The dispensing dilemma


Pharmacy should think carefully before devolving its primary dispensing role, experts warn

While the current trend is for pharmacy’s clinical role and responsibilities to expand, we should be careful before we devolve too much of dispensing to pharmacy technicians or assistants, experts have warned. 

In his editorial in the Journal of Pharmacy Practice and Research, Professor Chris Alderman said “it seems that enthusiasm for participation in the work of dispensing prescriptions is waning among contemporary practitioners”.

Clinical pharmacy in its various incarnations (e.g. specialist practice in various areas of therapeutics, home medicines review, pharmacy practice in aged care), medicines information, clinical trials etc. are all favoured ‘practice destinations’ for younger pharmacists, he said.

“It appears that a career based in the safe and reliable compounding and distribution of pharmaceuticals is a less attractive option for those entering the profession in the early 21st century”. 

Professor Alderman warned that while there is “great enthusiasm for devolving the traditional tasks of the pharmacy profession to those who don’t hold pharmacy-related tertiary qualifications”, this push does need to be questioned.

“Once transferred out of the hands of pharmacists, the unmistakable signal is that the traditional pharmacy-specific skill set is not essential to deliver these job functions,” he said.

“While the pharmacy profession seeks to reposition these tasks with pharmacy technicians, a dispassionate observer might well ask whether another workforce group such as enrolled nurses might be equally (or better) suited to take on this task”.

“Viewed through another lens, pharmacy practice where the profession is potentially divorced from drug distribution is a rather bleak vision, raising a future where a strong, distinct and unique skillset and practice focus is compromised or absent,” he concluded.

Alderman’s view was supported in another article, by Danielle Stowasser, program director, Electronic Medication Management Program, Metro North Hospital and Health Service, Brisbane.

She said that “in order to ensure safe prescribing, the full gamut of medication services is still required. Of most importance is medication supply, without which there is no medication treatment”.

“Handing over these services to pharmacy technicians, or nursing staff, may leave no pharmacy oversight of these complex processes,” she warned.

“It also reduces pharmacist responsibility and oversight in ‘[analysing] patterns of clinical data to improve quality of care, patient safety, and care delivery efficiency’ or, more importantly for prescribing safety, the functions of reconciliation and recognising patient choice in their medication management plan”.

Previous Button battery access defect
Next Crackdown needed on ‘underground’ solariums

NOTICE: It can sometimes take awhile for comment submissions to go through, please be patient.

20 Comments

  1. pagophilus
    10/03/2018

    Bravo. Finally someone is thinking. (Or someone is finally brave enough to speak out.)

  2. Debbie Rigby
    10/03/2018

    Dispensing is the core role of pharmacists and always should be. But dispensing is far more than the technical pick and stick. By devolving this part of dispensing, we endanger the perception of the other part ie assessment of the safety and appropriateness of the prescription for the individual patient and their understanding of the chance of benefit and risk of harm. Wise words from Chris and Danielle.

    • pagophilus
      10/03/2018

      Nurses had the right idea when they protested a push to devolve some of their responsibilities to lower-paid, lower-qualified assistants. They said they value ALL parts of their job and whilst performing the more menial tasks they could potentially pick up on a problem that could be missed by a lower-trained assistant. Likewise with pharmacists and dispensing.

      Ultimately it all comes down to money. I still maintain that if you gave ONE pharmacist enough time to dispense a script from beginning to end (check the script, talk to the patient, check the medication chart and/or history if in hospital, select, enter into computer, label etc, and then also give that script out and counsel the patient) there would be fewer medication errors than by devolving part of the process to techs and having pharmacists only do the checking. When checking someone else’s work I doubt many of us are as thorough as if we were doing it all ourselves (without the time pressure to get onto the next one).

      • Jarrod McMaugh
        10/03/2018

        I tend to agree with you on most points, but there is something to be said for the role of an editor.

        That is, sometimes the person doing the primary work is too close to that work to see their own errors.

        When I receive an item that has been dispensed, I check all the same things I would do if I were dispensing it. I will find an error in someone else’s work far quicker than I will find my own.

        • The reality is that you can’t “devolve” the total process right up to final stage of the dispending process for the reasons already explained in various comments.
          I’d also be concerned if pharmacists believed that reviewing medication and counselling imvolved anything other than a form of clinical surveillance. Just because they are ambulant it doesn’t mean that the obvious clinical issues can be dismissed or delegated
          eg.potential side-effects and tolerability, no unexplained issues arising from the pharmacist reviewing medication history, clear understanding by patient as to dosage regimen,and the pharnacist answering any relevant queries or other issues on their overall health management that the patient has, just to name a few-because that is what pharmacists do best!

          • PeterC
            10/03/2018

            Apart from not being sure why you say “just because they are ambulant” Ron, I think this is a superb comment. In many ways dispensing (clinical) pharmacists who form a regular/ iterative part of the continuum of care are at a an advantage to non-dispensing pharmacists. I think that Zuboff’s Laws are also true and that automation, informatics and digital control and surveillance will tend to be inexorable and they will will transform healthcare, and this can be a good thing for clinical dispensing/pharmacy practice. There is no reason for pharmacists to be luddites about this, we can embrace technology and para-professionals without relinquishing clinical responsibility.

        • pagophilus
          12/03/2018

          But some people when checking go into lazy mode, assuming it’s largely done correctly, and the check becomes a rubber stamp.

          Or sometimes you check and you have to redo things and it takes you longer than it would have had you done the whole process from beginning to end.

