Transitional Committee Blog

The presentation by Dr Brian Curwain (Member of the RPSGB Council and the English National Board) to the Southampton Branch of the RPSGB on Wednesday 15th October 2008 entitled ‘Who will lead and who will regulate Pharmacy in the UK?’ has brought certain issues about Community Pharmacy into sharp focus for me and wish to share these with the transitional committee (TransCom). In attempting to crystallise my viewpoint, I will make some generalisations, which I offer no apologies for. The main objective is to trigger a debate on these issues.
 
We have an important role to play
There is no doubt that pharmacists (across all practice areas) have a valuable contribution to make to patient care in the NHS especially within the context of a more complex and fragmented healthcare provision. I sometimes suspect that a significant majority of us don’t believe this passionately enough and I have seen this in the area of Medicines Use Review (MUR). This is one of the reasons I started working with a number of my colleagues on the MUR project (1). The project is ongoing and we wish (in our small way) to engender that self-belief and confidence in what we do as community pharmacists. The lack of self-belief in our role is more prevalent in community pharmacy practice relative to the other practice areas. The reasons for these are numerous but I feel by far the most important reason is that we default to community pharmacy practice when we perceive that we cannot get into other practice areas like hospital, PCT or industry. This is akin to the perceptions that we are pharmacists because we failed in our bid to get into medical school. This fuels an inferiority complex, which has served to undervalue community pharmacy in particular and pharmacy in general. For the new professional body to fully discharge its duties, it must begin to instill a greater degree of self-confidence and value in its members whilst clearly outlining the importance of their roles. We all have choices and maybe we need to start devising methodologies for identifying those who choose to be pharmacists (in general) and community pharmacists (in particular) rather than those who just happen to be there by default.
 
The tribal profession
We are undoubtedly a tribal profession. When Dr Curwain talks about a bunker mentality, it resonates very much with my experience. As a former clinical pharmacist in Southampton General Hospital, I wore this badge of self-importance about the job I have to do. This is no big deal. What was important was that I was enhancing my patients’ care. However, what is less helpful is if I start to perceive what I did to be more important than what a dispensary pharmacist in the same hospital does. Or if I were to stretch that even further and say my role, as a clinical pharmacist was more important than that of a community pharmacist. The perception that they (the hospital pharmacists) think they are better than the community pharmacist must be prevalent out there in community practice and may be based on evidence or the inferiority complex described above. The implication is that every tribe retreats into their bunkers and fails to engage constructively with one another. That serves no useful purpose for the patient who is after all at the centre of everything we are trying to do.

I guess some groups will feel threatened by the proposal to invite a wider range of experts to the new pharmaceutical society. These are real fears and must not be disregarded. Personally, I am quite comfortable with inviting a range of allied professionals to the society. This wealth of experience and talent can only add value to the new professional body. For this to work however, the interests of the community pharmacist must be safeguarded. I suggest that the interests of the community pharmacist must be one of the top considerations when decisions are being made. I will now describe why failures to put the community pharmacist’s interest at the heart of decision-making in Lambeth (or wherever else we end up) will adversely affect the reputation of our profession, which we are all jealously guarding.
 
We need a confident community pharmacist
The community pharmacists are the gateway between the profession and the wider society. They are our representatives to the wider world, which includes our patients, government, media etc. A community pharmacist lacking in confidence can only reflect a profession, which is not confident in itself. To understand how to address the confidence issue, we must understand the needs of a typical community pharmacist patient. To do this I will draw attention to a critical finding from some unpublished work I did on waiting time whilst working as a pre-registration pharmacist in the hospital. It will come as no surprise that inpatients were happier to wait a bit longer for their prescription than outpatients. Outpatients and by extension, primary care patients have entirely different pharmaceutical needs and requirements which must be met. In order to discharge his duty, a community pharmacist must be the expert in understanding these needs and requirements and adopt strategies to satisfy those changing needs. It is only when a community pharmacist successfully does this that the profession start to reap the desired benefits. MUR is a tool, which the community pharmacist can now use to engage with their patients. The community pharmacist must understand its integral role in delivering quality service for the patient and enhancing the profile of the profession. The community pharmacist is the expert at interpreting complex drug issues and presenting it in a way that will be relevant to and make sense to his patient. This is no mean feat. He must not only be clinically aware but must also have the relevant ’soft skills’ that will enable him to ‘connect’ with the patient. Only an expert can carry this off. The question must therefore be how do we make sure our community pharmacists realise their expertise?
 
