Can a practice consistent with pharmaceutical care as defined by Hepler and Strand1 be developed in a pharmacy in a cost-effective manner in the long term? That was the question posed by Professor Linda Strand at the start of the seminar, the aims of which were to look at the methodology underlying the new paradigm of pharmaceutical care and to identify six to eight enthusiastic pharmacists who would be willing to develop the practice of pharmaceutical care in the Liverpool area.
Emphasising several points which she had made during the previous evening's keynote address (see p874), Professor Strand reminded participants that pharmaceutical care was patient focused care and that, like doctors and dentists, pharmacists needed to build practices consisting of patients for whom they were responsible. As part of this, they had to define a role that was uniquely theirs and theirs alone. In pharmacy it was all too easy to move from project to project (eg, drug utilisation review), and while this was changing practice, it was not pharmaceutical care. "Pharmaceutical care is not a project. It is not something to try out."
In the context of collaborative work in pharmaceutical care between Liverpool and Minnesota, Professor Strand began by describing the work she had done in Minnesota. This involved developing pharmaceutical care practices - often from pharmacies run along traditional lines. A letter had been sent to every community pharmacist in Minnesota and, of these, 250 had attended a seminar which informed them how the study would be completed. There was little financial inducement to take part. The 80 pharmacists who finally agreed to participate were reimbursed for all expenses related to the project, except for what was needed for "the practice" (eg, redesigning the pharmacy to provide a quiet area, additional computers, etc). Reimbursement for the provision of pharmaceutical care could only be obtained if the pharmacists proved that it worked.
Initial funding for the work, which was obtained from Merck and Glaxo Wellcome, totalled about £1.2m. Drug companies were interested in this work mainly because they wanted to know if community pharmacists could influence drug utilisation decisions at the patient level, and also because they wanted a positive image in the pharmacy profession. Other interested parties were the managed care companies and insurance companies because they wanted to know whether pharmacists were a group that could be relied upon to provide care to patients.
Evaluating the potential "sites" for pharmaceutical care took four months. Being sure that the pharmacy support staff were willing to work in a pharmacy where dispensing was done by technicians rather than pharmacists and that the pharmacists were enthusiastic was vital.
"What pharmacists say they want to do and what they are willing to do are two different things. The pharmacists who wanted to take part were not the ones who go to every local [pharmacy] association meeting. These were no more interested than the man in the moon. This was the opposite of what we had expected."
Taking care of patients, which was what pharmaceutical care was about, demanded a different mind set from traditional pharmacy. Providing pharmaceutical care might, for example, involve being available for consultation out of hours. Although this had not happened a great deal in the Minnesota study, working out of hours was a difficult concept for pharmacists, Professor Strand said, because pharmacists were used to being in control and providing certain services at set times. This was fine, but it did not necessarily mean providing effective care for patients.
Dr Gaynor Bresnen (subject leader in pharmacy practice, Liverpool school of pharmacy) asked if this was not why some people chose pharmacy as a career rather than medicine. Professor Strand agreed that this was a real issue. Pharmacists did not have the expectation to care for patients but merely to "count and pour". Moreover, pharmaceutical care was not something that all pharmacists wanted to provide. Only about 20 per cent wanted to do this, and it was important to select these pharmacists at the start.
Professor Michael Rubinstein (head, Liverpool school of pharmacy) asked what implications this paradigm shift had for selection of pharmacy students. Professor Strand acknowledged that it was important to clarify for interviewees exactly what the job was about. The end point (ie, the "practice") had to be clearly defined and pharmacists had to decide for themselves how to get there. Thus, pharmacists could individualise the way they delivered pharmaceutical care, but the "practice" needed to be standardised. Pharmacists everywhere in the world - be they community or hospital pharmacists - needed to work towards this one practice. While hospital pharmacists often thought they practised pharmaceutical care, the reality was that many did not.
Pharmacists needed to understand this concept of a having a "practice". They had never had one, and they needed to understand that a "practice" relied on practitioners and was not dependent on a place or a setting. Thus, pharmaceutical care should be delivered equally in hospitals and in the community, and this left no room for the traditional rivalry which had often occurred between pharmacists working in the two settings.
Time and energy had initially to be focused on practitioners, Professor Strand said. Pharmacists needed to be removed from the dispensing process. Although it was often thought to be too expensive to employ more staff, surely it was even more expensive to have pharmacists counting tablets. Moreover, when technicians started to fill prescriptions full time, there were fewer errors and a faster service.
"The problem with pharmacists is that they are often trying to do three different things. But the one area that pharmacists have had almost a monopoly on during the past 30 years is dispensing, and it is run badly - very badly. It keeps pharmacists in employment, but pharmacists are being educated to increasing academic standards. It is a scam!"
In the Minnesota study, a time and motion analysis found that although pharmacists claimed to be spending 40 minutes an hour on patient care, it was actually only seven minutes an hour, leaving around 50 minutes an hour free for patient care. However, this time could only be freed if the pharmacist was taken out of the dispensary. Despite this being a difficult shift for pharmacists to make, the study showed that within six to nine months they had made the requisite change, and after that time, all they talked about was patient care. In addition, the patients' perceptions changed too. At the start of the study, the patients identified their pharmacy, but towards the end of the study, they talked about their pharmacist by name. This was one of the most dramatic pieces of data from the whole study, Professor Strand said.
