Supervision: what do we want from future reforms?

With the responsible pharmacist regulations now in place, what can we expect from the planned revamp to  supervision? The C+D Senate, met this month to give their views

MG: Looking at supervision, what changes lie ahead and do we support the idea of a pharmacy running without a pharmacist for long periods?

MS: I'm afraid that I'm probably in the minority here because I'm a final checker, and I know there aren't any of us left now. I understand the need for the pharmacist to delegate workload to properly trained technicians, but I am and will remain until I retire a final checker.

Frankly, I have never considered leaving a pharmacy that I was in charge of.

And I still continue to check all prescriptions. So I guess I'm a bit of a dinosaur.

GP: Can I ask the Senate, how would you like to see supervision changed?

AP: If the regulation stayed the same where overall responsibility was with the pharmacist, I'd be very scared to leave the dispensing and checking process. So supervision should change to ensure that the pharmacist doesn't have to be there for the final check. But at the same time [he or she] therefore doesn't take responsibility for a final check.

 ACTs have now been trained for years and years and accredited to do final checks. At the same time they should therefore take responsibility for that final check. If it means enhancing the qualification that they have then so be it. But I think that's the only way that pharmacists will come out of the dispensary and move forward to bring out more services.

MS: There's a very important point there though. If you can get ACTs to carry the can, like we do, you're going to have to double or triple their pay. Because they wont do it for £15 an hour.

AP: Yes. But if you're a pharmacist that's able to move out of the dispensary and bring in more services, you generate the extra money to pay them more.

GP: If ACTs take on full responsibility, what's the point of having a pharmacist?

AP: You're still going to do a clinical check on the prescription I suppose.

GP: Yes, but if they're taking on full responsibility why can't they do that as well?

AP: Well, then they'd need to take a pharmacy degree too, I suppose.

GP: So they can't take full responsibility. So you have to always have the degree of responsibility.

GP: Mark, how would you like to see supervision changed?

MK: I just want to get a clear understanding of what we all define this discussion to be about. Remote supervision hasn't been mentioned and I think we should mention that, because it was mentioned as part of the RP. And if the issue is to do with whether the pharmacist should be in the pharmacy or whether the pharmacist should be committed to be out of the pharmacy; that's what I think we're actually talking about perhaps.

And before I answer that I think it's important to set the context here. When I qualified as a pharmacist there was still the creams and the ointments and the preparations to make up.

That's not going on anymore. The view, not just in the Department but now widely in pharmacy, is if we continue to just embrace the dispensary and continue to be there with what is ostensibly now original pack dispensing, we will actually become an extinct profession. So, put that on the table because I think that is a given.

So the question is, what do we want to do there? Where do we want to go? What is the strategy? One view is that patients and healthcare will be best served with the pharmacy being left as some sort of automatically driven by SOPs' vehicle. The pharmacist takes responsibility for that and then goes and visits [patients] and residential care homes or what have you.

And the other view, which is the view that I have, is that our USP is we are the healthcare practitioner on the high street. That should continue and go forward and be developed upon. A patient's outlook on visiting the GP and pharmacy is very different. After two minutes in the pharmacy they're looking at their watch, chinking their keys and going: 'can you hurry up with that packet of tablets?' because I'm double parked.

If they go into a doctor's surgery and they're out in one minute forty seconds, they're upset because they haven't spent enough time with the doctor. Now what we need to engineer is a situation where we create that patient experience in the pharmacy so that the patient wants to spend time with the pharmacist and they value spending that time. So the perception of what is the pharmacist's service in the public eyes needs to move away from: 'it's the bloke who gives me the pack of tablets that you only need to stick a label on' to 'it's the clinician in the high street that provides me with that service'. That's what we need to engineer.

Now, if we adopt that and we accept that's a good argument, the idea the pharmacist should therefore be out of the pharmacy and remotely supervising from somewhere else far away, it rails against that, it's a really bad move. Because it not only destroys today's USP but the future model I've just described.

