C+D brought together experts last month (November 16) to discuss how pharmacy supervision can be modernised without compromising patient safety as part of the latest Big Debate on the C+D Community.

A formal Community Pharmacy Supervision Practice Group – which includes members from the Association of Independent Multiple pharmacies (AIMp), the Company Chemists’ Association (CCA), the National Pharmacy Association (NPA), and the Pharmacists’ Defence Association (PDA) – resumed talks on pharmacy supervision back in September, and if C+D’s Big Debate was anything to go by, the cross-sector group still has a lot to discuss and map out.

 

Do we need to change the law?

 

A large part of the debate around supervision has centred on whether the law actually needs to change.

But according to David Reissner, chair of the Pharmacy Law & Ethics Association – who joined C+D’s Big Debate in a personal capacity – change is inevitable. He stressed that: “The Department of Health and Social Care (DH) appears committed to changing the law as soon as possible ‘so that the clinical skills of pharmacists can be directed to helping patients’.”

So, while he isn’t personally advocating for a change in the law, he stressed that “it is going to be changed and the profession needs to get on board”.

However, NPA head of corporate affairs Gareth Jones questioned “whether legislative change is necessary or desirable”.

He said: “[There] is a tendency to look at this from a legal perspective, but it is helpful to think about what we know patients want: They want to be able to walk into a community pharmacy and speak to a pharmacist, something that is even more important now with greater problems accessing other primary care services.”

PDA chairman Mark Koziol agreed and suggested pharmacy “must first establish what kind of service…we want to provide to patients”.

“From that flows the solution as to how pharmacists and their teams will work best and then…we [can] consider what, if any, law changes will be required,” he added.

Jonathan Smith, superintendent pharmacist at Mayberry Pharmacy, joined the debate as an AIMp representative, but also as a practicing pharmacist. He questioned the differing interpretations of pharmacy supervision and feared this could land him on the “wrong side of the law”.

“We need to ensure that the term 'supervision' and its interpretation reflects what practically happens in the pharmacy,” he said.

“For example, when handing out completed prescriptions, the pharmacist must be on site to intervene…But should every completed script be handed out under the ‘supervision’ of a pharmacist? If I am away in the consultation room for 30 minutes with a patient, am I supervising the scripts being handed out? Can I really intervene?”

 

What could change look like?

 

Mr Reissner pointed out that inserting a definition of pharmacy supervision into the Humans Medicines Regulations could “make the law too rigid” and suggested instead that supervision could be satisfied if certain conditions are met.

He said: “The conditions to be met might include:

• The responsible pharmacist is on the premises or contactable

• Standard operating procedures that dictate what can be done by whom

• What medicines can be supplied without the pharmacist having a line of vision to the person handing a medicine over (eg repeats or medicines previously dispensed under a pharmacist’s supervision)

• What medicines cannot be handed out without the pharmacist watching

• Skill mix, eg supplies that are within the competence of a pharmacy technician to make without a pharmacist watching.”

Paul Summerfield, locum pharmacist and director of professional advice and support services organisation, Pharmaceutical Defence Limited, suggested using the term "close" instead of "direct” supervision in the regulations. This could ensure that a pharmacist would have to be on hand and in the same premises, avoiding the possibility of remote supervision (see below), he said.

However, pharmacy consultant Greg Lawton cautioned that “removing the requirement for a pharmacist to supervise the handout has the potential to remove one of the fundamental pieces of legislation requiring a pharmacist to be physically present in a pharmacy”.

He asked: “If it were to be removed in the case of dispensed, bagged up medicines, for example – ignoring for a moment the importance of the clinical check in such circumstances – what requirement would remain in statute to have a pharmacist present?”

 

Putting remote supervision “out of reach”

 

One of the reasons that discussions around pharmacy supervision discussions have always become heated is because of the perceived threat of removing pharmacists from the premises altogether – otherwise known as the practice of remote supervision.

However, one possible advantage of reworking the legislation – as Mr Reissner pointed out during the debate – is actually “the chance to put remote supervision out of reach”.

“Remote supervision is already legally possible, even though it isn't something that's happening, and all the contractor organisations have made it clear they don't want remote supervision. The law could be changed to ensure that remote supervision is no longer possible,” he said.

The NPA’s Mr Jones stressed: “We [the NPA] are against the practice of remote supervision in almost any conceivable circumstances.

“Reviewing supervision to ensure that the responsible pharmacist is able to delegate certain tasks is part of what we need. More NHS commissioning of clinical services from community pharmacies is another part of the picture.”

 

Pharmacists at centre of pharmacy practise

 

Mayberry Pharmacy’s Mr Smith said AIMp does not advocate remote supervision “in any shape or form”, but suggested that pharmacy supervision could be made simpler.

“We should put the pharmacist at the centre of everything we do to ensure pharmacists can exploit their clinical skills for the benefit of their patients and that we are in tune with how the profession is progressing,” he added.

The PDA's Mr Koziol liked Mr Reissner’s point about using this exercise to remove the possibility of remote supervision altogether. He reiterated the PDA’s previous call for “having more than one pharmacist per pharmacy and ultimately for the creation of something that resembles more [of] a high street health centre-style pharmacy and less of a shop”.

“[The] separation of the professional activities – 'the clinical checks and patient interaction' and the technical activities, [ie] 'the assembly of the medicines' – is an entirely sensible way forward to organise the work as far as future practice is concerned,” he said.

“It ensures that pharmacists work smart by focusing upon their unique skills around medicines. It enables them to start to develop an even greater clinical relationship with the patient and they can do this because the mechanics of the assembly – a technical role, could be undertaken by pharmacy technicians.”

As C+D's Big Debate showed, there are a multitude of different opinions about what the future of pharmacy supervision should look like. But until the DH decides to actually change the law, what that future could look like is still anyone's guess.

What are your views on pharmacy supervision? How do you think legislation could be changed? Catch up on the Big Debate and share your views on the C+D Community.

C+D’s next Big Debate asks: Is there a shortage of community pharmacists and takes place on December 15, 7-8pm. Save the date and have your say live on the C+D Community.