As an independent expert adviser in criminal cases, Richard Brown is demonstrating that pharmacists’ knowledge of medicines is unrivalled. Avon LPC’s chief officer talks to Neil Trainis…

“I’d love to think I might be the tipping point,” Richard Brown says smiling, tongue firmly in cheek, as he contemplates the idea his work as an independent expert adviser in criminal cases might finally convince the government and NHS England that community pharmacists’ unrivalled knowledge of medicines should ensure they are unconditionally supported by those in power.

The deep understanding community pharmacists across the UK have of the way medicines interact with the human body and other medicines, how they alleviate symptoms and how they can put us at risk, is an open secret in the NHS. Leading figures in general practice know it. Nurses do too. Even NHSE itself concedes on its website that “clinical pharmacists,” its provocative term for GP pharmacists, are “highly qualified experts in medicines” even though it’s been reluctant to extend that assessment to community pharmacists, particularly independents.

Richard’s career as a pharmacist has taken him from LloydsPharmacy to Avon LPC where he’s been chief officer for over 10 years and the driving force behind its eye-catching support of some 220 contractors.

But he is more than your conventional pharmacist. He uses his intimate knowledge of medicines to provide pharmaceutical testimony in criminal cases. His work is fascinating.

“I am listed as an expert adviser on the National Crime Agency expert adviser database and as such, my expertise can be suggested by the NCA to police and law enforcement agencies investigating criminal offences,” he says over a Teams chat.

“If instructed by police or other law enforcement agencies, I act as an independent expert adviser-witness of the court for the prosecution case. As an independent expert adviser-witness, I am also available to be instructed in criminal cases by defence solicitors.”

He makes it clear that although he’s listed on the NCA’s database, he’s not endorsed by it and he doesn’t work for it. He sets the scene; a criminal case involving drugs comes to light and a police force, for example, calls on Richard to evaluate the evidence and produce a report of his conclusions.

“Often, what happens is you’ll get presented with an amount of evidence and a set of questions you’re asked to comment on. You then give your professional expertise based on the evidence you’ve been shown and you produce a formal report that will be submitted to the court if it goes to trial and, potentially, you will get called to give evidence in the case and you have to stand up and be that expert in the witness box in a court of law.”

Cross-examination is inevitable

He hasn’t been called to appear in court so far and thus has avoided being cross-examined. But he insists it’s coming. The inevitability of being grilled in court does not fill him with trepidation though. He just calmly concedes it’s going to happen.

“I’ve been three days away from being called for one case and I got stood down on one of the other cases. So far in each instance that I’ve produced a report, my report has been accepted as fact by the court and I’ve not been required to give evidence on the stand.

“In that instance, my report will get read out to the jury as evidence for the prosecution. But (cross-examination in court is) coming. Literally, I’ve been close on a couple of occasions. And it will happen. You write the report on the basis that whatever you put in that report, you can be put in the witness box and be cross-examined by the opposing solicitors.”

Richard has put his pharmaceutical expertise to a variety of cases relating to unlawful injection, care home investigations, illegal drug use, diminished responsibility due to drug use, serious harm involving drug use, harm caused by medications. And murder.

He pauses when asked how many murder cases. “One,” he says, offering no details about the case. He is keen to talk about another case that sticks in his mind.

“(There) was a defendant who was found with an amount of cocaine, an amount the police would consider to be the cutting agent. The chemical they found was the cutting agent for the cocaine. The defendant was then prosecuted for the total weight for all of what they found.

“So, for argument’s sake, if you find a kilo of cocaine and 10 kilos of cutting agent, you’d be tried for 11 kilos of street cocaine. And that was really important to that case. But, in some instances, those chemicals are completely lawful chemicals to buy and the police have to demonstrate that was being used unlawfully.