So I would say the future needs to be the clinical role of the pharmacist, in the community pharmacy setting primarily. Whatever bits and bobs round the edges might require the pharmacist to disappear for a short while has already been delivered through the two hour absence, there needs to be no further dilution of the pharmacist's presence beyond that.

Because the danger is, if you create the remote supervision model you create situations where you will have more pharmacies running for longer and longer periods of time without pharmacists' cover. We will, over time, short time, lose that USP and it will be very difficult to make up the ground going forward. So that's the danger that must be halted. We mustn't allow remote supervision to come beyond the responsible pharmacist provisions.

MS: It's very important because of course in Holland there was a very, very real concern that one pharmacist could, in effect, supervise three pharmacies at one time.

GP: Nick, Paul, do you ever envisage one pharmacist managing multiple pharmacies regularly?

NM: No.

GP: Would it be in anyone's interests to do so?

NM: I can't answer that question. No I wouldn't want that. What I'd want to see from supervision is to facilitate the development of the profession, to allow flexibility in the practice of pharmacy to allow us to move away from our reliance on the supply function.

The difficulty is that the devil is in the detail of how you manage that process. I tend to agree with Mark somewhat on this in that there is a USP that pharmacy has; it's accessibility, you know we're there on the high street. Sometimes I think that can be a burden to us because people can come to us and demand our time unreasonably and I think we have to perhaps deal with how you manage that in the high street environment.

For me the clarity around supervision needs to be able to define what happens in that two hour period. Because currently my understanding, as we stand today, is that if you sign out a temporary absence and go off premises, the pharmacy goes back to being a shop that can sell GSLs and nothing else. Now, we've got to get some happy medium here between that and the total, removal of pharmacists from the process.

So it's around the devil being in the detail of how we do it. And I have to say I've expended so much time and effort in my role on RP that I haven't managed to give supervision a lot of detailed thought.

GP: In a GP's surgery you can give out signed prescriptions, even if the GP isn't on the premises. Could it be that they can give out checked, prepared prescriptions on a repeat prescription where there's no material change from the previous six months?

NM: Are you talking about the actual dispensing and assembly at or giving out of a prescription that has been completed under the supervision of a pharmacist? Because there's a difference there, Gary.

I think if it's been completed and done under the supervision of the pharmacist and its only literally going to be handed to Mrs Smith then I can see a logic in that and I think, with the appropriate safeguards built in, that's probably a logical step that you can see as a first way forward. As I say, the devil is in the detail, There's got to be something at the end of the rainbow for us to aim for to attack, to bring the income. Because this clearly will be more expensive for us to deliver, and we have to have the remuneration as well to get the right contract to have that in place.

So it's around facilitating the development of the profession. Because I think we were talking earlier about the qualified pharmacists that are coming out now that are being prepared by the schools of pharmacy are far more clinically orientated than when I came out. And once we engage in broader and newer services and their delivery, they are perhaps not as keen, all respect to Mike, to be a final checker for the rest of their career.

GP: Paul, ultimately, do you see future pharmacy services being delivered on the premises or more in the local community, away from the premises?

PB: I think it's going to be a mix. From a business point of view I think opportunity exists in both locations. I think there is absolutely still fundamentally a business model around attracting consumers into you bricks and mortar location. And the adjuncts that go with professional services around general health and wellbeing, helping people to feel good, and all of that.

I think there's actually also the opportunity to take the services out into the community, domiciliary care has been talked about for many a year. And I think there are many more services that can be delivered by the pharmacist in a patient's home for the future.

But to your example, Gary, where assembly has taken place and there's been a clinical check, but the pharmacist isn't actually there at the time when the patient comes to take their prescription item away - I'd love to see a world where that can operate. Because while that's going on the pharmacist could be doing something else. Market forces will dictate whether or not a pharmacist is physically present to deal with all the other queries that come in and many models of operation wont allow a pharmacist to be absent for a significant period of time anyway. So I think that almost negates much of that.

