Now that we see what Pandora’s box contains, where do we go from here?

In this article, Alan Rogers, of Epsom, Surrey, reflects on recent developments in health professional regulation and considers how the Royal Pharmaceutical Society could approach its future in the light of the Government’s demand that it separate its regulatory and professional functions.

Much has now been written on the future role of the Royal Pharmaceutical Society, once regulatory matters have been passed to a new General Pharmaceutical Council.There are widely diverging views on the way forward, and one can only agree with the editor of The Pharmaceutical Journal in asking “whether the Government understands what it is doing”, since “it has handed pharmacy a Pandora’s box” (PJ, 5 May, p512). The Society’s Council has been criticised both for failure to consult the membership, and for failure to issue strong leadership on the subject. In view of the contradictory nature of those obligations, and the timescale that has been set by the Department of Health, I have some sympathy with the Council’s dilemma. But a lay member, Bob Michell, has revealed that the DoH actually
tried to prevent the dissemination of information (PJ, 14 April, p436). Those of a cynical nature might suspect a campaign of subversion originating in the corridors of Whitehall.

Ten years ago, Bryan Hartley, the chief pharmacist at the DoH, praised the Society and said that the DoH needed the support of the Society if it were to be as effective as possible in healthcare policy development. The Society devoted the intervening decade to providing that support, and complied with every demand to change its governance, so that it could continue to perform both its regulatory and representative functions. In allowing the demands of the DoH to take priority over the needs of its members, it alienated the many pharmacists on whose loyalty it will now depend.

Now, at a stroke, the DoH has announced a change in policy, and expressed a lack of confidence in the Society’s leadership. Lord Carter’s working party was set up to review the implementation of the new arrangements for regulation of the profession, but the DoH also wanted to set up another working group to oversee the formation of a body akin to a royal college. This demonstrates an insidious desire to restrain our professional freedom, and perhaps explains the pressure that is now being placed on the Council and on the profession.

The chief pharmaceutical officers for England and Scotland both set out their views at a King’s Fund seminar on professional leadership in pharmacy on 20 March. Keith Ridge tells us that the “profession now admits there is a need for stronger leadership and has accepted that splitting the functions of [the Society] is desirable”. Really? I think we are simply accepting the reality of a decision that has been imposed on us. He goes on: “This is not simply a matter of evolution but of revolution. Only a minority of pharmacists would join [the Society] now were it not mandatory. Whatever organisation eventually emerges must be and must be seen to be a new organisation.”

It is an unusual and perhaps dangerous strategy for a government representative to call for revolution. It may also be unnecessary. Relieved of the burden of its regulatory responsibilities, the Society has greater potential to give effective leadership and representation than any new body. Although Dr Ridge appears to want stronger leadership, he does not mention professional representation in his description of what a royal college would do. He says “it would act as a central focus for the body of pharmacy knowledge in order to drive forward patient care”. He goes on to say that “there is not
much time to get it reasonably right and convince pharmacists of the value of a royal college”, but he is setting the onerous timescale and, as Bob Michell has observed (PJ, 26 May, p607), the outcome of this Government’s hastily conceived policies is grim, and certainly not in the public interest. What Dr Ridge describes as time-wasting, wiser men might refer to as meaningful debate.

Bill Scott mentioned “scholarship, and a body of knowledge” as characteristics and attributes of the profession in his presentation, but insisted that “the royal college would provide professional leadership and vision and it would be the authoritative voice and champion for pharmacists and pharmaceutical scientists”. He expressed concern about the 188 different organisations identified by the Society’s scoping exercise and believed that the proposed model would provide an opportunity to bring those groups, particularly those catering for specialists, into a single “royal college”. A close look at this 188 groups reveals that only a handful would be capable, or willing, to join together. And those that represent specialists would hardly be representative of the profession.

