Pharmacists: Exactly what the doctor ordered

'The nice thing about my job now is that it is all one-to-one'

This autumn, cancer patients at the Whittington Hospital in North London will be offered a choice of three different places in which to undergo chemotherapy treatment; at the hospital itself, at a local GP's surgery or in a high street pharmacist.

The innovative pilot scheme, being run in conjunction with the Green Light Pharmacy in Clerkenwell, not only offers more freedom for patients who can feel straitjacketed by their disease, but paves the way for community pharmacies to play an even more important role in primary care.

Postgraduate pharmacy student Helen Taylor, a cancer care pharmacist at the Whittington and the leader of the pilot scheme, believes that people with cancer often have strong feelings about where they receive treatment.

"For some people, the important thing is to avoid hospitals at any cost, but for others, the notion of going to a high street pharmacy for treatment would be a little like going into Tesco; even though the chemo will of course be administered by a trained nurse," she says.

"Privacy may be an issue if you are concerned that your friends and neighbours will see you going into a pharmacy, but at a time when most pharmacies have private consulting rooms for more confidential advice or services, this shouldn't be an issue."

While Taylor stresses the importance of pharmacists' skills in terms of managing toxicity and side effects in general, not all pharmacies would want the extra responsibility of cancer care.

Iqbal Gill, director of clinical commercial operations at the 1,524-strong Lloyds Pharmacy chain takes the view that pharmacies are better equipped to handle those services "where we have a recognised expertise."

He believes that while services such as diabetes testing and support for people with drug dependency are mainstream concerns for pharmacies, specialised cancer care work is, he says, "not an area in which we would feel confident."

There can be no doubt that the pharmacy profession is at a major crossroads.

Actively backed by politicians and health officials - both of whom want pharmacists to shake off their pill-dispensing stereotype and relieve the burden on GPs and hospitals still further - community pharmacists are offering a growing list of services that is getting increasingy complex.

Alongside emergency contraception, smoking cessation clinics, dietary and lifestyle advice and, in many areas, veterinary pharmacy for pets and working animals, a new generation of pharmacists are ready to offer advice and medication for anything from high blood pressure or asthma to diabetes, migraines and skin problems.

Many pharmacists are taking the opportunity to investigate a wider range of services for clients - including complementary therapies such as acupuncture and chiropractics - while routine pill-dispensing is left in the capable hands of pharmacy technicians; whose skills are also being upgraded.

Via the Medicines Use Review (MUR), high street pharmacists are already bridging the gap between a GP prescribing a drug and a patient taking the first dose.By actively talking to patients about what they like and don't like about their medicines, pharmacies are helping reduce the millions of pounds of waste caused by disaffected patients flushing their pills down the toilet.

More significant still is independent prescribing; a radical move which will for the first time allow pharmacists to sign peoples' prescriptions as well as dispense them.

While GPs will continue to diagnose what is wrong with their patients, independent prescribing - which will be rolled out in full next year - allows pharmacists to prescribe the drugs they think are appropriate to an individual's condition, without first having the t's crossed and i's dotted by the patient's doctor.

Although supplementary prescribing has been a reality for three years in many areas, with GPs and pharmacists working together on prescribing the right medication, the advent of full-blown independent prescribing is seen as a final part in the jigsaw for the pharmacy profession.

Independent prescribing was given the political go-ahead last April, but the precise nature of the academic content needed to back it up in pharmacy training was only given the green light at the beginning of August.

Under the new arrangements, pharmacies will eventually have full electronic access to GP and hospital patient notes so that they can make informed decisions about what patients or clients need. Robert Clayton, head of practice at the Royal Pharmaceutical Society and a pharmacist for over 30 years, says that the brave new world of the high street pharmacy is "both exciting and scary at the same time."

"There will be some pharmacists in their fifties who don't want to offer medicines for horses, or run clinics to prevent coronary heart disease in humans, but I predict that over the coming five years, we will see a new type of pharmacist emerging," he says.

"The new professional will see it as his or her duty to become very much more involved in public health and disease prevention," he says, "and will be as far removed from the notion of a robotic pill-dispenser as it is possible to be."

While on the face of it, it may look as if pharmacists are simply trying to take on the mantle of medics, Clayton believes that there remains a very clear distinction between the two roles.

"The idea is that the medics should have more time to concentrate on diagnosis while we are given more of a free hand with the medication," he says.

"We are the pharmacology experts who understand how a medicine will work and how well it will be tolerated and it makes sense for our expertise to be used far more widely throughout the primary care system."

Iqbal Gill believes that after many years of talk from the Government about using pharmacists' skills more intelligently, change is now happening. "One of our most important innovations at Lloyds has been the introduction of a free diabetes diagnostic test; not just into a few pharmacies here and there, but nationwide in all our stores," he says.

"We have completed more than 830,000 tests since 2004 and have referred 60,000 people to their GPs for further investigation; some of whom have told us that the discovery of excessive sugar levels in their blood has helped save their lives.

"We wanted to prove to the health service that we could take a really frontline role in primary healthcare and that's just what we have now done."

According to Clayton, there are two basic things that clients want from community pharmacists. One is a private consulting room where they can talk confidentially about their problems and the other is to see the same pharmacist each time they visit.

"People want to get to know their local pharmacist and feel that he or she understands their needs," says Clayton, "just like they want to see the same GP and not a strange locum.

"I believe that these two things will continue to be delivered as pharmacists are encouraged to come out from behind their dispensing counters and have an even more proactive relationship with their clients."

Hooman Ghalamkari, 36, runs DG Pharmacy in Dines Green, Worcester. The pharmacy offers specialist support for diabetics, podiatry services and a drop-in session with a local diabetes nurse specialist.

We are based on a council estate with 6,000 residents, but no doctor's surgery, so we are the closest thing to a local health facility. We began by offering prescription collection, delivery and checking to the father of a boy with diabetes, but we now have 150 diabetic patients on our books.

Because we see the same people day after day, and we are able to answer their queries without using technical terms, in an informal atmosphere, we have built up a real rapport with them.

Before we started the service, patients would be given medication that they either didn't want or felt they didn't need and the waste of resourves was enormous. It is important to get these things right rather than issue them uniformly without knowing exactly what each patient needs.

It seems to me that any pharmacist can offer a routine collection, delivery and checking service for customers and more of these services should be introduced.

Fiona Reid, 43, is primary case pharmacist for cardiovascular diseases at the Newbyres Medical Group in Midlothian, Scotland. Based at two GP surgeries, she runs clinics for people who have either had, or are at risk of developing coronary heart disease or strokes. Reid has been a supplementary prescriber for three years.

My background is in hospital pharmacy, where you would do ward rounds with a group of health professionals. The nice thing about my job now is that it is all one-to-one.

The GP and I come up with an individual plan for each patient and then I prescribe the appropriate drugs.

Because I see my patients on a one-to-one basis, I build up a rapport with them. If medicines work and are given to them on time, safely and effectively, I think most patients are happy for people other then their GP or hospital doctor to prescribe for them.

But I think we do need a publicity campaign to explain independent prescribing so the public is up to speed with how things are changing.

In the last 15 years, we've been able to do just about anything apart from actually signing the prescriptions.

Now this is happening too and it all makes perfect sense.