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Letters to the Editor
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The profession
Sleepwalking into a schism
From Mr N. L. Wood, FRPharmS
Clive Jackson’s
thoughtful contribution to the “Pharmacy
2020” debate (PJ, 29 September, p365) and your editorial (ibid
p338) raises the issue of schism in the profession when he states “the
conditions where permanent fissures (as opposed to divergence) in the
profession might occur …”. He goes on to say that the risk
of a fundamental split will “boil down to the number of pharmacists
who become clinical modernists compared with those who remain dispensing
traditionalists”.
I can only agree wholeheartedly having espoused
a similar viewpoint both publicly and privately for some time. My concern
is that the profession in Britain has been sleepwalking into schism without
a debate on the social and professional consequences.
Mr Jackson reminds us that in part (and in England at least) both medicine
and pharmacy emerged (after the Rose case of 1701) as separate professions
out of the earlier combined role of the apothecary. The similar conflict
between the “clinical modernists” and “dispensing traditionalists” is
probably perceived as between well-educated clinical graduates in pharmacy
and reactionary, mainly retail interests, intent on maintaining comfortable
lifestyles.
As an independent pharmacy owner I am almost inevitably lumped
with the reactionaries regardless of my real views. Yet we need to recognise
a few basic imperatives, which are society’s imperatives and not
ours as a profession.
The first is that in any moderately advanced society, someone has to
be responsible for the storage and distribution of medicines in a manner
that is acceptable by society: in a word, regulated. The second is that
the clinical responsibility for prescribing should be separated from
dispensing, an Arabic idea, adopted by Emperor Frederick II in the Edict
of Palermo of 1231 and which soon spread throughout continental Europe.
Thirdly, in many advanced societies, physicians are paid only when they
see patients and so the more patients they see the better. In international
terms the UK’s NHS-driven imperatives for pharmacists to take on
independent clinical and prescribing responsibilities for patients beyond
just over-the-counter supplies is an anathema to many of our professional
colleagues overseas, since it would lead them into conflict with their
physicians.
So where exactly is this all taking us? Western society, it would seem,
requires pharmacists to look after the nation’s drugs and for there
to be separation between prescribing and dispensing to demarcate clinician
and dispenser. However, here in the UK all these basic paradigms are
being challenged by the way pharmacy is developing.
In my view it is
time to recognise that in Britain we are quite likely laying the foundations
for two professions out of the one and it is probably already too far
developed to change. The clinical modernist pharmacists are independently
prescribing, building consultation rooms, undertaking diagnostics and
medicines use reviews, and (like Rose in 1701) will soon be leaving their
shops; the hospital modernists left their dispensaries some time ago.
Meanwhile
the technicians left behind in the dispensaries in the traditionalist’s
role, are entrusted with the safe custody of the drugs, have become registered
and regulated, are educated increasingly to diploma and sometimes degree
level and, crucially, are beginning to become responsible for checking
prescriptions. The technician’s future resemblance to a “traditional” pharmacist
and the “clinical modernist” pharmacist’s resemblance
to an apothecary general practitioner is in danger of becoming uncanny.
I believe, therefore, that after 2020 the inheritors of the clinical
modernist pharmacist will quite closely resemble GPs of today. The role
of the traditionalist dispensing pharmacist will then be performed by
well-educated technicians alongside those pharmacists unwilling or unable
to embrace the new paradigm. In this scenario, there is no problem in
embracing clinical modernism.
What, however, we do need to discuss and
prepare for is the emergence of a new profession of “pharmaclinicians” and
their professional separation from product-based technical and scientific
pharmacists. The Pharmacy 2020 initiative is a useful arena in which
to debate this crucial issue. Nicholas L. Wood
Past President
Royal Pharmaceutical Society
Continuity of service
From Mr J. A. Schofield, MRPharmS
Lindsey Gilpin has written in to contend that the views of locum and employee
pharmacists should be heard (PJ, 29 September, p353). She is absolutely
correct. Not only do locum and employee pharmacists constitute the majority
of the profession, the future of pharmacy is dependent on them.
At a recent meeting of the Sunderland and Durham local branches, I saw
a presentation by John Hall and Noel Dixon, two pioneers of the pharmacy-based
warfarin clinic. When asked about tendering for contracts, they made it
abundantly clear to those who were not already aware that, unless continuity
of service could be taken for granted, pharmacists should not bother to
tender.
As many pharmacies now run exclusively on temporary cover, it is important
that the locums engaged are accredited to do the work and motivated correctly
also. I am not talking solely about warfarin. There are currently schemes
for substance misuse, minor ailments, emergency hormonal contraception
and others that rely on a consistent response. Inconsistency will be the death
of the schemes and, as remote supervision of robots becomes more prevalent,
the death of community pharmacy.
The Journal of 29 September (p340) carries a story about Kamal Mahasuria,
director of Altwood Pharmacy in Maidenhead, Berkshire, who has started
an asthma clinic in his pharmacy that he operates as an independent prescriber
in collaboration with GPs, under the aegis of his local primary care trust.
Without a doubt this is the future. How will Mr Mahasuria promise continuity
during holidays and illness? It will have to be addressed if his shining
example is to be replicated across the profession and become part of core
service to replace dispensing as the robots take over.
Locums and employees must be engaged and motivated. They work at the sharp
end and can contribute massively to the design of workable solutions as
opposed to head office brainstorms. They are the people who carry out the
work and engender the confidence of the profession. Many complain that
locums are demotivated. Is that any wonder when they are so seldom consulted?
I think that:
• Local pharmaceutical committees should encourage locum pharmacists along
to training events
• Non-accredited locum pharmacists should not be allowed to operate enhanced
services and that companies employing them should have the responsibility
of ensuring appropriate accreditation
• Locum pharmacists should be consulted in the design of new services requiring
accreditation
• The future regulation of the profession is untenable if those who constitute
the bulk of the profession are not engaged, and the membership of the Professional
Regulation and Leadership Oversight Group should be reconstituted to include
representatives from locum and employee pharmacists
It is a disgrace that Ms Gilpin, who is a member of the English Pharmacy
Board, has not had a reply from either the Health Secretary or the Government
chief pharmacist. I would urge all pharmacists who feel slighted by this
to write to both parties.
I am aware of the rich resource the profession has among its membership.
The future is bleak if that resource is not cultivated, consulted and looked
after. Everyone who feels similarly should write to the guilty parties.
Tony Schofield
Jarrow, Tyne and Wear |
The
Pharmaceutical Journal