The discussion groups at the seminar pointed out that pharmacists would ask “what’s in it for us?”, but Mr Scott believed that, because of the rapid change in pharmacy practice, this was the wrong question. He is wrong: it is the right question. And it should be asked not just once, but at every juncture in this debate. What is in it for us as a profession? What is in it for us as individuals? What are the benefits? What are the risks? What are the alternatives? The issues are linked, and they are the key to the success of any body that arises from the ashes of our Royal Pharmaceutical Society.

Carwen Wynne Howells, chief pharmaceutical adviser for Wales, set great store by the fact that we were being given a blank sheet of paper (PJ, 24 February, p207), but what we actually appear to have received is the back of a cigarette packet, covered with the hastily scribbled and ill-conceived notes of a brainstorm by ministers and civil servants.There seems to be no consensus on the role of the new body: only a desire to destroy the old. Of course, civil servants have become used to empires being created and destroyed, of departmental boundaries being redrawn, all on the whim of a minister. But just as attitudes and policies within the DoH have changed drastically in the past 10 years, so they will again. It took the Pharmaceutical Society 147 years to earn its Royal patronage, and we must not allow it to be sacrificed in the latest modernisation purge. As Raymond Dickinson, a former deputy secretary of the
Society, asks (PJ, 26th May, p607): does the DoH now have the authority to destroy and create Royal chartered bodies?

We must hope that the political impatience perceived by Bob Michell is now matched by the impatience of the profession at this unwarranted interference. We have heard the views of the President Hemant Patel, of the “minority interest groups” and of the usual movers and shakers, and now we need to hear the views of every pharmacist (especially the generalists, as we are patronisingly described). Let us prove that we are perfectly capable of governing our profession without being bullied by Lord Hunt and his henchmen. So where do we go from here? The spectre of a body with “a role akin to that of a royal college” has given rise to reactions ranging from euphoria to panic, but the most common is confusion. What is its purpose? Will it be inclusive or exclusive? Who will decide, and when? What will it cost Perhaps it is time to read the small print. The phrase first appeared in the White Paper, “Trust assurance and safety — the regulation of health professionals in the 21st century”. Following from the announcement that the Society “needs to separate its regulatory system from its system of professional
and clinical leadership, allowing each distinct function to focus on its core role”, the White Paper continues that “the profession will need a strong and clear voice to assume the critical responsibility of a role akin to that of a royal college”.

So, it says nothing about actually becoming a royal college. It refers to both professional and clinical leadership; it says it should be a learned and authoritative organisation, supporting excellence, professionalism and innovation; it refers to both the science and practice of pharmacy; and it specifically gives the option of the Society redefining its leadership role. Only in the frenzy since its publication have people sought to move the goal posts, suggesting that we need a new organisation with a new name, and I fear that this is more about power politics than about excellence and professionalism.

Medical royal colleges are primarily concerned with improving clinical and professional standards, and membership is by examination or assessment. They manage to combine strong professional leadership and advocacy alongside their role in promoting high standards in patient care. They restrict membership to qualified medical practitioners and trainees, although the Royal College of Paediatrics and Child Health has an affiliate status for non-clinicians and the Royal College of Obstetricians and Gynaecologists “supports other organisations having similar objectives to those of the college”. (Perhaps this could be a non-controversial model for working with our technicians.) No college has either a regulatory or trade union role and fees are in the range of £100 to £400 per annum. There are precedents for societies
to become colleges: societies of psychiatrists and ophthalmologists were transformed more than a century after their initial formation.

If the medical royal colleges are presented to us as a role model, we must ask whether pharmacy has comparable influential organisations other than the Society? The final report of the Society’s “Scoping the profession project” identifies 188 unique support groups, but this figure is misleading in my view. Many of them are local or regional groups, such as pharmacy development groups, local pharmaceutical committees, networks and forums. Nationally, they included the National Pharmacy Association, the Pharmaceutical Services Negotiating Committee, the Guild of Healthcare Pharmacists, and primary care organisation support groups that would not fit into a royal college-type framework. The signatories to
the Waterloo agreement (PJ, 31 March, p357), which were vocal in opposing a revamped Society, were mainly small specialist organisations, most of which welcomed the chance to work together, but were wary of losing their identity.