To this end, I will offer this observation: A medical student, Mr ABC went to meds school, worked very hard and passed his exams then graduated. He becomes Dr. ABC. He is very proud of becoming a doctor (with the Dr title in front of his name). He continues to work hard and specialises in surgery and at this point he drops the Dr. title and now want to be called Mr. ABC. He will chastise you if you call him doctor. The message here is that something powerful happens to the mind when it becomes recognised as an expert. It stops trying to prove to people that it is knowledgeable but now focus on applying that knowledge to the benefit of its patients. The challenge to the new professional body is to adopt strategies, which will train and recognise the community pharmacist for their expertise. It is only then that the community pharmacist will become confident.

A community pharmacist expert is of great benefit to us all. A professional body, which is widely respected across the wider society, is powerful and various healthcare decision makers will seek its viewpoint. The new Royal Pharmaceutical Society of GB must look after all its gateways to the wider society and community pharmacy is an important component of these.
 
Kazeem Olalekan
(MUR Evangelist)
Community Pharmacist and
CEO Iforg Limited

There is evidence that indicates pharmacists when faced with dilemmas related to a conflict between professional obligations and legal requirements usually give overwhelming weight to the law and little to the best interests of their patients.    
 
I would like to suggest that this is the result of two factors: i) the perceived administration of the law by the Society ii) the education and training of pharmacists.   I feel that the demerger of the Society into two bodies, the General Pharmaceutical Council and the Professional Body provides an opportunity to reinvigorate pharmacists so that they become thinking professionals not slaves to rules.
 
Pharmacists operate under two controlling sets of rules: the Code of Ethics and the Law.    The Code, in its pre-amble, states that “from time to time you may be faced with conflicting professional obligations or legal requirements. In these circumstances you must consider fully the options available to you, evaluate the risks and benefits associated with possible courses of action and determine what is most appropriate in the interests of patients and the public”.   The Code also includes the following statement –pharmacists should “consider and act in the best interests of individual patients and the public”. and they should “comply with legal requirements, mandatory professional.
 
So why do pharmacists act with less consideration to their patients than the rules and regulations?   Unfortunately in the profession there is in an ethos of ‘fear’ and a feeling of over-regulation resulting in current practice..      
 
Undergraduates spend little time considering the best interest of the patient as they have to satisfy examiners on their objective knowledge of the Law, not considering the subjective needs of patients. Community pharmacists are occasionally visited by the Pharmaceutical Inspector who provides the voice of the Society.   The majority work for organisations (commercial or government (hospital)), which ‘inspect’ their work and dictate practice.    The organisation  ’overseers’ shout the language of the Law as do the superintendent pharmacist.       Pre-registration graduates experience the same pressures from their tutors in their year’s training.     This results in practitioners only hearing the one side of the controlling factors referred to above - rarely the best interest of the patient.   
 
It is a philosophy of “my certificate on the line” which pervades practice.        The administration of law should take into account  the best interest of patients rather than stultifying community pharmacy as a profession so that pharmacists are terrified to act autonomously.    Examination of  reports of the Statutory Committee shows few (if any) examples of disciplinary action taken against pharmacists who act in the best interest of patients.      
 
To alter the fear of the law phenomena there must be a change in the coursework of students so that they are made aware of the conflicts between law and professional duty.     Furthermore, the course must encourage them to make decisions based on ‘what is right’.       This process requires consolidation in the pre-registration year.
 
The executives and administrators of the new pharmacy bodies must accept that the present situation is untenable and work to change the way pharmacists are considered to be in breach of the law to such a degree that disciplinary action is required.   This change must be widely broadcast so that we can lose this unreasonable fear of the law.
 
While there are some defects in current legislation, I suggest it is
the interpretation and administration that undermine the concept of ‘in the patient’s best interest’: these need to be addressed.
 
Below is an abridged paper published in The Pharmaceutical Journal, 2008; 281: 301   Balon, DAJ

Pharmacists are frequently presented with conflicts between the various laws and rules which govern practice as well as their personal moral, ethical and religious beliefs. Such conflicts are the dilemmas of everyday practice, which often require instant solutions.
 
These conflicts all revolve around ensuring that our actions are in the best interest of our patient. In all cases of these dilemmas various rules, laws and personal factors interact so that the outcome is dependent on the decision of the individual pharmacist.
 
A survey has shown that a pharmacist’s top priority when faced with an ethical dilemma in the pharmacy was whether or not it meant they were at risk of being disciplined or prosecuted.   This result is hardly surprising in view of the legal constraints placed on pharmacists but at the same time it is hugely disappointing because it suggests that pharmacists place the best interests of patients after their own self-interest.
 
My interpretation of the Code of Ethics for Pharmacists and Pharmacy Technicians is that pharmacists should make the care of patients their first concern, using their professional judgement to act in the best interests of individual patients and comply with the intent of legal requirements, not necessarily the unqualified wording found in statute.
 
