The Pharmaceutical Journal
Vol 279 No 7477 p527
10 November 2007

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The “responsible pharmacist” — good for pharmacists and good for patients

By Tony Schofield

The recent announcement of a consultation on the subject of the responsible pharmacist is provoking much debate. Pharmacists have always been responsible for their actions. The courts and the Statutory Committee have seen to that.

However, just what is this new development all about?

Dispensing doctors take responsibility for the dispensing process but rarely, if ever have any hands-on role in the process. Solicitors do not actually do the searches for land conveyancing or the drafting of wills unless there is any complexity in which, say, an accountant may be involved. Accountants do not crunch the numbers for every corner shop they audit.

They all head a service and are capable of doing all the required tasks involved in creating the outcome but they take responsibility for those tasks and are available if required to assist, guide or direct their support staff and deliver the outcome. In some cases delivering the outcome may involve signing a letter or document but in other cases, depending on the complexity and seriousness of the issue, it may involve a face-to-face encounter in which the issues are presented by the professional who is available then to assist the client, customer or patient in making an informed choice.

How a surgery, an accountant’s practice, a solicitor’s office or a pharmacy is run is of no concern to the public. They are concerned only with the quality of service they receive, and that is measured against somewhat weak parameters, including personal friendship, prejudice, loyalty, price and speed of response. So when we ask the question about what a pharmacist is taking responsibility for, theoretically, the sky is the limit but, in actual fact, it is the limit of the aspirations and abilities of the individual pharmacist.

Any professional, in designing his or her wish list for their practice, is restricted by the perceptions and possible future perceptions of the end user. Pharmacists know that the Department of Health wants to keep people out of expensive hospitals and pharmacists know that they have a basic understanding of therapeutics that could be harnessed to assist the DoH in that ambition.

Aside from the traditional role where a pharmacist supplies medicines to a patient in accordance with the wishes of a prescriber, the pharmacist also has a duty, as defined in the Migril judgment, to ensure that a prescription is appropriate and safe for the patient for whom it is intended. Prescriptions need assessment before they are dispensed: some need a cursory nod and some need a full blown enquiry.

The systems in place in a pharmacy that distinguish between what level of intervention is required are the responsibility of the pharmacist.

The supply of medicines, due to the increase in prescription volume is fast becoming a massive “product shifting” operation and dispensaries frequently look like warehouses. Supplies are also made under the Disability Discrimination Act where repackaging into monitored dosage systems is deemed to be required.

And repeat dispensing has seen a shift in activity from GPs to pharmacists (something I have been delighted to take on since it eases the process and we can plan our work better).

Due to the development of support staff, particularly accuracy checking technicians (ACTs), the supply of medicines has become a slick process in which a pharmacist takes responsibility but does not have to do all the work.

The public is now aware that they can get smoking cessation services and minor ailments treated without prescription from many pharmacies. My staff are accredited level 2 smoking cessation advisers. They do all the work; I do not do any. The public love it and there is almost a waiting list of patients anxious to access the service.

With regard to minor ailments, a pharmacist is probably going to deal with most requests, first, because it is a responsibility to patients to triage them effectively and, secondly, such services are new and pharmacists need to take responsibility for ensuring that they work.

Supervised opiate substitutes and syringe exchange are services that are firmly established as enhanced but does every “transaction” need to be supervised by a pharmacist? It will be down to the individuals to decide, justify and take responsibility.

That list is not exhaustive but, clearly, if pharmacists perform every task without delegating, they will explode. So taking responsibility without actually performing the task is becoming more and more the norm.

Then there are enhanced services such as emergency hormonal contraception and chlamydia screening. I think most pharmacists would agree that services of such sensitivity should not only be the responsibility of the pharmacist and should be performed by the pharmacist.

However, to be able to do so properly, the pharmacist cannot be interrupted by staff requiring every aspect as described above to intrude. The pharmacist should be taking responsibility for the processes going on around and that means ensuring adequate training, mentoring, support and appraisal but it should not mean checking every monitored dosage system. That is an ACT’s job.

In the future, I believe that managing chronic disease by community pharmacists will hugely benefit the population and satisfy a need for the DoH: we are pushing at an open door when we say we want to do it. Medicines use reviews are a tentative first step and prescribing qualifications are the next step.

We will be required to perform such functions ourselves and cannot be distracted from such work by being interrupted to count the number of crepe bandages that a nursing home “officer in charge” is demanding because she is in a hurry. We will take responsibility for that which we do not need to do and we will perform and take responsibility for that which we need to perform personally.

Pharmacists are asking questions however. Top of the list is the worry that companies may reduce the cost of pharmaceutical cover exploiting the “responsible pharmacist” concept to reduce the attendance at the premises of a qualified pharmacist just while dispensing is being done.

Locum pharmacists are anxious about their “responsibilities” when they have had no part in defining or designing operating procedures and development of staff they must work with on a part-time basis. Is there an increased risk that the responsible pharmacist could be put in an untenable position with the superintendent?

Lingering doubts remain about the quality of support staff and there are dark murmurings that some companies creatively interpret the Drug Tariff minimum staff requirements, leaving locum pharmacists short of support.

Since the current supervision requirements conspire against a conscientious pharmacist who also has good quality, conscientious staff they need to be changed. The responsible pharmacist concept is one way of approaching it. However, if botched on introduction, it could become a charter for abdicating responsibility as opposed to delegating it.