“Now dispensing was his own by right; for many years he’d fought to keep the sacred privilege that by blood and brain he’s bought. But it, too, was wrested from him by the doctor down the way.”
At first glance, this tongue-in-cheek ballad from a 1911 edition of C+D could be lifted from a comment on the magazine’s website in 2016. It reflects the territorial attitude between some GPs and pharmacists over the services they provide – that continues to this day.
Only last year, hackles were raised in the GP community by the introduction of a national pharmacy flu scheme. The British Medical Association (BMA) took aim at the service, suggesting it would not improve vaccine uptake, arguing that GPs would be left with surplus vaccines, and criticising the scheme’s rushed implementation. The doctors’ union went a step further this year, suggesting that if an increase in uptake could not be proven, the scheme should be scrapped altogether.
The BMA is not alone. In May, the editor of GP magazine Pulse penned a controversial blog, questioning whether pharmacies are needed at all. He may have been playing devil’s advocate, but his words tapped into the fears of many community pharmacists that GPs are looking to encroach on their turf.
But has it always been this way? As C+D has discovered, the two health professionals have worked together in different ways over the years.
“The doctors were a class apart”
In the mid-19th century, there was no such person as a pharmacist. Instead there were apothecaries, chemists and druggists. The former evolved into what we would now recognise as a GP, explains Stuart Anderson, past president of the British Society for the History of Pharmacy and a Royal Pharmaceutical Society (RPS) fellow. It wasn’t until early in the 20th century that the pharmacy profession emerged, with the registration of pharmacists.
The evolution of the pharmacist into its current role can be linked to the growth of the welfare state – beginning with the creation of national insurance in 1911, Dr Anderson explains. “Part of that evolution is the changing relationship between the pharmacist and the GP,” he says.
A hundred years ago, there was a huge difference in status between the two burgeoning groups of health professionals. “The pharmacist was subservient to the doctor,” Dr Anderson says. “Contact between the two was, at best, infrequent – and more likely non-existent.”
Around this time, there was a three-way relationship between pharmacist, GP and patient. “The doctor’s patients were the pharmacist’s customers, and the pharmacist was keen to keep the doctor happy,” he says. “When the doctor would go to a pharmacy, a great fuss was made of them – the doctors were a class apart.” Prescriptions at that time would have also been handwritten and in Latin, Dr Anderson says. In an echo of their modern role, “pharmacists prided themselves on translating the doctor’s intentions”.
Following the inception of the NHS in 1948, things began to change.
“Large numbers of new drugs were coming through during the 1950s. Doctors were realising they hadn’t been trained for this, and perhaps they needed some help,” Dr Anderson says. “Potent medicines were available and doctors were becoming aware of the dangers.”
A decade later, and the relationship continued to equalise. Doctors were often grateful when a pharmacist pointed out a mistake with a prescription. “Pharmacists were building bridges with doctors – it was all part of showing they could be useful,” Dr Anderson says.
“When the doctor would go to a pharmacy, a great fuss
Dr Stuart Anderson, past president of the British Society
Credit: Royal Pharmaceutical Society Museum
Pharmacy reached a key milestone in 1967, when the profession limited its intake to graduates. Before this, pharmacists often served an apprenticeship before qualifying.
“By the 1970s, there was still a high regard for doctors, but they were not put on a pedestal as they were previously,” Dr Anderson explains.
In another echo of the current situation, this rise in pharmacists’ professional status did not automatically result in stronger relationships with local GPs. Mark Spencer, co-chair of NHS Alliance and a GP himself, remembers that when he started practising 25 years ago, there was virtually no relationship with pharmacists.
“The general view of pharmacy was that it was a dispensing mechanism,” he says. But, unlike today, the “lack of integrated care” was not an issue back then. “It isn’t negative to say that they were independent of each other,” Dr Spencer argues.
“No information, no communication”
So how have things changed since the Cold War era? Raymond Anderson, a pharmacist and partner at Anderson’s Pharmacy in Portadown, Northern Ireland, has been practising for 36 years, during which he has learned the importance of a strong relationship with GPs.
His pharmacy, along with the local GP surgery, won a C+D Award last year for setting up Saturday clinics to look after patients with long-term conditions.
