The Pharmaceutical Journal
Vol 271 No 7274 p657-659
8 November 2003

Society summary

Any structures that underpin reformed Council must satisfy five key tests

The future of the Royal Pharmaceutical Society of Great Britain appears to be hanging in the balance, says Marcus Longley. Are the members to be sold out, or is their future to be properly secured? In this article, he looks at the underlying issues

To the casual observer of the inner workings of the Royal Pharmaceutical Society, the debate on its future role and structures must seem rather puzzling. The passions are clear, the stakes appear to be high and matters of principle and fundamental trust are obviously being thrashed out. But what is it really all about? And how can one contribute to the debate?

The structure of the future Council has now been settled — subject to government approval. The proposal is that it should have 29 members: 17 pharmacists, 10 lay members and two technicians. But the question remains: what structures should be put in place beneath the Council?

This article looks at the underlying issues. It suggests five key tests for the proposed new structures which could feed into the Society’s new Council, and describes one such model in more detail. Next week, a second article looks will look at two other possible models.

Two roles: the government’s and the profession’s
Much of the complication in this debate stems from the fact that two key issues have come together — the Government’s programme to reform all the regulators of health care professions and the Society’s own agenda for professional leadership and development.

Regulation Within the next year, the Government will have transformed all the regulators into “modern” regulators, using Section 60 of the 1999 Health Act. The new bodies differ from their predecessors (“old fashioned” regulators) in that they are supposed to be much more proactive — making sure systems are in place to prevent things going wrong, rather than dealing with the consequences when they already have. This means that the modern regulator will be interested in issues such as developing standards and promoting continuing professional development, and assessing the performance of all professionals — as well as the “policeman” role of dealing with poor performance and misconduct. This is the only way, the Government argues, to make sure that tragedies, such as the Bristol babies’ heart scandal, cannot occur in the future.

The other major difference is that all the regulators will have to have a substantial minority of lay people on their governing Councils to ensure that professional regulation does not become professional self-protection. (Ten lay members out of 29 is the proposal for the Society. This compares with 11 out of 23 for the Nursing and Midwifery Council and 10 out of 29 for the General Dental Council.)

For almost all the other health care professions, that is the end of the story: a new regulatory body, a new agenda, new members, set up by an Order made under section 60 of the 1999 Health Act.

But not for the Society.

Professional leadership and development The Society has to take on board the government agenda. But it also has to decide what to do with a whole host of other functions which the General Medical Council and the others never had. The Society is unique in having been both a regulator and the body responsible for the interests of the profession. Hence it is alone among health care regulators in also having a Royal Charter (Figure 1), which empowers the Society to carry out this professional leadership role.



So the debate has raged over the past year about what the Royal Charter should contain. The debate goes to the heart of what one believes the Society should be and should do, since both of these are legitimised by the Charter. And this debate will shortly come to its conclusion, when the Council debates the final draft Charter at the beginning of next month.

Form follows function In recent months, more and more attention has focused on how the Society should organise itself to deliver both these regulatory and professional functions. On the basis of the old adage “form follows function”, once the overall purpose (the “function”) of the Society has been defined in legislation and Charter, we can sensibly decide on what structures should be put in place beneath Council to ensure that it can discharge its functions appropriately and effectively (the “form”). What committees, groups, ways of working are required?

Five key tests
Designing any structure like this is a tricky task, because so many requirements have to be satisfied. So how is one to decide? The various issues can perhaps be boiled down to five “tests” which any new model must be able to pass.

(1) Affordability Whatever is designed clearly has to be affordable. The Society can fund its work in two main ways — through retention fees and other charges, and through activities such as publishing. The latter makes a fundamental contribution to the work of the Society, but it is not guaranteed, and its capacity to raise additional income is limited. So, if any future structure is to cost substantially more than the present one, pharmacists will have to pay the extra. A key question is how much the new model will expect pharmacists to contribute.

(2) Integrated roles, integrated working The fact that the Society has the twin roles of regulator and professional body under one roof should be an immense advantage, because it means that all issues can be resolved by the one body. This is not the case in medicine, for example, where the GMC has to work with all the various royal colleges and faculties if it wants to introduce major change. At best, this results in delay and additional cost; at worst, it leads to confusion and tension.

