Examination of Witnesses (Questions 500-519)
DR SALLY
PIDD, MR
ROB DARRACOTT
AND MR
BILL O'NEILL
15 JUNE 2006
Q500 Dr Taylor: Is that day release
or night release?
Mr O'Neill: Basically they are
full-time ECPs.
Q501 Dr Taylor: You lose them for
two years full time.
Mr O'Neill: The programme is two
years long. We get between one and two days operationally out
of them depending on the student themselves. There is a lot of
flexibility.
Q502 Dr Taylor: How does this fit
with regulation? Your paramedics are regulated by the Health Professions
Council. We believe there are nurses in training as ECPs as well.
Mr O'Neill: Yes, some.
Q503 Dr Taylor: Surely the training
should be regulated by somebody.
Mr O'Neill: It will be, I believe,
but at the moment it is not. The British Paramedic Association
would like to see the regulation brought in under the respective
regulation for each different profession who is involved in this
programme.
Q504 Dr Taylor: A separate bit in
the nursing to do that.
Mr O'Neill: Nursing for nurses,
and paramedic for paramedics. I know there are other opinions
that there should be separate regulation for ECPs, and to the
best of my knowledge that has not been decided on yet.
Q505 Dr Taylor: Your people in training
are not yet out on the road as ECPs?
Mr O'Neill: No, but they are regulated
as paramedics.
Q506 Dr Taylor: On the medical back-up
that you think they should have, your paramedics who are giving
thrombolysis presumably are connected to a cardiologist?
Mr O'Neill: We do not use thrombolysis
in London.
Q507 Dr Taylor: Because you are able
to get them to a centre to consider re-vascularization quickly
enough.
Mr O'Neill: Yes.
Q508 Sandra Gidley: Before I move
on to the questions I was expecting to ask, can I just pick up
on that. If you have different bodies regulating the same role,
could you not end up with differences between the regulation depending
on whether they were ultimately regulated by the nursing body
or the paramedics?
Mr O'Neill: I have to be honest,
this is not a specific area in which I am involved.
Q509 Sandra Gidley: I have some questions
for Rob Darracott, and I need to put on record that I am a member
of the Royal Pharmaceutical Society. The written evidence commented
that the role of pharmacy technicians and assistants has been
extended in recent years. You alluded to this earlier but I would
like some clarification. Has extending the roles of non-professional
staff made the overall pharmacy workforce more productive or differently
productive?
Mr Darracott: In so far as I think
that extending the roles of technical staff allows the pharmacist
to do different things, I think it has extended the overall activity
of the pharmacy profession as a whole.
Q510 Sandra Gidley: The submission
also says that there is a predicted gap between supply and demand
of pharmacists. Does that mean it would become more important
to have more technicians or other pharmacy staff that are not
actually pharmacists?
Mr Darracott: That would be one
way of plugging the gap, because a significant part of the role
of the pharmacy profession is the supply of medicines and you
could see that could be fulfilled in some way by various forms
of automation. That is one way of dealing with that. Automation
in itself is not the answer because machines are only as good
as the people who are operating them. It does change the balance
of what is required but also the productivity goes up in terms
of the actual handling of the medicines themselves. With 700 or
800 million medical prescriptions a year being generated in the
NHS, that is a continuing growing burden of purely technical activity
outside of the cognitive activity that goes alongside it.
Q511 Sandra Gidley: The submission
seemed a little bit cautious about extending the roles of junior
staff and I wondered why that was. Is it a sort of doctor/nurse
situation where sometimes you get doctors wanting to hang on to
their traditional roles? Do you have pharmacists feeling threatened
by pharmacy technicians taking on extra roles?
Mr Darracott: I am sure there
is an element of that within the profession. The submission is
a little cautious because we are in a period of change. We are
regulating technicians at the moment only a voluntary basis and
we are expecting to have the statutory authority to do that shortly.
We are in a process of change anyway, and before we get to the
point where we have statutory regulation of pharmacy technicians
I think it is right to be cautious as to what we will do. The
other thing we have embarked upon in the last six months is a
major review of our education policy in how we regulate the education
of pharmacists and the education of pharmacy technicians. The
statutory regulation of technicians really means that we need
to take a fresh look at how we regulate the education of technicians.
