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19 September 2019

Earlier this week we began publishing pharmacy inspection reports for the first time. This is a significant milestone in pharmacy regulation and will give the public and the pharmacy sector access to a wealth of information that they can use to inform the decisions they make.

Publishing those first inspection reports on our new pharmacy inspections site was the culmination of many years of preparation and planning.It required a change in the law, supported by governments across Great Britain. We then held a public consultation on our plans to publish reports, and what we heard through that consultation really helped to shape our final approach.

Our team of inspectors have been working very hard to get ready for this major change, including making sure that the reports they write after each inspection are clear and useful for patients and the public and for the pharmacy team.

We believe that being able to find out the outcomes from pharmacy inspections will give greater assurance to patients and the public that almost all pharmacies are meeting standards.

Where a pharmacy has not met all the standards, the pharmacy’s improvement action plan will also be published. Members of the public taking part in the consultation told us that they wanted to be able to see improvement action plans, so they could be assured that improvement was underway. They wanted to be able to see what steps the pharmacy was taking to meet the standards, and to know that this was being monitored by our inspectors. Members of the public were also significantly more likely to say they would use a pharmacy that had not met all of the standards if they knew that the pharmacy was completing an action plan, when compared to if they didn’t know an action plan was in place.

Another key priority for us is to help promote improvement in pharmacy practice, by sharing what we have learnt from inspecting pharmacies.

We have published a new report sharing what we have learnt from carrying out over 14,000 inspections covering every registered pharmacy in Great Britain since 2013. Something that came through strongly to me when reading the report was that pharmacies will only perform well against the standards if pharmacy owners have made sure that their pharmacies have the right governance, systems and culture in place, and are investing in their staff. Once these elements are in place, the pharmacy staff are then able to deliver good and excellent practice for the patients and the public using their services.

To support pharmacy owners and the pharmacy team to deliver good and excellent practice, we have developed an online ‘knowledge hub’ for the pharmacy team, with short anonymised examples of notable practice identified through pharmacy inspections. This knowledge hub was developed in response to feedback from the pharmacy sector about how useful they found examples of notable practice shared by the inspectors during inspections.

You’ll see that the knowledge hub highlights examples of excellent, good and poor practice for the key themes identified by the report on our learning from inspections, as well as examples for the standards that have a key role in driving performance and the standards that are most commonly found to be not met. We will be regularly updating the knowledge hub with new examples, so make sure you regularly visit to see what’s new.

We hope you find the new information we are publishing helps you and your team to continually improve the services you provide to patients and public. And we want to continually improve the information we make available, so please do let us know your feedback about the new site. You can do this quickly and easily via the link at the top of each page on the new pharmacy inspections site.

Inspection visit

Aamer Safdar is one of our Council members who joined our Council in March 2019. He recently went with one of our inspectors on an inspection visit as part of his induction. 

Aamer reflects in the blog post below about his experiences and on how inspections can help the pharmacy team:

I recently took time off work and had the pleasure of visiting a community pharmacy with a GPhC inspector to observe what they do and learn as much as I can about the process. The pharmacy that we visit is part of a health centre. It’s very small, with one pharmacist and a couple of assistants.

As all GPhC inspection visits are now unannounced, the pharmacist- who is also the owner- has no idea we are coming. She is initially shocked when the inspector introduces herself, but soon calms down as the inspection process commences.

I observe while the inspector asks questions based on the inspection standards in a conversational manner, which is not what I was expecting! This is not the enforcement style with questions about why standards were not being met that I had anticipated. The approach is very supportive and helpful, even when some of the more important standards have not been met.

The inspector goes through a raft of standards, which include checking of expired medicines, temperature monitoring, standard operating procedures, controlled drug registers and storage of medicines. What pleases me most is the focus on the training of the support staff who are working in the pharmacy. This is an area close to my heart.

As there are times when the pharmacy is busy, the inspector allows the locum pharmacist who takes over from the pharmacist owner to get on with his duties, and I take the time to learn about the role of a GPhC inspector. We discuss a wide range of things in snatched conversations: the pressure that inspectors can feel when discharging their duties, how they write up their reports and how are these are quality assured in preparation to be published. The inspector also explains some of the difficulties, such as knowing what training is suitably accredited and recognised by the GPhC. We even have time to talk about community pharmacist independent prescribing.

