As pharmacy moves towards 2020, will it remain a profession of equals?
In this ninth and final article leading up to a consultation about the Royal Pharmaceutical Society's Pharmacy 2020 project, Clive
Jackson, chief executive at the National Prescribing Centre, lists the questions to be considered in developing a cohesive, effective strategy for the profession
Pharmacy has been evolving slowly, for more than a century, into the
profession we know today. In that time, there has been a range of major
professional challenges that pharmacy as a whole, and each pharmacist
as an individual, has had to adapt to.
For example, since the NHS was born, we have seen:
• Professional practice moving from predominantly in-house compounding
of medicaments, towards the dispensing of bulk manufactured and prepackaged
products
• Professional freedom being impacted upon by implementation of the Medicines
Act regulations, from 1968 onwards
• Greater clinically oriented pharmacist input into the monitoring and
optimisation of patients’ medicines, after prescribing by doctors
• Increased variety and potency of medicines being made available for
sale over the counter
• More systematic use of pharmaceutical skills to improve the strategic
management and use of medicines across the NHS — the pharmaceutical
adviser role
The product-focused pharmacist
The response to all but the last of these challenges has largely involved
the profession refining or expanding its primary and historical professional
role, namely, ensuring the safe and efficient supply of medicines and
advice to patients. It is true that there has always been diversity
in service development and delivery between pharmacists practising
in the community and those working in hospitals — our main historical
intraprofessional division.
However, the common professional bond remains
the fundamental requirement to supply the right medicines to individual
patients at the right time.
On the other hand, the challenge posed by the emergence of the pharmaceutical
adviser role involved pharmacists moving off their home ground and
into the less ordered world of health care management. This environment
creates
new challenges around doctor/pharmacist and pharmacist/pharmacist relationships,
plus the discomfort of the pharmacist/ cost-containment dynamic. The population-focused pharmacist
This latter challenge has also seen pharmacists moving away from the
usual, one-on-one patient/professional relationship towards the requirement
to consider optimum use of medicines and medicines funding on a population
basis. In a small number of cases, taking this perspective when decision-making
can mean that some individual patients (however few) might perceive
themselves as disadvantaged.
Being a pharmacist employed to provide professional and management
advice to health care organisations and other professionals has, on
occasions
therefore, put such individuals into potential conflict, where they have
to balance their historical professional instincts towards individual
patients (and the profession), with the strategic need to consider what
is best for the population served as a whole.
The development of this advisory role also led such pharmacists into
the area of local planning, development and management of the “contract” that
pays community pharmacists. This has given rise to sometimes heated internal
professional debates about capability for such a task and their broader
loyalty to pharmacy.
The development and expansion of pharmaceutical advice in primary care
over the past 15 years has, therefore, to some extent, inevitably divided
the profession in a different way than previously seen.
Nevertheless, pharmacy overall has now embraced pharmaceutical advice
as a new and strategically important development for the profession,
which allows pharmacists to influence health care policy and planning
at local (and often national) level to a much greater extent than previously
possible.
The fact that there have recently been up to 2,000 pharmacists
providing pharmaceutical advice shows the perceived value of this role
outside the profession and also the willingness of significant numbers
of pharmacists to embrace the challenge on offer.
What is clear, across all the examples of challenges cited, is that
pharmacy has ultimately achieved (albeit often slowly) the necessary
internal
change to accommodate them, usually by employing an evolutionary, rather
than a planned, process. Fortunately, pharmacy has, by and large, remained
united and tolerant of a range of professional divergence.
However,
adaptation techniques that have worked moderately well for the profession
in the
past, may no longer be adequate for meeting the challenges of the
early decades of the 21st century, some of which are already visible
on the
horizon. The patient-care focused pharmacist
A number of forthcoming challenges are already starting, or have the
potential, to
change fundamentally the equanimity and delicate harmony within pharmacy
in a way not seen before. Flux on such a scale could create the conditions
where permanent fissures (as opposed to divergence) in the profession
might occur, and this may ultimately lead to the demise of pharmacy
as we know it.
So what are these forthcoming challenges?
• Development of new services and independent clinical roles
• Development of new diagnostic and examination (medical) skills
• Requirement for formal registration of new specialist competencies
• Development of a new regulatory framework and registering body
• Development of new professional leadership and development organisation(s)
and support
• Emergence of active competition between clinical professionals, when
developing and delivering patient care
The relative risk of any fundamental split in the profession (and therefore
any damage or benefit), will ultimately boil down to the number of pharmacists
who become clinical modernists compared with those who remain dispensing
traditionalists. It will also depend on the vision, strength and timeliness
of strategic leadership within pharmacy over the next five to 10 years.
We should remember that, in part, both medicine and pharmacy emerged,
as separate professions, out of the original combined role of the apothecary — could
we be approaching a new, equally seismic (and not dissimilar) fracturing
of the pharmacist’s role?
