthening it to state: "all prescribers must have access to the patient's clinical and medication records". Only in rare instances should parts of a medical record remain confidential to the independent prescriber because any health professional considered responsible enough to be a registered supplementary prescriber could be assumed to understand the requirements for confidentiality.

The Society supports the proposal that there should be no general restriction on the range of medicines available for supplementary prescribing. However, while agreeing that medicines use should normally be in accordance with a licensed indication, it suggests that flexibility need not be limited to paediatric practice, provided the independent and supplementary prescribers are in agreement. It also expresses the hope that Controlled Drugs will be included as soon as possible so that supplementary prescribing can be extended to patients who need expert pain control.

On prescribing partnerships, the Society suggests that restricting a partnership to one named independent prescriber and one named supplementary prescriber is incompatible with continuing patient care and would severely limit the usefulness of supplementary prescribing. In secondary care the independent prescribers could be a specified medical team and the secondary prescribers could be pharmacists nominated by the hospital's chief pharmacist. In the community, the independent prescribers could be a designated group of general practitioners and the secondary prescribers could be pharmacists approved by the primary care organisation's pharmacy adviser.

On the roles and responsibilities of the supplementary prescriber, the Society says that it envisages a supplementary prescriber being able to vary the dosage, frequency or formulation of a medicine or to prescribe a different drug within the limits of a clinical management plan.

On training and preparation for supplementary prescribing, the Society says that it envisages training being undertaken jointly by the independent and supplementary prescribers. It adds that it foresees pharmacists ultimately undertaking independent prescribing.

Council members' fees and expenses

The Council agreed that the Society should continue to reimburse locum expenses incurred on Council business by any Council member who is effectively a sole practitioner operating a pharmacy business, even where the business is run through a company. The Council will seek an amendment to the Byelaws to remove any ambiguity and make the policy clear.

The Council had before it a paper drawn up after its decision in April that its policy for payment of locum expenses needed revision. The paper said that the locum allowance had been introduced in 1987 as a contribution towards the expense incurred by a Council member who was an independent proprietor pharmacy and a sole practitioner in his pharmacy, having a statutory responsibility under the Medicines Act 1968. It was paid (in addition to the attendance fees paid to all Council members) in circumstances where the Council member had to employ a locum to fulfil these statutory duties and attend Council business. It was paid to sole practitioners, whether operating as sole traders or having incorporated their businesses, but not to employees or self-employed locums.

A review of the fees and expenses paid to Council members had resulted in the introduction of a new fee structure consisting of an attendance fee of £160 a day plus reimbursement of expenditure on travel, accommodation and subsistence. The Council had accepted that Council members who were independent proprietors and sole practitioners working in their own pharmacies were disadvantaged. Following discussion with the Privy Council and the Department of Health, the Byelaws had been amended to allow the reimbursement of locum fees in such circumstances. However, it had since been accepted that the Byelaw as currently drafted was ambiguous.

Opening the debate on the issue, the PRESIDENT said that information had been sought on expenses for other pharmacy organisations and health care regulatory bodies. The Pharmaceutical Services Negotiating Committee paid an attendance or day allowance of £180 per day but paid no locum expenses and no practice fees. The National Pharmaceutical Association paid its board members an allowance of £190 per day, with no locum payment or practice fee. The Guild of Healthcare Pharmacists reimbursed only receipted travel and subsistence expenses.

The General Medical Council paid up to £250 a day for lay members only or members not in full-time employment or where the member's employer did not pay their salary when they were away on council business. In addition to the attendance/day allowance, a locum expense of up to £300 per day was payable for general practitioners only.

The General Optical Council paid £165 a day or part thereof as an attendance or day allowance. The General Dental Council did not pay attendance, day allowance or locum expenses, but it paid £306 a day or £153 a session (defined as three-and-a-half hours) to members in practice only. The Nursing and Midwifery Council paid an allowance of £267 a day for more than four hours or £135 per day for less than four hours.

CHRISTINE GLOVER said that a locum was a reimbursable expense because of the legal responsibility to leave a pharmacist in the pharmacy when it was open, which was not the case for a dentist, for example.

PETER CURPHEY said that all the other bodies for which he had worked in his career had accepted locum costs as a legitimate expense in addition to an attendance fee. It seemed inconceivable that his own professional body should believe otherwise.

