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Sandy Florence: Sometimes “we are our own worst
enemy” |
The Royal Pharmaceutical Society has been part of my life for much more
than the 40 years that I have been a member of it. It permeated my consciousness
for many years before that, as my father, Alexander Charles Gerrard Florence,
was a pharmacist, a product of the Royal Dispensary School of Pharmacy
in Edinburgh, and for a time we lived above the family pharmacy. The
particular aroma of a 1950s pharmacy and the sounds, too, permeated the
home.
This connection undoubtedly influenced my son, who is also a member of
the Society and senior lecturer in pharmaceutics at the University of
Strathclyde. Academic pharmacists, contrary to popular belief, do practise
pharmacy, perhaps in eccentric ways, but they are also occasional patients,
frequently parents, always observers and inveterate travellers. Their
views outside their true and linked metiers of education and research
therefore have some substance.
Practising pharmacy
I have practised community pharmacy although this was some time ago.
But I have mainly practised elsewhere, where I have not been a direct
danger to the public. In my daily work — and certainly on the
Committee on Safety of Medicines as it then was — I practised
pharmacy. Only recently I was discussing future trends in medication
and in particular the need for dosage systems so that personalised
medicines could be become a reality, and neglected groups like children
medicated appropriately. Time was when we academics had difficulty
to be regarded as practitioners at 1 Lambeth High Street.
A number of weeks ago, a paper bag fell out of my copy of The Pharmaceutical
Journal. The bag was jokingly supposed to cover your embarrassment when
you entered Superdrug to seek employment. Apart from the own goal of
the wording and the fact that the bag was fit only for a Homo floriensis skull the bag is somehow emblematic of what I want to say. First, can
one imagine such an object falling from The Lancet or the BMJ?
In 2000, I gave a talk at the College of Pharmacy Practice, rather presumptuously
entitled “The folly of presumption and Pogo’s prediction”.
The presumption element related to the fact that in pharmacy we have
made errors predicting the future, eradicating subjects like pharmacognosy
and much practical work from our undergraduate courses so that now some
graduates are terrified of doing anything remotely pharmaceutical. Even
The Lancet recently (2006;368:260) had an editorial pleading: “Don’t
forget pharmacognosy!” Arguments rage as much as they do in academia
about the value of practical dispensing. Once we misjudge it takes decades
to rectify, but by that time others can jump into the breach. The title
also quoted the character Pogo and his call to action: “Resolve,
then, that on this very ground with small flags waving and tinny trumpets,
we shall meet the enemy and he not may be ours, he may be us.” His
prediction, then, “we have seen the enemy and it was us” resonates
with me in relation to pharmacy. The paper bag epitomises it, but by
far and away the greatest issue I identify is that of the effect our
community pharmacies, has on the public, fellow health care professionals,
law-makers and others of influence.
Many community pharmacies are devoid of style, aesthetics, order, identity
even. We are in this respect our own worst enemy. It is difficult to
convey the image of the true professional through the baby clothes, the
Coca-Cola, sandwiches and medium of the
T-shirted pharmacist. Specious arguments are used to justify but not
explain the extraneous items that infiltrate our pharmacies and confuse
identity and purpose.
Those who spend time in France, for example, can compare French pharmacies
with ours. In Corsica — which, although a French department, is
perhaps not the most progressive in France — two pharmacies that
I know in the small town of Porto Vecchio sport robotic dispensing stations.
One, in fact, has three. That and their distinctive appearance marks
out these places as pharmacies.
If we believe that the image we project is of no consequence I can attest
that it does affect perceptions. It certainly affected decisions at the
Committee of Safety of Medicines, slowing down approval of pharmacist-reporting
of adverse reactions, or the transfer of medicines from POM to P. One
senior clinical pharmacologist not known for his wit once said,
tongue in cheek, when I opined that the ability to buy medicines in filling
stations was hardly the best way to proceed, that you get better advice
in a garage.