There are several examples where the integrated nature of the Society has worked to the advantage of pharmacy. Policy and standards in a variety of areas — emergency hormonal contraception, pharmacists’ prescribing, the future impact of genetics, the links between workload and safety/quality — all require the regulatory and professional strands to complement each other. Having control over both can only help. Therefore, any new structure must bring together the various departments in Lambeth and, more broadly, the profession as a whole, to work together, rather than reinforce individual “silos”. Otherwise, the advantage of having the integrated roles will have been squandered. The key question here is whether the model actively promotes integrated working.

(3) One line of accountability The question of accountability is a tricky one. The Council has decided that if it is to have these twin roles, there must ultimately be just one line of accountability running through the whole organisation: in the end, the Council must have responsibility for, and therefore be able to direct, everything done in its name. This elementary principle of good governance produces some difficulties, however. For example, is it acceptable that 10 lay people (plus two technicians) will have a say over the work of the professional body for pharmacy? Can these non-elected, non-pharmacists really be expected to champion issues which are of prime concern to the profession? Will the regulatory agenda crowd out the professional agenda? In this case the key question is whether the model achieves unity without compromising either of the dual roles?

(4) Ownership by all sections of the profession Although pharmacy is a relatively small profession in comparison with, say, nursing, it does nevertheless come in many different parts. There has been some concern over the years about whether each part receives adequate attention from the Society. “Non-dispensing” pharmacists in industry, for example, have argued that the Society is not always as interested in their future as it is in that of community or hospital pharmacy. There is some concern about the position of locum pharmacists and those developing new roles, and also the need to embrace the particular concerns of educationalists and others. Fundamentally, there is a need to ensure democratic control over the direction of the Society, while also ensuring that it meets the Government’s requirements and is effective. The key question here is whether the model ensures that every section of the profession will feel that the Society is for them?

(5) High quality outputs Last, but perhaps most important of all, is the question of outputs: relevant, timely, practical, forward-looking and acceptable policies on all the important issues for the profession?

The answer to this lies in looking at how well adapted is the model for each stage of the Society’s work. First, agenda setting: will the model ensure that all the important issues are identified in good time, and that they are acted upon? Second, policy development: will the model ensure that the detailed policy (on standards, workforce, education, etc) is practicable and achieves what it should? Finally, policy implementation: will the model ensure that good policy is translated into practice? The key question is whether the model provides effective mechanisms for all three stages of the Society’s work?

Some suggested models
Several different models have been suggested which address the five tests in different ways. None of them is fully worked-up: there are many points of detail which need further attention. Also, none of them has been properly appraised: this would have to happen before they could be implemented. But they are nevertheless interesting examples from which people may choose the elements they find most attractive.

One model is described below; the other two will be described next week. Readers who wish to take part in the consultation can comment specifically on the models, or use them to trigger their own thoughts. In some respects, the most useful feedback might be to create an entirely new model which best satisfies the criteria.

Model 1 — Senates and academies
Description This model was first presented — in somewhat different form — at the British Pharmaceutical Conference in 2002, and has been further modified more recently (Figure 2).



Starting from the requirement for integrated working and the need to have one governing body responsible for all the work of the Society, it identifies the work of the Society as having four principal foci: three to do with professional leadership and development (clinical and practice issues, education and learning, and science and technology), and one to do with regulation.

In reality, of course, the dividing lines between these are blurred, since most issues of any significance will have implications in all four areas. But in order to make the structure manageable, it requires some sub-division, and these particular areas appear to have credibility.

Taking each in turn, clinical and practice issues would be addressed by three “senates”, one for each of England, Scotland and Wales. The justification for this is that, increasingly, the way in which the NHS works — its priorities, structures, accountabilities — will vary between the three countries, as the Scottish Executive, Welsh Assembly Government and English Department of Health develop policy differently. Since most clinical and practice issues for pharmacy will be directly affected by this devolution of policy, it makes sense for the senates to have a primary orientation towards the three countries. This, it is to be hoped, will ensure that the profession is responsive to local needs, and is able to advance its case in the most effective ways.