I have learnt a lot from this visit as it has given me reassurance that the inspectors are diligent in their work and are focused primarily on the inspection standards whilst keeping patients and the public in the forefront of their minds. They are obviously there to help the pharmacy team as well and do this in a positive and helpful manner.

29 July 2019

I am not a pharmacy professional, so I am not able to register or revalidate with the GPhC. But for my Regulate blog this month, I have nevertheless chosen to write a reflective account. I have followed the revalidation framework and the standards for pharmacy professionals. In lots of ways they are very relevant to my 'practice' as a regulatory professional in a leadership role within the GPhC. I also wanted to test out for myself the revalidation guidance and resources on the GPhC website. 

The typical users of my services

My colleagues in the GPhC provide services for and work with:

  • pharmacy professionals and people preparing to join the professions
  • pharmacy owners, and employers of pharmacy professionals 
  • providers of pharmacy education and training
  • pharmacy representative and leadership organisations and a wide range of other organisations and agencies including government and NHS bodies and other regulators 

Although we work with all these people and more, we operate on behalf of patients and members of the public using pharmacy services, and in their interests.

How I meet the selected standards for pharmacy professionals

This year, the GPhC has asked pharmacists and pharmacy technicians to reflect on one or more of these standards:

  • standard 3 - pharmacy professionals must communicate effectively
  • standard 6 - pharmacy professionals must behave professionally 
  • standard 9 - pharmacy professionals must demonstrate leadership

I have chosen to reflect mainly on standard 3 (effective communication). I have re-read the standards as a whole, focusing particularly on what I can learn from standard 3 and how it applies to my work. Although I do a lot of talking and writing in my job, listening actively and attentively is essential in order to try to understand and empathise with the point of view and experience of people affected by my work. This was brought home to me really powerfully when I met with a number of women whose children had been affected by exposure to Sodium Valproate in the womb. I was really humbled by the dignity and compassion of the women I met, whose response is to work tirelessly to help reduce the risk of other families experiencing the same avoidable harm. Their example has motivated me to keep exploring what more we can do- with others - to achieve that same goal.

Working to try to understand, as well as I can at second hand, the day to day reality of practice for pharmacy professionals, many of whom are experiencing stress associated with workload and resource pressures, is another important communication challenge requiring more listening than talking from me. This was why it was so important for me to attend a round table event we organised to hear about the challenges which individuals and organisations are facing in implementing the guidance we have issued on safe and effective pharmacy team working

Reflecting on these two different listening experiences has helped me see an important connection between them, which is about understanding the obstacles which decent caring professionals can sometimes face in doing the right thing for patients and their families. A constructive regulatory response needs to be part of an ongoing collaborative effort to improve standards of care, in the way that many pharmacy technicians and pharmacists themselves are so passionate about.

We produced information on the safe supply of sodium valproate and sent it to all pharmacy professionals on our register. What we need to do now is understand how effective that was in making a difference to the decisions made by pharmacy professionals on behalf of patients and the public. This is something we can do through our collaboration with organisations who share responsibility for medicines safety and through our analysis of the learning that pharmacy professionals have done as part of revalidation.
 

30 May 2019

We often hear that the way pharmacy services are delivered will change significantly over the next five to ten years - but the pace of change was really brought home to me when I looked through the information about our proposed guidance on prescribing. Since 2016, the number of independent prescribers on our register has gone up by over 4,000 - which is more than double.

Although this is just a number, behind it are many pharmacy professionals taking on different job roles, working in multidisciplinary teams, in a greater variety of settings, and using new technology.

We want to make sure that we understand these changes and are able to respond to them - focusing more on proactively anticipating and responding to issues, and tailoring our responses to get results in the best and quickest way. To do this, we have begun work on a longer-term, ten-year vision and strategy.

As a first step, we need to understand more about how pharmacy professionals work now. To do this, we have commissioned Enventure, an independent research company to ask you to complete a survey about your role as a pharmacy professional as it is today.

This is the first time we have gathered data about the roles and responsibilities of pharmacists and pharmacy technicians since 2013, and we’re interested to see what has changed, and what hasn’t – we’re keen to share the results with you.

We want to get the most out of the information you give us, so we will also be sharing the same anonymised data we receive with other organisations who are responsible for workforce planning in all three countries of Great Britain.

I hope you’ll look out for an email survey invite in the coming weeks.  Your information will help us understand what pharmacy looks like now, and provide a sound basis for our future strategy.

21 March 2019

As an organisation, we are committed to promoting equality, valuing diversity and being inclusive in all of our work.

