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Electronicjuice
Vol 269 No 7225 p738
23 November 2002

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News feature

How skill mix affects the new contract

Extended roles for pharmacists and pharmacy support staff could lead to changes in the way community pharmacies are funded. Jonathan Buisson (on the staff of The Journal) gathers opinions and looks at what the discussion paper on skill mix presages


Patients are encouraged to speak to a pharmacist, but will the pharmacist be there?

One principle of the current model of community pharmacy is that all dispensing activities are carried out under the direct supervision of a pharmacist (and that a pharmacist should be present at all times when the pharmacy is open). This underpins remuneration for National Health Service dispensing.

The Department of Health's discussion paper, "Pharmacy workforce in the new NHS: making the best use of staff to deliver the NHS pharmacy programme", (PJ, 5 October, p469) suggests that, with suitably qualified pharmacy technicians operating under defined protocols, it might be possible for medicines to be supplied without supervision. This would empower technicians, the Department says, and leave pharmacists free to "provide patient services beyond the geographical limitations of the pharmacy premises" [Para 49].

Although greater development of the skills and roles of pharmacy support staff has received general support, opinion on whether pharmacists should be free to leave the premises is mixed.

Ask your pharmacist

John D'Arcy, chief executive of the National Pharmaceutical Association, says that the NPA believes a pharmacist should be present in the pharmacy at all times it is open. He defends this on two grounds: "The first is patient safety. Most errors in prescriptions are in the way they are written not in the dispensing. The second is access. One of pharmacy's key strengths is that the public can walk in and talk to a health professional. Both the NPA and NHS Direct are telling people to 'Ask your pharmacist'. It will not be much use if the pharmacist is not there."

Mr D'Arcy believes that the Department's report puts an overemphasis on roles for pharmacists outside the pharmacy. While he notes that some pharmacists are already carrying out these roles for primary care trusts, he adds: "If you look at these roles, such as home visits for medicines management, you have to ask if it is necessary for a pharmacist to do them. You could use a technician to take a medicines history from the patient and bring it back for the pharmacist to sort out."

Pharmacists need to delegate appropriate work to support staff, and not be tied to the dispensary. Pharmacists' key role is at the interface with patients. "Medicines management, smoking cessation, dealing with chronic diseases —?these are pharmacy-based services and the pharmacist should be there," Mr D'Arcy says.

Digby Emson, superintendent pharmacists at Boots The Chemists, also notes the importance of the issue of access to a pharmacist in a pharmacy. "The access implications need to be studied. If there are protocols and standard operating procedures which allow a pharmacist to leave and take on new roles, these will need to be balanced with the need for patients to have access to pharmacists."

He adds that, on the assumption that for public safety reasons pharmacists will still be accountable for all the professional services provided from the pharmacies they are working in, there could well be cost implications that might have to be reflected in a new contract.

Dispensing on the cheap?

One concern that has been raised is that if dispensing NHS prescriptions is seen to be carried out largely by pharmacy technicians, with pharmacists having a more distant professional responsibility, then the Department of Health would wish to lower the professional dispensing fee and find different ways of distributing the global sum to reward other services. For example, it could, say, reduce the dispensing fee by half (to around 50p) and allocate the rest of the money to primary care trusts for local pharmaceutical services schemes.

Sue Sharpe, chief executive of the Pharmaceutical Services Negotiating Committee, says that the PSNC would resist any attempt by the Department to get a dispensing service on the cheap. "It would be a profound waste of what pharmacy could offer to primary care," she says.

"Underpinning our negotiations on the new contract is the belief that supplying medicines is just one element of what pharmacy brings to primary care. There are opportunities for pharmacists to do much more in medicines management and repeat dispensing, for example." The matter has been discussed at PSNC meetings, Mrs Sharpe says. The issue there is not whether roles should be delegated, but how pharmacy services could be reconfigured and what might happen when or if the pharmacist is outside the premises.

Wally Dove, a member of the PSNC and of the Royal Electronicjuice's Council, has concerns about the direction indicated by the Department of Health's paper. "I think that the skill mix paper is leading us in the wrong direction. If pharmacists are not present in the the pharmacy then it is difficult to tell the Government what value pharmacy is adding.

"If we walk away from our pharmacies then we will keep walking. The Department of Health would be pleased to see it because it could then make draconian cost cuts."

Training the technicians

Concern has also been expressed at the costs and time constraints of training pharmacy support staff to the appropriate level (PJ, 9 November, p672) and changing working practices to accommodate, for example, accredited checking technicians.

Mr Dove says: "Using checking technicians needs several staff to work properly. It will not work in a small unit."

He adds that the Department of Health's discussion paper does not put any emphasis on increasing the numbers of staff working in community pharmacies. "Economic conditions have made hiring staff difficult. Employment law makes changing the terms of work for staff difficult. These changes will need to be made over a long period of time.

"We are going at this too fast ? we need to look at the practicalities of how we get to these extended roles."

Mr D'Arcy says that upskilling the entire pharmacy workforce, both support staff and pharmacists, will be a challenge. "The skills escalator that the Department talks of could lead to some people moving through all the National Vocational Qualification levels up to pharmacy degree level."

He points out that most of the drivers for the skill mix discussions are the National Health Service's own priorities — the NHS plan and its accompanying programmes. "The pharmacy plan is all about bringing pharmacy into the body of the NHS. But NHS employees have training budgets — where is ours?"

All of these matters, and more, will form part of the discussions between the PSNC and the Department over the new contract, but easy answers will be hard to come by.

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