|
Margaret Watson is MRC fellow in the department
of general practice and primary care at Aberdeen University and
Alison Blenkinsopp is professor of the practice of pharmacy in
the department of medicines management at Keele University
|
Over the past 20 years scores of prescription only medicines (POMs) have been reclassified to pharmacy only (P) status, and from P to general sale list (GSL) status. The greater availability of non-prescription
medicines (NPMs) means that the public is better able to self-care and
that community pharmacy staff have more medicines to recommend. POM-to-P
switches are set to continue with drugs such as proton pump inhibitors
and lipid lowering agents as possible candidates.
The Royal Pharmaceutical Society is one of many advocates for increasing
self-care and recently issued a briefing paper on the treatment of minor
ailments, providing further support and encouragement for the supply
of NPMs from community pharmacies. The briefing paper also covered a
significant development — the establishment and increasing spread
of NHS minor ailment schemes in community pharmacy. These changes raise
questions about the respective roles of pharmacists and medicines counter
assistants in relation to NPMs. Society policy has supported delegation
of much of this work from pharmacists to assistants. In this article
we ask whether this policy needs to be revisited and updated with an
eye to the future.
Budgets under pressure
Health care budgets in the United Kingdom and around the world are under
pressure with increasing demand for care, developments in technology
and the growing burden of disease due to ageing populations. Evidence-based
practice has been heralded as an attempt to promote better quality
of care and to ensure the effective and efficient use of these limited
resources. The code of ethics states that “pharmacists should
be aware of current evidence and ideas, applying these to their practice
and sharing them with professional colleagues and patients”.
As is often the case in health care, medicine and medical professionals
have tended to lead the field in the development of evidence-based practice,
but it is equally applicable to all other health professionals, including
pharmacists. To date, however, there has been little identification and
assimilation of evidence to inform the supply of NPMs from community
pharmacies. Some may question whether there is a need for evidence to
support this activity. Although there is a lack of evidence to support
the use of some (particularly older) NPMs the evidence is stronger for
more recently licensed ones, including those switched from POM to P.
We would argue emphatically that there is a large and growing need to
promote the evidence-based supply of these medicines. Furthermore, if
the reclassification process continues, as it most certainly will, with
more potent drugs becoming available for sale to the public, the need
for evidence-based treatment recommendations will be even greater.
Brave new world
A problem exists, however, with this brave new world of greater opportunity
for self-care and an enhanced role for community pharmacy. Most NPMs
are supplied by assistants, not pharmacists. Although pharmacists have
a professional duty to supervise staff it is unrealistic to expect
their direct involvement in every sale of every NPM and Society guidance
takes this into account. However, currently, assistants are neither
registered nor regulated. They are required to complete (and pass)
an assistants’ qualification within two years of commencing in
post. After that, there are no compulsory further training or education
requirements. No organisation or agency is tasked with providing any
form of ongoing training or continuing education for assistants. A
recent survey of support staff training needs in Northern Scotland
showed that 81 per cent of community pharmacists believed that their
support staff were not receiving enough training. Yet, it is these
staff who are faced with an increasing array of NPMs from which they
must make their recommendations. Articles in pharmacy magazines (often
good but generally without meaningful independent accreditation), and
promotional literature from the pharmaceutical industry may be their
only sources of information. It has been suggested that the supply
of NPMs is the activity in community pharmacies that is associated
with greatest risk, yet it is the least trained members of staff who
are often solely involved in the sale of these medicines.
A recent study conducted in Scottish pharmacies, which involved observation
of transactions for NPMs and interviews with pharmacy staff, showed that
many interactions with customers continue to be structured according
to the WWHAM framework for questioning. Although this mnemonic provides
a systematic approach to eliciting information from a customer during
the decision-making process to supply a NPM, this study showed that it
was often used as a matter of rote rather than in an informed manner.
It was as if WWHAM was being used as a safety net: if I ask all these
questions (whether they are appropriate or not), I will be doing the
right thing, or more importantly perhaps, I will not be doing the wrong
thing. The implications of this type of questioning and its effect on
outcomes requires further investigation. It is insufficient merely to
obtain information; the right information has to be obtained and then
used appropriately to inform the decision-making process. A previous
study that evaluated the effectiveness of educational strategies on improving
the appropriateness of sales of antifungal medicines for the treatment
of vaginal candidiasis showed that customer consultations in which pharmacists
were involved were more likely to result in an “appropriate” outcome
compared with consultations where a non-pharmacist member of staff was
involved. It is an unpalatable fact that research has consistently shown
that the quality of advice from pharmacists is better than that from
assistants.
The Government has introduced clinical governance as a strategy to promote
quality improvement and ensure high standards of care within the NHS.
One important component of clinical governance is the requirement for
all registered health care professionals to undertake continuing professional
development. CPD is recognised as essential if health care professionals
are to provide safe, effective and efficient health care. Mandatory CPD
for pharmacists becomes a reality in 2005. Pharmacy technicians will
soon be subject to a regulatory framework and they too will be required
to undertake CPD. But what about assistants and other pharmacy support
staff? A recent survey of community pharmacy support staff in Northern
Scotland showed that most staff have favourable attitudes towards training
with most respondents stating that they would prefer more training than
they currently receive. Over 25 per cent of support staff stated that
they currently receive no training.
Training needs
There is no suggested framework of registration for this large and important
cohort of pharmacy workers. It is questionable whether a regulatory
framework would indeed be appropriate. However, the continuing education
and training needs of these staff need to be recognised and addressed
if we are to achieve the goal of the community pharmacy as centre of
quality care for minor (and not so minor) ailments. We argue that pharmacy
support staff need appropriate and ongoing training to fulfil the Society’s
aim of promoting community pharmacy as the centre for self-care. |