The medical hierarchy’s view of pharmacy has been difficult to
change, possibly because of what they have witnessed. Through the efforts
of clinical pharmacists in the NHS and their undoubted abilities, gradually
but reluctantly changed the tone of some publicly uttered views, but
fundamentally the view was of a profession whose motive was turnover
and sales. This might be viewed as rather rich from a highly paid profession,
but prejudices are rarely logical. Rules can be stultifying
When are we going in our profession to act on gut-feeling, on inspiration?
It is, of course, against the precepts of evidence-based practice to
do any such thing. Historically we have been excellent at developing
rules and regulations for ourselves. Some are convinced that following
these to the letter is the mark of a professional, whereas rules can
be stultifying. They are the refuge of the timid. We have so much to
offer — as the Nuffield Inquiry report said 21 years ago — but
the potential needs still to be unleashed. Drop the tinny trumpets.
Hoist the massive banners.
Many pharmacists, unlike their community colleagues, work out of the
public gaze and one feels that in our publicity we are too community-centric.
Perhaps that needs to be but, if so, that image must be improved. There
are, of course, many individual examples of community pharmacies with
exemplary design and standards, but these are few and far between. We
are the enemy. We must promote and enthuse pharmacists and strengthen
the image of community pharmacy. Community pharmacists must be seen to
be part of a community of pharmacists who work in industry, in hospital,
with physicians, in government and in universities.
I have often been introduced in polite company as a professor of pharmacology,
which I am not. A head of a medical school in London, since knighted,
said to me, only a few years ago, that he could understand why we need
pharmacists in industry and even in hospital but that he could not see
the need for them in the community.
Where does one begin to answer and how is it that we have not put across
the message that if we did not have pharmacy we would need to invent
it? And if we did not have enforceable professional ethics we would need
to invent them. One only needs to look at pharmacy in India to realise
that to have pharmacy is not enough, but that high professional and educational
standards are required. In Myanmar, having fewer than 100 pharmacists
in the whole country led to illegal importation and sale of medicines
by unqualified traders, no quality control, no regulation; one realised
the need for us. Pharmacy as a profession is needed in regulation, in
quality control, in manufacture, in distribution and in primary and secondary
care. We need to use such basic arguments as a beginning, because people
still question what it is we really do. Where are our knights, our dames?
Where are our knights, our dames, our lords? Where is our influence
in high places? Is this Society structured so that the luminaries of
the
profession have their say, or are we not allowed to have such because
we are a humble profession? Or are we a profession that simply cannot
decide what it is?
My elementary proposition goes as follows. The impact of pharmacy
imprinted on the subconscious of the public derives from the community
pharmacy.
This, in turn, moulds opinion of what pharmacy is and attracts students
who find that environment satisfactory, while it deters talented young
people and especially young men good at science. Hence we attract undergraduates
whose attitude to their studies is already biased and, while many of
them are clever, many find their science too difficult or, more likely,
unconnected with their image of the need, and stampede for topics where
soft concepts abound and hard answers are difficult to define. The
articulate among these students gravitate towards the British Pharmaceutical
Students
Association, become officers and, before they know it, are elected
to the council. This leads to attempts to change pharmacy education
from
an excellent science-based course into a practice-based subject, without
that rigorous definition of practice. It can be an alluring option,
especially in these days of the shortage of highly qualified academic
pharmacists
and the mushrooming of schools of pharmacy. If they succeed, not only
will our schools lose their international standing, the profession
will not be prepared for the future that is only now unfolding.
Medicines are much more complex than they were or were perceived to
be even 10 years ago and certainly when I was studying pharmacy. We
find
out much more each day about the human organism. It behoves us to tackle
the future quickly. We predicate our decisions today on estimate of
what the future will be. If we wait for the evidence, as our profession
could
do, it will be too late and others will be there in the breach. May
I suggest that the Society urgently appoint a futurologist? Think-tank needed
We need a think-tank speculating intelligently what the future might
look like, not only in the way we use electronic communications to
free us for our technical tasks but how medicines will change and how
we are to prepare ourselves for that future of stem call therapy, gene
therapy, in utero therapy and personalised medication. What educational
preparation do we need for that future? It is not, I would posit, one
that starts with coughs, colds and haemorrhoids and GSL medicines for
minor ailments, nor is it necessarily the possession of prescribing
powers, because none of these are distinctive and unique to pharmacy.
