Tomorrow’s pharmacists will be clinical, dispensing will be by new “assistant pharmacists” and direct mail, and community pharmacists will receive a salary to deliver NHS “wellness” campaigns. So Dr Philip Brown sees in his crystal ball (PJ, 2 June, p749).
One tactic for predicting those activities of today’s pharmacists that are likely to succeed tomorrow is to compare, for each activity, how much knowledge pharmacists possess. When that knowledge is rare, let alone unique, the public will buy useful activities connected with that knowledge. Those activities will give pharmacists the edge in a competitive market, just as, in evolution, those species most fitted to survive do so. Let us examine pharmacists’ current activities using that perspective, bearing Dr Brown’s prophecies in mind.
Pharmacists are skilled as herbalists, chemists, laboratory diagnostic testers, prescribers, advisers, manufacturers, and dispensers.
Pharmacists-as-herbalists purvey “natural” plant products — a growth market; pharmacists know about pharmacognosy and phytochemistry, which can trace ancestry to the “materia medica” of antiquity. However, botanists, compared with pharmacists, know more about botany and botanists have colonised their ecological niche well. One activity down, six to go.
Pharmacist’s second role, as (pharmaceutical) chemist is also easy to dismiss, despite pharmacists being legally registered as pharmaceutical chemists. Chemists, compared with pharmacists, know more chemistry. There are also more unemployed chemists than pharmacists: witness more chemists than pharmacists applying for positions as lecturers in pharmaceutical chemistry in schools of pharmacy.
Pharmacists’ third role is as biochemical tester, such as of blood for cholesterol levels or urine for pregnancy. Pathological testing is not a “new” but an “old” role for pharmacists. The Pharmaceutical Society awarded the diploma in biochemical analysis (DBA) in pathological laboratory testing, including testing for cholesterol, starting in 1932, in order to give pharmacists including those “keeping shop” a “chance of increasing the professional side of his duties”. However, the DBA was discontinued in 1960.
Today, medical laboratory scientific officers (MLSOs) and biochemists, instead of pharmacists, have largely succeeded in colonising the occupation of pathological medical laboratory testing. Although recent developments in technology may permit pharmacists to challenge again, the present inhabitants know more.
Pharmacists may prescribe. Presently, this is generally across the shop counter, a medicine being sold as a result; pharmacists expect that some prescribing will shortly be “free” to eligible patients as part of the NHS.
However, that prescribing habitat has been colonised, for generations, by established sitting tenants: medical and dental practitioners. They possess academic qualifications that took longer to gain than even next year’s pharmacists armed with master’s degrees. NHS prescribing, in the opinion of some pharmacists, is an important goal. However, recently, the prestige of prescribing has been reduced because nurses now prescribe: that group generally possess lower academic qualifications than pharmacists and cost less. Pharmacist-as-prescriber does not seem a safe bet.
Pharmacists may advise about medicines: a territory where, especially in hospitals, clinical pharmacists have established sufficient roots to start to flower and scatter seed. However, medical and dental practitioners, let alone clinical pharmacologists, know more about therapeutics. Such practitioners may also combine prescribing with diagnosis during the same consultation — but pharmacists cost less. Clinical pharmacists may succeed, but remain in frontier territory. Pharmacists may also advise on general “wellness”; however, others, such as health promotion professionals, know more and cost less. Pharmacists-as-advisers also seems risky.
Pharmacists may manufacture in industry and hospitals. Here, at last, we encounter pharmacists’ “unique”, systematic, systemic body of theoretical knowledge: pharmaceutics. Yet, paradoxically, few pharmacists research, develop, produce or quality control medicines. For example, far more biologists and chemists than pharmacists take the professional examination required to become eligible for nomination as a European Union qualified person. Biology, compared with pharmacy, graduates are more likely to be unemployed and so be more attracted to pharmaceutical manufacturing.
Others, then, may overwhelm pharmacists’ existing, small, manufacturing niche.
Only pharmacist-as-dispenser now remains. Here again, pharmacists capitalise upon their “unique” knowledge of pharmaceutics. At last, we discover a place we know, a place where we feel at home, a niche where pharmacists are the dominant species, doctors and pharmacy technicians covering only a minority of the territory. That might be predicted from their lesser knowledge of pharmaceutics, although, as elsewhere in this article, many other social, economic and political factors are involved. However, pharmacists are more alert to the frailties of medicines and know how to ensure they are safe when they reach patients.
Yet, here we meet another paradox. Today, the pharmacist is striving to shed physical dispensing, instead relegating it to the “technician”, or, applying Dr Brown’s suggested title, “associate pharmacist” possessing lesser knowledge, who does not require a “pharmacist” on site. Some pharmacists feel comfortable with that; others feel threatened. Other possible terms for “associate pharmacist” include “pharmaceutical technical officer”, “pharmaceutical technologist” or “chartered dispenser”. The public already knows the word “dispenser”. “Can I see the dispenser?” a patient asked the other day and I was happy to oblige.
There is an implication if pharmacists volunteer to relegate dispensing to dispensers. Although those pharmacists would possess more knowledge than dispensers, they, instead of pharmacists, would provide what the public want: their medicines. If the public had to choose between physically receiving their medicines and receiving advice on pharmacokinetics, interactions and so on, I suspect the public would prefer receipt to advice. Basically, compared with the imperative of physically receiving medicine that heals them, advice is optional. That difference is crucial.
This perspective suggests that pharmacists would be prudent to maintain control over dispensing. How can they? One possible role model is the pathologist and the MLSO. The consultant pathologist is a medical practitioner who remains accountable for, but seldom undertakes, the work of MLSOs. Applying that model, an accountable pharmacist would manage dispensers, including audit of safe working systems and so on, in at least one pharmacy. The most sophisticated good dispensing practice systems, probably with the lowest error rates, would be in the direct mail dispensing factories. That would free pharmacists to undertake clinical duties.
“Clinical pharmacy” has been taught for a generation. What else is there? New, marketable combinations of knowledge may be invented; knowledge, previously in rigid compartments, can be reassembled in any way. For a contemporary illustration, scan a university prospectus; note the subjects mixed and matched to construct degrees — universities are supermarkets for ideas. You may be the first pharmacist who perceives, across pharmacists’ knowledge base, a kaleidoscopic combination connected with a new, profitable activity.
One aspect is certain. Pharmacists, by their behaviour today, will influence where they are tomorrow.
Malcolm Brown is a pharmaceutical consultant, a locum pharmacist and a sociologist from Beccles, Suffolk.