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Is this England's only community pharmacist with a clinical A&E role?

"This isn't a regular consultation a patient has with a pharmacist. It’s new, unique and exciting"
"This isn't a regular consultation a patient has with a pharmacist. It’s new, unique and exciting"

Ravinder Singh Cholia believes he is the only community pharmacist advanced clinical practitioner in a hospital emergency department. He tells C+D what it's like in his role

If I travelled back in time two and a half years and asked myself, “Ravinder, what’s an advanced clinical practitioner (ACP)?” I would have said something like: “I haven’t got a clue.” But ask me now and I could write an essay on it. 

I'm a community pharmacist and a fully qualified ACP in the emergency department at Queen's Hospital in Romford, Essex. On a typical day, I have a handover meeting at 8am; listening, learning, and contributing as part of a multidisciplinary team, which includes consultants, nurses, a paramedic, community treatment teams, and ambulatory care units, among others.

Exposure to different clinical areas

After the meeting, I am assigned an area to work in, which could be the resuscitation department, the major or minor injury units, paediatrics, or the urgent care centre. While I was a trainee, I exposed myself to all these areas, so that I could use my skills in any part of the emergency department.

I then pick the next patient to be seen. This isn’t like doing a medicines use review, or a regular consultation a patient would usually have with a pharmacist. It’s something new, unique and exciting for the profession. It’s also new for patients, who are seen by a fully qualified advanced clinical practitioner who just happens to be a pharmacist – and I won’t let them go without a thorough medicines review.

I walk into the busy waiting room, where patients wait with bated breath, hoping it's their name on my lips. “Mr Jones?” I call out. Just like in community pharmacy, the patient leaps up as if he’s got a winning lottery ticket, but in this case it’s a consultation with me – which is just as valuable.

I take his history, conduct a physical examination, and request relevant blood tests, as well as scans, if required. If I feel the patient needs cannulating then I can also do this, as well as prescribe fluids and medicines. Having these additional skills, as well as being an independent prescriber, means Mr Jones gets the care he needs from one highly trained professional. He can ask questions and I make sure he understands that we are making decisions about his care together.

"My title doesn't define me"

After I note my differential diagnoses, I present my findings to a senior clinician – which may be a registrar, my clinical mentor, or a consultant – if I feel a review of the patient is required. If this is the case, we discuss my findings and decide on the best course of action. Does Mr Jones need to be referred for surgery? Do we need to conduct an ultrasound, or shall we send him for a CT scan?

If the senior clinician wishes to see the patient they can, but as we have built a rapport over time, I have a certain amount of autonomy. If they concur with my diagnosis, it’s pleasing to know I am on the right track; if they do not then this is still positive – it means this is a learning point. That is what I like most, learning and developing.

At the end of the consultation, I let Mr Jones know that I am also a pharmacist. So far, I haven’t had anyone raise any eyebrows – and why should I? In the patient's eyes they have received the same care as they would expect from a doctor. My title doesn’t define me. The level of care I give defines me. 

I see many patients throughout the day, with cases ranging from tonsillitis, to seeing a child with a rash with the GPs in urgent care, to aiding a full cardiac arrest in resuscitation. The first time I did this, a consultant asked me to do chest compressions. It's not as easy as it is on a mannequin, although doing the compressions in time to Stayin’ Alive by The Bee Gees did help me keep time.

Ongoing learning

I am fortunate to be allowed to take some ownership of my learning, and have taken advantage by working in all areas of the emergency department, following the patient journey.

There's still a long way to go to before I become a master of my trade. So far my journey has included one day a week at university, with modules in physiology, examination skills, the complexities of different body systems, and clinical reasoning with diagnoses.

There’s also been what’s known as the four pillars of advanced practice: clinical practice, leadership and management, education, and research. This is coupled with practice portfolios, and a lot of blended and self-directed learning at home.

In the future, I would hope that there will be many more pharmacists in my role. As a profession, we can do anything with the right mindset.

What is an advanced clinical practitioner?

