The mammoth in your pharmacy
As community pharmacy enters a more service-led future, Malcolm Brown discusses the tensions between pharmacy and medicine, and the parallels with the mid-19th century
In just two years, a new kid will erupt on the high street: on initial registration, every pharmacist will become an independent prescriber (IP). This has profound consequences. I suspect that such pharmacists will become the new GPs and today's pharmacy technicians will become the new pharmacists, as suggested by Emeritus Professor of Pharmacy History, Stuart Anderson FRPharmS.
In that, I think we will just be going back to the mid-19th century, when the local chemist and druggist, or occasionally an apothecary, was the local GP. Only rich people could afford the patrician university-educated physicians and people generally avoided surgeons: chloroform and ether anaesthesia had only just been introduced.
You may think this is over-cynical; I look with my sociologist's eyes.
For centuries, millennia and perhaps even before recorded history began, the antecedents of pharmacists and medical practitioners have been engaged in turf wars. I have noted that some sociologists consider that British pharmacists are not yet as “fully fledged” as a profession as are, say, medical practitioners, despite pharmacists’ best endeavours. Over the last century, these jostlings about status have been courteous; I have great respect for medical practitioners.
But the last few years have shone an intense spotlight on all this. Just as during the Bubonic plague years when the physicians fled from London leaving the apothecaries, chemists and druggists to look after the common people, so during the COVID-19 pandemic, it was difficult to access a GP whereas community pharmacies remained conveniently open.
It is only fair to note that the members of many health professions died including in medicine and pharmacy. However, in 2023, professions such as barristers, medical and surgical consultants and university academics went on strike; pharmacists seldom or never struck. So, arguably, medical practitioners—compared with pharmacists—should no longer feel entitled to claim the higher moral ground of the fully-fledged professional. The public and politicians will remember that.
This matters because the connotation of trade trumps academic degrees; despite pharmacists being now more highly qualified academically than doctors: pharmacists have masters degrees while medical practitioners often "only" have (a couple of) bachelors. Before full registration, both professions also demand the successful completion of one year’s, closely supervised, practical experience.
I have left the fray as I am retired, but practising pharmacists should gird their loins now, for the turf wars between medicine and pharmacy for the same patients may shortly become hotter, possibly far hotter. That could be unfortunate for patients who may well gain far more by cooperation between medicine and pharmacy than conflict.
Another factor for pharmacists is so important that it is the mammoth in the room.
Pharmacists, rather than doctors, still have possession of the actual artefacts: the corporeal, empirical medicines that are things. This applies to urban pharmacies; their pharmacists need to urgently ponder whether they abandon that birthright; in (legally) rural areas dispensing doctors have long possessed.
After 1812, physicians gave drugs away free but charged for advice whereas apothecaries, for example, charged for the medicines but gave free advice. Community pharmacists have been paid for an increasing range of advice; an early type were Medicine Use Review. The balance has changed over history but broadly, the payment of pharmacists remains connected with the empirical medicines while doctors remain paid for advice. I cannot think of a more transparent and fair payment mechanism.
Can you? How will all this affect your practice?
Dr Malcolm E. Brown is a retired community, hospital and industrial pharmacist, and is a sociologist and honorary careers mentor at the University of East Anglia.