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Do you think all community pharmacists should receive training to become independent prescribers?

Started about 2 months ago


Whilst I enjoy David's well-articulated answer there, in all seriousness, with the fundamental shift within not just Community Pharmacy, but Healthcare provision from a multi-professional approach, it is my opinion that not only should pharmacists become independent prescribers, but it should also be a mandatory aspect of their training, starting from as early as University. We can take examples from Pharmacy Technicians, Paramedics, Nurses - these are all registered professionals that have expanded their roles beyond what they originally were, and they continue to do so.

Pharmacists, however, respectfully appear to be dragging their feet on this aspect. Within my experience of a decade, most Pharmacists' tasks of a day consist of primarily "spot the difference" on dispensed items. Pragmatically, Is this the best use for a Pharmacist?

A consideration as well is automated dispensing, as the technology, the legal aspects, and the process side of things develop and refine; the majority of Community Pharmacy workloads can be done without the need for human intervention. Barcode validation is an example of such technology; reading a prescription and medication provides more accuracy checks compared to manual methods, is overwhelmingly faster, and is perfectly accurate.

Where Pharmacists can place themselves effectively is in the non-urgent space, treating and supporting patients before they overfill into GPs, Urgent Care, and Emergency Services. Being able to prescribe is a key aspect to enable this, however.

Leon, are you a pharmacist?

If you are and you primarily play "spot the difference" with people's medication then I regret to inform you that you are performing a terrible job and putting people's lives in danger.

If you aren't a pharmacist then I regret to inform you that you are terribly ignorant of the pharmacist's job.

Dispensing robots only replace the physical act of walking to a shelf to select the product. Everything else needs to be done by a human.

PMR systems such as Titan which utilise barcode readings still require pharmacist clinical checks and occupy a very significant proportion of a their time.

Should all community pharmacists receive training to become independent prescribers? Don't see why not.

Unfortunately, I respectfully disagree with your assessment of the bulk of pharmacist's work or my alleged ignorance. It is - and let me make this clear so we don't circle back to a strawman fallacy, the majority of the work as a Pharmacist; work that takes up the bulk of one's time. Touching upon the other aspects, such as clinical checking and service provision is quintessentially the paradigm shift the pharmacist's focus is moving towards. And let us be pragmatic for a moment, this can be easily imagined by far few pharmacists remotely, and we already have several sectors that do like-work already. Think about how much that non-clinical staff at NHS111 filter just using a triage questionnaire, and incidentally another area that pharmacists could be far more effective in.

Your statement of Dispensing robots only replace the physical act of walking to a shelf to select the product is, unfortunately, incorrect, and you admit this yourself by reminding us all of the barcode validation, which is itself several accuracy checks. One that gets conducted several times more often than traditional methods. Titan is interesting to bring up because that was a project that suffered from obscene feature bloat whilst on the payroll of Well Pharmacy. Invatech then got dumped by the wayside by the latter because of it to become Titan. As of my last interaction with that particular combination of technologies very much identified it as a work-in-progress, with many, but not all, of the issues caused within the beta period by, you guessed it, human error and perhaps, a break from traditionalism. The classic example is a locum that would check local dispensing on the system and be searching for a box to sign on the label, and feeling very unsure when told it wasn't required. CAPA, as it was known at the time, was still teething. However, it was significantly faster than traditional dispensing. Centralised fulfilment / Off-Site Dispensing required even less manual workload, to the point you wouldn't even see the prescription until it had arrived on schedule. The challenge came from coaching people.

Ultimately, dispensing will no longer be a manual activity, eventually. Objectively, once the systems have been streamlined and perfected, there should be next to nothing left in a dispensary to do minus the odd acute. Modern pharmacy is nothing more than a logistical challenge, not a clinical one, which is why businesses should be afraid of the Amazonisation that is coming. Lloyds saw a massive increase in their online pharmacy usage because of covid, Boots is developing their online offering, and others are following suit.

Regardless of how you feel about my simplification of spot the difference, Pharmacists are getting a lot of time back in their day-to-day. The opportunity to grow and evolve this provides is clear. Perhaps independent prescribing is part of the way forward?

Leon, you fail to answer my question regarding if you are a pharmacist. I shall therefore presume that you are not a pharmacist. Please feel free to correct me if I am wrong.

I work in pharmacies with robots that only select the product. Obviously it needs to have a software program to identify which product to select but that is the only function it serves. It plays no part in accuracy checking. Your statement above says this is incorrect. Please do not be a reality denier.

