How did Royal College status drop off the RPS strategy?

 Recent discussion on Twitter concerning the removal of the Royal Pharmaceutical Society’s Director of Education and Professional Development role highlighted the non-inclusion of the pursuit of Royal College status in the RPS’ current five-year strategy.  Spirited responses from pharmacists maintained that Royal College status was a part of the Society’s strategy following the 2010 demerger of professional and regulatory roles to RPS and GPhC respectively.  

 

RPS President, Claire Anderson, confirmed in an email to members that there was a consensus of Assembly members attending the March 2021 meeting not to pursue RC status.

 

I looked through the Assembly minutes that are available on the website, expecting to find periodic monitoring of progress against the Strategy, but no!  The March 2021 minutes mentioned completion of the 2021-26 strategy, with Assembly to approve the final version during the closed part of the meeting.

 

How did Royal College status drop off the strategy, without the knowledge of members?

 

The Strategy documents as published are very high level to the point where I consider them to be more an explanation of the vision, to indicate ‘direction of travel’.  To me a strategy is captured in the definition ‘a plan of action designed to achieve a long-term or overall aim’.  I expect to see a high-level plan within the strategy, to provide information about how the goals are going to achieved.  Something that interested members can follow.  Assembly should also be periodically discussing high-level progress in open business so that it is captured in minutes that members can access.

 

Looking at the 2021-26 strategy, the first goal is:

 

Shape The Future Of Pharmacy And Medicines Use - We will be the recognised leaders in influencing and shaping practice, policy and education, for pharmacy, pharmaceutical science and the safe use of medicines.

 

How will we do that?  How do we know when we get there?  I want to see the strategic elements that will deliver this goal.

 

Although the day-to-day operation of the Society is under the control of the CEO, one of the main tasks of the Assembly is to ‘agree the overall strategic direction and top level objectives of the Society, including European and other international dimensions’.  In addition, duties of Assembly members include ‘taking decisions about the prioritising of strategy according to the importance of the issue to the Society and the profession and the availability of resources.’  Assembly members need to be reviewing progress against the strategy action plan on an ongoing basis to identify when any changes in priority are needed.  This may occur in the closed part of Assembly meetings but a regular review of a high-level action plan needs to be made in open business to keep Society members informed.

 

Personally, I’m not convinced about the need to change the name to Royal College as I think the RPS could deliver what a Royal College delivers with the current name, but I know that to some the perceived additional prestige of the name is important.  However, of greater concern is the removal of the role of Director of Education and Professional Development.  If we are to achieve that first goal of the 2021-26 Strategy, then a dedicated director level role is necessary to attract leadership with the required skills and expertise and provide assurance to organisational partners.

 

 

Remote supervision, could it work?

Not very easily.

Why?

All elements of supervision could not be delivered remotely to an acceptable standard.  If the pharmacist were off doing other professional activity then they are unlikely to be in a position to be interrupted as the need arose.  Supervising multiple locations would give inadequate professional oversight and conflicting priorities - much too risky.

Potentially, prescriptions that had been clinically checked by a pharmacist and no pharmacist discussion with the patient was necessary, dispensed and accuracy checked, could be issued under remote supervision.  If I were that pharmacist I'd want this to be by a registered pharmacy technician.

What about people coming in asking to speak to the pharmacist?  We're trying to encourage this, not having one available downgrades the importance of our expert advice.

Opportunistic intervention?  Er, no.  Quite an important role in my experience.

I would not be that responsible pharmacist.  Too risky.

Guest post - Social media and blogs

I've not blogged for a while, so to kick things off here's a guest post written by a pharmacist whose identity I know but who wishes their post to be anonymous.

Social media and blogs are just what the internet was designed for.  The ability for anyone who has access to a computer anywhere to find out what someone is thinking on the other side of the world - in “real time”.

Just let that sink in. In Real Time.

Not 3 weeks later when a copy of a news paper or a journal lands on your mat.  But instantly. And it’s the views of a “small person” (in relation to a world leader).  And what’s even more amazing is that you can reply back, in real time....

Just take a moment to let that sink in.......

You can instantly communicate with someone, articulate your thoughts - disseminate ideas - discuss and learn.....all in the time it takes for a few key strokes to happen.

I would argue that this has been the greatest achievement of the late 20th/early 21st century...and...its greatest negative.

Take for instance right now.  I’m sat at a table, with my ear phones in, typing this into my phone whilst two men have a face to face conversation about all sorts whilst drinking tea or coffee.