The senates would each have a governing body or executive, elected by pharmacists in that country, which would determine their priorities and workload, subject to the final endorsement of the Society’s Council. The distribution of places on the executive could be structured so as to reflect all sections of the profession. They would contribute to all three stages of the Society’s work — agenda setting, policy development and implementation. The chairmen of the senates would attend Council meetings, but not vote. The senates would play a leading role in linking with the branches.

The lead responsibility for “education and learning” and “science and technology” would fall on two academies created for the purpose, covering the whole of Britain. Their task would be to advise the Council on all issues within their remit, and to provide specific expertise on the many “technical” issues relating to pharmaceutical education and science. Membership of the academies would be primarily by appointment on the basis of personal expertise, although there might also be an element of shared membership with the Council and the senates.

Finally, regulation and fitness to practise would be the responsibility of the Council itself and the new fitness for practice machinery. As noted earlier, however, the distinctions between the four foci are somewhat arbitrary and it is likely that most major issues would require an input from several (if not all) of the senates and academies as well as from the Council itself. One can envisage a range of working groups, drawn from the various bodies and other experts, empowered to develop detailed policy on a variety of cross-cutting issues, subject to the final approval of Council.

Let us now look at how this model fits the five key tests.

Affordability It is impossible to assess affordability without a detailed appraisal, which in turn would require decisions on many detailed aspects of working. In broad terms, though, the senates in Scotland and Wales might be seen as being comparable to the existing executives; the English senate would be new. The academies are also new, although much of their activity might replace the work of existing committees.

Integrated working This model addresses the need to divide the work of the Society into manageable “chunks” by creating five bodies subordinate to Council. The responsibility for ensuring that they do not become five “silos”, each working in isolation, will presumably fall on the Council itself and whatever mechanisms it creates for this purpose. One might imagine, for example, a small co-ordinating group with a representative from each body, to allocate tasks and ensure cross-fertilisation. Whatever the structures, however, working practices and the dominant “culture” are probably more important.

Single line of accountability The Council has clear authority over all aspects of the Society’s work in this model, which is a strength. But this raises difficult questions about how the tensions of devolution, for example, will be managed. If the Scottish and Welsh devolved administrations demand different changes in areas of practice from each other and from England, it might be difficult for one united British professional body to respond, particularly since “regulation” remains a power reserved to the UK parliament.

Ownership by all sections of the profession To some extent, there may be a tension between the need for a single line of accountability and the need to ensure that both professional and regulatory activities attract equal prominence. This model does not provide for any body to co-ordinate the work of the senates and academies other than the Council itself (with lay members and technicians). Will there be a danger, therefore, that the lay members and technicians on the Council will not regard professional issues as being as important as regulation, with the result that professional leadership and development is left to wither on the vine? Also, will smaller sections of the profession be able to get their voices heard at the highest level?

The response is that pharmacists will still constitute a majority on the Council and that, in any case, lay people and technicians will recognise the mutually supporting nature of regulation and professional leadership. Similarly, they will recognise the need for the Society to be inclusive of all sections of the profession and will establish appropriate mechanisms to ensure that this occurs.

High quality outputs As always, the question of outputs is the acid test. The model tries to combine expert input (the academies) with a broad base and sensitivity to the realities of everyday professional practice (the senates, linked to the branches). The Council would have the ability to engage whatever parts of the overall structure it believed to be appropriate to any given task; agenda setting would be the work of all (subject to Council’s final decision).

The answer?
The answer is for pharmacists to decide. There is, of course, no simple verdict — this model (like the two others to be discussed next week) contains a series of compromises designed to achieve the best overall structure. Also, it has not been subject to a detailed appraisal.

But the whole point of this consultation is not to run a beauty contest between three models. The intention is to gather opinion on some of the underlying issues which the models tackle in different ways, and from this to design something that really does work and commands support. In particular, answers are needed to the 10 questions were posed in an earlier article (PDF 150K) introducing the consultation (PJ, 27 September, central pull-out section).

Responses to the consultation are required by 1 December.