As a GP with 25 years’ experience, a strong interest in medical education, and married to a community pharmacist, I am constantly amazed by how pharmacy has allowed itself to be sidelined and passed over by other medical-related professions. Salaries have not kept pace with similar groups, and there has been little in the way of role development and extension of skills. What few initiatives there are, such as minor ailment schemes, have been piecemeal and under-resourced.
The nursing profession, by contrast, has seized its opportunities and gradually evolved, gaining hugely in role, respect, and thus remuneration. When I first started to work in general practice the then few practice nurses were employed mainly to change dressings, conduct phlebotomy, give vaccinations and other somewhat menial clinical tasks. By undertaking courses supported and approved by the Royal College of Nursing, this extended into chronic disease management of conditions such as asthma and diabetes, and then, increasingly, into their own clinics undertaking triage and minor ailments.
Nurses were fast adopters of prescribing and were granted these rights in 1992 (pharmacists did not gain this until 2003), initially as supplementary and, later, as independent prescribers. Nurses then went on to develop the nurse practitioner role, functioning relatively independently within surgeries, seeing a wide variety of patients limited only by their own experience and confidence. Skill mix changes then saw practices training up administrative and reception staff or recruiting school leavers to become healthcare assistants, who now undertake the tasks such as dressings, phlebotomy, electrocardiograms, spirometry, etc, that nurses have now outgrown.
There is a huge shortage of GPs nationwide, with up to 30% of practices currently reporting unfilled positions, and a number of practices closing down or being taken over when shortages prevent them from providing a service. Nurses have moved to fill this opening with further development into advanced clinical practitioners (ACPs), often providing much the same service as the GPs, including twice daily surgeries, home visits and a share of the on-call rota. Salaries above £50,000 are now commonplace for advanced nurse practitioners (ANPs), and they are treated by patients and colleagues alike as members of the doctor team. This has been made possible by the formation of ANP and ACP training courses, with modules such as prescribing, diagnostic skills, acute disease management, encouraged and supported by the Royal College of Nursing.
The Royal Pharmaceutical Society (RPS) seems to have seen the light, and I was extremely excited to have been awarded with a contract to host one of the ‘clinical pharmacist in general practice pilot’ pharmacists in my group of practices. This scheme aims to encourage the placement of experienced pharmacists into general practice and use their prescribing, consulting and management skills within surgeries.
However, having now seen the limited information available, it seems the aim after three years of in-practice training is for these pharmacists to undertake medication reviews and chronic disease management clinics, something our junior nurses already perform for a fraction of the salary. This scheme is undervaluing the skills pharmacists have to offer in general practice. It should have an aim of creating pharmacist advanced clinical practitioners operating independently to diagnose, investigate, treat and refer patients as appropriate.
The pilot appears to have some major flaws. There is, as yet, no curriculum, no set of standards, and no assessment mechanism. This is easily achievable by using the best practice examples of the ACP training schemes, or the Royal College of General Practitioners’ registrar’s curriculum and e-portfolio system of regular assessed consultations, case-based discussions, reflective learning, etc. More importantly, with pharmacists already appointed to some pilots, no one seems to have even considered the provision of medico-legal legal indemnity for this role. The Medical Defence bodies, which allow nurses and ACPs to be covered under GP practice schemes, have no provision for the participants on this scheme.
Community pharmacy needs to act quickly to halt its decline and regain its respect or it will continue to deteriorate into the role of glorified shopkeepers. Political leadership needs to talk to those of us outside the profession who want to help, and can offer practical advice before it is too late. Defending what pharmacy historically was, and to some extent still is, is not good enough – the future requires open mindedness and the ability to change and develop.
Limes Medical Centre