Something may then fall out of that. The key to all of this is
to identify the sort of scopes of practice. You have the scope
of practice of pharmacists changing as they explore and go to
new areas, something which has been supported by policy documents
from the Government here but also in the devolved administrations.
There will be a knock-on effect into exactly how we define what
actually is the technician's scope of practice.
Q512 Sandra Gidley: You mentioned
legislative change earlier and the Health Bill has provisions
for changing the way that the community pharmacy particularly
is supervised, so instead of the current situation we have the
pharmacists continually on the premises. That could actually change.
Does that not mean that there is a greater need for regulation
of technicians? What are pharmacists going to be doing if they
are not on the premises?
Mr Darracott: First of all, I
think the regulation of technicians is an important part of that
because any of the changes which are suggested may come about
as a result of the Health Bill will, if the pharmacist is going
to do other activities, either on the premises, which means they
are not in a position to directly supervise the supply of medicines,
it will require that activity, if that activity is going to carry
on without their direct and personal supervision, to be done by
somebody who is trained to do that. I would expect the pharmacist
not to leave patients in that position without that being the
case, but I think having regulated technicians is part of that
package. So whilst we welcome the flexibility that the Health
Bill offers and we look forward to the discussion on the regulations,
I think there are two other things which we will be very mindful
of. First of all, that any new system ensures that patients' safety
is not compromised; secondly, that one of the things we have talked
about often in office, that pharmacists are readily accessible
health officials. I think what you have alluded to is that if
we are allowing the flexibility for pharmacists to undertake activities
outside of the pharmacy then there is a question, therefore, about
how access to that service is going to be maintained. So in developing
those regulations I think we need to be very mindful of both of
those points: that patients' safety will not be compromised if
pharmacists are undertaking other activities, which I think fundamentally
requires the regulation of other practitioners within the pharmacy
setting, and secondly that we do not throw the baby out with the
bathwater and lose the access to the pharmacy service which is
currently available out there now, right now, walk-in off the
street and there it is.
Q513 Sandra Gidley: You mentioned
earlier that the role of pharmacy was changing and one of the
suggested questions, which I thought was rather unkind—I
will read it out, and I do not expect you to answer it—"Are
not most pharmacists over qualified for many of the tasks which
they actually perform given that prescribing is mostly done by
doctors and the majority of drugs are pre-packaged?" I think
that displays a lack of knowledge, personally, about what pharmacists
do do. I just wanted to put that on the record. Would it be fair
to say that the new contract gives pharmacists a lot of opportunities
to provide different services, but how is that actually benefiting
the patient when a lot of those services are just extensions of
what is happening maybe in a GP's surgery or could also be provided
by nurses?
Mr Darracott: I would answer your
initial question by maybe saying I notice that the NHS workforce
survey says that there is a 65% increase in the pharmacy staff
in the last 10 years in hospitals, and I say about time too. I
think what is very important is that what we are starting to use
now for the first time is the very expensive training that pharmacists
get in the use of medicines, and pharmacists are uniquely qualified
to deliver that service. Frankly, my view is that if those services
are delivered by anybody else because of the complexity of modern
medicines then actually we are not doing right by the patients,
and that the extended role begins to use for the first time, in
a fuller sense, the very training that pharmacists spend five
years acquiring.
Q514 Sandra Gidley: I have to say,
if I felt that my training had been used I probably would not
be sitting here today, I would probably still be a pharmacist;
so I have to concur with that. Finally, practice-based commissioning:
will pharmacists get a look in? Is there an opportunity for pharmacy
or will it be dominated by GPs?
Mr Darracott: It should be but
the earlier signs are not good. I think that is partly just the
way things are but also partly because of the pressures within
the service generally. But I think there is scope there and if
other health professions do not recognise and help that along,
then I think they are also missing a trick actually.
Q515 Dr Naysmith: Dr Pidd, I want
to explore what this role extension and substitution that we have
been talking about has meant and potentially could mean in the
future for mental health services. You have already mentioned—and
you have also written in evidence that you have submitted to the
Committee—that there is a shortage of psychiatrists in the
UK. So to what extent have mental health services compensated
for this shortage by extending the roles of other groups? Again,
you have already mentioned clinical psychologists this morning,
and the New Ways of Working Report, which I think you yourself
authored.