Involving the patient's general practitioner at an early stage was important. GPs were still ultimately responsible for the care of their patients and trust between doctors and pharmacists had to be engendered. GPs, in Professor Strand's experience, tended to be positive about pharmaceutical care. Pharmacists were providing something which doctors could not and GPs tended to send their patients to pharmaceutical care pharmacists in the expectation that those pharmacists would stop them (the doctors) from making mistakes.
Dr Mike Berry (senior lecturer, pharmacy practice, Liverpool school of pharmacy) asked what role academics could have in moving pharmaceutical care forward. Professor Strand replied that there was a great temptation among academics to listen to pharmacists when they said they wanted educating in therapeutics, and then teach then too much therapeutics without any application. What pharmacists needed was to be taught to be practitioners.
Dr Terry Nolan (deputy head, Liverpool school of pharmacy) said that the pharmacy degree programme should be directed towards what pharmacists would be doing in the year 2020, and that the "practice" should be identified and understood by pharmacy students from day one. What was so radical about the practice was its simplicity, and if adopted, pharmacy students would know exactly what they had to do. The concept of a pharmaceutical care plan had to be understood by all academics so that they could integrate their subject into it.
Professor Strand said that the content of the pharmacy degree did not have to change dramatically, and agreed that pharmaceutical care had to provide a focus for all teaching. It was important to identify what the student needed to know in order to practise, and this was quite a shift for pharmacy educators because they had never taught "to a practice". However, none of this meant that teaching could be superficial. Students had to be taught to deal with common patient problems really well and there was a need to impart knowledge in the way in which it would be used by the practitioner.
Dr Bresnen asked how pharmacists could be sure that what Professor Strand was saying was right. In response, Professor Strand agreed that no one could be sure that she was right, but that there was no time to wait for an answer. In any case, the "practice" she was presenting had nothing to do with her - it was not, in a sense, her idea. Pharmaceutical care was relevant in the wider context of health care delivery, and the practice of health care delivery had undergone scrutiny in every country in the world. This was its strength. "In any case, pharmacy does not have a better idea."
Mr Laurie Goldberg (consultant pharmacist) asked for a description of a day in the life of a pharmaceutical care pharmacist. In other words, how could pharmacists develop a practice? What should they do next? The crucial thing, Professor Strand replied, was to create a technician driven dispensary first so that the pharmacist had time to be involved in patient care. The next step was to set up appointments with patients. This could be started on one afternoon a week and gradually built up to more afternoons. But time was needed to build the practice - time to educate the support staff on their new roles and time to develop pharmaceutical care plans and evaluate them.
There were three main criteria for building up a pharmaceutical care practice: a qualified practitioner, documentation, and patients.
A qualified practitioner meant someone trained to deliver pharmaceutical care. In the US study, the training programme lasted eight weeks. A postgraduate diploma was not needed to provide pharmaceutical care. Documentation was vital and involved much more than keeping patient medication records. Documentation provided evidence of what had been achieved in terms of patient care and was a prerequisite to reimbursement. Pharmacists would not be paid for patient care unless they could supply proof of what they had achieved. Documentation included a full list of all the patient's medication, including over-the-counter medicines and also generated a pharmaceutical care plan for both the patient and the pharmacist. Patients were seen by appointment and first time assessments could be conducted in 15 minutes, with repeat appointments taking seven to 10 minutes.
A pharmaceutical care practice could be situated in a community pharmacy, a hospital pharmacy or a GP surgery. Pharmaceutical care was perhaps easier in a GP surgery, and, if provided in a community pharmacy, there was certainly a need to have a good relationship with the local GPs. In the community, some pharmaceutical care problems were not acute and could be left until the patient's next visit. This was in contrast with the hospital situation in which more problems tended to be acute and had to be dealt with immediately. An advantage in hospital compared with community was that patients could not go anywhere and pharmacists had to make the most of the situation in which they worked.
Once the three criteria for pharmaceutical care had been met - the practice, the documentation and the patients - a management system was needed to support them. Managing a patient care practice was not the same as managing a product based pharmacy. Responsibilities had to be defined and it was the role of management to resource these. Resources needed included:
In addition to the three pharmaceutical care criteria and a management system, a system for evaluation of pharmaceutical care was needed. Evaluation needed to answer two separate questions: how well patients were managed and how well the practice was managed.
Reimbursement was also vital, but it had to come after building the practice and proving that pharmaceutical care worked. In other words, pharmaceutical "problems" had to be identified, solved and documented. In the US study, the state health system in Minneapolis had provided reimbursement. Mr Peter West (pharmaceutical adviser for Liverpool health authority) said that, although reimbursement in the UK was still mainly based on prescription numbers, there was already the possibility to pay pharmacists in some geographical areas for additional services. If pharmacists shifted their emphasis from product to patient and pharmaceutical care was taken forward as a model, the door to increased funding might well open, he said.
Professor Strand identified the importance of leadership. "In the US, so little is being done by the leaders in our profession to move this forward. Yet they have so many resources and could influence education and practice so much. Those in leadership face an enormous challenge. Unless our leaders stop burying their heads in the sand - pretending that none of this is happening - all our own activity will go to waste. But this won't stop the provision of pharmaceutical care. Pharmaceutical care will happen. There is no doubt about that. But the question is who will provide it? Unless the pharmacy profession acts now, it may not be pharmacists. We must define what is uniquely ours. If we don't, we won't even be here in 10 years time."
| 1. Hepler C, Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47: 533-43. |