But I would see a supervision debate be about enabling the profession to go and do some of the stuff its been wanting to do for some time without us losing the accountability of the pharmacist.

MG: How quickly do you think we're going to see this? I mean we talked about supervision in the RP consultation. Is this going to be in the next two years, the next three years, or further down the line?

MK: What? Remote supervision?

MG: Well, the changes to supervision and remote supervision. The next step after RP?

SB: I think the debate should start now. It was a long process to get to RP, we would be foolish to lose the momentum on the debate side. The profession is notoriously cautious as illustrated by the pre-RP discussions.

My take on supervision is aligned pretty much with everybody, it takes pieces from what all of you have said. It's about the personal control... It's about the physical presence of the pharmacist and what that means.

If you look at the bare bones of the medicine act, any act of supply requires the physical presence of the pharmacist. And that patently doesn't fit in with the modern way of services. It's restrictive to registered pharmacy premises where it clearly doesn't happen in hospital settings and dispensing doctors' settings and other settings where drugs are supplied and dispensed. And if we're talking about patient safety issues if things haven't gone horribly wrong in those settings then you can't argue that it's not safe for such changes to take place in registered pharmacy premises.

So I think there are a lot of things that can be achieved but I think we'll be quite cautious at the beginning.

GP: Interesting that you say the debate should start straight away. Looking at it from the outside you could argue it looks like the Society is quite focused on separating its two roles and it doesn't know what size or how powerful the new PLB is going to be. Is there a danger that, because it should naturally be the leadership organisation that leads on the changes on supervision, we could miss the boat?

JT: I don't think so. Certainly the NPA would be taking a very keen interest in helping to shape supervision.

AP: It should have started, hand-in-hand, when the responsible pharmacist was being talked about really; an overall plan to say this is what will happen.

You know, responsible pharmacist will bring this much as stage 1 and we already have these plans for supervision which will be stage 2, just to break up the implementation instead of having everything happen on October 1. It should have already been planned out just to make it easier to implement.

MS: Surely it's already started? I mean, the fact that we've got ACTs in place would suggest to me it had already started. Again, am I missing something here?

SB: Yes, we've already developed support staff. We've already got the activities that can clearly happen. I think, yes, you're right, we've already been moving down towards changing supervision. Or at least addressing the issue that is supervision; of course there's no official definition of it.

GP: Can I just ask, have there been any instances where you have had to define the level of responsibility between the registered technician and the registered pharmacist if an incident occurs.

SB: We have had cases where there have been both registered technicians and pharmacists involved in the incident and both have been held accountable. But as currently is the pharmacist is held accountable and responsible for the supply that takes place under their direction. So yes, the technicians are held accountable for their part in that.

GP: Yes, but equally?

SB: Equal is difficult because we would have to say we would have to measure the sanction to see if it was the same. They both go through the process, they are both investigated, they both may or may not receive a sanction depending on the events of the case. And technicians have had sanctions through the fitness to practice procedures.

MK: If I can just, from a slightly different angle talk about the timing... I know when the whole Health Act was debated in Parliament we as the PDA were very active in Parliament at that stage and became aware of one thing: that both the Conservative and the Lib Dem politicians thought the idea that you've got a pharmacy without a pharmacist in it was absolutely potty.

And that we believe is why eventually it was decided, on pragmatic grounds, to deal with the RP first because there appeared to be fewer concerns about that, and put the remote supervision issue on the back-burner until such time as one issue was tackled. The people who will drive this will not be the professional leadership body, it will be the Department of Health. They will either decide to enact the enabling 2006 Health Act legislation or not.

And that will depend on whether they have lost the will to live over what has happened with the RP, because I don't believe that this is going away today or tomorrow.