      • Rohan Elliott
        10/03/2018

        While I agree that pharmacists should not totally devolve responsibility for dispensing and drug distribution, clearly there is a very important and beneficial role for employing well trained techs to assist with the non-clinical aspects. There is plenty of evidence that this frees up pharmacists to spend more time on patient care, and there is also evidence, including from an Australian randomised controlled trial, that techs actually make less dispensing errors.

        • pagophilus
          12/03/2018

          Evidence from one trial? Has it been replicated, by people who are not impacted by the results (i.e.non-pharmacists)? I often read studies performed by pharmacists and wonder whether the study was designed to get the result it did.

  3. pagophilus
    10/03/2018

    Or let’s think of it this way: Imagine a doctor did the groundwork to decide what to prescribe, and then devolved the actual scriptwriting to an assistant, and then only did a final check. Would there be fewer or more prescription errors?

  4. Grant Oswald
    10/03/2018

    I have been saying this for ages now. Let’s make sure we do what we are supposed to do properly and better than anyone else before we try and do something else. Dispensing and counselling are core to our patient’s health. Please let’s not forget this!!

  5. Jarrod McMaugh
    10/03/2018

    A lot of this article says is very true, in that the role of dispensing is far more than the technical/physical role of dispensing. Problems will arise if this technical role is “devolved” (i don’t agree with that terminology), and the clinical role is lost in the process.

    Unfortunately, I think a significant number of pharmacists have already done this – they are performing a technical role only, and not applying their clinical knowledge.

    This is the thing – dispensing is a clinical role. Professor Alderman’s quoted line discusses the attractiveness of “clinical pharmacy” but it doesn’t mention that dispensing is a clinical role. I perform my clinical role a few hundred times a day, yet the term “clinical pharmacist” is regularly used to describe pharmacists who do something other than dispensing – it shouldn’t be used as a term of differentiation.

    Pharmacists who dispense, pharmacists who compound, pharmacists who provide medical information, pharmacists who provide medication reconciliation, etc etc – these are all clinical roles.

    I spend much of my day in a community pharmacy – this is primary care. I can spend an hour dispensing 30ish prescriptions, or I can spend an hour with a patient who has a new sleep apnoea diagnosis and start them on a course of therapy. If you present these two scenarios to some people, they would describe the time I spent with 1 patient initiating treatment and counselling on their condition as clinical, while the hour of dispensing is not…. yet I make far more clinical decisions in that hour of dispensing that I do with a sleep apnoea patient.

    There needs to be a change in attitude – the role of dispensing is definitely clinical. It should be described as such, and it should be PERFORMED as such.

    • Geeta
      10/03/2018

      Agree with you 100 %… dispensing is not just a technical function but a cognitive one and you cannot / should not be doing dispensing without the clinical reasoning that is such an integral part of it. I don’t agree with the notion that ‘clinical pharmacy’ is what happens within the 4 walls of a hospital or in a practice or when u do an HMR.. if a patient walks in with a script and asks me about a prescribed medicine – I use my ‘clinical expertise’ to check whether the medicine is appropriate in all respects, ensure that there are no potential issues with other medicines they are taking normally, any CAMS they might be using as well as any OTC items they pick up from the supermarket etc etc… even if the question is about availability of a medicine, not necessarily ending in dispensing, and the query requires me to look up the evidence behind the use of the medicine and cost factors – I am using clinical skills – all the core functions of a pharmacist involve clinical skills. A pharmacist in a community pharmacy provides clinical pharmacy services within their scope of practice as much as a pharmacist in a hospital does or an accredited HMR consultant does.

  6. Andy Hawken
    10/03/2018

    There’s always some one trying to turn our profession into a passive income stream. If you are prepared to stand there in your Ben Casey, greet, pick, stick, talk and repeat, its a wonderful and honorable way to feed your kids. If you can still find a corner of the universe to do that now, you’re very lucky.

  7. JimT
    10/03/2018

    Pharmacists just don’t dispense. It depends very much on the situation he/she is in. One person show with no other staff, to pharmacist and front of shop staff, to pharmacist and disp. technician and front of shop staff, to pharmacist and disp. technician and front of shop staff and front of shop manager, to 2 or more pharmacists and all the extras to boot. Hence depending where you slot in will govern the type of work you do. I have worked in all the said scenarios as proprietor and salaried pharmacist over the 40 odd years of my pharmacist working life and have had to adapt to what was required in each work environment and what was required by the people above me. ONE size doesn’t fit all….not even close.Amen.

  8. Bluebottle
    10/03/2018

    All scripts should be entered by a pharmacist with consideration to the patients history and the dispensing fee should reflect the professional care (Techs can do the collating and ordering). Dispensing should be the backbone of community pharmacy not something you have to subsidise with OTC sales.

    • D.Pharm
      11/03/2018

      Bluebottle can you clarify, you say a pharmacist should “enter” the scripts, I take that to mean the computer keyboard ‘typing’ work as well as the history check etc., then who do you propose should check the completed “dispensing” and also who should hand the script(s) to the patient & provide any counselling needed or answer any questions the customer/patient may have? Do you propose the “tech” do that? or the same pharmacist who did the “entering” or a different pharmacist?

      • Bluebottle
        13/03/2018

        It’s always a personal preference but one option is;
        A pharmacist receives the script, enters the data and counsels in a forward position
        At the same time a tech does the collating
        A pharmacists checks and hands off to cash and wrap
        The professional interaction happens at the start rather than the end.

Leave a reply