*First posted as a guest blog via the excellent @MrDispenser*

I’m taking advantage of being a guest blogger to do something that doesn’t always come naturally, and that’s to admit that I’m wrong. Actually more than that, I’m confessing that I’ve been exactly wrong for more than the last year.

A couple of weeks back I was at an intimate strokey-beard meeting on commissioning with various representatives from the DH, NHS Commissioning Board and such, and it was there I realised just how wrong I’ve been.  The meeting was tabled as a discussion on the place in the new NHS of Local Professional Networks – designed in principle to be pools of subject experts that could be pulled upon by the NHS CB for input into the commissioning process – but it transpired that for various reasons they no longer exist in the new NHS framework:  a three-in-the-morning decision if ever there was one.  This, and the recent news that pharmacy commissioning representation in the Local Area Teams of the same Board is absent, made me realise my folly.

Because right now, who will commissioners go to for pharmaceutical advice?  More importantly, who will champion the role of pharmacists so that commissioners even know that they are a viable option?  Some may seek support from their emerging CSU, others will house some expertise in their CCG. But how many of them fully understand the breadth of pharmacist’s potential and the services that can be offered by pharmacists, and more so in the easily accessible sites that are retail pharmacies? 

Perhaps some of you will suggest our governing body the GPhC. Well personally I’m not so sure, after they responded to my P-medicine self-selection query.  So what about Pharmacy Voice? The PSNC perhaps? The AIMp? The legendary Chemist and Druggist Senate? The NPA then? The CCA? The PDA? The UKPCA? No? OK, surely the PCPA? The GHP?  The PPRT?

And herein lays my concern: there are too many organisations that ‘represent’ parts of pharmacy, and too few that represent ‘pharmacists’.

In 2010 I decided that the Royal Pharmaceutical Society wasn’t worth my money, mainly after hearing a local (then) RPSGB branch member say that the cleaving of professional and regulatory functions wouldn’t actually change anything other than their logo.  But now in late 2012 I know that was the wrong decision based on someone else’s flawed attitude.

From my experience so far the RPS has changed. It is not always the speediest or responsive of organisations (their statement on 3-for-2 offers was praise-worthy, but I think we’re still waiting to hear their position on salbutamol by PGD?) and their coverage doesn’t extend fully to all sectors including my own speciality in community services, but that’s down to individual members, and the pharmacy ‘representatives’ above, to influence.  But what they do deliver on is media engagement, and this is important for three reasons.

I thought that my first blog-proper would be a pending guest post for the excellent Mr Dispenser, but an e-mail today from the General Pharmaceutical committee (GPhC) has forced my hand.

Some of you may have seen my Twitter rant when I first heard that self-selection of Pharmacy-only medicines was to be allowed as part of the GPhC’s overhaul of the standards for registered pharmacies.  After reading the detail of their consultation response report, I couldn’t understand why the decision was made, so I asked them for clarification via an e-mail.

Today’s response e-mail from them contained a word document embedded with seventeen PDFs most of which I’ve uploaded for your reading pleasure (all well worth a read: there are some gems in there).

Firstly, a sincere doff of the hat to the GPhC for responding swiftly and in full: this level of transparency is both welcome and refreshing following RPSGB days. 

However, I’m still left unconvinced by the decision on self-selection and fail to see what the benefits to patients will be, and what the evidence or risk/benefit balance is to support the move.

The bottom-line is that the GPhC wants to be a light touch regulator, allowing pharmacies to manage themselves within a framework of professional standards that focuses on patient safety and outcomes, so they can focus their regulatory efforts on risky practices or services.  So, given there isn’t a law actually prohibiting self-selection of P-medicines, the view is that maintaining the existing RPSGB prohibition would be an inconsistent hands-on regulatory approach.  With my community services hat on I can see this is exceptionally CQC-esq: I can only hope they’ve learnt lessons from such existing regulators especially as they recognise this approach runs the risk of losing confidence (ref 650), a theme that has already been raised on this particular issue.

So can I see it from their perspective? Well, yes I can: they want to be hands-off, the law doesn’t prohibit self-selection, so they won’t get involved in restricting it.  It also appears some justification is to match internet pharmacies, where the argument is that consumers are free to browse P-medicines online so why not in store? To me this is a fragile comparison, and given previous problems exposed with this sector I don’t think it’s the best benchmark, and against the context of their approach and the detail of the standards, I don’t think it quite fits and may cause unintended conflict.

The GPhC go on to make continued references to their move away from a prescriptive rules based approach, to an outcome-focused set of standards which sit under four principles and include examples of how pharmacies can evidence compliance.  These standards are mandatory, and the pharmacy owner or superintendent “must satisfy inspectors how they have met the outcomes.”

Self-selection sits predominantly under Principle 4, Standard 4.4 which can be paraphrased as ‘the health, safety and wellbeing of patients and the public are safeguarded as medicines are stored securely and are safeguarded from unauthorised access’ .  The GPhC suggest that owners and superintendents can evidence this by “[considering] where medicines are displayed, including whether medicines should be available for self selection or not”.

At this point I have two worries. Firstly, copying CQC methodology, ‘considering’ self-selection is not a patient-safety focussed outcome, it’s a ticked-box action, and if it’s the standard that is meant to also be an outcome, then this will be hard to demonstrate. Secondly, superintendent implementation of self-selection may not be compatible with one of the GPhC’s other aims of encouraging “pharmacists to use their professional judgement” let alone principle two of the GPhC’s standards of conduct, ethics and performance.  Professionally I feel it is inappropriate to allow self-selection of codeine based products, but if my superintendent has implemented self-selection what are my options as responsible pharmacist?  Throw in 3-for-2 promotions and the GPhC’s assertion that medicines are ‘not normal items of commerce’ doesn’t stand up to scrutiny.

The GPhC then go on to list the five ‘for’ arguments, again which seem fragile:

1. “Should be safe to rely on the professional judgement of pharmacists who decide what medicines should be on display”.
   We know this decision can only be made by owners or superintendents so that a tiny proportion of registered pharmacists will be dictating how otehr retail pharmacists will practice.
2. “Cost and time benefit”
   To whom? What is the benefit? What evidence is there to support this?
3. “Reflects that one size doesn’t fit all”
   Huh?!
4. “Supports informed decision making”
   Picking something up off a shelf and having someone run through WHAMM questions is not ‘informed decision making’: talking to someone about options based on the symptoms you present is. 
5. “Encourages collaboration and dialogue”
   Well doesn’t all of pharmacy, including the current arrangements prohibiting self-selection? If not, we’re probably already screwed as a profession. 

But in the end does it matter? I dare say probably not.

The position of the GPhC will not change and given that only 298 pharmacists responded to this consultation apathy to change remains abound in the majority of the profession.

I still believe this move is not in the best interests of patients or the professionals working in retail pharmacy, and safeguards should be introduced to allow the responsible pharmacist to remove self-selection items if they think it is professionally right to do so.  I’m sure we can all envisage how wrong this could go, so if given the opportunity I will be responding to any future consultation on the necessary GPhC draft compliance guidance: I hope other pharmacists will consider the options and comment below – and then go on to respond to any consultation.