And this commitment is not just to make sure that we are meeting our duties under the Equality Act 2010. It is because we strongly believe that every action we take, every decision we make, should be fair and inclusive to everyone, and we should make sure we are eliminating discrimination in every area of our work.

Our clear aim is to build equality, diversity and inclusion into everything we do. For this to be effective we need to be continuously challenging ourselves to look at our processes and to evaluate the information about how they are working.

One key area of our work is the fitness to practice (FtP) process. Although a very small proportion of pharmacists and pharmacy technicians are ever involved in the fitness to practise process, it can have a significant impact on them. It’s important to do everything that we can to make sure that the process is robust and fair for all involved, starting with how and why concerns are raised with us.

We have previously looked at our data and shared high-level reports on fitness to practise and equality and diversity. These show some trends that we need to do more to understand, including that Black, Asian and minority ethnic (BAME) pharmacists are more likely to have fitness to practise concerns raised about them than White pharmacists.

We already use a variety of mechanisms to assure good decision making, including eliminating discrimination from decisions.  This includes unconscious bias training for decision-makers and using decision-making guidance at each stage of the process for both our investigative staff and independent panels. We also quality assure our decisions, both during the investigation and after the final decision.

This coming year we are planning to review and update our strategic approach to equality, diversity and inclusion, looking across all our regulatory work (not only Fitness to Practise) to see what further opportunities there are to use regulation actively to promote this agenda, as well as continuing to eliminate any scope for discriminatory decision-making. We expect this review to include building our understanding of what the data are telling us and to look at practical measures such as the role of inspection in promoting equality and eliminating discrimination in pharmacy services, as well as considering the possibility of extending anonymised decision-making within the GPhC.

We will share the results of this work and keep you posted, as well as asking for your help and engagement.

17 January 2019

You will have seen that last week, the Prime Minister launched the NHS Long Term Plan in England. This document, put together by NHS England and NHS Improvement following a consultation with the sector, provides a vision for the NHS in England over the coming decade. It emphasises clear role for pharmacy professionals as part of NHS multi-disciplinary teams. The Scottish and Welsh Governments have also previously underlined the importance of strengthening the role of the pharmacy team through their national strategies, including ‘Achieving excellence in pharmaceutical care’, and ‘A healthier Wales’ respectively.

Revising the standards of initial education and training for pharmacists

The role of pharmacists continues to evolve at pace in response to changes in the sector and in pharmacy practice. Every day we see the vital role that pharmacies play in delivering care and in helping people to maintain and improve their health and wellbeing. As it is for other healthcare professionals, the pharmacist’s role is a flexible one and varies between settings and sectors. Whatever the circumstances, pharmacists are experts in medicines. The role’s flexibility means that pharmacists can work in registered pharmacies; in primary, secondary and tertiary care; in nonhealthcare settings; or in combinations of these.

Importantly therefore, initial education and training also needs to evolve to reflect these changes so that pharmacists are equipped with the skills they need to develop new services. The standards of initial education and training we set for pharmacists are vital in making sure that pharmacists are appropriately prepared to deliver pharmacy services and improve them. The initial education and training of pharmacists must give them the necessary knowledge, attitudes and behaviours to successfully take on their roles and provide safe and effective care for the people using their services.

On 9 January, we launched a landmark consultation to modernise the initial education and training of pharmacists. Our proposals seek to give pharmacists the knowledge, attitudes and behaviours they will need to be prepared for future practice.

We recognise that our proposals may present a number of challenges for course providers, employers, commissioners and students, and may involve some difficult decisions. But we also believe it is the right time for us all to think innovatively about how education and training needs to change so that the pharmacists of the future are fully equipped for the roles they will need to play.

15 November 2018

Pharmacists and pharmacy technicians are often the last health professionals that patients will see before they take their medicines. 

As such, the conversations that patients and the public have with pharmacy professionals during these interactions help patients make informed decisions so they can manage their treatment and care in the best way for them.

In order to safely and effectively undertake the role, it is fundamental that professionals keep up to date with the right skills, knowledge and behaviours required of them. This also means ensuring that the right procedures are in place and are followed. 

In this issue we look at the safe and effective supply of medicines in practice. In our ‘focus on’ article we have outlined a case study around the drug sodium valproate. As you know the consequences of dispensing this drug without following the set procedures could be serious, so please do take a look and re-familiarise yourself with the requirements when dispensing.