The President had given information about other bodies. The GMC example was interesting, but the Council should not be looking at the PSNC and the NPA because they were trade associations and people went to their meetings to discuss business.

Mr Curphey begged the Council to consider the signal it was sending to colleagues in pharmacy who were effectively being disbarred from standing for the Council unless they were wealthy. In addition, there was no logical argument in stopping the payments of expenses to Council members but continuing with them for the Scottish and Welsh Executives, for members attending the Community Pharmacists Group Committee and for observers to the Council meetings.

Dr GORDON APPELBE said that he agreed with most of what Mr Curphey had said but he was concerned from the Inland Revenue point of view. The locum fee should be reimbursed to an individual pharmacist Council member who incurred that charge. He drew the line at paying locum fees to corporate bodies.

HASSAN ARGOMANDKHAH said that locum expenses should be paid to any Council member in sole charge of a pharmacy and personally responsible for ensuring adequate pharmaceutical cover, whether a sole proprietor or a superintendent.

SULTAN DAJANI said that the other side of the coin was that the pharmacy was still earning and therefore some might argue that somebody having the locum expense reimbursed was being paid twice.

ANDREA ROBINSON said that local health groups in Wales paid locum expenses to pharmacists who were board members. She asked the Council to consider the message that would be sent out to pharmacists in Wales if local health groups paid locum expenses but their professional body did not.

ANDREW BURR said that a pharmacist could be a sole proprietor who never works in the pharmacy but could put a locum in and claim locum allowance.

On a point of principle he found it difficult to support the idea of paying locum expenses. He regarded it as a decision that a person had to take at the point of standing for Council membership. At that time such a person would know the situation.

The VICE-PRESIDENT said she was fully behind what Mr Curphey had said. It was not just members of Council who were affected. It would apply to everybody. It could cost some members of Council a lot of money to attend Council meetings.

Dr NICOLA GRAY said that she had heard nothing different from previous debates on locum expenses. The Council should endeavour to stop the circular debates and move on to the work it should be doing.

Preparing to put the matter to a vote, the PRESIDENT said that the paper's first option was that the reimbursement of locum expenses to sole practitioners operating a pharmacy business should cease.

Dr APPELBE asked what "sole practitioners" meant. Reference had been made to sole practitioners running businesses. The terms were nonsense. A sole practitioner meant a pharmacist who ran a pharmacy as an individual and accepted all the liabilities that that might mean. He did not have any limited liability. He was not a body corporate.

The Council then rejected the option of ceasing to reimburse locum expenses.

The PRESIDENT then put forward the second option, "that the reimbursement of locum expenses to sole practitioners who are independent proprietors operating a pharmacy business should continue and if so that an amendment to the Byelaw be proposed to remove any ambiguity and make the policy clear".

The SECRETARY AND REGISTRAR said that the aim of the option was to capture the intention of the Council's policy from its inception. The difficulty in previous debates was in words and meanings. Council members had to be clear that they were talking about pharmacists who owned a pharmacy and were sole practitioners in it as independent proprietors, whether or not they were incorporated. The Council would have to seek to clarify the Byelaw.

Dr APPELBE said that they would not only have to seek to clarify the Byelaw but the matter would have to be clarified with the Inland Revenue. He did not believe that reimbursement could be paid to a body corporate.

Mr BURR asked about the situation where a pharmacist spent more time at other activities than working in the pharmacy.

The PRESIDENT said that the spirit of what was being said was that the person normally worked full-time in the pharmacy except when away on Council business.

Mr BURR said that the problem was that they were talking about the spirit but people interpreted that differently.

Mr CURPHEY said that if the pharmacist did not normally work in the pharmacy, he would not need to employ a locum to replace him. The whole point was the need to replace the pharmacist.

The Council then voted in favour of the second option.

Dr NICOLA GRAY made it clear that she had abstained from voting.

LINDA STONE said that the debate had covered the sole practitioner, but there was also the situation of the large company that might require its pharmacists to be responsible for arranging their own locum cover. There could be some difficulty regarding whether reimbursement was justifiable in those circumstances. Perhaps, having dealt with the one person/one pharmacy situation, the Council needed to look at the example, as previously raised by Ashwin Tanna, of those who were expected by their employers to reimburse the locum personally.

ASHWIN TANNA said that the matter might be challenged in a court of law for a judicial review.

