I have recently made a personal financial contribution to the crowdfunding efforts of doctors who plan to take legal action against their regulator over the use of ‘medical associate professions’ and I believe that many pharmacists should support this too – but why?
Anyone following developments in UK healthcare can work out that there is now an enormous, almost factory style, production line of new groups of healthcare workers intended to support or, as some fear, even replace the principal healthcare profession to ‘beef up’ the workforce. As a result, pharmacy is not alone in its debate about the future role of pharmacy technicians. For doctors, it is Physician Associates (PAs), Anaesthesia Associates (AAs), and Surgical Care Practitioners – collectively named as ‘Medical Associate Professions (MAP)’ by the Regulators, the Department of Health, the NHS, and others.
Healthcare skill mix models can work well, increasing capacity and improving the service. A good example would be in dentistry where dentists and dental technicians work hand in glove within a framework of clearly defined complimentary roles resulting in a superior service to patients.
However, in recent years, as the healthcare workforce has been put under increased pressure, a worrying trend has emerged where the structure of a clearly defined role has been replaced with a blurred thought process. When skill mix is replaced with role substitution, patient interest is evidently no longer being prioritised and issues around patient safety emerge.
During a recent visit to the World Health Organisation (WHO), I expressed concerns with the WHO Director of Health Workforce, Jim Campbell, about the lack of definition of the scope of practice of pharmacy technicians by the GB pharmacy regulator – the General Pharmaceutical Council (GPhC). Patients may not know who they were dealing with in the pharmacy; a master’s degree qualified pharmacist or an NVQ level 3 qualified, or even grand-parented, pharmacy technician. This was leading to a situation where members of the public were now beginning to raise concerns via their patient representative bodies in Parliament and elsewhere.
He explained that there was a strong policy move by WHO to encourage support staff in locations where there were no healthcare staff and therefore no alternatives in cases of emergency. Clearly, their training would not be of the standard of a fully qualified healthcare professional, but nonetheless, they still had a useful role to play. For example, a schoolteacher in a country in the Global South being taught how to handle anaphylactic shock in school children, or a postmistress or village elder given advanced first aid training to stem the blood loss from a farming injury are good solutions if the nearest doctor was more than 200 miles away.
Mark Koziol with Jim Campbell, Director of Health Workforce at the World Health Organisation (WHO)
However, it would appear that some advanced healthcare system countries (like the UK) have also been developing a heavy reliance on less well-trained groups of staff, not because of a better than nothing approach, but principally because it reduces costs and potentially the size of queues of those waiting to be treated.
You don’t have to be a rocket scientist to work out that the price paid for such an approach is a diminution of patient safety.
PDA members will already be aware that such is the disquiet in medical circles about the prospect of role substitution by MAPs, and concerns over safety, that the British Medical Association (BMA) and Anaesthetists United are taking legal action against the doctor’s regulator, the General Medical Council (GMC). In a previous PDA article, we explained that their concerns are very similar to those being expressed by many pharmacists about pharmacy technicians.
Recently, PDA officials met up with the doctors who are leading the legal challenge, and it quickly became apparent that their objectives are very similar to the solutions that are required in pharmacy.
The media has reported the concerns of the parents of an actor, Emily Chesterton, who had sadly died after a Physician Associate with only two years training had misdiagnosed her as having anxiety and a sprain, whereas in fact she had a clot on the lung. In a double page spread in the Mail on Sunday on 22 September, Mr and Mrs Chesterton described how they felt hoodwinked by the head of the General Medical Council when he tried to re-assure them that in future, regulation of ‘Physician Associates’ by the GMC would ensure that there would be ‘no more Emilys’.
However, they later discovered that the GMC was not going to do the one thing that would have made a positive difference, which was to define the limits of PA roles to stop them performing doctors’ tasks. The GMC explained that the government had not required it to limit the PA’s tasks, it just required it to set standards for their training and skills. It says that the Department of Health could have ordered the regulator to impose such limits, however, it chose not to.
The GMC explained that PAs should have some degree of supervision, this however, would not be specified by the GMC, but instead by employers. Furthermore, they explained that there is no need for the PAs to inform patients of their experience or qualifications.
In the letter seen by the Chesterton family, the GMC suggests that it might be the role of the Royal Colleges to set out some guidance on the scope of practice, however, Royal Colleges have no regulatory powers, and the GMC has not said it will enforce the guidance that they produce. I believe that this is a classic ‘whole system’ buck passing exercise that fails to deliver patient safety; the kind of thing that is historically scorned and ridiculed in one public inquiry after another following large-scale scandals – it is patently a disaster waiting to happen.
