SINCE taking office last year Scotland’s Chief Pharmaceutical Officer (CPO), Professor Rose Marie Parr, has made significant efforts to engage with the profession at all levels. She has visited every health board in Scotland, and pharmacies in many locations from hospitals, to prisons to community to get a feel for the issues they face, has attended and spoken at many conferences and events, and now has regular monthly meetings with Community Pharmacy Scotland (CPS).
It’s easy to see why the consensus of opinion is that Rose Marie Parr is one of the best things to happen to pharmacy in Scotland for quite some time. The enthusiasm she has generated is palpable.
So, how does she feel about her first year in the job? “I’ve been really happy, comfortable and passionate about the pharmacy bit, but I’ve had a steep learning curve around the policy areas, as it’s all new to me. I’ve seen bits of it, but seeing it from the inside is quite different, and it’s a whole different culture in civil service compared to the NHS, and I’ve only really worked in the NHS.”
Despite this however, she says “It’s a fantastic job, it’s one of the best jobs out.”
So, has she achieved everything she wanted to in her first year? “Absolutely not,” she says emphatically. Despite the inevitable frustrations caused by passion and determination coming up against the realities of working within a complicated system, she is determined to keep working on her 5 strategic areas:
- Pharmaceutical care
- Safer use of medicines
- Evidence base and outcomes for pharmacy
- Strategic engagement
- Pharmacy profession and professionalism.
So, how much personal influence does the CPO have on policy? “The good thing is, I don’t think any one person has complete autonomy, and I think that’s probably safe. We probably wouldn’t want that.
“My role is more about strategic engagement and being more collegiate and actually, it might take a bit longer, but it’s the right thing to do.”
So how do we ensure grassroots pharmacist are involved in this process and any changes are achievable and realistic?
“Community pharmacy is the bulk of our profession and we definitely want them to move on with the changes around primary care, prescribing and pharmaceutical care. We want vibrant community pharmacies that are sustainable and can focus much more on patient care.”
However, for this to happen, the focus of the community pharmacy contract needs to change, she explains: “How do we get to a place where the contract is much more focussed on patient care and pharmaceutical care and less on items of service?
“The future for me is about a clinical, digital future.”
This means “IT has to be enabling”, as there are still “£1.5 billion worth of prescriptions that need to be dispensed. We need to think of clever ways for pharmacists to have more clinical engagement and that’s what Prescription for Excellence (PfE) is all about,” she says.
It’s easy for civil servants to sit in their offices and have no understanding of what’s happening on the ground, so when did Rose Marie last spend some significant time in a community pharmacy “last week,” she says, and it sounds like this is a regular occurrence.
She explains that it gives her “more insight into what the problems are” and “credibility for the things we are doing, as I can speak from the heart, as I have seen it.”
Rose Marie has a firm understanding of the benefits of community pharmacy: “A vibrant community pharmacy that is local is absolutely a brilliant place to be. It’s the pharmacist who understands the social, behavioural and cultural issues around that area, and you want to make the care for those people appropriate.”
She is acutely aware of the wider contribution community pharmacies makes to communities and the importance of safeguarding access: “Sometimes you don’t know what you’ve got until you lose it, and if you lose it, it would be very hard to get that back.”
The problem for community pharmacy, however, is that while there are “really strong and powerful stories” about the contribution of community pharmacy, “the profession isn’t very good at publishing and disseminating them”.
So what services should be introduced into community pharmacy as a priority? “Clinical pharmacy services, so being more patient focussed with medicines.”
This means “refreshing Prescription for Excellence and sorting out a model of pharmaceutical care, not just in GP practices, in community too.”
Patient safety is an important area that needs tackling, she says: “too many medicines are not taken or not taken incorrectly. There’s lot’s of information on the internet about medicines, but there’s no intelligence, that’s where where pharmacists come in.”
