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Insider's view: Pharmacy supervision proposals 'don't exist'

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Rob Darracott: There are hundreds of people worried about a proposal that I don't recognise
Rob Darracott: There are hundreds of people worried about a proposal that I don't recognise

Proposals to allow pharmacy technicians to supervise medicines supply "don't exist", Rob Darracott – former member of the board responsible for "rebalancing" pharmacy legislation – has said.

Contractors warned Royal Pharmaceutical Society assembly candidates last month that “many community pharmacists are extremely concerned” that the Department of Health programme board plans to “empower pharmacy technicians to supervise pharmacies” as part of its strategy to “rebalance” pharmacy legislation.

But Mr Darracott told C+D this morning (August 25) that "as far as I am concerned, no member of the board has even suggested it".

"The statement just doesn't exist," said Mr Darracott, former chief executive of Pharmacy Voice, who left the board in April.

"We now have hundreds of people concerned about a proposal that is not a proposal that I recognise at all," he added.

In a letter sent to Labour MP Hilary Benn earlier this month, health secretary Jeremy Hunt said “the government has not brought forward any proposals to allow pharmacy technicians to supervise pharmacies”.

Mr Darracott suggested this would have done little to console concerned pharmacists.

"In one respect, getting [Mr Hunt] to write a letter that says it doesn’t exist [doesn't work], because everybody goes: ‘Well, who trusts the secretary of state?’"

"Extreme scenario"

Mr Darracott served on the board responsible for “rebalancing” pharmacy legislation since its creation in 2013, but left in April when Pharmacy Voice closed its doors for good.

Pharmacists are right to be concerned about the "extreme scenario" that has been painted in recent months around pharmacy technicians legally supervising the supply of medicines, he added.

It is important that the sector has a "robust debate" about how pharmacy currently operates, as it has changed "dramatically" since Mr Darracott first qualified, he said.

But these discussions should not be clouded by a non-existent proposal: "It is not on the table and nobody has suggested it."

"I don’t think it is very helpful to get people worried about something that isn’t true," he added.

9 Comments
Question: 
Do you think pharmacy technicians should be allowed to supervise medicines supply?

Graham Phillips, Superintendent Pharmacist

Is the hierarchy losing the plot over supervision and skill mix?

The Pharmaceutical Journal30 MAR 2002By Graham Phillips

 

The combined pressures of the pharmacy manpower crisis, the failed global sum system and our enthusiasm for new roles leaves the community branch of the profession at risk of oblivion.

Before I am branded a Luddite, let me make clear that I strongly support the use of dispensing technicians: I have no wish to see pharmacists wasting their time licking, sticking, pouring and counting. My own company policy is to employ technicians wherever possible to carry out the mechanical aspects of dispensing, thereby freeing the pharmacist to spend as much time as possible at the medicines counter. I do, however, insist on a pharmaceutical assessment of every prescription.

I am actively involved in medicines management, having spent the past three years as a primary care group/trust prescribing lead, and I currently sit on the local PCT executive committee and board. I would submit, therefore, that I am as committed to “Pharmacy in the future” as anyone in this profession. Nevertheless I believe passionately that a community pharmacist’s fundamental place is in the pharmacy and that our prime function is to add value to medicines — all medicines — whether sold or dispensed.

Consider the following two scenarios:

(1)?The husband of one of our regular patients requested symptomatic relief on behalf of his wife. My qualified medicines counter assistant determined that a pharmacist’s intervention was required. A brief oral history revealed that the patient had upper gastrointestinal symptoms, felt bloated and was unable to eat. Inspection of her patient medication record revealed poly-pharmacy for rheumatoid arthritis (fenoprofen plus methotrexate with only ranitidine 150mg bd as a mucosal protectant). Of course the patient’s symptoms could be the symptoms of uncomplicated upper GI dysmotility, but the medication history and inadequate mucosal protection (a proton pump inhibitor was indicated) meant that the patient was at risk of gastric erosion, duodenal ulcer or worse. I opted to recommend a pro-kinetic agent (domperidone) plus a liquid food supplement (Build Up) with advice to see the GP within 48 hours if symptoms persisted or worsened.

(2) We received an apparently straightforward request for a product advertised on television. The parents described a pyrexic six-year-old with a history of asthma and febrile convulsion. Paracetamol was not adequately controlling the temperature. The advertised product is a pad which adheres to the forehead, releasing a cooling vapour, thereby inducing a cooling effect. Clearly it was important to control the temperature but the obvious option of adding ibuprofen suspension was contra-indicated. I gave appropriate advice regarding optimal dosage and use of paracetamol suspension together with cooling techniques (tepid flannel, increased ventilation) which should control the situation.

Any community pharmacist reading this will find both these scenarios entirely unremarkable. They are typical of the interventions we make (but do not yet record) every day, many times a day. However, I describe them because the truth is that the policy-makers at Lambeth and elsewhere are so far removed from the daily practice of pharmacy — especially community pharmacy — that they need to be reminded what it is like.