All of this of course sounds very familiar to the emerging situation in pharmacy, where the establishment loudly lauds and supports the ambitions of the pharmacy technicians, despite privately knowing that all is not well. As with the NHS and GP practice, pharmacy employers are currently capable of determining what the pharmacy technicians should be doing. In the case of pharmacy where we are largely an employee and locum profession, we know that the decisions of employers are significantly motivated by cost and organisational considerations.
Furthermore, the whole educational standard for pharmacy technicians is one where more than 50% of the current register had joined in 2011 at a time where there was no GPhC entrance examination; in effect, they joined via a grandparenting clause and even today, the GPhC does not have any records of their prior education.
The doctors are also concerned about the liberal use of the phrase ‘medical professionals’ which they have stated not only undermines doctors and the rigorous training journey that they have been on, but it also confuses patients. The PDA has argued for some time that the same applies in pharmacy, where the use of the phrase ‘pharmacy professionals’ gives patients the impression that pharmacists and pharmacy technicians could be on a similar level – which clearly, they are not.
As the GPhC takes a very similar approach to pharmacy technicians as the GMC will do for physician associates (that which has been pre-determined by the Department of Health), then the legal action being taken against the GMC by the doctors is very relevant to all of us in pharmacy.
The legal action being taken by Anaesthetists United seeks three things.
- Clear and enforceable definitions on what associates can and cannot do (their Scope of Practice) and clear rules on levels of supervision.
- The current ‘Good Medical Practice’ guidance replaced by two separate sets of guidance for the two separate professions. (In pharmacy we have one set of standards that applies both to pharmacists and pharmacy technicians).
- An end to the use of the ambiguous term ‘Medical Professionals’ used to describe two separate groups misleadingly. (In pharmacy, the government, regulator and the NHS use the phrase ‘pharmacy professionals’).
In pharmacy we have some very similar concerns about the performance of the regulator, the government, the Royal Pharmaceutical Society and the Association of Pharmacy Technicians UK. When attempts to raise sensible discussions about role definition, skill mix, defining scope of practice and the link to patient safety are made by the PDA, they are sometimes labelled as unhelpful and even toxic.
Just like with the GMC, no one appears keen to establish the scope of practice for pharmacy technicians and the blurring of the roles and responsibilities is getting worse. This was evidenced by the recent addition of pharmacy technicians onto the list of professions that can deliver Patient Group Directions (PGDs).
The PDA has already made clear that we believe that those pharmacists supporting the uncontrolled blurring of the lines between the roles of pharmacists and pharmacy technicians do nothing more than collude in the demise of their own profession and they damage the protections enjoyed by members of the public. The legal challenge against the GMC which is being crowd funded is therefore very worthy of our support.
The PDA will ensure that learnings from the legal case being taken by the doctors against the GMC will be used by the PDA in the public interest to support safe pharmacy practice.
PDA members have told us that pharmacists very much want to work alongside pharmacy technicians in a symbiotic skill mix model. We fully support working together with pharmacy technicians in a symbiotic way as doing so will help to deliver a wide range of new benefits to patients, but the discussions and agreements to ensure that this occurs are just not happening.
Instead, what pharmacists currently face is a seemingly uncontrolled ‘wild west’ which is being driven by the healthcare workforce crisis, employers who are exploiting the new regime, senior NHS pharmacy officials who are encouraging pharmacy technicians to push the boundaries of their practice beyond sensible limits, and a lack of decisive regulation. Meanwhile, various membership bodies are either waiting quietly in the wings or expressing enthusiastic support, perhaps eager to add some pharmacy technicians to their relatively small membership numbers?
I have today made my personal donation to the ‘crowd funding’ appeal and I would encourage PDA members to make their contributions too. Already £117,000 has been collected against the required £200,000.
The link to the crowd funding page can be found by clicking here.
Members can rest assured that the PDA continues to take a very close interest in this case and will maintain its contact with those who are seeking to challenge the establishment on this important matter.
The PDA will use the lessons in its pursuit of a sensible approach in the discussions around skill mix, scope of practice and the roles of pharmacy technicians in our profession.
Mark Koziol is Chairman of the PDA, Secretary General of the Employed Pharmacists of Europe federation (EPhEU) and a Council member of the International Pharmaceutical Federation (FIP)
Learn more
- PDA writes to Pharmacy Minister about the differences between pharmacists and pharmacy technicians
- BMA’s legal action over the term ‘medical professionals’ and implications for pharmacists
- Misdiagnosis: Bereaved mum calls for physician associate role clarity
- Stop misleading patients – Physician Associates cannot replace doctors
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