Clare Mackie is a 37-year-old pharmacy graduate of Strathclyde University. She has been a community pharmacy contractor since 1984 and currently has three pharmacies. She has made a name for herself as a trend-setter in pharmacy practice and has espoused the cause of pharmaceutical care and is a researcher in this field. She is active professionally and politically within pharmacy. She is a member of the executive of the Scottish Department of the Royal Pharmaceutical Society and is a new member of the Society's Council. She is heavily involved in continuing education and practice development matters within Scotland. Her appointment, rather than a dyed-in-the-wool academic, as the new head of the school of pharmacy at the Robert Gordon university in Aberdeen caused a few eyebrows to be raised.
The editor of The Pharmaceutical Journal, Douglas Simpson, went to Aberdeen recently to visit the school of pharmacy and to talk to Professor Mackie about her new job
Professor Clare Mackie applied for the post of head of the Aberdeen school when it was advertised in The Pharmaceutical Journal. The advertisement said that the school was looking for a pharmacist by training and an entrepreneur by instinct who would be able to demonstrate an ability to lead in a teaching and research environment. The new head would also be required to anticipate the future needs of the profession and to equip the university to be outstanding in meeting those needs. Was she interested? She was, so she applied.
This had not been the first time that the post had been advertised. First time round, a more conventional academic appointment had been envisaged but the job had been rethought after applications had been received. The change in direction took into account widespread consultation within the profession. The principal of the college had also changed in the interim period.
Professor Mackie said that she was delighted to have been offered the post - she began work in Aberdeen in May of this year - and said that she feels that she can deliver what the Robert Gordon university authorities are looking for.
Some might perceive the switch from practice to academia as a major change in direction. Professor Mackie does not see it that way. She regards her new appointment as a natural progression for her. When she had graduated, her ambition had been to go out to change pharmacy practice. She had not wanted just to go out and work in pharmacy. She had also wanted to teach. There was no way, she said, that one could teach practice unless one had experienced it. She set about acquiring pharmacies and by 1990 had four. They were innovative and delivering pharmaceutical care (see PJ, July 12, 1997, p71).
But in the meantime, she had retained her links with the academic world. In 1990, she started a part-time MSc in clinical pharmacology and therapeutics. This was a multidisciplinary course because her main interest was in working with other disciplines. Subsequently, she became an honorary lecturer in the University of Strathclyde.
What will Professor Mackie be doing with her pharmacies? She will be keeping them, but needs to work out some new administrative arrangements. The job in Aberdeen, she said, was every bit as challenging as she thought it would be and, to do it really well, she had to be totally focused. There was a danger in spreading herself too thin. The pharmacists who ran her pharmacies all practised clinically and were not involved in the paperwork. She had yet to find a means of delegating the general administrative duties but she, nevertheless, had decided to retain the pharmacies, developing them as research bases focussing on a UK model of pharmaceutical care.
Coming in to lead a major academic institution cannot be easy. What had Professor Mackie been doing to prepare herself for the new role?
The first priority had been, she said, to do a lot of thinking and consulting. She had reflected on the progress of the profession over the past 10 to 20 years and had sought to define where she thought the profession was likely to be in the next 10 or 20 years. It needed to be remembered that the people who were being taken into university today would be practitioners five to 10 years hence. They would be the ones taking forward changes in practice. It was quite an onerous task to get the course right to fit them for the conditions that they would experience when they became practitioners.
Professor Mackie added: "We have been having discussions with GPs, nurses, and pharmacists and we have tried to get a feel for what people aspire to and how we could provide the training for resourceful practitioners who would be able to deliver that." A university establishment could not deliver ideas in isolation. What they did was to bring in the wider profession. Her job was to inspire the staff and give them energy and enthusiasm to take forward the collective ideas.
What she needed to do, she said, was to share in everyone else's views and ideas about where the profession should be going. Only by doing that would everyone be committed to the chosen route.