We know many of you are currently playing a critical role in making sure people are receiving the flu vaccine. In this issue, we are also encouraging all of you to protect yourself, your patients, your colleagues and family by making sure you also get the flu vaccine. By protecting yourself, you reduce the risk of spreading flu to patients and your family and of disruption to your services.
 

27 September 2018

In 2016 I told you about my New Year’s resolution to start using social media. Half the world now has a social media account in some form, and we know it has advantages. It can be an extremely useful way to speak directly to people you would never otherwise have access to, learning and listening, discussing and developing new ideas.

We have also seen some very positive benefits for patients through social media. The #HelloMyNameIs campaign for example, launched by Dr Kate Granger MBE as she fought and sadly lost a battle with cancer, asks all health professionals to introduce themselves by name before speaking with those in their care. This simple campaign has been taken up widely across the NHS and beyond, winning awards for its compassion and effectiveness for patients. 
Unfortunately, as I said in my 2016 post, despite the many and varying positives of social media, there are some decidedly unsocial trends flourishing. It seems online forums are used too often to bully, ridicule or embarrass, rather than inform and enlighten. Perhaps because we can upload our thoughts at the touch of a few buttons, we do so unthinkingly, without fully considering the consequences. It can give a megaphone to words that should only be said in private, if at all.

For me personally, social media was not something I wanted to continue with after my first dalliance. However, we do use social media regularly and positively at the GPhC. For instance, we tweet from our Council meetings to keep you updated, respond to questions and queries and provide links to our latest consultations and events through our social media channels.

We know that many of you are also using social media in both your personal and professional lives. We would encourage everyone to look again at the guidance we published on Demonstrating professionalism online in 2016,  which offers practical advice to help you use social media successfully and to continue to meet the standards we set:

Do:

  • act professionally
  • treat people with respect
  • maintain confidentiality and privacy at all times
  • maintain proper professional boundaries
  • think before you post, privacy settings do not mean that something will remain private and a statement that these are your own views means little in practice

Don’t:

  • bully, harass or intimidate
  • unlawfully discriminate
  • post inappropriate comments
  • share information about patients or their care
  • get drawn into negative, unconstructive discussions

We thought it may also be useful to have the perspective of someone working in the health world who themselves uses social media successfully within their role.  And so in this edition’s ‘focus on’ article, we asked Shaun Lintern, the Patient Safety Correspondent at the Health Service Journal and a regular user of social media, to give his advice on how to get the best of social media, and steer away from that less inclusive side. 
In this edition we are also outlining some important information about revalidation - so do take a look, and we are highlighting an exciting opportunity for three registrants to become members of our Council. We know it’s so easy to think this type of position isn’t for you, but believe me when I say that you should genuinely consider it. To help you decide, two of our current Council members have outlined what they think of the role and their experiences so far. We want to hear from both pharmacy technicians and pharmacists across Great Britain, so if you are looking for a new challenge and have the skills and experiences outlined on our website, we look forward to seeing your application. 
 

19 July 2018

New ways of delivering health care, using advances in technology, have the potential to improve accessibility and convenience for patients. But they can also carry particular risks which need to be successfully managed.

We are seeing a growing number of providers offering online primary care services, including online pharmacy services, using a range of different online technologies and offering a range of different services.

We have always said that we encourage responsible innovation that may benefit patients, but are also clear about our responsibility to protect people who want to use pharmacy services. This means understanding potential risks and taking action to help make sure these risks are mitigated as far as possible.

Why are more safeguards needed?

Regulating healthcare services on the internet is complex, with different organisations and agencies responsible for different parts of the service. We have been working closely with other regulators in Great Britain involved in regulating online prescribing services to help make sure patients receive safe and effective care at each stage, from when they first visit an online primary care service to when they receive their medicines from a pharmacy.

But we are aware of situations where patients have been put at risk because of the inappropriate prescribing, sale and supply of medicines on the internet. This includes through concerns raised with us and through our work with other regulators.

As an example, the CQC’s recent report, The state of care in independent online primary care services, sets out their findings from their first full programme of inspections of primary health care provided online.  This highlights significant concerns around patient safety, including around safeguarding and inappropriate prescribing.

We have become increasingly concerned about the way some primary care services appear to undermine the important safeguards that are in place to protect patients from accessing medicines that are not clinically appropriate for them. It sometimes appears to be too easy for people to obtain prescription-only medicines; someone can obtain a prescription-only medicine with just a few clicks on the screen, answering a short online questionnaire and submitting some credit card details. But medicines are not ordinary items of commerce and must not be treated as such.