I think we need to trumpet what we are and what we have achieved in
heath care: we must throw away our tinny trumpets for trombones. We
must recruit
our champions to the cause and enthuse our future pharmacists. We need
a new intellectualism and robust debate. Where are the voices raised,
for example, about the creeping corporate take-over of our profession?
How many decisions on our future will be determined in board rooms rather
than in the melting pot of professional debate? The truth would do no
harm.
A profession unaware of its heritage is emasculated. What do David Jack,
John Stenlake, Malcolm Stevens, Patrick Humphrey and Roy Brittain have
in common? All are pharmacists, all discoverers of drugs. Asked another
way, what have salbutamol, temazolamide, atracurium and sumatriptan in
common? There were all discovered by pharmacists. How many on the Register
are aware of all this? This is not an exhaustive list — only people
I know or knew. How many British pharmacists are internationally known
for their science? British clinical pharmacy is envied in Europe, and
many of its practitioners are on the European stage at least. This Society
through its publishing arm makes a huge intellectual contribution to
health care. So we have much to celebrate. But still on the high street
I sometimes look the other way.
We need our science more than ever. We need pharmacists who can do things,
other than put their hands on fevered brows and counsel patients. They
must be able to do things with their hands, even to make medicines. Surgeons
after all get their hands dirty, bloody even, and have quite a reasonable
standing in society. John W. Gardiner said: “A society which scorns
excellence in plumbing simply because it is plumbing but rewards mediocre
philosophy simply because it is philosophy will soon become a society
in which neither its pipes nor its theories hold water.”
We need to reinject research as a norm into practice. The School of Pharmacy
set up with committed staff at Great Ormond Street Hospital and the Institute
of Child Health a Centre for Paediatric Pharmacy Research to provide
an academic underpinning to practice and at the Royal Free and University
College Hospitals instituted a chair of clinical pharmaceutics. I believe
we fundamentally need practitioners who can perform the exciting basic
function of the pharmacist. Producing medicines for individual patients
for the future must move in that direction. The folly of past prediction
is to say that extemporaneous pharmacy is dead. The crude science versus
practice debate needs refining. What is science and, more importantly,
what do we mean by practice? That requires us to define what we are as
a community of pharmacists and to appropriate the role as guardians of
the quality of medicines and quality of outcomes.
Academics need to engage not just with the theory of practice but with
bringing the science of medicines to bear on daily practice. And there
is plenty for pharmacist of the future to do: undertaking highly technical
analyses for patients (so analytical chemistry in schools of pharmacy
is not dead) and preparing personalised technologies such as three dimensional
printing or nanoparticle-based systems (similarly, extemporaneous dispensing
and formulation are not dead). Ultimately a research-based ethos, this
will allow each prescription to be the start of a mini research project,
insisting on follow up to complete the picture. Centre for health
Our pharmacies could be recognisable centres for health, where the
public could tap into the broad scientific knowledge of our graduates
and
use their technical skills in ensuring the future of personalised
medicines in the post-genomic era.
I am more and more convinced of the value of what we do collectively,
but I am frustrated that we do not always convince those in high places.
We must promote this community to which we belong and support those
who wish to experiment with their practices. An impeccable, modern,
clinical
pharmacy near the Houses of Parliament might be the best advertisement
that we could ever have. Then we would be not the enemy but the force
that we should be. Acknowledgements I thank the President of the Royal Pharmaceutical Society
for the invitation to address the Council on 10 October and for the warm
reception that I received on the day in question. I have always felt
that I have received the support of Presidents and Secretaries and Registrars
over the years, even though often they must have disagreed with my views. |
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Pharmaceutical Journal