|
Tanya Samuels and Karen
Hassell are researchers
at the University of Manchester school of pharmacy and pharmaceutical
sciences
|
Recently, the term skill mix has acquired popular currency in pharmacy
policy circles. The Department of Health has used the term in documents
outlining plans for the modernisation of pharmacy. The document “Pharmacy
workforce in the new NHS” refers to skill mix, and a need to “liberate
the talent and skills of all the workforce so that every patient gets
the right care in the right place at the right time”. Nobody would
disagree with that, but skill mix is seldom clearly defined and, as a
result, the concept is poorly understood, which makes it difficult for
pharmacists to engage with skill mix debates in any meaningful way.
The definition that we will use for this article is the “balance
between trained and untrained, qualified and unqualified and supervisory
and operative staff within a service area as well as between staff groups”.
Training, experience, qualifications, ability and teamwork will contribute
to the skills held by individuals and a disciplinary group.
Skill mix and role diversification were introduced into the hospital
pharmacy sector nearly two decades ago, in response to developments in
clinical pharmacy, and a shortage of pharmacists. Pharmacy technicians
in hospitals perform an enormous range of tasks, and their role has extended
beyond what was originally envisaged. These developments have resulted
in a range of specialist training opportunities, and a job grading system,
which illustrates the range of skills, competencies and experience in
the sector. Developments reflect a trend away from constraints about
who should do what, to a more task-orientated, multidisciplined approach
to pharmaceutical care.
Proposals for skill mix have received mixed reactions in community pharmacy.
The NHS is keen to introduce skill mix initiatives to assist in the modernisation
process and control costs. One could imagine that the multiples will
also embrace skill mix initiatives, because they employ large teams of
support staff, and expanding their role will reduce costs and improve
the organisation of their work, releasing pharmacists to provide additional
services.
However, half the profession works in the independent sector, and it
is from here that the greatest resistance to skill mix initiatives appears
to have emerged. Pharmacist proprietors, and pharmacists working for
them, perceive skill mix as a threat to their profession, and are concerned
that if technicians perform more of their functions, the role of the
pharmacist will be undermined. Furthermore, many independent pharmacies
believe they are too small to introduce skill mix initiatives, or benefit
from the incentives that are on offer, including encouraging community
pharmacies to contract services to GPs or a primary care trust. Small
pharmacies consider the costs prohibitive, and the difficulties associated
with identifying, releasing and training suitable staff as daunting.
Before ruling out skill mix initiatives, pharmacists should consider
what the future holds for those who fail to confront the challenges that
skill mix presents. Pharmacists will inevitably lose more of their traditional
dispensing functions as the preparation and packaging of medicines becomes
more advanced. The introduction of mandatory qualifications and registration
for pharmacy technicians may well drive role extension for technicians,
as happened with nursing assistants in Canada. Pharmacists should ask
themselves whether they will continue to receive the same financial rewards
for services that can be provided more cheaply by pharmacy technicians.
Pharmacists have been identified as and “untapped resource in the
NHS”, which implies a recognition of the need for pharmacists to
explore opportunities to apply their clinical skills, to situations where
technicians can be no substitute.
Pharmacists need to consider how to convert these perceived potential
threats into opportunities. Several of the skill mix initiatives that
have been documented, such as the “accredited checking technician” may
be unsuitable models for small pharmacies. Instead, pharmacists should
consider creative ways to delegate their activities to support staff,
releasing them to pursue areas, which they find more personally rewarding.
This may be managing the business side of the pharmacy, or alternatively
concentrating on areas with the greatest impact in terms of the quality
of services, such as patient counselling. Pharmacists may consider shaping
their services to meet the demands of particular patient groups such
as the elderly, or chronic medication users. Through skill mix initiatives
and substitution of skills, the opportunities for refinement of existing
services, or new services are likely to appear.
Pharmacists should draw from the experiences in other countries, and
disciplines such as nursing, shaping the development of skill mix interventions
to suit their own needs. A report recently commissioned by the Department
of Health reviewing workload data in nursing, found an inadequate division
of labour, with no logical mechanisms for deploying staff. Analysis revealed
that 25 per cent of health care assistants were doing more technical
work than qualified nurses, highlighting that the skills of various staff
are neither being used effectively or efficiently. These findings should
concern nurses, because, if health care assistants are used interchangeably
with nurses, but at a lower cost, the jobs of skilled nurses may be vulnerable
to further skill dilution.
A recent trip to Denmark highlighted the potential dangers of ignoring
proposals to introduce skill mix and develop the role of pharmacists
in parallel with support staff. One development which has been introduced
in Denmark has been to extend the role of pharmacy technicians or “pharmaconomists”,
by advancing their training to incorporate several new areas. Pharmaconomists
assume responsibility for many of the tasks traditionally associated
with pharmacists, without the supervision of a pharmacist. However, there
has been no parallel development in the role of the pharmacist, and it
is sometimes difficult to distinguish between the two, and people may
begin to question the value of employing a pharmacist when the tasks
appear to be adequately performed by pharmaconomists.
By contrast, other professions seem to have taken a different route.
For example, in the legal profession, legal executives are qualified
to practise in certain specialised areas of work under the control of
solicitors who have a broader range of qualifications, which enable them
to identify problems, which cross specialist boundaries.
Pharmacists should engage with skill mix debates and discussion around
possible role extension. One way to do this is to develop:
• A shared vision among all staff of what is intended by skill mix and
an understanding of how it can can benefit both the individuals and the
pharmacy
• Operational structures to help community pharmacies achieve the desired
skill mix. which may require identifying additional training requirements,
clear organisational structures, lines of responsibility, and changes
to the working environment
Community pharmacists cannot be expected to do this individually. The
profession as a whole should explore the opportunities both for the pharmacist,
and for their support staff. They might find that the win-win solution,
so beloved by management consultants, will offer greater satisfaction
and security to pharmacists, offers greater appeal for potential new
entrants, better careers for the support staff, and a wider range of
services for the public.
If pharmacists fail to seize this opportunity to shape skill mix developments
there is a danger that the process will evolve in a haphazard and unmanaged
fashion, which may jeopardise the future role and security of pharmacists. |
The
Pharmaceutical Journal