I am totally disconnected from “reality” as I’m immersing myself about a blog to do with the digital world.

And there is one of the, if not the biggest drawback of being connected/being online. 

We lead so much of our lives online now, the lines blur and merge.  For youngsters it may even be able to not differentiate - to them it’s just life.

As more people go online - so it therefore means their work follows.  This is all good....but also bad.

People spend what seems like every waking moment cataloguing, replying, posting, liking, disagreeing, re-posting.  

There never seems to be a switch off.  Even on holiday - there seems to be an intrinsic need to take a selfie from a far flung shore or a picture of a relaxing alcoholic drink somewhere warm.

I’m just as guilty of all of the above.  I’ve been involved in the digital world from the early 1990’s, I’ve seen the evolution from message boards to social media platforms and have been involved in them all.

And whilst I still have “e-friends” from the very beginning on IRC (internet relay chat)....I’ve still not met some, across the various platforms, in real life. 

I do wonder looking back at nearly 25 years of internet connectivity and contrast to today - are we spending too much time online?

Everything is online in one form or another. 

But is this a good thing for us?

I am starting to feel that for professionals it isn’t.  We need a break from being online for our own sanity.  People seem to just live and breathe work online from the moment they turn their phone on/wake up until they go to bed/turn their phone off.

It’s instant gratification.

By that I mean you’re always checking to see what people have said, have people replied to something you posted or replied to something you have replied to.....it is extremely addictive and also very destructive.....

Instagram, snap chat (snap chat filters), Twitter, LinkedIn, Facebook; where does it end????

So whilst you read this, smile at the irony of me saying “disconnect more”.......

And then disconnect - have a day off, go for a walk in the woods, go swimming, read a book and listen to the radio or your favourite music, talk to someone random. Revel in human-human interaction!

The author is a practising community pharmacist who has been qualified for 20 years.

Administration of prescription only medicines - settling a dispute, the final part

Further scrutiny of the Human Medicines Regulations 2012 and discussion yesterday with expert colleagues has brought me to the conclusion that I was wrong.  This causes me much distress.  Not that I could be wrong, I sometimes am though not that often, but because the Regs leave the administration of non-parenteral POMs effectively unregulated.

In most healthcare settings additional governance is delivered by treating non-parenteral POMs in the same way as parenteral POMs, so administered by health professionals and prescribed or authorised under PGD.  Ambulance services appear to be the only health sector allowing unregistered staff to administer non-parenteral POMs under a local protocol.

Hmm.

Administration of prescription only medicines - settling a dispute: part 2

Ah well, my initial idea didn't stand up in court.  I accept @aptaim's comment that 'administration' inherently contains an element of supply and 'supply' (as defined in the Regs) does not apply.

I'm reviewing the other relevant Provisions of the Regs to see if anything negates the interpretation used by ambulance services.  I've not found anything yet...

If this interpretation is not negated then it opens up a spectrum of opportunities for administration of non-parenteral POMs by a range of persons operating within a regulated service under local protocol.

Hmm

Administration of prescription only medicines - settling a dispute

It's common practice in ambulance services for staff members, both registered and unregistered, to administer non-parenteral Prescription Only Medicines to patients under the 'authority' of locally drawn up organisational guidelines.  The argument is that anyone can legally administer a non-parenteral POM and the ambulance service can 'possess' the POMs so no further legal authority is required to administer them.  This article in the Journal of Paramedic Practice covers the rationale.

I dispute that this is a correct interpretation of the Human Medicines Regulations 2012, as if this were the case there would be limited need for the exemptions in Part 12 Chapter 3 - for instance why do other healthcare services bother using Patient Group Directions for administration of non-parenteral POMs if a local protocol would do?

So I refreshed my memory of the HMR and gave it some thought.  Here is my understanding of the Regs.

Provision 214 states:
(1) A person may not sell or supply a prescription only medicine except in accordance with a prescription given by an appropriate practitioner.
(2) A person may not parenterally administer (otherwise than to himself or herself) a prescription only medicine unless the person is - 
     (a) an appropriate practitioner other than an EEA health professional; or
     (b) acting in accordance with the directions of such an appropriate practitioner.

• From 214-2 it can be deduced that a person MAY administer a non-parenteral POM without being either an appropriate practitioner or acting in accordance with the directions of one.  
• Sale, supply and administer are three distinct activities, defined in the Regs. 
• A person could administer a POM to a patient, with no additional authority, providing the patient legally possessed the POM. 
• If the patient didn't possess the POM, the person would need to SUPPLY the POM to the patient prior to administering it.  Supply is not permitted under 214-1. 