Internally, Professor Mackie has completed a series of half hour interviews with all of the 40 or so staff of the school - secretarial, technical and academic. She had wanted to know how much of their time was involved with teaching, research or administration and whether the balance was right for them. As a result of this, she had been able to identify groups of people working together as teams and from this she would be able to map out a strategy for training and research direction and at the same time adjust administrative loads where necessary. She would also be able to help the various teams to network with the outside world, where she had a lot of contacts through her membership of various working groups and other bodies. At the end of the day, what the school of pharmacy delivered would be made up of what the various teams delivered.
The obvious question that springs to mind with a practitioner being appointed as head of school is: will there be a new emphasis on practice in the Aberdeen course and will pharmaceutical sciences be downplayed? The obvious question does not, however, lead to the obvious answer. Professor Mackie does not plan to place more emphasis on practice or to reduce the emphasis on science. Rather, she wants practice to be taught in a different way and for the science to be more focused on solving the problems of practice. There would not be any less science. In today's multidisciplinary world, Professor Mackie said, it was the pharmacist's scientific knowledge that allowed him or her to make a contribution to health care. Pharmacists who became divorced from science ceased to develop as practitioners.
But although there might not be any change in the emphasis on practice - the course at Aberdeen has always been very practice orientated - there will be considerable changes in the way it is taught. The school's three organisational sections - clinical, practice and pharmaceutical sciences - are to be reduced to two, with the clinical and practice sections being combined under the broad title of "clinical and professional sciences" (CAPS).
The most revolutionary development will be the establishment of a "pharmaceutical care centre", where practice conditions are simulated, to act as a focus for CAPS teaching. The laboratory where dispensing practice is currently taught is to be transformed. As well as workstations for pharmacy students, there will be workstations for GPs, practice nurses and practice pharmacists. A hospital pharmacy scenario is also to be created, complete with bed, Kardex, etc. There is to be a counselling area, complete with video camera, where response to symptom scenarios will be played out and recorded. There is going to be a reception area with about 10,000 sets of patient case notes.
The transformation work will take place next summer. The architects have been called in and preliminary drawings are being prepared.
Undergraduates will be assigned to their workstations, where they will have a computer and a telephone, as they would in practice. GPs, practice nurses and practice pharmacists will be paid to come into the school to be on the receiving end of the telephone calls from the undergraduates. In the first, second and third years, academic staff from the school will take the telephone calls and simulate the actions of other practitioners but in the fourth year, the students will be on the line to real practitioners attending the school on a sessional basis.
Practical work in the pharmaceutical care centre will be graded in terms of difficulty over the four years of the course.
In the first year, said Professor Mackie, undergraduates would be presented with prescriptions to dispense which they would check for administrative correctness - was the prescription signed and dated and so on - and whether doses are appropriate. If they found a fault they would telephone through to the practitioner concerned to seek to resolve it. They would seek to negotiate a change in dose, if that was the problem discovered, with the GP.
In the second year, the prescription would be the same but a check with computer records would show that the dose might be too high for the known condition of the patient. Thus, in the second year, students would be expected to telephone to challenge, in a non-confrontational manner, the prescriber's decision.
In the third year, additional challenges would be presented, such as second conditions which might interfere with the treatment for the condition which the doctor has prescribed. This might involve negotiation with a third practitioner, say, a nurse running an asthma clinic. This could require the student to negotiate with the nurse on such issues as whether protocols for treating particular conditions needed to be reviewed.
Even more complicated issues would be tackled in the fourth year. This might involved advising a GP on prescribing in a certain area where examination of primary and secondary reference sources might be required. Scenarios presenting in real practice would be used as the raw material for this kind of teaching.
Was there any point in changing the course if practice for many pharmacists remained heavily focused on the mechanics of the dispensing operation?
Professor Mackie did not agree that practice was stagnant. It had moved on in many areas. When she had undergone her preregistration experience in 1981 she had introduced a patient medication record system, using cards. Now over 95 per cent of pharmacies had patient medication records on computer. What had not changed to the same degree was the remuneration system. If the schools produced versatile and resourceful practitioners, those practitioners would want to take the opportunities that were presented to them. Increasingly this would involve working with others. They were to be taught in a shared learning environment where they would discover that their job was to interact with other health care professionals and with the patient.
