It is difficult to overstate both the scale of changes and the rate of transformation of pharmacy since the start of the 21st century. Driven by government policy, professional ambition and public expectations, they have been truly astonishing. The government’s new 15-year plan for the NHS workforce is extremely ambitious and, combined with the Royal Pharmaceutical Society’s (RPS’s) call for all pharmacists to be prescribers, represents a paradigm shift for pharmacy in Britain. Along with the boost in training places for pharmacists, the government’s targets for 2031 include a doubling of medical school places to 15,000 places per year and a 50% increase in GP trainee places, as well as an increase in the number of training places for physician associates to 10,000 places by 2036.
Pharmacy’s direction of travel is confirmed with the commitment to make all new entrants independent prescribers from 2026. The journey now underway seems to have an inevitable outcome — the return of pharmacy to the medical fold. The need to double the number of medical school places, and the likelihood of reducing medical training to four years, demands a massive increase in medical training facilities. An obvious solution is to combine medical and pharmacy training in the first four years, and to re-designate schools of pharmacy as medical schools.
Yet such an eventuality has long been on the cards. It dates at least from the 1960s, with the profession becoming more patient- and less product-focused. By the 1980s, clinical pharmacists were operating in most hospitals and, by 2000, all hospital pharmacists were expected to be clinical practitioners. By 2010, most community pharmacists were engaged in clinical activities of some sort and, by 2020, substantial numbers of pharmacists were working alongside GPs in GP surgeries.
These developments occurred within an explicit policy framework and were greatly facilitated by technological developments, especially the wide range of digital tools now available. They have enormous implications both for pharmacy education and technician training. Indeed, the expansion of education and training for medical students, physician associates — as well as pharmacists — will require a level of collaboration between existing institutions, such that schools of pharmacy will need to participate fully in the training of all health professionals.
Universal prescribing roles for pharmacists, combined with expanded roles in the diagnosis of a wide range of both acute and chronic conditions, brings their role much closer to that of GPs, and demands an education differing only in emphasis at the later stages. The inevitable outcome of this process is the inclusion of pharmacists on the medical register. Yet the fact that they are not already is largely a consequence of the RPS’s history. When Jacob Bell founded the Society in 1841, he was in no doubt about his aim; it was to establish chemists and druggists as a fourth branch of medicine, alongside physicians, surgeons and general medical practitioners (formerly apothecaries).
The relationship between pharmacy and medicine was a key theme in the medical reforms of the 19th century. The issue was clarified in the courts in 1828, when Mr Justice Park ruled that there were “four degrees in the medical profession — physicians, surgeons, apothecaries, and chemists and druggists”. In 1842, Bell noted “the position which pharmacy occupies, or ought to occupy, as a branch of the medical profession”. He repeatedly returned to this theme, stating that “we have always maintained that our body is and must be considered a branch of the medical profession, and that whatever regulations — respecting education, registration or protection — may be considered necessary for medical practitioners, the same or similar enactments are no less requisite in our department”.
But medical reform progressed slowly, and Bell was anxious to secure legislation to protect pharmacy; it was the 1852 Pharmacy Act that established a register of pharmaceutical chemists. Medical registration only occurred six years later, following passage of the 1858 Medical Act. Since pharmacists were already listed in a statutory register, they could not be included in the medical register. If the register for pharmaceutical chemists had not already existed, it is entirely possible that pharmacists would have been included as a fourth register under the Medical Act.
The future of today’s pharmacists is already clearly mapped out. Recent developments in pharmacy all point in the same direction; to the ultimate inclusion of pharmacists as “pharmaceutical physicians” on the medical register. They are already committed to a totally patient-focused role, dealing with the wide range of services and activities embodied in such initiatives as ‘Pharmacy First’ and ‘Pharmacy First Plus’. The implications are clear. “Pharmaceutical physicians” require the same basic medical education as physicians, surgeons and GPs, with each specialising after the fourth year. While GPs remain the key contact for new symptoms and acute disease, pharmaceutical physicians are increasingly the key contact for the management of chronic illness.
But if a central role of pharmaceutical physicians is prescribing, can they still retain a role in dispensing? History says that they cannot. In the negotiations for the 1911 National Health Insurance Act, Lloyd George found it necessary to “separate the drugs from the doctors”. The separation of prescribing from dispensing roles remained an issue for many countries throughout the 20th century. Any remaining elements of dispensing practice by pharmaceutical physicians will inevitably have to be discarded.
That role will need to be taken on exclusively by highly trained pharmacy technicians, who have been a registered profession in their own right for some years. Many already have substantial supervisory and checking roles and take the lead in pharmacy supply functions. Their roles continue to develop, and they have already taken over many of the traditional roles of the pharmacist. Further development of their education may be necessary to embrace all aspects of the supply function, perhaps to first degree level. In many ways, pharmacy technicians are already the ‘new pharmacists’.
Arguments on both sides of this debate have of course been ongoing for some time. Yet those who aspire to be pharmaceutical physicians need to cast off the shackles of supply once and for all. People will continue to obtain their prescribed medicines through community pharmacies, but the dispensing role will need to be separate and distinct — both contractually and in the personnel involved — from the prescribing role undertaken by pharmaceutical physicians, who may operate from the same premises. It seems a distinct possibility therefore that, within 200 years of the founding of the Pharmaceutical Society of Great Britain, the register of pharmacists maintained by the General Pharmaceutical Council will have transferred to the medical register held by the General Medical Council. Pharmaceutical physicians will have been joined by the 1,500 current members of the Faculty of Pharmaceutical Medicine of the Royal College of Physicians in a new Royal College of Pharmaceutical Physicians. The journey has been underway for some time, and the destination seems inevitable. Jacob Bell would be pleased.
Stuart Anderson, emeritus professor in the history of pharmacy at the London School of Hygiene & Tropical Medicine and Fellow of both the Royal Pharmaceutical Society and the Royal Historical Society