This will continue and people will learn as the weeks and days and months go by, what a real dog's dinner it was. And secondly, when the general election will be. Because I don't believe that either the Conservatives or the Lib Dems would be happy with the levels of bureaucracy and paperwork associated with RP, let alone their concerns over remote supervision.

So if we want to do some real politic here, I think we've got to, if we can get past the next few months to Christmas, if that consultation has not been launched by the Department of Health on remote supervision, I believe the only debate that will occur will be the inter-professional debate. But we'll see what happens. I don't believe there'll be an appetite for this under any other government. And possibly not even by this one, after they've found out what's happened with RP.

MS: My closing comments are that there are three very important points here. The first one is I think we're in real danger of making a mountain out of a molehill out of this. The fact is we're all professional and as John has said as professionals we have a way of putting our house in order.

To that end I'm relatively relaxed about it. I accept the fact that as a final checker, I'm a dinosaur from a past generation but as long as there is adequate supervision in the dispensing process by adequately trained technicians, I don't have a problem with that.

I think the two things that are very, very important are that we must maintain our place as pharmacists at the interface with our patients. The most important relationship that we have is of that with our patients. And I think that anything that we do that in anyway lessens the opportunity of the patients to spend time with the pharmacist is a bad thing, which I'd be totally opposed to.

I have real concerns about the ability of independents to deliver domiciliary services purely on a resource issue. Which is, as both of our supers have intimated, many of their pharmacies will have two pharmacists, which not a lot of independents can afford that luxury at this time. If they can then there's no problem.

GP: Just an interesting point there, there's this perception that multiples have two pharmacists in every branch so its easier for you to do it. For independents is the solution to come together, as GP practices have, and offer a service where you share the spoils together. If you were neighbouring pharmacists, is that something you would consider doing?

AP: It's difficult. In an ideal situation it would work brilliantly. But at the same time the way a GP practice is run, in terms of funding, money and a way a pharmacy is run. Pharmacy, I think, is a lot more every man for himself to make sure you do get a decent living at the end of the day. GPs are different in how they get their funding.

GP: Okay, so you're already competing and it's already trying to nick a bit of extra business from the other person. But if you could combine and offer a domiciliary service where you share the costs and split the revenue, isn't that a better option than where you are now?

AP: Yeah. I suppose the biggest hazard is convincing a thousand people that that is the better option. It's difficult to say really.

GP: What about you Elaine?

ES: I think for independents and sole traders there has to be collaboration if you're going to go forward. Unfortunately, it's got to be based around the pharmacist with special interests. If you want to go forward and deliver new services you're not going to be able to provide everything within that health authority. So why can't a couple of independents come together. Obviously there are the business problems around that.

But if you can still have your core business but form some sort of consortium to deliver domiciliary services then you're gaining in both areas. You've still got your core, community customers, you're still able to deliver the day-to-day stuff that you already do.

And, anybody can see, going forward, its all going to be near patient services. It's also going to be about well-centres. You have to look at what we can provide on the high street and like you said, if we're not still there allowing people to come in for advice we're stupid, but you have to look at what's outside the door as well and get some new opportunities.

GP: If, for instance, you had a branch near some independents would that be a problem in forming a consortium to deliver a local service?

PB: Absolutely not. I'm sure there are massive examples of that, where multiples are working in partnership with independent pharmacy owners and operators to provide services around the country. And I think much more of that would be very beneficial. Because what this is about, I know this sounds like an old drum beat, but its not about independents and multiples operating against each other its actually about how do we grow the size of the healthcare market that pharmacy has. And I think the more we collaborate on those opportunities then the stronger the opportunity will be for pharmacy and for all of us individually as a consequence of that.

JT: That's a really important point. In terms of the evolution and where pharmacy wants to be in its vision we absolutely need to create cakes. We've got to go into new areas and create new services and pharmacy has got to work together to do that. Because, rather than scrabbling over a few crumbs we need to come together and work together to create a cake. After that we can decide who gets what slice.