In the survey, a pharmacist is quoted as saying, “I do try and look after the patient’s best interest but I won’t put my certificate on the line. … more covering myself … rather than looking after the patient”. There is conflict between the legality of action and acting in the best interests of their patient: in most cases the legal aspect took precedent.
 
Why is this so? ?  Each professional will rationalise his or her decisions and provide reasons.    The past draconian view that a single medication error could result in severe repercussions resulted in pharmacists being terrified to take any action that could be seen as infringing the law — hence their overriding fear of the law.
 
Law related to pharmacy is taught at University but little attempt is made to relate it to real dilemmas. This fear of acting autonomously may be the result of many pharmacists having experienced their preregistration training in large organisations that instil an unreasonable fear of the law and the trainee’s responsibility to the superintendent pharmacist.   As the preregistration year is the basis of qualified practice, pharmacists who experience these values carry them forward through their working lives.
 
The vast majority of “problems” I have encountered are related to the conflict between law and the best interest of patients: moral and ethical considerations are few.
 
Here is an example: a prescription for “MST tablets 10mg 28 (twenty eight) om” was refused (referred to prescriber) because it did not state “1 om”. The prescriber’s intentions are clear but the law does not allow pharmacists to use professional judgement.
 
Another Controlled Drug example was when a misuser failed to collect a weekly supply of methadone on a Friday evening, the supply date on the prescription. The patient turned up on Saturday but was refused supply as the specified wording which permits “missed days” was not on the prescription. How is this in the best interest of the patient who may well go on to “score”?
 
Consider the dispensing of medicines in a monitored dosage system. A patient who was usually at home and was capable of taking the correct dose from normal dispensing containers attended a day care centre on Tuesdays and Fridays and requested some medicines in an MDS.
 
The pharmacist in charge was concerned that the doctor’s instruction request did not specify the patient, the required days, that it was undated and would not be valid for the following weeks. There was also concern that a locum pharmacist on future occasions might not regard the instruction sheet as valid.
 
Consider, too, emergency supplies. A pharmacist refuses to issue an “emergency supply” for regular patients if their doctor is on duty. Thus at 5.50pm on a Friday night a patient presents and states he has run out of, say, bendroflumethiazide and asks to have some for over the weekend. The prescriber’s surgery is local and closes at 6pm and the request is refused on the grounds that the doctor is available to write a prescription and the request therefore is outside the law.
 
Although this is correct, is it in the best interest of the patient who may or may not be in time to see the prescriber? What is gained by the strict adherence to the law? Surely this kind of approach lowers the public’s perception of a pharmacist’s rights and conveys the perception that he or she is a shopkeeper with no legal standing.

It would appear that current laws confine practice so that the majority of practitioners act in their personal interest (the “I must look after my certificate” philosophy). We need to have the rules and laws changed so that we do not have so many conflicts and we are freer to act in patients’ best interests.
We also need our “controllers”, the Royal Pharmaceutical Society and its successor to provide more sensible interpretation of these “regulations”. The judgement of the appropriate action taken by pharmacists should primarily be based on the benefit to the patient and not on the absolute word of the law.

Derek Balon

Ethnic minority pharmacists view the recent pharmaceutical society as ‘white male and middle aged’. The Society has failed to lift barriers for ethnic minority members who face stereotyping, according to views at independent events in the north west.

I prefer that the new Transitional Committee call for widespread change.  There is a ‘widespread perception’ among ethnic minority pharmacists that the Society is predominantly white, male and middle-aged, which operates, whether consciously or not, an old boy network.
 
Many of the ethnic members feel that they are denied opportunities for progress not because of overt discrimination but because processes operate in a way that denies them the opportunities and fails to recognise their potential.  Members from ethnic minorities are held back by a lack of mentors, lack of challenging assignments and stereotypes.  
 
Almost one in five pharmacists (19.1%) has a recorded ethnic origin of Asian, with Indian being the predominant group (13.5%), followed by Pakistani (3.6%) but we do not have anyone to represent our ethnicity.  

Due to the present climate and the negative press given to the ethnic community I feel the Society need to have pharmacists to be at the forefront of negative press and I feel that the new Committee needs a member to address needs of such matters and concerns.

Having such a role model would benefit the new committee and I would personally look forward to taking an opportunity if it became available.