With that in mind, what about pharmacist access to patients records or the summary care record? “I would absolutely want pharmacists to have access to patient records in going forward. For me, it is a very important enabler to allow pharmaceutical care to happen, and it is a patient-safety issue. At present when pharmacists are talking about and potentially prescribing for people they do not have the full story around their medicines.”
“It is most definitely on my list of issues to take forward, and we are currently trying to progress this as soon as possible.”
However the challenge, as always, is making time for this, how do we do that?
“It has to be about how we do the processes better,” she says, and that is about “automation and skill mix”, and there is also a need to “free up of some of the quite old legislation and regulations around pharmacies to enable this”, which would include “all the quality assurance systems that are in pharmacies, such as the superintendent, the responsible pharmacist, pharmacists and their team. How do we ensure that is more about patient care and some of the older legislation disappears?”.
These changes had to be “more enabling, so that pharmacists were in control,” she says.
Digital and clinical future
Moving forward also means making better use of technology, and the refresh of PfE would address this: “We want to refresh e-pharmacy where some of the IT enablers are. We know it’s clunky, so we’ve brought back the e-pharmacy team and so hopefully we’ll address some of these issues.”
This includes improving the IT for the Chronic Medication Service (CMS), and sorting electronic prescribing for independent prescribers, as the current paper system was “a barrier, and patient safety issue”.
It’s fair to say that CMS has somewhat stalled since it was introduced in 2006, why is that?
“When I started, I did my rounds and I got the message CMS is broken, either kill it, or cure it, and that message was very standard across Scotland. When looking into it a wee bit further, the principal is right, but the enaction of it is not very good.”
CMS needs to be looked at, says Rose Marie, and she believes there are some critical changes that need to take place: “We need better GP engagement, as they don’t understand it and they don’t like it until they do understand it and it gets some wins for them.
“We also need to make sure that it works for patients, we definitely need patient engagement as I don’t think we’ve got that and they don’t understand it, and we need the IT to work better.”
So far in Scotland, we’ve had a less bumpy road than contractors in England, and perhaps Rose Marie’s approach is different, as she believes in “collegiate working with our contractor body and others to allow us to take some of the clinical agenda forward”.
And so far, this seems to be working well: “In the year I’ve been here, I’ve had nothing but positive conversations with CPS. It doesn’t mean to say we always agree, but we’re talking and we talk regularly, and we talk a relatively similar language.”
However, Rose Marie is aware that there are inevitable challenges: “I think generally in the health service, because we are in tighter fiscal challenge, it’s going to be really tough, there is no money. But it’ll make us do things differently.”
The advantage for Scotland is its size: “we’re small enough and we know enough of each other to allow us to make some of these things happen, and you see pockets of it all the time. Some health boards are working fantastically, how do we mainstream that? How do we make sure something that happens in Highland will work in the Borders?”
Another issue is sharing evidence and outcomes better: “There is not enough dissemination of good practice, or research to show that we are doing a good job. Our evidence base needs to grow a bit better,” she says.
So turning to evidence, what is Rose Marie’s view on evidence-base of products sold in pharmacies? “Do no harm comes into it. I have no problem with people buying things as along as they are aware they may well be placebos.
“Personally, I think as pharmacists we are scientists, and so we should work in an evidence-based way and we should be seen to do that.
“For me, homeopathy can have a role if we say there is no evidence for it, being honest and open is the thing. If things don’t work, we should be big enough and man enough to say that.”
Turning up the volume
With ambitions to provide more pharmaceutical care, what about the prescription volume issue? “There is no easy answer to volume, it will include the use of automation and skill mix to free up pharmacists to be their own masters about decision-making, so they are not tied to the bench or prescription volume.”
Does this mean there was a possible threat to community pharmacy with dispensing hubs and a possibility of losing the supply side and associated income? “I don’t think so, I haven’t had that discussion. The challenge is freeing pharmacists’ time for clinical roles.
“But the issues around supplying medicine will still be there and the prescription volume isn’t going to disappear, if we can help through automation and skill mix that’s the thing to do.”
