The Pharmaceutical Journal
Vol 279 No 7470 p324
22 September 2007

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The final nail in pharmacists' coffin?

By Stephen Axon

Harold Macmillan defined consultation as telling the other side what you are going to do. True to form, the Department of Health has announced that “some time in the future, as yet unspecified consultation and changes to legislation will be undertaken over the introduction of the concept of remote supervision” (PJ, 15 September, p279). The use of the word “will” makes it all too likely that this consultation will be of the Macmillan variety.

Remote supervision

For years pharmacists have been encouraged to come out of the dispensary talk to patients. Now the DoH is happy for pharmacists to move out of the pharmacy completely. Whether this will be “modernisation” of the profession or the final nail in pharmacists’ coffin remains to be seen.

The Pharmaceutical Journal accurately describes the DoH decision as “pragmatic” but suggests that, if the concepts underpinning the responsible pharmacist and supervision are not sorted out at the same time, pharmacists are likely to be confused (ibid, p278).

Here are some of the principles underpinning remote supervision:

• Pharmaceutical services are patient led

• The presence of a pharmacist is not necessary to ensure patient safety

• Dispensing will take place without a pharmacist seeing the prescription

• Pharmacists assume the role of director of dispensary activities

If we look at these in pragmatic terms, “supervision of” becomes “responsibility for” the dispensing activity in the pharmacy. Thus the concepts of “supervision” and “responsible pharmacist” are disposed of without too much confusion.

As the DoH will still require a competent person at the dispensing bench presumably, with remote supervision, registered pharmacy technicians will supervise dispensing and deal with the pharmacy/patient interface. In the case of error the new regulator (regulating both pharmacists and technicians) will allocate blame and determine punishment.

Multiple pharmacies

Whatever the outcome of the consultations, as the business models available to the chain pharmacy are greater and more adaptable than those of the independent practitioner, no doubt the multiple sector is robust enough to be able to survive the change.

Indeed, if one pharmacist is permitted to supervise a number of dispensaries then, as technicians are cheaper to employ than pharmacists, multiples could benefit from a reduction in the number of pharmacists needed in order to comply with the contract — particularly where extended hours are being provided.

Independent pharmacies

If the independent pharmacy is a small chain then it might be able to adapt in the same way as the multiple. If not the future appears less than rosy. Whether sole practitioners or small chains, the outlook might be improved if they were afforded an opportunity to open additional pharmacies (remotely supervised) under their existing contract.

On the one hand this type of arrangement could be introduced as another exception to the control-of-entry arrangements but, on the other, the Office of Fair Trading might well argue that remote supervision, once more, highlights the restrictive nature of the control-of-entry regulations.

A unified approach

Without a unified approach from pharmacists remote supervision may result in their consulting themselves out of existence. With too much emphasis on what some regard as the wider role and with the passing of the core responsibility of medicine distribution and advice at the pharmacy/patient interface to others, pharmacists are being left with functions that many patients may not want and for which primary care trusts may not be prepared to pay.

Unfortunately unity of purpose has always been sadly lacking in our profession and this has been a principle weapon in the DoH’s armoury. Nowhere is this more apparent than in the representational structure throughout the profession.

When it comes to the consultation exercise the mixed model within pharmacy means that, from the community pharmacy perspective, despite the best attempts of the Pharmaceutical Services Negotiating Committee or the National Pharmacy Association, their response could come down to a vote based on the loadings of the various groups on the bodies and the business profiles of those elected as “independent”. Neither the NPA nor the PSNC has places reserved for what used to be referred to as sole practitioners or even for the Federation of Independent Pharmacists.

In the final analysis the views expressed by the NPA and the PSNC are, therefore, likely to be the same and similar to those of the Company Chemists’ Association, Co-operative Pharmacy and the Association of Independent Multiples. This response could then well be taken by a pragmatic DoH to indicate unity of purpose within the community pharmacy sector.

Patients

For patients, remote supervision could result in the movement of the pharmacist from the pharmacy into surgery premises, enabling provision of services that patients and PCTs require within the surgery while remote supervision of dispensing services takes place in the shopping area. This would advantage those pharmacies that could afford the “key money” and completely undermine control of entry.

But it could be possible even if (under new regulations) a pharmacist were allowed to “remotely supervise” one pharmacy only. A nightmare scenario perhaps — but where is the flaw? For it has been announced that, as part of the NHS review, health minister Lord Darzi wants to discuss with Boots and Lloyds-pharmacy the possibility of providing space for GPs to facilitate access for people who would otherwise have to take time off work to see a GP (The Times, 18 September, p11).

The Department of Health

Perhaps it is cynical to suggest that the DoH may have joint objectives in mind — providing a cheaper medicine distribution service to patients through remote supervision while playing to the vanity of the profession by transferring money from dispensing to wider role services which, ultimately, PCTs may not commission.

Perhaps the much maligned “global sum” based on prescription numbers with its “balance sheet” based on unit costs was not so bad after all. Patients will always need prescriptions to be dispensed.

The DoH has prepared the ground well. Is it surprising that the more controversial aspects are to be sorted out once the profession is committed to the change. Will we ever learn that this is the way the DH always conducts negotiations and consultations?

Technicians

Technicians have everything to gain. They will have increased responsibility, be regulated by the new regulator and are subject to the same code of ethics as pharmacists. They are represented by their own body as well as having a presence on the Royal Pharmaceutical Society’s Council. It will be interesting to see whether the Council and the Association of Pharmacy Technicians UK will have a unity of purpose as the boundaries within the profession become more blurred.

Consultations

Although the major impact will be upon the community pharmacy sector, remote supervision will change the face of the whole profession of pharmacy forever. Could we see our continental colleagues accepting this type of change? This issue must not be one to be decided only by those already in established businesses or managerial position.

Newer entrants to the profession, in particular, need to focus upon this because, in the final analysis they may find it difficult, in future, to obtain employment as a pharmacist and impossible to open a pharmacy.