Khalid Ahmed

Pharmacist

We write on behalf of the UK Medicines Information network (UKMi) and would like to outline how we feel information services could be developed as we work towards a new professional body charged with providing leadership to pharmacy. We believe that the future of pharmacy, as outlined in the White Paper, revolves around the recognition that pharmacies should be the knowledge centres for medicines. However to support that function in all pharmacies we need to build on the solid foundations that are already in place to ensure that all pharmacy staff have access to the same level of high quality information support that will be needed to support an increasingly clinical role.

UKMi is a network operated by NHS pharmacists that provides medicines information services for all healthcare professionals in primary and secondary care.  The UKMi network is well established, with over 260 hospital-based medicines information centres across the UK answering up to half-a-million clinically orientated enquiries a year.  The service aims to support medicines management by providing evidence-based, impartial, accurate, and timely information tailored to the specific needs of the user.  Our support ranges from advice to influence individual patient-related decisions to national collaborating to produce resources that guide commissioners on the clinical and financial implications of new medicines. The portal to access all our active outputs is the National electronic library for Medicines (NeLM – www.nelm.nhs.uk). This website is used by over 10,000 pharmacists to receive daily emails alerting them to a wide range of important developments in medicines, and almost 2 million records are downloaded from the site every month.

When answering enquiries and publishing material, NHS medicines information centres operate to a nationally agreed set of standards and are independently audited to ensure a high level of compliance with those standards. All medicine information staff are also trained using a nationally agreed set of training materials to achieve a defined level of competency. All these factors help ensure that service users can be confident that they are receiving a high quality service irrespective of which centre is involved.

One of the challenges for the new professional body must be ensuring information services adequately support pharmacy practitioners throughout the profession.  As we work towards a new professional body it is timely to consider how best we can achieve this and whether an expanded service could draw upon the apparent synergy between activities within UKMi and the information services currently provided by the RPSGB. 

An information service for a professional body will have a specific domain on which neither UKMi nor any other party has a right to encroach.  The UKMi network does not, for example, wish to impinge upon a professional body’s obligations to provide important historical information, respond to member’s legal and ethical concerns (although these might now become part of the regulators remit), or ensure a relevant library service.  There are, however, areas of professional activity where UKMi would add value; and where, suitably remunerated, we could enhance the delivery and use of medicines information across the pharmacy profession.

The unique clinical focus of UKMi makes it well-placed to ensure the provision of timely and pertinent information to support appropriate medicines use.  We would argue that we are better placed than any other organisation to respond to requests for information from within the profession related to individual patients.  Our long history of promoting the principles of evidence-based practice, and our unique pharmacy focus, also makes us well-placed to provide and evaluate the evidence to support pharmacy practice.  To this end, we would be interested in exploring possibilities to develop our portfolio of resources (available at www.nelm.nhs.uk) in conjunction with a new professional body.  For some years, UKMi has promoted the use of information technology in medicines information—almost all in the pharmacy family are involved in the provision of information and we are keen to explore how our strong track record developing IT in this area could be best utilised.

UKMi is a strong professional network within pharmacy whose members are dedicated to quality in the provision of medicines information.  The new professional body should draw on our experience when considering the information services it may wish to provide to pharmacy practitioners.  UKMi would be happy to work with the new professional body to explore the considerable collaborative potential we believe exists.

We would particularly recommend that the professional body’s information provider should meet the long-standing national standards developed by UKMi, and we would welcome a common information provision strategy between UKMi and the professional body to maximise benefits from member and NHS investment.

Ben Rehman and David Erskine

Directors of London North Thames and London & South East Medicines Information Service

Pharmacists (and pharmacy technicians) are key members of the HIV multidisciplinary team and have been at the forefront of many developments in hospital pharmacy (e.g. establishing pharmacist-run clinics, pharmacist prescribing and consultant pharmacist posts). Medicines are the mainstay of the treatment of HIV infection and a consistently high level of adherence to effective antiretroviral therapy is essential for sustained benefits to be realised.

In this speciality there is thus a strong emphasis on interprofessional working to facilitate the engagement of patients in treatment decision-making processes and empowering them to manage their medicines appropriately. We believe that much of what we have learned and services that we have developed are transferable into other specialities/areas of practice (e.g. management of other long term medical conditions), including community/primary care pharmacy.

 In addition, the life expectancy of most people with HIV in the UK has increased considerably since the advent of Highly Active Antiretroviral Therapy, and at some stage most patients are likely to present to a primary care practitioner with a non HIV related condition. There are thus great opportunities for us to share knowledge and skills with our primary care colleagues in the management of these highly complex patients

We would like our new professional body to promote the development of stronger links between different sectors of pharmacy practice to enable such opportunities to be realised.

We also need a professional body that offers real leadership champions our skills and helps to break down the oft-held public misperception of pharmacists as “shopkeeper chemists who hide in the dispensary and ‘just’ count tablets”! 