A&E

Health Education England (HEE), the NHS education and training provider, oversees the framework for ACPs. 

It defines advanced clinical practice as being “delivered by experienced, registered health and care practitioners....[with] the ability to manage clinical care in partnership with individuals, families, and carers”.

“It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master’s level award, or equivalent, that encompasses the four pillars of clinical practice, leadership and management, education, and research, with the demonstration of core capabilities and area-specific clinical competence.”

SourceHealth Education England, Multi-professional framework for advanced clinical practice in England.

Ravinder Singh Cholia has a postgraduate diploma in advanced clinical practice and will be discussing his role at a session at the Pharmacy Show on October 7. 

Register for C+D's free careers events this September

Getting your foot on the career ladder can be a daunting prospect for pre-registration and newly qualified pharmacists. That’s why C+D – in association with Boots – has created two careers events, in London and Bradford, to give new pharmacists a valuable insight into the range of options out there.  

We’ve assembled a diverse array of speakers across the spectrum of pharmacy sectors – from community pharmacies and hospitals, to GP practices and academia.  

Each speaker will be sharing their unique experience and advice both on stage and with attendees while networking over complimentary food and drinks. 

Career options for pharmacy

51 Comments
Question: 
Would be interested in a role as an advanced clinical practitioner?

Marc Krishek, Pharmaceutical Adviser

I think that there is a lot of unecessary negativity. Where there are medicines or patients taking medicines or being prescribed medicines there should be a pharmacist. Where there is a multidisciplinary team, like an emergency department, this should include a pharmacist, including a community pharmacist. Ravinder has passion and developed unique clinical skills to work outside the box and still proud enough to call himself a community pharmacist.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Marc, by Mr Cholia's own admission, he is employed as an ACP and not as a 'community pharmacist'. He is a pharmacist who became an ACP while retaining his GPhC registration. Are you suggesting that pharmacists should all change jobs and become ACPs? Is becoming an ACP 'career progression' and something we aspire to? Are ACPs a higher form of pharmacists you think (I don't know if he is band 7 or 8)? Feel free to correct me if I am factually incorrect.

I have no objection in people changing jobs and do something else, but disagree about bragging, putting oneself up as some sort of role model and implicitly calling me an 'ordinary pharmacist'.

I actually know a few pharmacists who have changed jobs and went to medical schools and became real doctors. They have not felt they have to write about their experiences here yet. If the C&D is interested in publishing their stories, I am happy to supply their names, with their permissions of course.

Beta Blocker, Primary care pharmacist

Jonny.. What do real pharmacists do?? And what is your definition of a Pharmacist?? 

 

 

 

Pharmacist Pharmacist, Community pharmacist

I think in Jonny's opinion a 'real' pharmacist is someone who complies with the rules, regulations and ethos of the multiples, abide to and maintain their unrealistic sales and so called 'professional/clinical' services income and basically work for them, and them only, without looking at wider opportunities elsewhere for progression.

The only route of progression is within the company and being morphed into a manager with the company's way of thinking and working. 

 

Basically if the company says jump, you are expected to ask how high?!

Chris Maguire, Community pharmacist

Ravinder, I do not know you but can I just say it is amazing to hear of your job, your skills and your journey. Pharmacists need to keep pushing themselves and bringing the profession forward. I don’t believe you are trying to imitate a doctor. I believe you are using your pharmacy knowledge and acp knowledge to allow you to work at the height of your ability. And in the end it’s the patient who benefits  from all this. Keep doing what you’re doing and ignore the haters on here(bizarre!!!)

Imogen Savage, Academic pharmacist

Thanks CandD for a very thought-provoking news item. My first thought on reading it was:  I wish I could have done this! I wonder how many other older pharmacists thought the same thing. But the piece also raises the question: what does "being a pharmacist" mean these days? I wasn't sure if Ravinder is employed in A&E specifically as a pharmacist, or if he is (probably) the first ACP with a pharmacy degree. Either way, best wishes to him for finding a fulfilling role. Any chance of a follow-up piece with more details of how he got there?