We therefore want to play our part in strengthening the safeguards in place for patients and the public trying to obtain medicines online through the guidance we set for pharmacy owners and through our inspections of online pharmacy services.

In 2015, we published guidance which sets out what is expected of pharmacy owners who provide pharmacy services at a distance, including on the internet. We think that the time is right to update this and are proposing to strengthen the guidance.

We want to hear people’s views on these proposals, to make sure we have addressed all the key issues in this rapidly changing area. I’ve set out the key points below, and how you can help shape the final guidance.

What are we proposing?

We plan to include the following points in our updated guidance:

  1. Transparency and patient choice
    We are proposing to set out what information the pharmacy should give people about the online primary care services being offered, and who is providing them, so people can make an informed decision about where to obtain medicines and other services.
  2. Making sure medicines are clinically appropriate for patients
    We are seeking views about whether it is appropriate for pharmacy websites to allow patients to choose a prescription-only medicine, and its quantity, before having a consultation with a prescriber. We want to know the potential benefits and risks of patients being able to do this.
  3. Further safeguards for certain categories of prescription only medicines
    We are proposing that certain categories of medicines, including antimicrobials (antibiotics) and opiates/ sedatives, may not be suitable to be prescribed and supplied online unless further action is taken to make sure that they are clinically appropriate for the patient, such as contacting the patient’s GP. We would make clear that it is not appropriate for pharmacy owners to work with prescribing services unless they are assured that the safeguards we’ve identified are in place.
  4. Regulatory oversight
    It is not appropriate for pharmacy owners to work with online prescribing providers who may try to deliberately bypass the regulatory oversight which aims to ensure patient safety throughout the healthcare system. We raise concerns in the paper about potential additional risks to patients if pharmacy owners decide to work with prescribers or prescribing services operating outside the UK. We plan to make it clear that if a pharmacy owner decides to work with prescribers or prescribing services operating lawfully outside the UK, we expect the pharmacy owner to manage the additional risks this creates.

You can find the full details of our proposals in our discussion paper. Please read it and then let us know your views by responding to our survey.

17 May 2018

A vital component for delivering professional, safe and effective care is the environment in which health professionals operate. Strengthening the regulation of the places in which they work is therefore a critical part of assuring and improving care.

I want to talk about some of the work we are undertaking to strengthen our regulation of registered pharmacies. This includes a new major consultation, and new guidance for pharmacy owners on ensuring a safe and effective pharmacy team.

Developing our approach

Today (17 May 2018) we launched a major consultation on how we are planning to develop our approach to regulating registered pharmacies. This includes publishing inspection reports for the first time. These proposals, if taken forward, would significantly change how we regulate pharmacies., We want to hear from you about our proposed approach to make sure we are getting it right.  We also want to know what you think the impact will be for pharmacy owners, the pharmacy team and, most importantly, the people using pharmacy services.

Over the last five years we have made significant strides in how we regulate registered pharmacies. The independent evaluation we commissioned and the feedback we have received suggest our approach is working well.  Since we introduced the new approach to inspections in 2013, we have inspected around 13,000 registered pharmacies across Great Britain and expect to have inspected every registered pharmacy in Great Britain by the summer.  And we have found that the vast majority of pharmacies (85%) were meeting all of the standards we set.

It is now time to reflect upon and improve our current approach. As a regulator we want to move to a more flexible and agile way of working, so that we can more effectively respond to the changing needs of patients and the public and to changes in pharmacy.  We will also soon have new legal powers, including powers to publish inspection reports.

We aim to strengthen the assurance we provide to the public that pharmacies are meeting standards and will help to drive continuous improvement in the quality of pharmacy services and care. As part of this, our new approach will increasingly use information and intelligence, using our data and insight to effectively target our resources where they can have the most impact.

You can read about our proposals in this Regulate article

And then please don’t miss your opportunity to respond to the consultation and help to shape the final proposals- you can respond here to our online survey 

New guidance for pharmacy owners

You may recall we consulted last year on new guidance for pharmacy owners. This outlines what they are expected to do to make sure everyone in the pharmacy team can provide safe and effective services to patients and the public.

We received a lot of very helpful feedback through the consultation, which our Council has discussed in detail at its recent meetings.

