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Jonathan Buisson is a member of the Royal Pharmaceutical
Society’s Council and the Society’s Health Act working
group
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The Broad spectrum feature is
open to any reader. Contributions of around 1,100 words commenting
on topical issues
may be posted to Graeme Smith, managing editor, or
e-mailed to graeme.smith@pharmj.org.uk for consideration
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At the beginning of George Orwell’s novel ‘Animal farm’, the inhabitants of the farm are told that “all animals are equal”. By the end of the book this has changed, almost without them noticing, to reveal that “all animals are equal, but some animals are more equal than others”.
Will we see a similar change of emphasis around
the subject of the responsible pharmacist?
Changes outlined in the Health Act 2006, and due to be introduced by
secondary legislation in the next 18 months, will mean that any pharmacist
taking control of a community pharmacy or registered hospital pharmacy
will be (or have to be) a responsible pharmacist. He or she will take
on specified duties and responsibilities and, most importantly, there
will be a log maintained stating who was the responsible pharmacist for
any particular pharmacy at any given time.
The duty of the responsible pharmacist “to secure the safe and
effective running of the pharmacy” while he is present in the pharmacy
is broadly comparable to the current duty of a pharmacist in personal
control of a community pharmacy. The provision for the pharmacist to
be absent from the pharmacy, however, leaves the pharmacy in the control
of trained support staff who will be expected to work to defined procedures.
It is this element of the proposal which is generating the most heat
and smoke. The day 1 phenomenon
Under present arrangements, newly qualified pharmacists can and do
take personal control of a community pharmacy immediately after joining
the Register. This is clearly a nerve-wracking moment and potentially
a period of higher risk to the public.
These new pharmacists are clearly competent; they have successfully
completed a preregistration year and passed the Royal Pharmaceutical
Society’s
registration examination. What they lack is two things that can only
be gained, not taught: experience and, hence, confidence. The more one
has of the former the more one gains the latter.
However, the “day 1” phenomenon is not unique to pharmacy.
Just as pilots are not real pilots until they have flown solo, all professionals,
at one point or another, find themselves in charge of a new situation
for the first time. New qualifications can be introduced, or the period
of supervised experience extended, but this only postpones “day
1”.
In general, the public seem to accept this. As long as the newly qualified
person is clearly not attempting something that is out of his or her
depth, a certain amount of “it’s my first day” nervousness
is allowed. We should not overplay the element of risk in this period
as it will always be present in some way and there does not seem to be
any public or media outcry about it. Most pharmacists successfully make
the transition, probably because the eyes of the world are not on them.
So, given the “day 1” phenomenon, how can pharmacists become
responsible?
Another way of looking at the problem might be to ask what it is that
newly qualified pharmacists should not be doing in the earliest part
of their careers, whether that is the first month or the first year.
In terms of what the Health Act envisages, the most obvious thing is “be
absent from the pharmacy” while remaining its responsible pharmacist.
Other possibilities include taking responsibility for the development
of standard operating procedures (SOPs) or the direct management of pharmacy
staff.
This, however, raises questions such as: “who will do this, if
not the responsible pharmacist?” and “how, and where, do
I gain experience, if not by acting as an responsible pharmacist?”.
This may, or may not, be addressed by changes in skill mix or technology
within pharmacy.
As it currently stands, the workforce for community pharmacy is built
on an assumption that each summer a large (and growing) contingent of
newly qualified pharmacists will join the Register and go immediately
into pharmacies to assume personal control, whether as employees or locums.
The majority of these will be working without other pharmacists alongside.
The “fallow year” in 2000, caused by the switch to the four-year
MPharm in England and Wales, showed how problems arise when the flow
of newly qualified pharmacists is interrupted. Any period of post-registration
experience which might be needed to become an responsible pharmacist
merely introduces an equivalent fallow time. More than one kind?
Whenever the responsible pharmacist concept is examined in detail,
it always seems to resolve into three distinct categories. There are
the “non-responsible” (perhaps “less
responsible” but hopefully not “irresponsible”) pharmacists,
sometimes referred to as supervising pharmacists.
They undertake the
same sort of work that is done by pharmacists today, but do not assume
ultimate responsibility. This is normally because they are working
alongside another pharmacist (who is the responsible pharmacist), or
are in some sort of post-registration training post, perhaps in a hospital,
similar in concept to the registrar role in medicine.
Then there is the plain responsible pharmacist, as envisaged in the
Health Act. The responsible pharmacist takes on the final responsibility
for
day-to-day activities, including during specified periods of absence
(although the detail of this has yet to be decided), and is signed in
and out of a logbook.
Then there is the “more responsible” pharmacist, occasionally
referred to as “responsible pharmacist-prime”. This person
is more akin to a branch manager, having an ongoing responsibility for
the running of one pharmacy or department, even during holidays, without
necessarily being responsible for every individual transaction.
This
person might be more likely to have responsibilities for writing SOPs and staff training than perhaps a string of locums acting as responsible
pharmacists. This type of person might be more common within a large
pharmacy chain or in a registered hospital pharmacy than in a single
independent pharmacy. A crucial division
Above them all is the superintendent pharmacist, setting the framework
within which, for example, SOPs are written.
Given the proportion of the community pharmacy workforce that currently
works as locums — 37 per cent in the most recent census — the
division between “less responsible”, “more responsible” and
just plain vanilla “responsible” pharmacists is going to
be crucial. If this were to be too prescriptively defined, then it might
lead to the “death of the locum” (or the temporary closure
of a lot of locumless pharmacies).
If the definition were to be based
on time since registration then it introduces fallow periods. If it were
to be based on experience gained, then this might have to be assessed
at great time or expense.
On the other hand, if the definition were to be too loose, then it might
be difficult to see what problem it was that the responsible pharmacist
concept is supposed to be solving.
There are also an awful lot of existing pharmacists who will need to
become responsible pharmacists. Any new regulations will have to cope
with their wide range of experience and qualifications. At present, the
Register is only divided into “practising” and “non-practising”.
Adding
additional annotations of “RP” would begin to subdivide
the practising section, potentially leading to further ramifications
for the increasing numbers of pharmacists who work across different sectors
or in roles which are only patient-facing part of the time or on occasion.
The Department of Health has launched its consultation on its proposals
for introducing responsible pharmacists (PJ, 27 October,
p457). This will clearly be a tricky path to tread.
As the Act is currently
framed, “all
responsible pharmacists are equal” but will the Department find
that “some responsible pharmacists are more equal than others”? |
The
Pharmaceutical Journal