“The defence might offer up an excuse of ‘it’s a medicinal product.’ And how do you prove it’s not? And that’s where they might come to a pharmacist and say ‘for that to have been an lawful medicinal product, it would’ve had to have been prescribed.’ If it was a manufactured special, there would’ve had to have been a register of it. It would’ve had to have been dispensed appropriately from a pharmacy.

“So, to have been a lawful medicinal product, all that criteria would’ve need to have been met. Now, I’m not saying it’s unlawful. What I’m saying is for it to have been lawful, this criteria would’ve had to have occurred. When the prosecution presents that to the defence, the onus is on the defence to go ‘here’s the GP record that shows it was prescribed as a medicinal product.’

“Or in this instance, they realise they’re not going to get away with this as a defence because I’ve demonstrated the holes in their defence by demonstrating it probably isn’t being used as a medicinal product. And not when the chemical in question in this instance would’ve created a quarter of a million throat lozenges. It was being suggested that it might have been used as a local anaesthetic to treat throat cancer.”

It is a compelling account of how good a pharmacist’s knowledge of pharmaceuticals is. Richard says it’s all about the “expertise a pharmacist brings” but suggests with a hint of regret that “even our colleagues in general practice don’t see the huge value a pharmacist brings to the medical profession.” And he doesn’t stop at general practice.

“It’s probably the same thing that investigative techniques have probably not realised the vast knowledge base that sits within a pharmacist for supporting with crime.

“Some cases have things that go across different components of them. From a pharmacist’s perspective, that’s just a small snapshot of the things that we have expertise in.”

Authority on medicines

His criminal case work is a fairly regular source of income – “over the course of the year, I might get brought into three or four cases” – he reveals. It occurs to me that independents feeling neglected by the government may as well put their knowledge of pharmaceuticals to good financial use and do what Richard has done. He says he doesn’t know any other pharmacists who are doing it.

“But lots of other healthcare professionals are,” he insists. “There are nurses. A good friend of mine is a nurse who is an expert, similar kind of thing. Doctors who work in all sorts of settings are experts as well. There’s expertise across all sorts of fields that the NCA will have listed on their database.

“As an expert, it’s not just about being medically trained, it’s about being an expert in your field. There’s experts from all walks of life that are available to be called upon by law enforcement agencies as and when required.”

Richard wants to raise awareness among pharmacists of his work as an expert adviser because they might want to get involved. And by getting more pharmacists involved, he suggests, word will spread that their authority on medicines manifests itself way beyond the pharmacy.

“If you think about it, a pharmacist has a huge amount of knowledge around clinical governance, the safeguarding of medicines, the safe supply of medicines, the act of medicines on the body.

“What’s really apparent is legal teams and police forces are only just starting to see the benefit because pharmacists generally don’t do this type of work. It’s probably only in its infancy that people are seeing this which is why it’s then useful to talk to you about it because actually, other pharmacists reading this might look at it and think ‘actually, that could be something I might be interested in finding out more about.’

“Sometimes, investigations need this kind of expertise that a pharmacist can bring and by showcasing it as a possible element of a pharmacy career, it’s also quite useful in that sense. Pharmacists will look at this and think ‘I’d be interested to find out more about that.’”

The Pharmacists’ Defence Association chairman Mark Koziol once said pharmacy should launch a public awareness campaign, with posters on bus shelters, on the side of buses and on London Underground, conveying the message that pharmacists are the experts in medicines. Richard says his work “raises awareness of that” but, with a touch of frustration, suggests “pharmacists are very good at hiding the things that they do well.”

“Genuinely, the actions of medicines on the human body is the expertise of a pharmacist. When crimes are committed, people will often go to doctors, they’ll often go to other parts of that medical-related healthcare because they’ve not experienced anything else. They’re not aware of the fact that pharmacists have this expertise.”

He suggests NHSE “secretly probably already know pharmacists are the experts in medicines” and recognise the “brilliance pharmacists bring which is why they’re funding pharmacists working in general practice.” Yet it feels like he’s frustrated by a lack of acknowledgement of community pharmacists’ brilliance.

