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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.

Read more: I didn’t need an eye injury to see the NHS is broken

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.

Read more: The way forward: Remote supervision in community pharmacy

But a problem remains for pharmacists: the miasma of trade amongst community pharmacists and this trumps the professional prestige of a degree. Indeed, some pharmacies are geographically located within, and owned by, basically grocers. A remnant of “the bazaar tendency” remains the propensity to stock whatever will turn a profit even if only remotely connected with pharmacy. Extreme illustrations include bananas, beach umbrellas, hot water bottles, perfumes, photographs, sunglasses and ironing water. One way of reducing that stigma is practising as a clinical pharmacist within a GP surgery and, recently, many pharmacists have “voted with their feet.”

 

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.

Read more: Is community pharmacy’s luck finally about to turn?

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. 

Read more: Is Pharmacy First addressing the sector's root challenges?

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.

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