However, Rose Marie is aware of other issues which impinge on pharmacists’ time, and she says its important to reduce the amount of time pharmacists spend on things that weren’t patient focused. Although, she also knows that for some of it they have no choice, such as dealing with medicines shortages and monitored dosage systems (MDS): “Some of the MDS stuff is frustratingly wrong, it’s a cost issue for me, as people are just transferring costs onto community pharmacies to put pills in boxes.”
One of the first things she did when she took office was try to make headway to tackling the MDS problem, but admits it is slow progress: “We need to stop doing this, there are patient safety issues. I’ve heard stories that would make your hair curl. Most people understand the issues, but the solutions are sometimes more difficult. But we need to do it.”
One of the aims in PfE is for all pharmacists to be independent prescribers, is that going to plan? “We are getting there. There are over 1,000 prescribers in Scotland and people are still going through the training and are keen to do it.” Rose Marie believes all patient-facing pharmacists should consider doing the course, as well as training on clinical and consultation skills where appropriate.
“I hope the refresh for PfE will clarify some of that and prioritise it, so for me it’s about not having targets that are less appropriate, but about patient care and being iterative about it.
“The PfE refresh is coming to an end, and we are quite clear on where we are going next. It will focus on some of the hot areas, such as how pharmacists and their clinical skills can help GP practices.”
So, can these roles also be done in community pharmacy? “Absolutely and I would want that to happen. It’s appropriate that some things do happen in GP practices and they are part of that team, but that’s not the end of it, I see that as a real continuum.”
She would like to see pharmacists specialising in a range of subjects, not just in primary care, but also in community pharmacy as well, and transfer of skills between existing boundaries to benefit patients, which would also result in the creation of interesting career options.
This means that instead of focusing on sectors, focusing on the range of skills pharmacist have, and where they are on their professional experience and what they can deliver.
So, is the Royal Pharmaceutical Society (RPS) Faculty useful for helping to develop this? “I think we need a career framework that works for us in Scotland, why would we not use something that is there already? People would have that recognition of what they have done in their career, and the Faculty is one way of doing that. How can we use the Faculty for other things, such as professional leadership to allow pharmacists to articulate and be recognised?”
What about pharmacy technicians, should they be allowed to be members of the RPS? “The technicians as a registered profession need a professional body, but in Scotland there are very few who are member of a professional body. So, if it’s not meaningful for Scotland, then we need to look at options that does make it meaningful.
“I would have no problems if they had allegiances with the RPS. In Scotland there is a vacuum, so that needs to be progressed and if technicians want that to happen we should support it, but it’s not progressing just now. It should be more important for us for pharmacy technicians to have a professional body that is strong. Why would you not want that?”
With recent claims of corporate environments affecting professional autonomy, does the profession have a problem?
“I think there are always going to be issues around how we translate some of our policies such as the Minor Ailment Service and CMS. We need to get it right, so that people do the right thing.
“I think pharmacists do need that strength, that autonomy. For me it’s about professionalism. We are professional people, we are registered, it’s my registration and no one else’s, no one can take that away from me, but we also need a strong leadership body and regulator to function in that way. Professionalism is the answer to that as a team. We have to be brave sometimes, but it is the right thing to do.”
So, what does Rose Marie want pharmacists to deliver for her?
“Continue to talk to me, and show me the areas they continue to excel in patient care. Give me some feedback that I can use to shape policy to enable pharmacists to do what they are good at.”
This means focussing on patient care: “I think that’s what the profession wants, it’s an exciting future, but how do we get to that? It’s frustrating that we aren’t able to do it really fast, but we will work with the profession to do it.”
So, does she have any key messages for pharmacists?
“There’s a really positive future for pharmacy and community pharmacy. There is a clinical, digital future, but we need to get better with the IT and we need to allow pharmacists to focus on pharmaceutical care.
“The Future is really bright for pharmacy. We’re wanted everywhere, but we need to be really sure that we work in a safe and effective manner.”