Heather Leake Date, Consultant Pharmacist HIV and Sexual Health

Naomi Swaden, Consultant Pharmacist HIV Medicine

For the first time in fifteen years I’m starting to receive potentially useful information from the RPSGB ahead of the event. The email that was sent around on Wednesday alerting members to the results of the recent Which mystery shopper expose was timely and I’m sure allowed members to arm themselves ahead of the inevitable comments from patients, customers and smiling GP’s!

After receiving the email I began to think that maybe the Society is at last, listening to its members and beginning to change… I only hope so. As a result of this sniff of change, I decided to start a blog on the Transcom site to try and inform the Transcom members about the hopes, fears and wishes of the 36% of pharmacists who work as either locums or relief pharmacists.

Let me start my comments by stating my long term aim of the profession of pharmacy particularly pertaining to community pharmacy as I admit that I don’t know enough about hospital locuming to comment usefully.

My hope and I believe only hope of fully realising the potential of pharmacists,is to allow pharmacists to become independent of all employers and instead contract directly with the NHS. In the same way that the vast majority of GP’s are in fact self-employed and contract their services to the NHS, I believe that the NHS will only derive maximum benefit from pharmacists if they contract directly with them. In this way local PCO’s could insentivise pharmacists to deliver real change to local communities and target resources to areas with particular needs and shortages.

I’ve worked for the multiples and independents and fully understand that both are primarily businesses one who’s prime driver is to deliver maximum benefits for it’s shareholders and the other to deliver maximum business and personal benefits for it’s owners. There’s absolutely nothing wrong with either model but both will stop pharmacists making a real difference to the health of the nation.

My alternative model would allow contractors to engage the services of a particular pharmacist in a given location. That pharmacists will be paid by the NHS and derive the benefits of an NHS pension etc. The contractor would still benefit in the same way from the professional services delivered by the pharmacists but it takes away completely the commercial aspects of the pharmacists job. Additional monies could be made available by PCO’s for the delivery of additional/enhanced services and the contractor would benefits from this cash injection. However the onus on delivering the services would fall on the NHS engaged pharmacist to use the facilities and deliver the changed that have been highlighted as a priority by the local PCO’s.

Could this model work? Absolutely and it already does. Locum pharmacists live and die by the service they provide. Their services are engaged by contractors (sometimes via agencies) on an ad hoc and sometimes on a long term basis. Contractors leave their business in the hands of a pharmacists they don’t employ and know that the professionalism of the individual means that their business is in safe hands.

Shaun Hockey

Pharmacist and Managing Director - PL-UK Recruitment Ltd

I look at the range of societies and groups that I belong to as hospital and clinical pharmacist, and have to ask the question ‘why?’ Why do I feel the need to join them at a cost in addition to paying the retention fee I already pay to the RPSGB? The answer is partially because they provide education and information for me in my specialised areas of clinical practice, but more than that I feel supported by them, there are networks I can tap into for advice and help (and in return maybe I can also offer some help), I feel included, and involved. I’m kept informed of developments in the area, courses that are coming up and so on. I don’t have the same sense of inclusion with the RPSGB.

Most of my recent contact with the RPSGB has been around the area of prescribing.  I wrote to the RPSGB when the issue of an annual retention fee for prescribers was raised and received no acknowledgment – just a supplementary retention fee form, and information that this was to cover the various resources the Society had provided. I accessed these when I did the conversion course – one was out of date, and the other was very relevant for primary care, but not secondary care. Better communication at this point, better maintenance of the information available would have left me feeling involved and wanted, rather then disengaged and a problem.  There’s been a recent chance for the RPSGB to make me feel part of it – the development of post nominal letters for prescribers. I appreciate the fact that they thought of it, that maybe we’re not just a problem group but a development in practice that they’re actually proud of, but then why did the announcement get tucked away, why weren’t the prescribers as a group personally informed – there aren’t that many of us. As a prescriber I am annotated on the register as such, the Society has my email address, it should be a simple matter to select us from the register and for those that have electronic mail, send an email notifying them of the change, but this didn’t happen. An opportunity lost for the Society to make me feel ‘part of it’.

It will always be difficult for a professional body for pharmacy to provide the specialised support I get from some of the other societies, as a group pharmacists work in too many different areas, but there are areas of practice such as prescribing which cut across the healthcare boundaries where the support of a professional body would be invaluable. There are going to be developments over the next years in the ways we work – some of them unimaginable today - we will need leadership, foresight and courage to get there – the RPSGB may be able to do that – but at the moment that’s not evident to me.

Emma Graham-Clarke

Consultant Pharmacist – Critical Care