**1. Introduction**

The National Health Service (NHS) in the United Kingdom (UK) is under immense pressure to deliver quality healthcare with restricted resources [1]. The devolution of healthcare in the UK has led to significant differences in the commissioning of community pharmacy services across the four nations. In Wales, community pharmacies have been identified as a strategic priority for enabling the local delivery of public health and clinical services, with less focus on the supply of medicines [1–3]. These proposed changes have the potential to impact on the future roles and responsibilities of the community pharmacy workforce in Wales. In order to achieve the Government's strategic objectives, it is crucial that the skill mix of the pharmacy team is utilised to its optimum effectiveness [4]. The General Pharmaceutical Council (GPhC) (2018) reported that there were 23,318 pharmacy technicians (PTs) registered in the UK on 31 March 2017, with 53,967 registered pharmacists and 14,403 registered pharmacy premises [5].

PTs made the transition from an occupation to a profession in 2011, following introduction of professional registration—the title 'Pharmacy Technician' is protected in UK law [6]. Pharmacy technicians must renew their registration every year, by declaring that they remain fit to practice, in accordance with the GPhC's professional standards. The registration requirements are mandated by the GPhC and are the same regardless of sector. These are Level 3 National Vocational Qualification (NVQ) Diploma Pharmacy Services Skills (or equivalent), plus a Level 3 Diploma Pharmaceutical Science (or equivalent) and a minimum of 2 years' relevant work-based experience under the supervision of a pharmacist. Level 3 qualifications are equivalent to A-levels in the UK, a prerequisite to accessing a higher education diploma or degree. Pharmacists in the UK study to reach level 7 (Master's degree) qualifications in higher education institutions (i.e., universities). Pharmacy technicians in the UK are therefore not qualified at degree level.

PTs play an important role within the delivery of pharmacy services in the UK [7]. Defining the role is inherently difficult as there is no agreed definition or clear demarcation of the boundaries with the other members of the pharmacy team [8,9]. As a general overview, PTs are specialists in the technical aspects of medicines supply, e.g., procurement, stock management, sale, dispensing and final accuracy checking of dispensed medicines. PTs may provide guidance on the use of prescribed medicines and public health advice. PTs may manage technical staff and/or the provision of technical pharmacy services. For comparison, pharmacists are considered specialists in the clinical aspects of medicines supply, e.g., ensuring prescribed medicines are safe and appropriate for patients in terms of dose, form, interactions and contra-indications. Pharmacists are legally accountable for the safe and effective provision and delegation of pharmacy services. Current UK pharmacy legislation requires PTs to work under 'supervision' of a pharmacist. The law also recognises that pharmacists have scope to delegate tasks to appropriately trained and competent members of the pharmacy team. Despite the law and professional registration (specifically professional accountability) having been put in place to enable delegation, there appears to have been limited impact on the development of the pharmacy technician role.

The PT role differs significantly across the pharmacy sectors, particularly between community and hospital, which are the two sectors in which most PTs are employed [9]. Anecdotally, PTs working in the community pharmacy sector have traditionally focused on the sale and supply of medicines and related administrative functions. In recent years, accuracy checking of prescriptions has become a more established part of this role [9]. However, there has been limited scope for further development, which could, in part, be due to the lack of career structure and/or progression opportunities [10,11].

Evidence suggests that the PT role in community has remained similar to a 'dispenser' or 'pharmacy assistant' role [12], which is often limited to dispensing medicines and stock related activities. In general, dispensers or pharmacy assistants do not undertake the final accuracy checking of dispensed medicines, provide advice on prescribed medicines or manage pharmacy services. The terms 'dispenser' and 'pharmacy assistant' are used interchangeably (the term 'dispenser' will be used in this paper), to describe non-registered support staff who are trained to NVQ Level 2 or equivalent. Level 2 qualifications are equivalent to GCSE level education in the UK, which is typically completed in Grade 10 and 11 of high school.

#### *1.1. Roles of Pharmacy Technicians*

A recent systematic review concluded that PTs who are capable of performing more patient care activities are being underutilised [13]. In 2018, Desselle et al. surveyed 5000 pharmacy technicians across eight states of the United States of America (USA), to establish their involvement with specified practice activities [14]. They reported significant differences between community and hospital roles and a significant involvement with prescription receipt and dispensing. Less involvement was reported for roles such as supervising and checking the work of other technicians, despite participants expressing confidence to undertake such roles. Lower levels of confidence and involvement were reported for clinical roles, e.g., discussing effectiveness of treatment plans and providing medicines related advice. This is consistent with Koehler and Brown's global online survey of pharmaceutical services in 2017 across 67 countries, where procurement and stock ordering were the most autonomous functions of the PT [15]. John and Brown (2017) also found that the sale and supply of medicines remains the core function of the PT's role in the UK [9].

A 2016 UK study by Boughen et al. [11] explored PT roles across all sectors, including community pharmacy. Survey responses from 71 community pharmacy technicians (CPTs) described a comprehensive list of roles that were undertaken, which mainly related to sale and supply, with some reference made to extended roles. There was no indication of the proportion of time spent on each of the tasks described, in order to provide an accurate picture of the current role. These findings are useful to inform further research, however, they cannot be generalised, due to limitations in the way the sample was recruited. Boughen et al. concluded that community pharmacy technician roles are less expansive and less clinically oriented than hospital pharmacy technician roles.

In 2016, Bradley et al. [7] surveyed a random sample of 1500 pharmacists and pharmacy technicians in England, to explore perceptions of risk associated with the delegation of duties to support staff carrying out roles without direct pharmacist supervision. Participants categorised twenty-two activities as 'safe' (e.g., dispensing), 'borderline' (e.g., issuing prescriptions and sales of medicines) or 'unsafe' (e.g., clinical activities). When compared with PTs and hospital pharmacists, community pharmacists were found to have a significantly higher perception of risk for the delegation of borderline tasks to support staff and were the least ready for change. This may be a barrier to the full realization of changes in practice and development of the PTs role in a community setting.

To date, there has not been any research to explore CPT roles within Wales, where the Welsh Government is prioritising and investing in the community pharmacy sector, as a mechanism to address localised health needs [16].