HELEN REMINGTON asked that the minutes should record that further debate was needed beyond the terms of reference of the current debate. The Council needed to address the fact that the current arrangements disadvantaged many other pharmacists. The matter needed to be expressed in terms of business cost. It was a business cost to Boots The Chemist; it was a business cost to a National Health Service trust. There might be problems with the Byelaws but the Council would have to find solutions otherwise the Society would continue to disadvantage a large number of pharmacists.

The SECRETARY AND REGISTRAR stressed the need to be careful about double payment in some circumstances. Expertise would have to be brought in to consider the matter.

KIRIT PATEL felt that the paper had fallen short in not addressing Mr Tanna's concerns. It was important to address the situation where anybody was disadvantaged by Council attendance.

The SECRETARY AND REGISTRAR said that the Council should be careful not to encumber the Society with expenses that ought to be paid elsewhere. What she had said about double payment needed to be taken into account. The costs of running the Council could be doubled, and the impact of that would be that they would do less for the profession as a whole.

The PRESIDENT said that he hoped that Mrs Remington would write to the Secretary and Registrar on the matter that she wished to have considered.

Code of conduct

The Council agreed that members who have not signed the Council code of conduct should be ineligible to chair any Society committee and also be precluded from serving on the Adjudicating Committee, the Audit Committee and the Remuneration Committee. They are already barred from serving on the Infringements Committee by a decision of the April Council meeting.

The Council made its decision on the recommendation of the Corporate Governance Group, which believed that because committee chairmen frequently represented the Society externally in that capacity they would be expected to seek to uphold the tenets of the code of conduct and the broader principles espoused by the Nolan committee on standards on public life. The group also believed that service on the three named committees should be barred because those committees dealt with particularly confidential and/or sensitive information or made decisions of a nature that would require some assurance of the governance of the committee. Service on the Resource Management Committee would also be inappropriate but there was no need to name that committee because Council members served on it only in their capacity as chairmen of other committees.

ANDREW BURR said that the problem with the group's recommendations as set out was that they allowed a person who had not signed the code of conduct to become President. That was a fundamental flaw. He was also concerned that the Council was making a meal out of the issue. If it were not careful, it would be perceived as using a tool to do things that it was not trying to do.

LINDA STONE said that the election of Officers followed self-nomination by Council members and it was difficult to prevent somebody from self-nominating, whether or not they had signed the code. The Corporate Governance Group had recognised that.

GERALD ALEXANDER said that as a new member of the Council he had no problem with signing a piece of paper and handing it in. But what was the material difference between a verbal undertaking for an honourable member of Council and a signature filed in the office? A verbal undertaking would, in his experience, be good enough. It was almost like swearing an oath.

The SECRETARY AND REGISTRAR said that the signature was an explicit statement that the person had read and understood the code. It was not uncommon for codes to be signed by employees of organisations and certainly by board members.

The PRESIDENT said that when members of other regulatory bodies signed a code of conduct — which they had read and understood, which was formally lodged, and was a public document — it reinforced public confidence in that organisation. If the Society had Council members who refused to sign, then that would affect the way it was perceived by critical bystanders, such as patients' representatives.

Professor MICHAEL SCHOFIELD said that drawing up a code of conduct was a proper thing to do in the context of Nolan and other reports. If members supported the code they should be expected to sign it. The Council had to make sure that no one took a seat on the future Council without agreeing to observe the code.

Mr ARGOMANDKHAH pointed out that the code was currently a voluntary one. Imposing sanctions for not signing a voluntary code made no sense.

The PRESIDENT suggested that the Council should spend no more time on the matter. There was a proposition relating to the situation of individuals who did not sign the code. Only two had not signed. The rest of the Council were not affected.

On a vote, the Council approved the recommendations.

On the motion of Mr BURR, seconded by ASHWIN TANNA, the Council agreed to refer back to the Corporate Governance Group the issues concerning the Officers.

Modernisation programme

Significant progress in the Society's modernisation programme since the previous Council meeting was described to the Council by the President. However, concerns were expressed that progress was too fast for the Council to keep up with it, with Council members unable to make the input they would like into the modernisation steering group's discussion papers.