I work in pharmacies without robots that have PMR systems that utilise barcode scanning of products as part of an accuracy checking function. These are still limited by lack of certain required abilities, e.g. identify expiry dates, and therefore are still unfit for purpose as a sole accuracy check and still needs human intervention. Please don't deny this reality.

PMR systems that include functions such as drug interaction checks are highly inaccurate. This has been the case for years. Any pharmacist/pharmacy that depends on the PMR system for drug interaction data is acting without due care and attention.

Pharmacist knowledge, skills, experience and ability to reference data combined with a well trained and highly skilled support team of technicians, dispensers and healthcare staff will trump an automated dispensary on all accounts. As a result accuracy rates within pharmacies are already high.

Instead you pursue the ideology of a mostly automated dispensary which smacks of nothing other than job cuts with the lowering of business costs. Such an unhealthy faith in the supposed benefits and safety of automation only contributes to the continual downgrading of the importance of dispensing.

There should be a push for an increase in the number of pharmacists, and support staff, within a given pharmacy bringing them inline with other primary and secondary healthcare providers which have more than one health care professional within one practice, e.g. GP surgeries, dental and optometry practices, hospitals, etc. This would lead to reduced workload and thereby even higher accuracy rates allowing one pharmacist to provide clinical services and another to conduct the dispensing service. I assume you will disagree and say its not possible, not because it isn't, but because it doesn't fit your agenda.

I felt that my thumbnail might have been a slight giveaway for your eagle eyes there! No, I have over a decade of experience managing several pharmacy premises and also spent a number of years working in implementing and testing automated systems, so I feel I am experienced to talk in-depth about automation.

Jokes aside, a key point of order here is that what you appear to be describing is different from an automated dispensing process, but rather an argumented robot dispensing process, which I concede, is more like replacing the walk to the shelf analogy that you described earlier. I've worked in those before, the last one used custom software as part of an outpatients department and literally would just select products and chute them down to you, minimizing the space required for stock holding to a glorified cupboard. Can be quite the timesaver, although dispensing is more a dispenser's job, less of a pharmacist's.

I'm afraid I still have to disagree with your concept of barcode validation, at least my development of the software. Barcodes, both 2D and QR are available, thanks to the failed implementation of QR codes, at least in the UK. A unique identifier is now required, consisting of a product code, serial number, batch code, and expiry date. So yes, the information is available for automated dispensing and accuracy checking, as well as some additional safety checking such as expiry warnings and batch recalls. Technology has a distinct advantage here.

Now, let me discuss clinical checking. This is definitely where pharmacists are needed and cannot be replaced. However, it can be optimized. Let's be clear in noting that a patient on, for example, long-term medications with little in the way of changes only really need assessment at the first instance and a follow-up after a reasonable amount of time. There's an argument to be made that these should be done in-house at the patient's general practice, over the telephone, or via the internet. Community pharmacy can be completely cut out in this respect. And then, pragmatically, someone will ask the question: What do we pay for a pharmacist in a community pharmacy for? Especially when most pharmacists can’t alter a prescription because they aren’t prescribers. And that's the key message there circling back to the topic question.

You discuss job losses and pay cuts. I'm reminded of the history of the loom when it was introduced as a revolutionary technology to modernize the fabric industry and many of the same challenges as you've presented here were echoed. There's no denying it; companies see some great efficiency savings to be made using automated dispensing models. Because they are so much better objectively at dispensing compared to humans. Dispensing in itself is nothing more than a logistical challenge, the clinical aspects of it - that is a process that runs alongside dispensing and can be done at any stage. Rather than a mostly automated, the ideal would be a fully automated dispensary. A closed system is far less likely to be affected by human error, after all.

I quite agree with your statement about a multi-professional approach to healthcare. It's one that many of the sectors you have described have already begun to adopt and have benefited greatly from. I fear it's is however less about throwing more people at a problem, but rather being smarter about the problem. When automated systems can remove the majority of the workload at a lower maintenance cost, it's hard to justify your stance. Not to disagree with increasing support within pharmacies, as a fellow locum, I'm sure we've both seen pharmacies with a skeleton level of staffing struggling because of a lack of people, and those definitely need a review into the resource available to them from my experience. It's not a long-term fix and doesn't address the fundamental issues.

So, with respect, whilst our thought processes are different, we are seemingly both in agreement that pharmacists should be used in a more comprehensive way, and mandatory independent prescribing training is a good way towards that.