A tweet earlier today got my blog reflex twitching over retail pharmacy, and the difficult balance it has providing quality patient care against  generating sufficient profit (or breaking even) in a pressured economy.  Added to this was the recent PJ article on the new RPS multi-compartment compliance aid guidance which in the opening column mentioned the business pressure that’s led to an increase in their use.

I’ve blogged before about such devices (and delusionally imagine the RPS read it before writing their guidance) and I’ve obviously no problems with business turning a profit, but I remain worried that the professionals working in this sector may be forced to lose its way over time; the PDA are usually ludicrously over-dramatic in their reporting, but the ‘perfect storm’ scenario isn’t an unreasonable extrapolation.

But as I went to blog proper about this I was reminded of something I wrote three years ago that was published in the PJ, and thought that I would instead post that.

I know it won’t be to everyone’s tastes, and I know a whole bunch of decent pharmacists on Twitter that this definitely does not apply to, but still felt it was worth being dusted off: we’ve moved on from some points, but some of it still chimes relevance with the current situation.

Who knows – maybe in another three years I’ll post it once again so we can see how much further we’ve all come. See you in 2016?

Perhaps “retail pharmacy” is a better descriptor than community pharmacy.  By James Andrews

Fri, 18/06/2010.  The Pharmaceutical Journal2010;284:604

I agree with the points of the Broad spectrum by Blenkinsopp and Bond entitled “Another reason for telling colleagues about pharmacy services that work” (PJ, 22 May 2010, p500), but there is one aspect of the BMJ article they refer to that remains unaddressed.

Richardson and Pollock concluded that recent change has “allowed the dominance of large corporate providers, which has implications for service provision that are not well understood in the UK, and which could undermine attempts at expanding pharmacists’ professional role”. I believe this is a key aspect of practice that deserves examination.

Perhaps community pharmacy may no longer be seen by others as a profession, and that the term itself may be misleading. What is not questioned though is the professionalism of the individuals working in this sector, of which I am one.

I see constant examples of pharmacists providing quality patient care in demanding and stressful working conditions, and the non-pharmacists I work with in primary care regard them as hard-working experts in their field. However, there remains the intimation that changes to practice are doing our professional image no good.

The many definitions of  “profession” tend to describe a group of qualified autonomous individuals, trusted to apply their responsibility and expertise to the benefit of others. However, in a dispensary operating for a large multiple, today’s focus appears to be on corporate financial benefit rather than the benefit of others.

Previously, I have described the pressure I was subjected to by an area manager into performing medicines use reviews outside corporate procedure and legislation (PJ, 27 March 2010, p315). This was a partial description written in conjunction with a grievance case I raised. In reality, the conversation was wider ranging and more personally focused than I reported.

Continuing PJ correspondence suggests this is not an exceptional circumstance, with the Pharmacists’ Defence Association reporting that pharmacists are under such pressure to deliver results they resort to fraudulent behaviour.

A brief review of my employer’s online pharmacist forum reveals descriptions of “bumping up” figures by claiming MUR intervention payments for confirming a patient’s international normalised ratio level before dispensing warfarin even when no intervention follows.

Other pharmacists on the forum describe having to allow disturbances while conducting MURs so they can check prescriptions or answer queries without fear of under-achieving company-dictated customer satisfaction and waiting time targets.

It is right to aspire to give patients a quality service and I have no discomfort with profitability within healthcare services, but there is only so far a professional should take this. None of these scenarios describes a profession and, when pharmacists feel they have no option but to forgo their autonomy and professionalism to chase targets contrary to their code of ethics, we must all ask why this is the case.

The responsible pharmacist legislation should empower us all to do something about the demise of our autonomy but, in practice, this does not appear to be happening.

We have taken on responsibility previously held only by well remunerated superintendent pharmacists, but have received no recognition of this from our employers, apart from the expectation we use the two-hour allowable absence for rest breaks, during which we must remain contactable to allow continued trading in defiance of safe practice and European legislation.

Challenges to this disregard are heavily resisted by employers so we are left in a position of ultimate responsibility with no employer acknowledgement within our terms and conditions.

The case of Elizabeth Lee (PJ, 11 April 2009, p401) highlights how corporate employers might use the responsible pharmacist Regulations to avoid culpability for an error regardless of the underlying situation of staffing level, pressure to achieve targets and rest breaks, over which the individual pharmacist involved has little or no control.

In practice, it now seems difficult for a community pharmacist working for a large multiple to practise in a way that allows the autonomy expected within a profession, and this situation is likely to become more difficult in companies that delegate accountability for pharmacy clinical governance to non-pharmacist managers as a result of restructure.

Based on the Royal Pharmaceutical Society description, this means that, for me, the safe and clinically effective running of the pharmacy will rest with a non-pharmacist store manager and non-pharmacist area manager, either of whom, as a non-pharmacist, may put targets and profit before safe practice.

It is difficult to reconcile this move with the ethos of the responsible pharmacist legislation, adding justification to the European Court of Justice warning that “operation of a pharmacy by a non-pharmacist may represent a risk to public health” (PJ, 23 May 2009, p604).

The job of supporting pharmacists with professional issues now falls to the new professional body. For a body committed to responding actively to our needs, its silence on the pages of the PJ regarding pressures and stress over MUR targets is disappointing but not surprising given that it is likely to have a sizeable proportion of its future funding from joining fees paid by large multiples.

The suggestion of Richardson and Pollock that commercial interests may undermine the professional role of pharmacists seems timely, and the historical lack of drive to gather and publicise evidence to the contrary highlighted by Blenkinsopp and Bond has left community pharmacy in a difficult and indefensible position.

At this fresh time in the political world, a strong pharmacy voice could make a massive difference to the professional standing of all pharmacy sectors by highlighting their ability to deliver quality patient care individually and as an integrated whole, but current isolation and a lack of cohesion will remain if the needs of patients and pharmacists are overlooked by our leaders for corporate benefit.

The new health secretary’s announcement that changes to the NHS must be evidence based and supported by GP commissioners may make integration of community pharmacy services into real patient care pathways more difficult, with a danger that our only function becomes medicines supply.

The description of the prescription factories of the high street and large out-of-town pharmacies miles from the nearest house as “community” pharmacies appears a misnomer at a time when the NHS is rightly moving more services closer to patients. In practice, “community” services are delivered by multidisciplinary teams providing care directly to patients within an integrated care pathway.

These pathways should formally include community pharmacy, but do not. Next time you are at work, consult your manager or corporate documentation to see who they think benefits from your application of expertise. If the answer is customers rather than patients, then perhaps “retail pharmacy” is the better descriptor.