The role of a Pharmacist as defined by the General Pharmaceutical Council (GPhC) is to ensure that all medicines supplied in the UK are suitable and safe for the patient to take, as well as issued within the remit of the law. Pharmacists are expected to advise patients regarding medication; this can include explaining how to take medicines, how to use devices, what reactions may occur and answering any questions the patient may have. It is important to clarify that medicines can mean anything from tablets to inhalers; chemotherapy to intravenous solutions. Every medicine has safe dose levels, side effects, interactions with other medicines (some even with food!), and toxic levels. Pharmacists are trained to check prescriptions for clinical appropriateness i.e interactions, doses, appropriateness of treatment; and to check dispensed medication for accuracy i.e. ensuring the label on the box matches the medication inside the box.
Every pharmacist works hard to prevent patients from ever coming to harm from medication – prescribed, bought, herbal or homeopathic. Pharmacists form the third largest healthcare profession in the UK and are currently massively underutilised due to constraints within the British legal system. For this reason, they are also side stepped within the NHS. Pharmacists are unable to make meaningful contributions to help restructure the NHS to make it suitable for the 21st century.
The training for Pharmacists is gruelling to say the least. They spend four years at university to learn specifically about the properties of medicines, as well as diseases and the best practice for improving health outcomes as set out by the National Institute for Health and Care Excellence (NICE). They then must work for one year, passing 76 practical competencies and at the end of that year must pass a standardised national exam set by the GPhC – where only 3 attempts are granted before the applicant becomes barred from sitting the exam and ever registering as a Pharmacist in the UK. Even the most intelligent and competent students take a minimum of 5 years to complete the whole process. Compare this to other healthcare professionals, and pharmacists are in training for as long as junior doctors. This training is only getting harder each year as ever more precise and complex medications and devices come to the market. This also means Pharmacists are in a constant state of learning to ensure their knowledge is up to date and to ensure they are best able to help patients.
There were over 1 billion prescriptions issued in 2016 in the UK and that number is rising yearly(1). The General Medical Council (GMC) found in 2012 that 5% of prescriptions written by a GP for ‘unique’ (new or uncommon medications) contained a clinical error. This means there was risk of harm to a patient. Any prescription error is serious for Pharmacists as they are usually the last checking point and in effect a safety net for all prescribers. Paradoxically, Pharmacists practicing in the community sector have very little access to patient information, something that GP practices takes for granted. Studies have shown that members of the general public visit their Pharmacist more often than their GP. In the UK 96% of the population lives within a 20 minute walk or bus ride from their local community pharmacy and do not need an appointment to speak to the Pharmacist (5). Pharmacists by their very nature are safe and responsible practitioners, however without all the necessary patient information they will struggle to keep patients safe and improve healthcare provision.
The secondary role of a Pharmacist historically is the accuracy check. This is where the pharmacist needs to ensure dispensed medication is physically correct and issued as per the prescription after it is deemed clinically safe. To try and ease this ever increasing pressure the role of an accuracy checking technician (ACT) was developed. Whilst ACTs are regulated by the GPhC as registered pharmacy technicians in their own right, legally if the wrong physical medication goes to a patient after the accuracy check, it is the Pharmacist who is deemed to be at fault from a legal perspective. It is worth noting that in 2015 the government undertook a consultation on changing the law, however the results of the consultation are still to be released despite having closed the consultation in the summer of 2015(3).
All Pharmacists will agree that there should be accountability and some form of penalty for serious errors. However, the law should direct the penalty to the offending practitioner rather than defaulting to the Pharmacist as the rules currently in place state. The 1968 Medicines Act does not mention the difference between a clinical error (whereby interactions or other patient safety event is missed by the Pharmacist) and an accuracy error. The law also does not mention pharmacy technicians, nor does it state what ACTs are legally accountable for. The law is vague and addresses pharmacy practice in 1968. Nearly 50 years after the passing of this law, Pharmacists are still at risk of being imprisoned for errors. No other healthcare professional in the UK faces such harsh sanctions, let alone for another practitioners error.
Take a general practice as a parallel work location. Each individual healthcare professional in the practice is allowed to work autonomously and under their own individual licence number. If a nurse misses something that should have been escalated the practice is not at fault, the nurse is. Whereas the staff in a pharmacy all operate under the Pharmacist’s license. What this means in short is that everything that happens in a pharmacy is entirely the responsibility of the Pharmacist on duty. Currently every sale and dispensed item in a pharmacy, no matter who was involved in the process, is the responsibility of the Pharmacist on duty. This is a staggering workload for one professional to be expected to undertake in the modern world of healthcare.
Pharmacists are keen to make more use of their clinical skills and showcase how they can benefit the NHS and their patients. They want to do this by stepping out from the dispensary and onto the counter, helping advise patients on the best product to buy and talk to patients as they hand over of medications. To this end, there are services such as medication use reviews, flu jabs, weight management, asthma management, minor ailment services and emergency hormonal contraception among others. However, until the law is changed to be more balanced Pharmacists are reluctant to hand over the final accuracy check responsibility and so feel trapped in the dispensary. The lack of support for Pharmacists in this context is preventing the NHS from making use of an outstanding resource freely available on most high streets and supermarkets across the country. If Pharmacists were given the freedom to leave the dispensary and spend more time with patients delivering tangible benefits to patient care, then A&E waiting times would decrease, there would be fewer hospital admissions, better long term disease management and many other benefits to the local communities and nationally.
The Pharmaceutical Services Negotiating Committee (PSNC) promote and support the interests of all NHS community pharmacies in England, and are recognised by the Secretary of State for Health as the body that represents NHS pharmacy contractors. They recently engaged PricewaterhouseCoopers (PwC) to determine the value of community pharmacy. PwC reported that community pharmacy contributed a net value of £3 billion(4) to the UK economy annually. If Pharmacists were able to step out from the dispensary to focus on sales and handing out medicines without risking their licence, this value would rise and the pressure on GPs and A&E departments would be more effectively lifted. Patients, Pharmacists and other healthcare professionals need to ensure the government decriminalises dispensing errors to ensure Pharmacists are free to leave the dispensary without risking their licence.
Pharmacists are experts in medicines which is why their presence is essential in every operating pharmacy to oversee dispensing, and sales. Whilst technicians can check accuracy, the clinical knowledge required to keep patients safe is the remit of the Pharmacist who trained for 5 years and undertakes professional development consistently after qualification. This key distinction can often mean the difference between a patient being treated, and a patient being poisoned.
It is imperative that the government recognises the contribution Pharmacists can make to the NHS by passing meaningful laws; it is essential the government decriminalises dispensing errors; and it is only right that Pharmacists are not held responsible for the errors of other regulated professionals. For clarity a clinical error would constitute a missed interaction between prescribed medicines, or a sale of a medicine which can cause harm; whereas an accuracy error would constitute giving the wrong medication to patient or sticking the wrong label on a box of tablets.
Every pharmacist works hard to prevent patients from ever coming to harm from medication – prescribed, bought, herbal or homeopathic. To risk criminal charges for an accuracy error they did not make is unreasonable, illogical and wholly inappropriate. The legislation must be updated to allow a currently failing NHS to make better use of the resources available and ultimately provide a much better healthcare experience to patients.