MG: Okay. Thank you for that. I'm just going to bring things full circle to finish us off. We started off going round the table to ask about the responsible pharmacist, the biggest opportunity for a long time or a possible threat? I just want to go back round and ask everyone, factoring in supervision and some of the discussion we've had around responsible pharmacist, I'd like to put that question again - supervision and the responsible pharmacist: is this the biggest opportunity ever or something we've got a lot to be concerned about.

 SB: I think those choices are too extreme. "The biggest opportunity ever" is broadly too extreme. I still maintain my position, that it's a good thing for pharmacy; I think that it's enabling. I think the discussion on supervision is very enlightening and very positive and I think that we do need to move to a position where we resolve supervision. And I think this is the first part, responsible pharmacist. Whether we like it or not they decided to do it in stages and this is the essential first stage that sets the framework. So I retain my belief its necessary.

JT: For me it's absolutely positive because it's enabling of where pharmacy wants to go. Although I do dream of a world which probably returns a little bit to the past, whereby, as a profession, we allow professionals to act without the huge burden of regulations and rules and guidelines.

MK: Similar to what I said at the outset. Strategically a huge opportunity for pharmacy and pharmacists but one which today, operationally, requires open heart surgery.

ES: I think again, like I said at the start, the long term opportunities of this are fantastic. Not only opening the doors to different views on supervision. And also everybody working together in different ways to actually say, let's move the profession forward, lets have a different model where pharmacy is as important as some of the other health services.

But on a separate note, the way it's been launched perhaps hasn't been as effective as it should be. This should be seen as a learning curve; that for future models there's perhaps a bit more assessment, a bit more discussion at the earlier stages and involving a lot wider people across the profession so that when it is launched people are more comfortable and we can go forward. Rather than the profession saying: 'oh, I'm not sure about this', if we as a profession say 'fantastic' and this is where we're going I think that's going to be a really unified voice for pharmacy.

AP: I think it would have been a good opportunity and on paper is the right direction. But I think, as of today, it's a missed opportunity and as Gary mentioned earlier, maybe will become a lost opportunity, because of the way... The split of the Society, and so on. It's almost like pharmacy has become like a bad GP. When a patient starts getting side effects to a medicine after 5 minutes they're prescribed something else, until they're on eleven medicines. Similarly I think pharmacy is headed that way. It maybe needs to take a step back to have a look at everything and start fresh again.

NM: I think the positive I take from today is from everyone round the table there is a clear desire to move the profession forward, to have a strong profession, to have a strong healthy pharmacy market that we can all, in our various organisations, participate in. I do believe, as I said at the beginning, it is a missed opportunity to RP in isolation, I would have preferred to see the total package.

I think the debate we've had about "is the RP an opportunity or threat?" , it might have been a cracking debate if we'd been talking RP and supervision. But perhaps we maybe had better influence early on.

So, I'm encouraged by today, I have to say.

PB: It still feels to me that it's more like a regulatory burden than actually something to celebrate. But then I guess I'm drawing at the moment from what everybody said was the lock and key scenario.

If this is the key, I'm feeling the burden of having to carry it around a bit. If the RP key unlocks supervision for us and enables us to do something much more progressive in the future then that's a positive thing. So perhaps I was being a bit too black-hatted earlier on, although I'll wait to be persuaded a little further on that.

I think the acid test to me is, so what difference has it made to our patients. And at this moment in time I see very little difference. With a full and thorough debate about supervision, hopefully there will be significant benefit to our patients. And I guess the one big lesson I hope we can learn from the journey we've been, on up to October 1 with RP is that if we've got particular issues that we all passionately believe in, we should take time to talk to each other about them, flush them out earlier on so we don't end up on the eve before the implementation with new issues, fresh issues to deal with. Because that doesn't do any service to our practitioners who are at the coalface.