“That’s the bit that’s missing. If you think about it, the thing that’s coming down the line, the independent prescribing pathfinder project, that is the single biggest step-change the community pharmacy sector is going to experience possibly in my 20-year career. That moves community pharmacy into a world of prescribing. That’s a massive shift-change from what we’re already doing.”

Good relationships in Avon

Contractors in Avon have been in very good hands. Their LPC has had strong relationship with NHSE, local authorities, acute trusts and academic health science networks, and that has led to the commissioning of new services and continuation of existing public health and local enhanced services. 

The secret of Avon LPC’s success is not revelatory. Put simply, Richard says “it comes down to the support infrastructure that we’ve put in place across the LPC.” It works to clear parameters. He is “accountable as chief officer for working with its committee to create the strategy” and he owns “the key strategic relationships with NHS England, integrated care boards and local authority colleagues.”

His operations team provide on-the-ground support for contractors to deliver services. The community pharmacist consultation service is an example. It has been difficult to pull off in some parts of England. Not so in Avon.

“In December across the LPC, we did over 5,000 CPCS consultations. In fact, we probably did more like 5,800 CPCS consultations across my 200 pharmacies,” he insists. “In February, we’ve just pulled the data, we’d have done about 4,700 CPCS consultations. We’ve supported the pharmacies in being able to deliver that.

“Not only that, they would have also delivered somewhere in the region of 1,500 to 1,800 supplies against PGDs for the month. That’s for urinary tract infections, sore throats and for a couple of other conditions and again, that’s down to the hard work of my ops team supporting those pharmacies.

“We’ve also supported them with hypertension case-finding and we’ve got a large number of surgeries chomping at the bit to live with the contraception supply service.”

Richard says he has “good relationships at integrated care board level” and working “really closely” with the community pharmacy clinical lead in the ICB has “been hugely important.”

“We have a really clear strategic plan around pharmacists delivering these clinical services. We’ve not gone for a scatter-gun approach. We said we are going to do consultations for common ailments and we’re going to do it really well.

“When you go to the ICB, the chief executive, you say ‘in December when the whole world was struggling with strep A, we freed up 5,000 GP appointments that month.’ Now that has real cut-through.”

He says the CPCS has been a success largely thanks to Judith, his implementation manager, who “has a fantastic relationship with the surgeries where she goes to implement it in.”

“We’re committed to funding that implementation support within our own budget. We have, across the other parts of the operations team, a primary care relationships manager. Barbara manages and holds meetings between surgeries and pharmacies in their local areas and we manage that process so they are talking to one another.”

Listening to Richard, it’s tempting to think contractors on his patch work without any difficulties but he points out that’s not the case. Yet he uses the CPCS again as an example of his pharmacies working together to avoid trouble.

“Don’t think for one moment the CPCS across Avon is problem-free. It’s not. But we react to those problems and we support both general practice and pharmacies to find solutions. There are times when a pharmacy will go into absolute crisis and just can’t take any more referrals.

“Rather than just switching it off in its entirety, we encourage those pharmacies to talk to the surgery to say ‘look, I can’t do any at the minute but I know this pharmacy is still able to. But don’t inundate that pharmacy because you’ll sink them.’”

Contractors in Avon are feeling the impact of poor government funding but there’s a strong sense of purpose there where independents resolutely carry on.

“The only ones that are going to closure at the moment is our Lloyds estate. We’ve had one close and merge of an independent, one consolidation. I’d like to think we’ve helped our pharmacists bring in those clinical services to bring in additional revenue,” he says.

“We brought in the PGDs. Some of our pharmacies have delivered private services as well, so not all their eggs are in one basket of the NHS. Over the past three years, that level of emphasis for pharmacy teams to work to deliver additional benefit for the pharmacy contract has kept them solvent. I’m not saying it’s still not perilous. A number of them are close to the edge as they continue to be.

“But it really is only the multiples at the minute that have had to actually close their doors.”