THE plight of community pharmacy, particularly in England, is perilous. Community pharmacy is being forced for the first time in recent history to consider a post-supply era. The split of income in community pharmacies varies greatly, but at its worst, this could mean a drop in top line income of up to 90%.
These are terminal numbers.
It is in this context that community pharmacy is forced to say yes to schemes, projects, and services that they cannot properly resource. They are being set up to fail and are restricted in their progression by a lack of investment from government.
The ‘Send your child to the local pharmacy first’ is a good example of this. Spotting a sick child is in relative terms quite easy. The art lies in knowing whether that child is going to get worse in the next few hours or recover completely. Any GP I have spoken to would admit that this is one of the trickiest things to get right in general practice. Politically, this scheme costs the government nothing but creates a great headline.
The harsh truth in community pharmacy is that with the exception of the motivated few, who swim against the items driven revenue chase, we are not good enough at examining, diagnosing and subsequently managing patients safely within the community pharmacy setting. These patients include those children that are shortly going to be encouraged to visit community pharmacy first.
Also, for the profession to begin to progress to the next level we really need to dismiss the idea that pharmacists don’t diagnose. Saying this simply shuts the door to future progression and development collectively. As a profession, we are spectacularly good at removing the starting line never mind crossing it. We are so good at this form of self-mutilation that I have concluded that in general, commercial interests simply must be putting a brake on this development.
To add context if a patient comes into the pharmacy with a presenting complaint of an ‘odd feeling tongue’.
You take a history to rule out red flags, you examine by asking that person to open their mouth, you diagnose thrush, you treat by selling the patient miconazole oral gel and finally you safety net by giving a specific worsening statement. You have made a diagnosis after ruling out red flag differential diagnoses. One thing I think community pharmacy needs to consider is how, without deploying some basic clinical skills, they can be sure that patient is systemically well.
Critique aside, this is a routine general practice appointment managed very nicely in community pharmacy. We also need to start recording these interventions properly. I think we articulate that we do this type of consultation well to the general public but I think we could do better at articulating to the wider multidisciplinary team. The rest of the team often don’t know what we do clinically in community pharmacy largely because we cannot write directly into the record. Thankfully this is changing and will soon change north of the border too.
I would like to continue to add context by describing a typical, completely fictitious case. It involves a ‘minor ailment’ or if you prefer a ‘common clinical condition’.
The male patient presents with a cough aka a ‘minor ailment’. Our patient is 50 years of age. He is a smoker, he had asthma as a child (subclinical as an adult) and was recently in a cycle of repetitive chesty exacerbations. Asthma was listed as resolved on his patient record and there was no other relevant medical history recorded.
This guy was ripe for a diagnosis of COPD, asthma, cancer, all of the above or something else!
This cough had lasted 11 weeks and that day he was prescribed his 3rd lot of antibiotics in four months. He had shortness of breath so he was given prednisolone too. He was referred for spirometry, referred for a chest x-ray, his sputum was sent away to be tested and he was initiated on NRT. He was started on an inhaled corticosteroid and given a spacer too after a chat about inhaler technique. He was safety netted and a follow-up appointment was made for him in a month with a pharmacist in a post exacerbation clinic and then with a GP post spirometry.
The point here is that this appointment was billed as a ‘minor ailment’ or ‘common clinical condition’ and to be honest I don’t think the title fits what actually happened. Everyone will work to different levels, I get that, but I think we should call a spade a spade and be cautious about limiting ourselves by condition.
Historically I think this condition led thing happened because of the nature of the prescribing course where you had to choose a clinical area. If I had my way I would do away with any mention of common clinical conditions or minor ailments because it implies that we are in some way inferior in a clinical sense. The term ‘general practice’ appointments, even if conducted in community pharmacy, with all the required competence that goes with that, is preferable to me.
I would guess that most community pharmacists would pass that patient over to another healthcare professional as soon as they realised that a cough had lasted more than 11 weeks. However, in my new general practice role, I could scoop this ‘minor ailment’ patient up and manage him through to the optimisation of therapy in a chronic disease clinic at the other end. If this example came to me at my level of development I would seek help from a GP to make the differential diagnosis of COPD, asthma, cancer or something else. However, I would not rule out being competent someday to do the diagnostic bit myself.
Just because we are clearly not ready as a profession in significant numbers to practice to our full potential I reckon we shouldn’t shut the door or shoot ourselves in the foot before we get over the starting line.
Unless we don’t want to get over that line of course…
The deep question we need to ask ourselves as professionals is at what level are we willing to engage. With the ‘take your child to the pharmacy’ thing we are choosing not to fully engage in my view. We do some basic questions, no clinical assessment and then pass the patient to another health professional. The confidence required to hold on to that patient and manage him/her in the pharmacy is I feel quite far off.
I read a comment on Twitter recently defending the role of community pharmacists. It mentioned that because indemnity premiums for community pharmacists are relatively low this somehow means these pharmacists are low risk and practice safely. Well, of course, they are low risk because they are choosing not to expose themselves to this new arena of risk.
And this leads to the reason I think community pharmacy is being set up to fail. Pharmacists and even some contractors skirt around this central point simply because there is no incentive to take that significant leap in risk.
Both camps, contractors and employed pharmacists, are driven by the money. And there isn’t much of that. The chronic underinvestment in community pharmacy over the years, particularly in England is coming home to roost. The decoupling of clinical input from the supply function is happening at an unprecedented pace. The petrol that has recently been poured on this inferno is the evangelical rush to head to the promised land that is ‘general practice’.
To build a genuinely autonomous profession we need pharmacists to be developing other pharmacists to deliver better pharmaceutical care, particularly in community practice, not just training each other to chase the numbers.
We have come far too late to concepts like supervised practice, competence frameworks and small group learning in community practice. And the reason is simply money.
Or lack of it.
By all means, take your child to the community pharmacist first, but know that they will probably choose not to fully engage for a number of reasons.
None of these reasons include a desire not to help the patient.
All of these reasons can be tracked to a lack of government support and investment in one of the most underutilised, unappreciated and ultimately undervalued professions in this country of which I proudly belong.
Pharmacy.
Johnathan is a pharmacist who works part-time in general practice. He is also a member the Royal Pharmaceutical Society Scottish pharmacy board. In this article he is writing in his personal capacity and his views do not necessarily reflect those of the organisations he represents.