 

Jonny Johal, Pharmacy Area manager/ Operations Manager

Imogen, good to see an academic here. I have so many questions about today’s education, and I think the way students are taught is a big part of some problems I encountered, eg those pre-regs/pharmacists who refuse to manage stock because they were taught not to engage in 'non-professional' activities. Don’t you think too much teaching emphasis is on the ‘clinical’ ego to the detriment of bread and butter necessities?

Then there is a question about the quality of university entrants; when I started my degree course in 1975, only about 5% of school leavers went on to higher education, now about 50% do, given the IQ of the general population how do you maintain equivalent quality or don't you? In recent years, I have come across young M.Pharms who (apart from telling me that they are more qualified than me, because they have been taught that way) are signed off as competent in everything but totally lacking in mental flexibility - I do get the feeling that Schools of Pharmacy now, more or less, admit anyone and pass everybody.

And what do you mean by ‘older pharmacists’?

The question academics in Schools of Pharmacy should ask is whether they want to teach reality pharmacy or, aspirational pharmacy, just to satisfy the cravings of those who failed medical school entry?

Sharon Stone, Communications

Johnny Johal is absolutely correct. Well said.

Peter Sainsburys, Community pharmacist

Yes, he speaks the truth, but there are so many deniers who don't want to hear it. I'm not sure how anybody could try and deceive themselves about what is going on right now. 

Zero job prospects, no regulation or professional body. Run a mile.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Career Dismorphic Syndrome

Pharmacist Pharmacist, Community pharmacist

Jonny Johal I think you are a non pharmacist manager? Or maybe you are a pharmacist but because of your role as a manager you no longer see through the eyes of a pharmacist.

Pushing boundaries and making moves into a new field is part of development, and this happens in every field and position of work. Even as a manager, in your case a pharmacy manager, with your experience you can move into a managerial post in a totally different sector. One does not need to stay in their historical stereotyped role. If you have the abilities to move and progress then you should go for it.

In terms of training, advanced practitioners in hospital have a brilliant support program and the pharmacist in question will have the relevant backing to complete the role.

So please do not make negative comments without proper backed explanations.

Peter Sainsburys, Community pharmacist

Hang on a minute. Many people may not like what Jonny Johal says. But it seems that he has his ear to the ground and actually does understand what is, and is not going on in the industry.

He may make some negative sounding comments, but I would have to agree with him given the current issues with pharmacy in the UK.

The career of the pharmacist in the UK is basically over, and like it or not, these extraneous additions to the role are the last gasp of the profession. If this guy in the article can keep his pretence up a bit longer because he is calling himself a super mega practitioner or some other garbage, then good for him. But I certainly wouldn't lend him 200k for a mortgage knowing what I know about the profession.

And I agree with his above comment. Why try and be a junior A&E doctor when you only have a pharmacy degree?

There are a lot a pharmacists who genuinely believe that by doing a prescribing course, and enhancing their skillset, that they will be able to ride out the storm. These people are idiots, the government wants pharmacy gone and handed over to a company that can do all of their jobs for a fraction of the price. And I can assure you that this will happen.

Get out fast, and find someone or a career which appreciates your skills because this is not it.

Pharmacists are a drain on the UK government's resources, because Amazon can do everything you do, but better and for a fraction of the price.

It's a bitter pill to swallow, but the sooner you realise that nobody wants your useless services, the quicker you can find a better job.

CRAIG TIBBITTS, Primary care pharmacist

So pharmacists are a drain on the UK government... why are you a drain on the UK government......still a registered pharmacist?....If so.....quit! Sounds like your Johny Johal's little Princess....you two seem to send comments together, back up each other's silly negative comments and back each other up...cute?! Then I read your last comment ...."It's a bitter pill to swallow, but the sooner you realise that nobody wants your useless services, the quicker you can find a better job.".....That passionate about pharmacy and you make a comment like that! WOW!