The PRESIDENT said that, following the Council's decision that a reformed Society would fulfil both regulatory and professional functions, the need was to look ahead and to build on that decision. The next stage was to consider the future responsibilities and composition of the Council, and the Modernisation Steering Group was to seek views to help inform the proposals that would come to the Council for decision. To encourage debate, three discussion papers were planned. The first (PJ, 15 June, p855) focused on the overall responsibilities of the Council, its size and the proportions of pharmacist and lay members (PDF* 165K). The second paper (PJ, 22 June, p883) looked at geographical and sectoral representation on the Council and methods of election or appointment of members (PDF* 165K). The third paper would examine issues such as terms of office, frequency of elections and the offices of President, Vice-President and Treasurer. The Council would have opportunities to discuss all those issues at reserve days before considering proposals from the steering group.

The Society was working to a tight timetable. The Government planned to establish the Council for the Regulation of Health Care Professionals in early 2003. The other professions within that council's remit were further forward with their proposals for reform than the Society was. It was therefore important that, by the end of this year, the Society should be in a position to demonstrate that its modernisation proposals were well advanced.

ANDREW BURR said that it was totally unacceptable for Council members to have no opportunity for input into the steering group's discussion papers. The Council could have had a constructive debate. The way the steering group was operating was not necessarily in the profession's long-term interests.

The SECRETARY AND REGISTRAR said that because the new overarching council would be formed at the beginning of next year, the Society was expected to produce proposals by the end of this year. That was the reality of the time scale.

LINDA STONE said that she sympathised with Mr Burr. There was a real issue about how the modernisation process was being managed. The officers should look at the problem as a matter of urgency.

Dr GORDON APPELBE said that many Council members were worried about the process. The matter was not desperately urgent and it was important to get it right. Council members should be kept informed of what was happening. He agreed with Mr Burr that the position was unacceptable.

HASSAN ARGOMANDKHAH said that there had to be transparency in the process. Everybody had to know how things were developing. The matter needed to be addressed urgently so that Council members were not suddenly faced with documents on which they had to make a snap decision.

Professor MICHAEL SCHOFIELD said that he supported Mr Burr entirely. His anxiety was that the matter was being approached in the spirit of tweaking the Society here, changing it there, modifying it a bit elsewhere and adding a couple of wing mirrors to produce something fit for the future. That was simply not good enough. There should be a more fundamental review of what was needed and what structural processes were required to support it. There might not be another opportunity for two or three decades. The steering group was skating over many matters, and the membership were being led towards a particular conclusion.

CLIVE JACKSON said that as a Council member he would expect to be asked, and be able to answer, questions on the paper before the Council (the steering group's first discussion paper). He should be in position to defend the paper and give a positive spin on it. Therefore he would expect to be in a position to comment on it before it went out.

PETER CURPHEY said that the Council was still tempted to put its finger in every pie. The steering group had been tasked with looking at alternatives and consulting on them. The Council needed an opportunity to feed into the modernisation group, but the group itself ought to be able to send a paper out to the membership. The paper was a document for the members and was before the Council only for information.

Council members should not redo the work of the steering group: they should trust it to do its work. The Council had already had input through discussion of the issues at Council "awaydays". He would be disappointed if the steering group was not allowed to get on with what it was trying to do and was forced to wait until the Council meeting had a debate before it could send out a paper.

Mr Curphey added that he had a lot of time for Professor Schofield's argument, but the time scale made it impossible to start with a blank piece of paper.

Mr BURR said that he was not satisfied that the steering group had addressed points made by the Council in the past. That was unacceptable.

Dr NICOLA GRAY felt that the situation was the Council's own fault. It gave authority to working groups and committees and then took it back. It was a symptom of a much bigger problem.

PAT HOARE said that the membership perception was that a paper published in The Journal had been discussed and sanctioned by the Council. No other committee had authority to put out anything into The Journal until it had been through the Council.

The PRESIDENT thanked Council members for their comments. The position was that the modernisation group was set up to get on with a difficult job that required the Council's support. As chairman of the group, he wished to ensure that Council members were informed and had the opportunity to develop policy. Policy development largely took place at awaydays, and it was disappointing that probably one-third of Council members had failed to attend some or all of the awaydays. Frankly, that did not help, because some people had information that others did not have. Therefore there was an inconsistency of approach at Council meetings.

The President added that he could give no assurance that everything in the future would be perfect, but he would seek to take account of the important points made.