Dr Pidd: Undoubtedly one of the
drivers for new ways of working for psychiatrists was the chronic
shortage; we have historically had vacancy rates of 15%-ish for
psychiatrists, which remains stubbornly stuck almost whatever
we do, and it seems that we have so far failed to bridge that
gap. That has meant pressure on psychiatrists and their working
practices. So I think some of the driver for looking at how mental
health services as a whole can be provided does come from that
starting point. But I think there is also recognition that psychiatrists
have not always been doing things that only psychiatrists, only
people with medical training could do within the mental health
workforce; and also a recognition that we work within multi-disciplinary
and multi-agency teams. Therefore, looking at the skills at each
of those members of the team and how they can be enhanced to provide
a better use for the service users and carers I think has underpinned
all the work on new ways of working. Because alongside that we
were disappointed with the demise of the Modernisation Agency
because the Changing Workforce Programme was a big driver for
looking at developing new roles and extended roles and supplementary
roles to enhance the overall mental health workforce. So I suppose
it has partly been to make up for the lack of fully trained psychiatrists,
but I think it has also enabled us to think more critically about
what it is that each member of the mental health workforce can
bring to the care pathways of patients.
Q516 Dr Naysmith: It is interesting,
is it not, that when talking about the Choice Agenda—and
we are not here to talk about the Choice Agenda today—people
do suggest that one of the things that people using mental health
services would like would be the ability to chose their main worker,
whether it is the psychiatrist or clinical psychologist or a social
worker or a psychiatric nurse, and that ought to be a driver too,
ought it not?
Dr Pidd: Yes, I think it certainly
is. I think one of the problems about changing roles is that patients'
expectations sometimes do not match the workforce changes that
take place because often people say that they would like to spend
more time with their psychiatrist, whereas in fact under the CPA
arrangements the person they are probably likely to see most of
is their care coordinator, who may be from a number of different
disciplines but is unlikely to be a doctor. So I think there is
something about respecting patients' choice but also trying to
provide them with a rationale for why seeing a psychiatrist is
not perhaps what is needed on a weekly or a more regular basis,
and seeing somebody from another discipline can meet their mental
health needs in a better way.
Q517 Dr Naysmith: Have psychiatrists
been reluctant to give up tasks that have normally or traditionally
been allotted to them, to other staff groups? Has there been a
reluctance in the profession at all?
Dr Pidd: It is always very difficult
to generalise because psychiatrists are not known for being like
sheep, which are all of a same mind. There is undoubtedly a hard
core of psychiatrists, probably of an older generation, who have
a very clear idea what their role is and do not wish it to change.
I do not think that is true of the majority of psychiatrists.
We have all trained in multi-disciplinary settings and very much
see our role as to be part of a team, whether it is an inpatient
team, a community team, an Assertive Outreach team. So certainly
amongst the younger generation of psychiatrists there is an expectation
that their role is very different from that of a psychiatrist
who had their own huge caseload which did not really interact
with anybody's caseload at all.
Q518 Dr Naysmith: We have been told
that the new role of Graduate Mental Health Practitioner has not
been particularly successful in the sense that few local services
have made use of them. Is that true in your experience?
Dr Pidd: I am surprised that that
is what you have heard.
Q519 Dr Naysmith: It was the head
of the National Health Service Workforce Review, Judy Curson,
said that.
Dr Pidd: It is a relatively young
role and so I think it is perhaps unfair to make judgments at
this stage about it. I would guess most services have only had
the experience of graduate workers over the past two or three
years. Also, I think when graduate workers were first introduced
there was not a robust framework within which they could work,
so I think some graduate workers were placed into primary care
as a sole practitioner, and really with quite a limited remit,
without perhaps enough backup from other services. But I think
with the development of primary care mental health services, which
I think is going to continue apace in the coming years, the graduate
workers will be working alongside clinical psychologists or nurse
specialists with CBT skills; they will be working alongside counsellors,
they will be working alongside community psychiatric nurses who
are doing rapid screening and triaging of patients, as well as
offering short-term intervention. So I think the graduate workers
will find their place, and I think it is one of the problems of
workforce planning and workforce changes that sometimes not enough
time is given for new roles and new services to bed down before
a judgment is made as to whether they are going to be effective
or not.
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