To help answer this question, we need to consider the impetus and imperative
for change, especially that emerging from the enactment of new regulations
enabling pharmacists to prescribe almost any recognised medicine independently
of another profession’s input.
What is the issue? Well, in the short term, most pharmacists probably
think that the emergence of independent prescribing responsibilities
is broadly a good thing, and long overdue recognition of the detailed
pharmaceutical knowledge and skills inherent within the profession.
It
is seen as something only a small minority of pharmacists are likely
to be undertaking, in the short to medium term, and, as such, not of
primary relevance to the mainstream of the profession.
Dismissing this major new opportunity as little more than a fringe
activity for
pharmacy could be a major strategic miscalculation. Why? Because health
care provision in the UK is undergoing extensive reform and pharmacy
will have to respond in a planned and proactive way to survive and
prosper.
The relevant key driving principles of the reforms include: • Regulating professionals in a more uniform and transparent way, which
makes the patient and public interest paramount
• Removing unnecessary historical demarcations between the professions
and their practices
• Changing payment for service delivery to a system based predominantly
on quality and patient outcomes, rather than on volume and throughput
• Increasing the range of service providers and engendering competition
between them (the “generic professional battleground”)
• Providing patients with much wider choice of high-quality service provision
and, therefore, improving convenience
As a result of these reforms which are already partly in place (eg,
the latest community pharmacy contractual framework), pharmacists’ are
having to extend their historical dispensing, supply and advisory roles.
However, attention now also needs to be given to the likely (and necessary)
emergence of a new style of clinical expertise and an alternative professional
ethos in pharmacy.
To deliver pharmacy’s true potential over the next 50 years, and
build on the excellent work we have done in the previous 50, the profession
needs to move its centre of gravity significantly towards delivery of “treatment-initiating,
patient care-managing” clinical practice and rely much less on
the “product- and volume-focused, patient supply and advisory” functions
that dominate pharmacists’ activities today.
This change would require broad acceptance and agreement among a substantial
proportion of practising pharmacists, that the profession should become
much more hands-on with patients and the public. Thus, there would be
a requirement to develop and refine broad diagnostic and consultation
skills, plus medical examination techniques, while linking them to new
prescribing responsibilities and some of the more traditional pharmaceutical
skills.
All pharmacists are equal …
 All
pharmacists are equal now, but some will become more equal than others.
Many pharmacists (especially those who have been qualified the
longest
and, therefore, who are most likely to have influence over change in
the profession) will feel, at best, uncomfortable by such a shift — patients
are often seen as people best interacted with at arm’s length,
across the counter.
Others will wish to see rapid
and widespread movement in the hands-on direction.
If this shift does not happen, the current pharmacist’s role could
arguably become slowly redundant as it is (rightly?) squeezed between “up-skilled” and
less costly technicians taking on responsibility and accountability for
technical and professional dispensing tasks, and the clinical aspirations
of other, potentially more outwardly ambitious and vigorously led professionals,
such as nurses.
If accepted, the change would, however, require a fundamental revamp
of the undergraduate curriculum, preregistration training programme and
postgraduate development framework — in short, radical modernisation
of part of the foundations of today’s profession.
Such modernisation
would take time in the most motivated and focused of professions but,
historically, even limited educational change has often taken far too
long within pharmacy. The fact that our professional body is currently
being forced to put much of its efforts and resources into reconfiguration
could make educational change even harder to achieve.
The alternative to this radical change would be to split the undergraduate
curriculum and preregistration training programmes into two distinct
levels — although this might be seen as a slippery slope to the
profession fracturing permanently.
Probably of equal importance is our need to consider the impact of independent
prescribing, together with the ad hoc, out-sourced development of new
diagnostic and examination skills, on the dynamics within the profession
and the potential for creation of an expanding elite in pharmacy.
The
flip side to this is the emergence of an underclass of pharmacists
who work to a different level of competencies, and who increasingly become
indistinguishable in practice from leading-edge (registered) pharmacy
technicians, other than by salary.
How will these two elements of the profession decide to interact with
each other? Will pharmacy find a way to maintain them under one professional
umbrella in the longer term? Will the emergence of a new style of pharmacist
be good for the profession as we know it, or will it lead to argument,
mistrust and ultimate fracture? A 20:20 vision for pharmacy
These are some of the questions we now have to consider in looking
to develop a cohesive and effective strategy for the profession leading
up to 2020.
Some decisions will not be comfortable and some will have detrimental
effects on existing pharmacists and their current practice — that
is the nature of the rapidly changing environment that we work in today.
On the other hand, if we get the direction of travel right, identify
the major hazards in advance and plan to minimise them, the profession
could emerge as a major player in health care delivery throughout the
whole of the first half of the 21st century. |
The
Pharmaceutical Journal