Professor Mackie said that the one thing she would like to see introduced to really take things forward would be patient registration. The system should be voluntary and focus on patients with chronic diseases. Pharmacists could receive a capitation payment. This would totally revolutionise the way that pharmacy was practised. It would allow pharmacists fully to take responsibility for the provision of pharmaceutical care for particular patients.
Another change that was needed was abandonment of the pretence that all pharmacists were the same. Professor Mackie said that she would like to see special registers for those who aspired to become extremely skilled in certain areas.
Her membership of the Crown Review of "prescribing, supply and administration of medicines" had shown her, she said, that the emphasis in other professions was on reaching a high level of practice. For pharmacy, there was just the lowest common denominator. Pharmacists were too nice. They did not encourage people from within the profession to stand head and shoulders above the rest. Because they had not done that, they had missed out on many opportunities.
Professor Mackie said that she would also like to see greater recognition for practice research. Scientific type research was properly valued. However, the progress of the profession depending on gathering evidence based on practice. The profession would not be able to motivate people to develop that evidence if it was not given its proper recognition. The profession had to tackle that issue.
Professor Mackie made it clear that she supported the concept of pharmaceutical care but she indicated that she did not particularly espouse the Minnesota model where the pharmacist took responsibility for the patient's therapy and was held accountable for that commitment. Her view was that a team was responsible for the pharmaceutical care of the patient. She does not feel that the pharmacist could legitimately claim sole ownership of the patient's treatment. The conditions might be different in America but in Britain the health system lent itself to a team approach. But whether it was the Minnesota or some other type of model, pharmaceutical care would only become reality in Britain with patient registration. The GPs said that they would like to interface with the pharmacist to discuss patients but they found it difficult because they did not know where the patient was going to go when he or she left the surgery with a prescription. In most areas patients could go to any one of a dozen pharmacies. That represented the biggest barrier between GPs and pharmacists.
In short, Professor Mackie sees pharmaceutical care as a team working concept and the only way that the team can be effective is when they can identify each other.
For the future, Professor Mackie believes that pharmacists can take on a prescribing role within the pharmaceutical care concept. The prescriber would assess the patients and provide the diagnosis and ask the pharmacist to prescribe. The pharmacist would discuss treatment with the patient. The patient would be apprised by the pharmacist of the pros and cons of all treatment options and the pharmacist, with the patient's agreement, would choose a particular form of therapy. A care plan would be documented and treatment would be followed up by the pharmacist. All this would follow a model of concordance which hopefully would improve compliance. The pharmacist would be responsible for monitoring treatment, referring back to the GP where necessary.
But to prepare for this new age, pharmacists needed to develop their clinical skills above all else. Professor Mackie said that she often heard pharmacists say that they were the experts on drug therapy. They were not. Collectively, as a profession they might be, but individual expertise was not of the same order. Many pharmacists' knowledge of drugs was theoretical rather than practical. To know about drugs in practice, they needed to follow treatments through with real people. Pharmacists' knowledge of clinical effectiveness and patient outcomes was extremely slim. That was the part they desperately needed for pharmaceutical care.
Pharmacists should be patient focused and be at ease and skilled in a multidisciplinary environment. They needed education and training and a commitment to lifelong learning.
Professor Mackie said that she had been involved in discussions on medicines management, as now being proposed by the Pharmaceutical Services Negotiating Committee. One of the things said in those discussions had been that pharmacists needed communication skills and inter-professional skills and that the clinical knowledge they needed could be got on to one side of A4 paper. That was nonsense. If pharmacists could get all they need to know about a drug on a sheet of A4, they were not needed at all. That kind of input could be made by an auxiliary. Pharmacists needed an intimate knowledge of drugs, and of clinical pharmacy, pathology and therapeutics. If they did not have these things, they should back off and leave patient care to someone else.
It was quite clear from talking to Professor Mackie that that was not an option with which she had any sympathy.