Peter Sainsburys, Community pharmacist

I am out of pharmacy so not a drain on anyone. I work freelance in an entirely new role. I create my own work and attract my own clients, and work in my own time at my own pace.

I provide services which people actually want and will pay well for.

I do not make a habit of backing anybody up, Jonny Johal included, but have to agree with some of his comments.

Pharmacist Pharmacist, Community pharmacist

Well said Craig.

Roy Sinclair, Community pharmacist

Why so many negative comments. Ravinder has obviously decided not to limit himself to what is seen by some as the traditional role of the Pharmacist and is pushing the boundaries and is proud of what he is doing and happy to tell people so.  He is having a positive effect and helping to provide healthcare in a difficult setting.  He is not defined by his title or thinking of pay. He gets 5 Stars plus from me. Go for it and show what Pharmacists can do if they want to !

 

Brendon Jiang, Community pharmacist

Thank you for the insightful article and raising the profile of ACPs. Having spent some time shadowing practitioners in A&E, I have a deep respect for what you are doing, Ravinder. Multidisciplinary working is the way forward for healthcare and our profession, and you sir are a leading light. The role you have carved out is quite different to that of traditional hospital pharmacists and even many pharmacists in urgent care so I am unsurprised that others fear the unknown. Pharmacists are not known for being very hands on with patients but there is no reason why that needs to be the case. I’m confident your skills, knowledge and experience as a community pharmacist are highly valued by your colleagues.

Keep up the great work and continue to drive yourself and our great profession forward!

CRAIG TIBBITTS, Primary care pharmacist

I couldn't agree more! Surely it's about time each sector should be working together for the common good......enhancing patient care! This is not about pharmacists pretending to be doctors or studying the wrong degree! Pharmacists are more than able to take a blood pressure reading, take blood from a patient and make diagnoses. I'm not sure why the same area managers and superintendants have the desire to mock others for following a different clinical career path? As leaders of the profession, I would expect more constructive comments. However, from my own personal experience there tends to be a reason such people follow the management route. Usually lack of people/patient skills. Mr Cholia....keep up the good work....keep inspiring future and current pharmacists....hopefully one day those making the negative comments will realise the future of pharmacy is changing! 

 

 

Jonny Johal, Pharmacy Area manager/ Operations Manager

This just reinforced my view that many pharmacists are failed medical school entrants and doctor-wannabes. Please note that this is a one way process, in that I don't see any doctors coming into pharmacies to dispense. What you call "enhancing patient care" is actually a step backwards; a pharmacist is now interposing between the patient and clinician possibly delaying or administering wrong treatment (in some cases, no doubt). Just ask yourselves, when you go to an A&E deptartment for whatever reason, do you expect and want to see a 'ACP'? Wouldn't you be more assured if your e.g. daughter is seen by a properly trained and medically qualified doctor right from the beginning? Where is this "common good" or "enhancing patient care" you mentioned by seeing someone less qualified and originally trained to do something else? You might as well ask a carpenter to install your new gas boiler.

CRAIG TIBBITTS, Primary care pharmacist

GPs dispense in our surgery on a daily basis. Step backwards? Do you not realise that these pharmacists act within their competence...they refer when they need to....if doctors didn't want them in their business/clinics/hospitals they wouldn't be their...if they weren;t competent they wouldnt be signed off as being so. You have just highlighted that you are in fact behind the times, stagnant in a role you trained to do....not expanding your knwoledge or skills....just doing a role you trained to do. #SnoreBore. What a role model you must be......you keep your pharmacists at a checking bench, completing their amazing MURs that they "trained to do!"