Of these signatories, the UK Clinical Pharmacy Association is the largest. It was founded in 1981 with the aim of supporting and encouraging the emergence of clinical pharmacy. It has around 2,000 members, who do not have to be pharmacists. Another, the College of Pharmacy Practice, was founded by the Society in 1981 to promote excellence in pharmacy practice along with continuing education and training. It became independent a few years later.

Associates submit a record of their continuing professional development each year, and may move to full membership by undertaking a portfolio assessment. The college has suffered a fall in membership in recent years, and now has fewer than 1,000 pharmacists on its roll. It has independent faculties of prescribing and medicines management, and of neonatal and paediatric health, as well as a public health interest group.

Although both these bodies have achieved great success with small groups of enthusiasts, they have not been able to recruit widely in the mainstream of community pharmacy, or to become established as a respected body outside the profession. Let me, therefore, submit a commonsense blueprint for the future, one that at least offers a starting point for a debate.

If our new organisation is to hit the ground running and to be sustainable, we must build on the strengths that we have. I hold no brief for the Society, and I have frequently been vocal in my criticism of its leadership. However, it has the infrastructure and a solid reputation we need to form the umbrella organisation for professional leadership. The Society should be split immediately into two distinct departments, regulatory and professional, each with its own separate budget. All the other national pharmaceutical bodies should then join with the Society in a “confederation”, which would review current activity, explore areas of common ground, and put forward proposals for alternative structures, governance, policy and remit for a future body. The Society’s greatest fault in recent years has been poor communication, both with the membership and with the public. These discussions must be well publicised, with an opportunity for members to comment, or submit their own ideas. A dedicated website should be set up for this purpose, and written comments and journal articles should be posted on the site. The difficulty of this transformation process should not be underestimated: working together as part of a team; trying to integrate minority interests without upsetting the majority; splitting off the regulatory function safely; and meeting a tight deadline. The President must provide inspirational professional leadership at this critical time and ensure that members are told the full facts, however unpalatable, in plain English rather than in management jargon.

The College of Pharmacy Practice could form the ideal vehicle for driving forward clinical leadership and excellence but it must once again become part of the Society to maintain cohesion and financial viability. The UKCPA and the small special interest groups could become faculties within it. This would offer an interim solution to the inclusive/exclusive argument, namely, membership of the Society for all pharmacists and pharmaceutical scientists, with a voluntary route to higher qualifications via the college. Pharmacy technicians should be eligible for affiliation to the college, offering them access to higher qualification, but they would continue to be represented by the Association of Pharmacy Technicians UK, avoiding any potential conflict of interest. The Society’s local branch network is currently dependent on the enthusiasm of volunteers, and must be strengthened to provide a local face for the college.
Boundaries should correspond to primary care trust areas, and local pharmacy development groups should become part of the branch structure.

The Society’s information resources, including the library, are probably underutilised, and should be marketed as part of the educational package of the college. Consideration should be given to working closely or even combining with the NPA’s information department.

I have tip-toed around the crucial problem of funding. Even using the main Society infrastructure as a starting point, the new body will face a several difficult years adjusting to its new role. Members will also take a few years to decide whether it is fulfilling its purpose in terms of professional leadership and clinical advancement. It will need a guaranteed income to achieve stability, in addition to Government funding to finance revalidation and to compensate for the work forced upon us. Membership will have to remain mandatory for a transitional period of, say, five years.

And one last plea: can we please boycott this wretched term,“body akin to a royal college”, which has caused us so much grief? Let us pull together to create our “body for professional and clinical leadership”. If we can achieve this remarkable transformation, then we can consider giving it a fancy name.

Last updated
The Pharmaceutical Journal, PJ, June 2007;()::DOI:10.1211/PJ.2023.1.171222

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