The Pharmaceutical Journal
Vol 269 No 7219 p520
12 October 2002

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Are workforce shortages affecting all professions driving skill mix changes?

Workforce shortages are being experienced in many health care sectors, notably pharmacy, nursing and general medical practice. Coupled with expansion of existing roles, this is driving some of the issues behind the skill mix debate. Jonathan Buisson (on the staff of The Journal) reports

There may be a shortage of as many as 2,500 full-time equivalent pharmacists in community pharmacy, researchers from the University of Manchester estimate (PDF 95K) (PJ, 31 August, p291). More than 10,000 new general practitioners are needed if all the targets in the National Health Service plan are to be achieved, according to the Royal College of General Practitioners and the British Medical Association's General Practitioners Committee, and around a quarter of all registered nurses will be eligible to retire within the next five years, the Royal College of Nursing says.

For pharmacy, all this is added to a continuing rise in prescription volumes. All the national service frameworks and National Institute for Clinical Excellence guidance have to be implemented and monitored. Repeat dispensing and pharmacist prescribing will be a reality next year. There just are too few pharmacists (and other health care professionals) to go round.

This is the background to the Department of Health's skill mix report, "Pharmacy workforce in the new NHS", published last month (PJ, 5 October, p469). According to the report, the 21,000 community pharmacists and 5,500 hospital pharmacists working in Britain are supported by around 13,000 qualified technicians, 16,000 dispensing assistants and 40,000 medicines counter assistants [Annex 2]. Expanding the roles of support staff is seen as a crucial part of achieving the pharmacy plan for England.

Evolution or revolution?

The evolution of pharmacy technicians' roles has been proceeding continuously in the hospital sector for many years, Chris Cairns, director of pharmacy and dietetics at University Hospital Lewisham, London, says. This has been in parallel to the development of pharmacists' roles.

"Most hospitals now have accredited checking technicians. They undertake the final technical check of dispensed medicines, after the prescriptions have been screened at an earlier stage by a pharmacist," he says.

Pharmacy technicians have taken on many management roles in hospitals that were previously carried out by pharmacists. These include managing dispensaries and aseptic production units, running clinical trials and carrying out medicines procurement.

"Technicians manage these units and supervise the technical rather than professional aspects of junior pharmacists' and preregistration trainees' work."

Mr Cairns says that several factors have driven the increased use of technicians. There have been long-standing problems in recruiting sufficient basic-grade pharmacists, who used to undertake a lot of this work, and a desire to see pharmacists move out of the dispensary so that they can work more closely with patients and junior medical staff. Developing the skills and roles of technicians has been seen as essential to retaining their services in a competitive market and increased demand for hospital pharmacy services has promoted innovation.

"Necessity is the mother of invention and many of the inventions have been good," Mr Cairns says.

Changes have also occurred in community pharmacy, albeit more slowly, driven by some of the same pressures. John D'Arcy, chief executive of the National Pharmaceutical Association, says that there is a natural tendency in any professional group for roles being undertaken to change and progress.

Many pharmacists are still doing the same basic dispensing work they did 10 or 20 years ago, although at much increased volume. What has changed, Mr D'Arcy says, is that there has been a great increase in the amount of advice, mostly undocumented, that pharmacists give to customers.

"People are handling more prescriptions and giving more advice and are reaching the limits of their available time. To cope with this they have a number of options. They can limit the work they do, such as no longer filling monitored dosage systems, or take on more staff. The latter has cost implications and there is the question of where all these new staff will come from," he says.

Lesley Morgan, president of the Association of Pharmacy Technicians UK, says that if more appropriately qualified pharmacy technicians are needed in both hospital and community pharmacy then a structured programme to train them will be necessary. She points out that training for pharmacists is already structured, in that there is a progression of a known number of pharmacy students through universities and then into preregistration training posts.

"Perhaps we even need schools for technicians, as they have in Denmark," she says.

The Department of Health's skill mix report foresees pharmacists taking on a number of new roles, such as prescribing, medicines management and specialist services for patients with chronic diseases [Paragraphs 4–11]. Some of this work is a natural extension of what community and hospital pharmacists already do. Some of it is taking on work from other health care professionals, particularly doctors, in order to relieve in part their own workload problems and, as a result, improve services to patients.

The new contract for GPs suggests that pharmacists could take on some of their work. Pharmacist prescribing and voucher schemes whereby pharmacists can supply non-prescription medicines on the NHS to patients who are exempt from prescription charges (and who would otherwise visit their GP for a prescription) are cited as examples.

With prescription volumes expected to continue to rise, how will pharmacists cope with their increased workload?

Automation the answer?

Automation has become the norm in wholesaling. Automated dispensing is beginning to appear in hospitals and may soon appear in community pharmacy. It will be boosted by electronic transmission of prescriptions and electronic prescribing systems in hospitals. A move to full patient pack dispensing would also help with automation.

Mr Cairns says that automation is only one of the options available. "Automation by itself only frees small amounts of time for pharmacists and technicians, but it does give safer systems. I believe that for community pharmacy the use of checking technicians or group pharmacy practices with more than one pharmacist available are other options."

Mr D'Arcy says that automation in community pharmacy is likely to appear as and when it becomes affordable and once dispensing from bulk ceases. It has already appeared in some American pharmacies.

However, Mr D'Arcy adds, skill mix is also an attitude: "There are lots of pharmacists out there who do not feel locked in the dispensary. They want to be there, because that is where they feel they are adding value, and no end of technicians will get them out."