 

Jonny Johal, Pharmacy Area manager/ Operations Manager

Craig, I am sure you may not be aware that ACPs are usually employed by Trusts (here in the Midlands), and the ACP M.Sc course is mainly aimed at nurses and midwives as their career progressions. There is a difference between expanding one's professional envelop and joining another trade. Mr Cholia is working as an ACP and not a pharmacist. Do please read what he wrote carefully. ;-)

Anyone is free to join another trade if properly trained and if they want to, do you find that inspirational? You are free to join him (which is Mr Sainsbury's point), but that doesn't mean pharmacists in general will mutate to become ACPs en masse. LOL

Pharmacist Pharmacist, Community pharmacist

Jonny Johal

1. Doctors are getting involved in pharmacy. Have you not seen the hundreds of GPs who have shares in a pharmacy business??

2. In A&E depts you will see many ACPs. Maybe youve never noticed but there are many nurse practitioners. Are these nurses medical student rejects or doctor wannabes as you claim? Are you saying they are not qualified enough to see patients?

Your comments are very insulting and demeaning.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Pharmacist, there is one point about nurse practitioners you failed to mention they are Band 7 or higher. Compared with staff nurses, that represents an improvement, financially and professionally. 

Peter Sainsburys, Community pharmacist

It could well be an ex-pharmacist coming to install your new gas boiler! A certified gas engineer earns a lot more than 17/hr!

Jonny Johal, Pharmacy Area manager/ Operations Manager

Pharmacists will do it for nothing. :-)

Muhammad Siddiqur Rahman, Primary care pharmacist

I applaud Mr Cholia for taking a brave step into the unknown in urgent care from a community pharmacy background. The amount of hard work and sweat that this gentleman has had to go through as well as proving himself to the A&E multidisciplinary team is nothing short of exceptional and one of the few forward-thinking bright sparks in Pharmacy. The savage comments made by the majority of pharmacists here is nothing short of a disgrace and is an embarassment to the profession that they would put down a fellow colleague who is actually leading the way and opening up more sectors for future pharmacists as there is more to pharmacy than community, especially when there is an over supply of pharmacists who are heavily underutilised in the NHS.

 

Beta Blocker, Primary care pharmacist

 

Couldn’t agree more with your comment. Some folk on here will have a go for any reason. Hats off to Mr Cholia for upskilling and bettering himself whilst the rest of the profession takes a nosedive.

 

Advocatee Jones , Hospital pharmacist

I am a bit shocked at reading such an article and disappointed that C+D did not check the veracity of the content of the article.
What I can say is that Mr Cholia is completely exaggerating his perceived role, responsibility and capability. He may well work in an emergency department setting but just as us nurses are posted to different areas within the department, it doesn't mean we get to shock people or administer thrombolysis without senior input. I have been in ICU and coronary care. Doesn't mean I can pass myself off as a cardiologist or anaesthetist.
From what I gather, there are other pharmacists training in similar emergency departments. So what makes him "The only community pharmacist with an A&E clinical role"? Such an absurd observation by someone trying to set themselves above the hard working nurses and doctors AND pharmacists who have tirelessly worked for over 20 years.
Mr Cholia, take a step back from your flights of fantasy as sometimes articles like these can bite you in the back side.
To C+D, do better at research please.

Lilian Anekwe, Editorial

We asked the question in the headline, as we are aware it is uncommon for a pharmacist with a background in the community sector to work in this capacity as a fully qualifed ACP.

Mr Cholia has given an honest insight into the nature of his work in a hospital emergency department. He has not "passed himself off" as anything other than his role as stated in the article. We are satisfied the article is factually accurate. 

Lilian Anekwe

Deputy editor, C+D.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Lilian, I think you missed the point, accuracy is not the issue here. This should be published in the British Medical Journal or the Journal of Emergency Medicine and not here. This is not about pharmacy, it is about a frustrated pharmacist misfit. BTW, good to know I am not alone in my views.

Am I right in thinking that the ACP course is aimed primarily at nurses and midwives, you don't need to be a pharmacist to get on the course. Mr Cholia is working as an ACP and not working as a pharmacist. The C&D might as well publish articles on former pharmacists who left the profession and working in other trades. For example, when a pharmacist becomes a plumber and the C&D publishes a similar article, that doesn't mean pharmacy is moving towards plumbing. Let's put things in perspective here.

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