The Pharmaceutical Journal
Vol 269 No 7218 p480
5 October 2002

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Protocol medicines supply: an end to supervision in community pharmacy?

The Department of Health’s long-awaited discussion paper on skill mix in pharmacy was published last week. Its most controversial proposal would see the effective ending of direct supervision by pharmacists of the supply of all medicines within community pharmacies. Jonathan Buisson seeks opinions on how this might work and what concerns pharmacists have about it

Supervision is one of pharmacy's greatest shibboleths, holding that the sale and supply of medicines (at least within community pharmacies) is always under the direct personal supervision of a pharmacist. It also defines why there is a pharmacy only medicines category.

However, supervision is also seen as chaining pharmacists to the dispensing bench. Since nothing can happen without the pharmacist's presence, the pharmacist cannot leave the pharmacy for more than a few moments. Thus the development of all pharmacy's extended roles is undermined and a new breed of primary care pharmacists has arisen to take on some of the advisory roles proposed for community pharmacists.

Relaxing the rules governing supervision has been proposed on a number of occasions. The Nuffield inquiry into the future of pharmacy, published in 1986, recommended that pharmacists should delegate activities to suitably trained support staff. When this was taken up by the Royal Pharmaceutical Society, it ended in a special general meeting of the Society, held in April 1989 (PJ, 18 April 1989, p438). This meeting was won by the so-called "final checkers" who insisted that pharmacists should make a final check of each prescription before it was handed to the patient. The current position on supervision remains that a pharmacist must see every prescription at some stage in the dispensing process and decide on what action is necessary.

Checking technicians

While the position in community pharmacy has remained largely unchanged over the past 13 years, the situation in hospital pharmacy has changed markedly. Driven by acute shortages of pharmacists, particularly at basic-grade levels, a desire to free pharmacists to undertake clinical roles plus enhancements to the training of technicians, many of the larger hospital pharmacies now make much greater use of pharmacy technicians in supervising the technical aspects of dispensing.

Now the Department of Health is proposing a much wider role for technicians throughout the profession. In its discussion paper "Pharmacy workforce in the new NHS: making the best use of staff to deliver the NHS pharmacy programme", officially announced at the British Pharmaceutical Conference in Manchester last week (PJ, 28 September, p432), pilot "protocol medicines supply schemes" are proposed. In these "suitably qualified and accredited pharmacy technicians, working within standard protocols, can dispense and supply medicines without the personal supervision of a pharmacist". This, it says, would leave pharmacists free to undertake roles such as medicines management, prescribing or medication review.

The Department is at pains to say that this is not settled policy, noting that such schemes would require changes to both pharmacists' term of service and medicines legislation. Registration of technicians would probably also be necessary. According to the Department, any changes in the supervision rules would apply throughout the United Kingdom, as they are covered by the Medicines Act, but regulation of support staff would be a devolved matter.

Discussion is needed on how these schemes might work, the Department says. This could cover accreditation of the schemes, training and qualification of technicians, protocols and governance arrangements, the inclusion of Controlled Drugs, the need for a separate contactable pharmacist for each pharmacy and what pharmacists could do when not on the premises.

Open to abuse?

Community pharmacists whom The Journal contacted are concerned that without considerably more detail being available on how the protocol schemes might work in practice, the schemes might be open to abuse. They are also worried about the cost implications of using more trained staff.

Jonathan Burton, owner of Campus Pharmacy, Stirling, says: "I am tied to doing my own dispensing because, as an Essential Small Pharmacy, we cannot afford to employ a technician. I would use any loosening of supervision restrictions to have a bigger impact on patient care in my pharmacy but will everyone see it that way? It will depend on what checks are in place.

"The facility to leave the pharmacy would be useful but what are we going to use that privilege for? I also find it difficult to imagine everything running smoothly without the pharmacist being present."

David Sharpe, owner of Care Chemists, Mill Hill, north London, echoes these concerns: "I am not clear as to what is a reasonable period for the pharmacist to be absent. I understand the Department's desire to free pharmacists for other activities but will it be at the expense of what is still the core role of community pharmacy — dispensing? Contact by mobile phone is not the same as seeing the product or the prescription." Mr Sharpe adds that he is also concerned for the future of the P medicine category if pharmacists are to be absent from pharmacies for several hours at a time.

The National Pharmaceutical Association says in a statement that the protocol schemes could deny patients access to a pharmacist-led pharmaceutical assessment. "This will have serious implications for the quality and safety of services to patients ... it is imperative that detailed discussions of the design of these protocols are made before any decision is taken on their implementation," the NPA adds.

Sue Sharpe, chief executive of the Pharmaceutical Services Negotiating Committee, says that easy access to a pharmacist is one of the strengths of the pharmacy brand and this must not be adversely affected.

Speaking at the UniChem convention in Mauritius last week (see p499), Helen Darracott, the Royal Pharmaceutical Society's head of professional standards, said that pharmacists need to challenge "the existing comfort zone of the dispensary". Pharmacists should reserve their professional activities to those that would be of benefit to patients, and which were more professionally rewarding, and delegate other activities to trained and competent staff.

The Department is seeking comments on the proposal by 31 December. Over the next few weeks The Journal will be looking at its proposals in more detail.

Until those details are available, the last word must go to David Sharpe: "On skill mix, I think the Department is asking pharmacists to run before they can walk."

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