 I rest my case...

A community pharmacist's ethical dilemma - the sequel

When I posted my last blog 'The community pharmacist's ethical dilemma' I said that I may share my views in a future blog.  So here they are.  I waited a while as I was asked by one of the pharmacy schools if they could use my blog as a discussion tool for their students and didn't want anything I posted to influence people forming their own opinion.

The Discussion

Mrs A comes into the pharmacy and tells you that her GP has recommended hydrocortisone 0.5% ointment for her face and said it can be bought over the counter.  The 0.5% product is POM but the 1% product is P and could be supplied, although the product licence excludes use on the face.


As the GP has diagnosed the condition and recommended the treatment, does that make the pharmacist any less professionally accountable for the sale?

• I don't think so.  The GP has diagnosed the condition but has recommended to Mrs A to purchase the medicine over the counter so the GP is not involved in the transaction.  The transaction is between Mrs A and the pharmacist so the pharmacist is entirely  responsible professionally for satisfying themselves that the medicine is suitable for the intended condition as described by the purchaser.  In addition to professional considerations of appropriateness, under The Consumer Rights Act 2015, the purchaser has the right to expect that 'the goods should be fit for the purpose they are supplied for, as well as any specific purpose you made known to the retailer before you agreed to buy the goods.'

What if the pharmacist sold the 1% ointment and advised Mrs A to use a very small amount, is that equivalent to supplying the 0.5% product?  And why or why not?

• No.  The 1% is double the concentration so the chances of being able to spread a 1% ointment to half the thickness of what Mrs A theoretically may have done for a 0.5% ointment is slim.  It's hard to spread thinner than 'spread thinly' and there's no guarantee that Mrs A won't use too high a dose in these circumstances.

 

What could be the reason(s) that use on the face is not included in the marketing authorisation?

• Regular use of topical steroids can cause skin damage, such as thinning, changes in pigmentation, redness and dilated blood vessels.  Although over the counter hydrocortisone 1% ointment should be used for no more than seven days, because of the 'inherent risks' of adverse effects coupled with 'inherent misuse with therapeutic intent' (using a larger dose than advised and/or using for longer than the recommended period of treatment) I believe that the MHRA would have required that facial use be excluded from the indication for the marketing authorisation (MA).

 

What is the impact on Mrs A of a delay in starting treatment by refusing to sell and referring her back to her GP?  Would this make a difference to your decision?

• Mrs A would experience a delay in starting treatment but I would make this as short as possible.  I would explain why I could not sell the item, with Mrs A's permission I would contact her GP surgery and advise that I was referring Mrs A back for a prescription for the item and the reason.  I would provide Mrs A with a written referral note as confirmation, with contact details should the GP wish to discuss the matter with me.  No, it wouldn't make a difference to my decision as I consider I am acting in the patient's best interest overall.

 

How do you think advising a use not included in the product's Patient Information Leaflet could influence Mrs A's approach to instructions of OTC medicines she purchases in the future?

• As a pharmacist I would be wary of telling a person that although it says something in the PIL it is ok to ignore it.  This goes against the safety messages we regularly give to take medicines as directed.  There is a risk that Mrs A may in the future decide that other medicines may be safe to use differently from the directions provided.  People's approach to and beliefs about medicines vary considerably and it cannot be assumed that everyone would respond in the same way.

Does your professional indemnity insurance cover the additional risk involved when selling a product outside of its marketing authorisation? 

• This will be for each pharmacist to check.  I'm not currently practising as a community pharmacist so my indemnity insurance doesn't cover community practice.

As P medicines are awarded a marketing authorisation so that they are sold under the supervision of a pharmacist, if a pharmacist sells outside of the MA under what authority are they doing this?

• None.  The award of P status will be dependent on the specific indications, strength and dose specified in the MA.  As pharmacists must supervise the sale of a P medicine to ensure it is appropriate, there is no authority that permits them to advise on a different indication or dose.  The RPS MEP mentions in its guidance on over the counter supply of chloramphenical eye drops/ointment that pharmacists should be satisfied that the supply is in line with the MA.  I can't see any reason that this product should be particularly singled out , so consider the advice applicable to other reclassified medicines.

 

Do you agree?

These are my personal views based on the regulation and professional guidance information I described in my previous blog.  Do you agree?