In the consultation, we had proposed some changes to the regulatory framework for unregistered members of the pharmacy team.  After carefully considering the feedback, we have decided further work is needed in this area before we make any final decisions. This will be taken forward as part of our ongoing programme of reviewing the standards of education and training for the pharmacy team.

Another key theme in the feedback related to staffing in registered pharmacies, and in response we have added a new section in the guidance about what pharmacy owners should do to make sure there are enough staff, suitably qualified and skilled, to provide pharmacy services safely and effectively.

At our May Council meeting last week, our Council agreed that we can shortly publish this new guidance, once a few final changes are made.  Please look out for this guidance, which we expect to publish next month, and consider what it means for you in your role and for those you work with.

15 February 2018

The legal framework governing the UK’s health professions regulatory bodies needs reform. That is the clear message we gave to the Department of Health and Social Care recently, in our response to their consultation about reforming the regulation of health professionals. 

The government’s consultation provides the opportunity to identify how regulation needs to change so it works as well as possible for patients and the public, and effectively supports the professionalism of all health professionals. And we hope this consultation will lead to positive reforms.

In our response, we made the case that we need to change the way we regulate to improve protection and assurance for patients and the public, and better support the professionalism of all health professionals.

 Health and social care has changed considerably to meet the changing needs of the population, and it will continue to change. Regulation must change too to match that.

Changing the legal framework

Regulation is most effective at ensuring safe and effective care when it has a wide range of flexible regulatory tools that can be used to provide assurance and help to promote improvement.  We are seeking changes to our legal framework, which governs how we work, to improve our ability to regulate effectively, and to give us the flexibility we need to be able to respond effectively to external changes. 

In return we need to be held to account. We would gladly, and indeed should, provide more assurances to the Parliaments and Assemblies across Great Britain to whom we are accountable, to ensure there are checks and balances over our decisions and actions.

We are conscious that this consultation has taken place at a time when there are many other demands on government and on the parliamentary time needed to legislate for the changes proposed, and so none of us yet know what will happen following this consultation. More importantly, we also appreciate that the consultation has taken place at a time when everyone in pharmacy, and in healthcare generally, is exceptionally busy caring for their patients in a rapidly changing and uncertain environment.

Number of regulators

What hit the headlines in relation to this consultation was the proposal that there should be fewer regulators, and that some of the existing regulators should be merged. We think it is right that this debate is had, and we have an open mind about this issue.

The number and configuration of regulators is of course ultimately a decision for governments. In our response we argue that the contextual understanding of professions, where and how they work must not be lost. We all need to probe the evidence base for changing the number of regulators and explore whether any particular proposals would lead to better outcomes for patients and the public, which is the important thing.

Supporting professionalism

We welcome the clear focus within the consultation on supporting professionalism. We have long said that regulation is more than enshrining and enforcing minimum standards. Our focus should be on promoting and supporting professionalism because it enhances patient safety and quality of care.

As part of that, we need to make sure that the environments in which health professionals work enable them to meet professional standards. This consultation focuses on reforms to regulation of health professionals, but in our response we say there should also be a debate about our powers to regulate registered pharmacies. As the regulator of both pharmacy professionals and registered pharmacies, we believe the environments in which health professionals work are critical to the context for delivering professional, safe and effective care. Strengthening the regulation of both the professionals and the places in which they work is therefore a critical part of assuring and improving care.

Having a debate about this is particularly important at a time when there is increasing focus on how the environments in which health professionals are working could affect patient safety. Both in pharmacy, and in other areas of healthcare, professionals are raising concerns that the environments in which they are working are affecting their ability to provide safe and effective care.

Most recently, the case of Dr Bawa-Garba has raised a number of concerns among health professionals. These include concerns about how their regulator, and the courts, may respond when they make errors when working in often very challenging environments.

This is a difficult and tragic case and we will be considering any implications with others. We will actively engage with the rapid review commissioned by the Secretary of State and led by Professor Norman Williams, and carefully consider all of the outcomes of that review.

I would encourage you to read the statement we’ve issued in response to the issues raised in this case. And I would strongly urge you to continue to report errors and take part in processes to learn from errors. It is undoubtedly difficult to speak up when things go wrong, but it is vital for patient safety that errors are reported and discussed.

And I want to make clear that this responsibility lies with all of us. As the regulator, we will work hard to promote a culture of openness, honesty and learning across pharmacy, and we will be urging everyone who employs pharmacy professionals to do the same.