The Pharmaceutical Journal
Vol 278 No 7444 p340
24 March 2007

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New roles, new risks — pharmacists must understand their limitations

By Brian Curwain

For years various pharmacy organisations have been putting out messages about other roles pharmacists could and should be taking on. They have said that we are not using all our skills, and that we can become much more clinically focused. This is now happening, though perhaps not as rapidly as some would wish.

What we have to learn to live with, as we become full scale clinical practitioners, is a level of risk around a range of issues that we have not had to deal with before.

We have always lived with risk, but it has been perceived as being mainly around dispensing or compounding errors. We have coped with it through our training, by personally supervising what goes on, and checking the final results ourselves. The fact that a dispensing error is a criminal offence, and that a series of errors might lead one before the Statutory Committee, has militated against our relationship with risk being an easy one.

The upside of managing dispensing risks is that they are well known and clearly defined. There is not a lot of room for opinion, at least in terms of whether the medicine is correct according to the prescription. It does get harder when trying to decide whether a prescription should be dispensed in the first place.

We seem comfortable with treating minor ailments but surely that is a modest aspiration for a profession claiming to be the experts on medicines. Indeed the term “minor ailments” carries with it the risk that the activity is seen as being able to be carried out by relatively unskilled personnel. I would prefer to call them “short-term conditions”.

As our new roles develop, we are being faced with managing a different sort of risk: that of making documented clinical or therapeutic misjudgements, which might have serious repercussions for patients. As independent prescribing grows, more of us will feel this pressure. Even medicines use reviews (MURs), one step towards a full clinical medication review, have been taken up more slowly than many hoped, even though it does not require much more than our traditional counselling skills around prescribed, and over-the-counter medicines.

Our increased level of anxiety might be because not only must we now record what we do, but also that the paperwork will be seen by another health professional with knowledge of the patient.

The MUR normally finds its way into the permanent patient record. Being part of a team evidently has its downsides as well as benefits, particularly for a pharmacist used to single-handed working.

So we have established that not only are we beginning to take on more clinical responsibility, but also that any misjudgements of ours will be much more visible. My own experience of working in GP surgeries bears this out.

For several years I conducted reviews both of the computer record and then face to face with patients. It got easier as time went on. I communicated my findings and recommendations to the doctors either by discussing the cases with them, via notes on bits of paper, and then by using specific forms that we developed for this purpose. When the new general medical services contract came in, I was asked to record the medication review as a consultation on the practice computer. A little extra anxiety was attached to that since my name was now indelibly on the patient’s electronic record, along with any recommendations.

Actually writing prescriptions for potent prescription-only medicines will bring yet more risk and anxiety our way. This is partly down to an inherently responsible attitude among pharmacists and needs to be managed not just ignored.

Underlying this is the risk attached to the decision to prescribe and any associated diagnostic activity. The same is true, for me at least, when switching patients’ medication, even as part of an agreed programme. To remove one drug and replace it on the list of repeat medication with another still gives me a tiny shot of adrenaline even though I will not be signing the prescription. I am not uncomfortable with this, but it is there none the less.

What about other clinical health care workers? GPs in the NHS live with a high level of clinical risk in my view. This is reflected in the levels of indemnity insurance premiums (around £3,000 per annum) which GPs pay. They are frequently prepared to “wait and see” when a patient describes their symptoms. They must filter out the serious from the trivial. Because we do not pay to see our GP, they get to see a lot of trivial conditions. That will continue, even though various mechanisms are being devised to transfer this part of their workload to other health professions such as nurses and pharmacists. To separate the trivial from the serious requires significant clinical skills and experience. Even then mistakes will be made.

While many headaches are related to no serious underlying disease, some are and, on occasions, patients are not referred for investigation as soon as they should be. In privately funded health care systems where the patient or an insurance company pays the bill, patients are far more likely to be sent off for an immediate brain scan that they probably do not need.

The general physician working in this system has less reason to live with risk or to develop the level of clinical judgement needed to identify situations in which to do nothing is the best policy for the patient.

The training of the various groups will also have an effect on their attitudes. Traditionally, doctors have trained in a robust environment where, from relatively early in the course, they are expected to make clinical judgements which are then subject to public scrutiny by senior medical staff. Although education through humiliation is probably less prevalent than it was, many GPs currently practising will have experienced it.

Nurses and the therapy professions seem to understand clearly the notion of practising within their competence. Indeed a colleague once said to me that you can never get a nurse to do anything until she has been on a course about it. That was, of course, an exaggeration. Yet, from the patient’s point of view, it does not sound such a bad idea.

We will learn to live with an increased level of clinical risk. So long as we act in good faith, act in accordance with a body of opinion, understand our own limitations, nurture our support networks, refer on or take advice if in doubt, and pay our insurance premiums, it will be OK, honestly.