We must never forget that it is the wonderful combination of accessibility and availability that makes community pharmacists uniquely valuable, and often the most serious and significant interventions flow from apparently trivial initial enquiries. The work flow in community practice is entirely unpredictable and it is impossible to know in advance which queries will be sufficiently significant as to require a pharmacist’s intervention and which will not.

The use of dispensing technicians undoubtedly frees community pharmacists’ time, but it is generally accepted that only 90 minutes are freed each day, and that the free time is not made available in usable chunks. Certainly there is not enough free time to allow the pharmacist to absent himself from the pharmacy to conduct a clinic at the local GP surgery or to perform a medication review of a patient at home.

The public hugely values the prompt, professional advice that community pharmacists give. To propose that either of the patients in the two scenarios above could reasonably be expected to wait an hour while the pharmacist returned from, say, a prescription review at the surgery is flying in the face of reason — and worst of all it is most certainly not patient focussed.

It is a fact that most care is self care. Pharmacists have unique skills here. For reasons that I fail to understand, supporting self-care seems to have lost its profile and is at risk of being trivialised. This makes no sense because self-care is high up on the Government’s agenda. The Royal Pharmaceutical Society has just published an ambitious set of proposals for “pharmacy only” or “pharmacist prescribed” medicines. Under the heading of minor ailments, the proposals include switching proton pump inhibitors, topical antibiotics and topical metronidazole. Appropriate recommendation for use will inevitably require the input of a pharmacist.

Any suggestion that all of the above could be handled by well-trained dispensing technicians is clinically unsafe. Technicians are excellent dispensers (I am quite certain that the best of them could check one another), but there will always remain the need for a pharmaceutical assessment of each prescription. Even the best technician cannot replace a pharmacist, a health professional present in the pharmacy, with a remit to add value to all the medicines available there.

For some, the answer to the manpower crisis is effectively to abandon supervision. There is a massive political risk in this. If we are prepared to accept that a pharmacy can run perfectly satisfactorily for an hour in the absence of a pharmacist, then why not for a day? If for a day, then why not for a week? In fact, why do we need pharmacists in community pharmacies at all? It then follows perfectly logically that the dispensing fee will be cut because there is no longer the justification to fund a professional salary.

There is, rightly, a huge debate within the profession about the balance of skill mix and supervision. Certainly practice must change, and of course we must embrace the modernisation agenda, but that does not mean that clinical supervision or pharmaceutical assessment can be abandoned. A naive extrapolation of changing practice in the secondary care setting, where there is generally no self-care consideration and patients may wait hours for a prescription, simply does not work in the community.

There are those within the profession, especially within the hierarchy at Lambeth, who have entirely lost the plot. In my view, they have a level of access to Government ministers which is frankly frightening when one realises just how distant they are from daily practice.

Now is the time for those of us in the real world to stand up and tell it like it really is before it is too late. If we do not, we will be courting political suicide and walking into professional oblivion. And who would be the greatest losers? The public.

 

Graham Phillips, Superintendent Pharmacist

This debate (well it's not a proper debate- more an attempt by NHS leadership to impose its view, acting by stealth) has gone on for the best part of 20 years. 

http://www.pharmaceutical-journal.com/opinion/comment/is-the-hierarchy-losing-the-plot-over-supervision-and-skill-mix/20006376.articleI wrote this in the PJ in 2002, and its pretty-much as relevant today as it was then: 

Chemical Mistry, Information Technology

Fake news !!

fatnose pansies, Sales

It's surprising that Mr Darracott would say that no member of the board has even suggested that pharmacy technicians could supervise medicines supply. APTUK, who are members of the board, have been suggesting it since 2011, most recently in July this year. http://www.aptuk.org/about-us/position-statements/

There's also this quote from November 2015: “With the current rebalancing and changes to legislation, the role of the pharmacy technician can become really important, not just in terms of supervision but in what they can deliver to the patient in the absence of a pharmacist”. https://www.pharmacyregulation.org/sites/default/files/lpet_ucl_iet_stds_analysis_pts_final_report_november_15.pdf It was from one of the stakeholders in the list starting at the bottom of page 13, many of which are also represented on the board.

Ben Merriman, Community pharmacist

You're confusing the situation with facts, Peter...

Ben Merriman, Community pharmacist

Very interesting, Mr Darracott.  I presume you've actually been to these meetings, yes?  Supervision of the sale and supply of medicines is repeatedly mentioned in position statements and minutes of these meetings.  But why confiuse the situation with facts...

 

Ben Merriman, Community pharmacist

And for anyone wanting to confuse said situition, here are said facts: https://app.box.com/s/75cii16v58e80r2g1p9k/folder/7782559933

Tony Schofield, Community pharmacist

Technicians have embraced new ways of working and enabled pharmacists to do so also. However, even with the undergraduate diplomas available from Bradford they do not have the knowledge and skills to take sole responsibility for a dispensing operation 

Ilove Pharmacy, Non Pharmacist Branch Manager

Their skill base will be irrelevant when the multiples want to push through their intentions. Money is their sole God. The rest is not really of concern. All they'll do is come up with a suitable new title to confound and confuse the public. For example Superintendent Technician or Medicines Manager. 

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