However, after enjoying a close working relationship lasting three decades, the local GP, Dr Colin Matthews, retired – and with him went the mutually beneficial relationship Mr Anderson had enjoyed.
He now believes that communication links with doctors are currently “the worst they have ever been”. When he started practising, he could “lift the phone and speak to the doctor”, but now it is like “Chinese whispers”, he explains.
“There is no information and no communication,” Mr Anderson says. “When I was running the Saturday clinics I had direct access and could annotate [patient records]. We had proper communication channels.”
And as for now? “We don’t really have a clear model of what we want to be doing. Sometimes there are mixed messages.”
Despite the setbacks, Mr Anderson has experienced, Dr Spencer thinks relationships are slowly progressing. Much of this progress has been triggered by the introduction of technology in primary care, he argues.
“One [step] was the advent of computerised prescription mechanisms, and the ordering of repeat medication,” he explains. “The second was the increased complexity of patients and [their] significant polypharmacy [needs]. That started moving pharmacists from the high street to work in clinical teams.”
David Branford, hospital pharmacist and an RPS English pharmacy board member, remembers how the introduction of ward-based clinical pharmacy changed the relationship between hospital pharmacists and doctors. At the start of his career, the kind of work done in community and hospital pharmacy was very similar, as both sectors had very little contact with medical staff.
But hospital pharmacists today attend ward rounds with doctors and are more involved in selecting treatments. While “there have been many initiatives over the past 20 or 30 years” to try and create a similar role change in community pharmacy, “they don’t seem to have succeeded to the same extent”, he says.
Mr Branford also points to the burden of community pharmacists’ dispensing responsibilities as a barrier to forming a closer relationship with GPs. He feels that as the dispensing load continues to rise, “the chances [of this] are less and less”.
A new start?
Mr Branford suggests that the growing interest in working in GP surgeries – as part of NHS England’s and the Scottish government’s practice pharmacist schemes – offers a “new start” for community pharmacists, and a chance to have a more active clinical role.
“The practice-based pharmacist would have a close working relationship with the GPs in the practice and they would also have a close working relationship with community pharmacists,” says Mr Branford, who has been a vocal supporter of the concept.
“This would enable more collaborative working than what we’re seeing at the moment – particularly where the only relationship with the GP is telephone
messages saying there is a problem with the prescription,” he adds. “I see this as a game-changer.”
While Dr Spencer is also clear about the advantages that practice pharmacists can bring to GP practices, he warns against “putting all our eggs in one basket”.
“The high street pharmacies are the real linchpin of the community,” Dr Spencer says. “There is a danger we will lose that by bringing everyone into primary care teams. The high street pharmacy [should] remain there but should be integrated within primary care.”
This integration would require appropriate indemnity cover, and more education and training for community pharmacists, he says. “The professional respect around medicines has always been there,” he stresses. “But GPs have to get our clinical pathways to include community pharmacy.”
GP Keith Hopcroft suggests that politicians are starting to realise pharmacists are over-qualified, and so have decided they could be better deployed elsewhere in primary care. He refers to the practice pharmacist schemes as a means to “plug the massive workforce issues in GP land” rather than a representation of “any real government planning”. “They may have ended up in the right place for the wrong reason,” he suggests.
Despite the cynicism, the promotion of practice pharmacists is an important turning point in the history of the GP and pharmacist. But as emphasised by Dr Spencer, it seems
risky to invest everything in these initiatives if it ends up being to the detriment of community pharmacy.
One thing everyone agrees on is that a stronger relationship between community pharmacists and GPs will enable professional development for pharmacists, reduce pressure on over-burdened doctors, and benefit patients.
Historian Dr Anderson suggests that in one sense, not much has changed in 100 years, as: “You still get an attitude from GPs that pharmacists are muscling in.” But he points out that “the issue of professional boundaries has been around a long time”.
Over the past century, the two health professions have witnessed the creation of the NHS, the arrival of more innovative medicines, and a fundamental shift in how the public views them and their own health.
Looking to the future, Dr Anderson urges community pharmacists and GPs to try and nourish the better working relationships primary care will need. “There has been a development where pharmacists are [GPs’] partners and their friends, and not just doing their bidding. The reality is GPs have more than enough to do and I think the relationship is on a sound footing.”