The profession needs to build capacity for pharmaceutical care, according to Dr John Rovers (assistant professor of pharmacy practice, Drake University, Des Moines, Iowa).
"If we cannot come to the market with enough practitioners doing this [pharmaceutical care] we will be ignored," Dr Rovers declared. Insurers would not be interested in working out how to pay pharmaceutical care providers if they were few and far between. Furthermore, insurers would need proof that pharmacists were good at providing the service and there should be standard outcome measures on which to base a payment system.
Dr Rovers indicated that there were pockets of pharmaceutical care development in the United States. A project funded by the insurers Blue Cross/Blue Shield in Iowa reimbursed pharmacists for providing pharmaceutical care for patients with asthma, diabetes, hypertension and coronary artery disease. Pharmacists had not performed universally well in this, but they had outperformed a control group. In Ames (Iowa) a series of pharmaceutical care programmes had been developed that could be sold to various payers. In Wisconsin, Medicaid (providing indigent care) had begun to reimburse pharmacists for episodic patient care. In Washington, pharmacists were being paid to help patients on complicated therapy. In Mississippi, Medicaid was paying certified pharmacists to provide management for various diseases, including diabetes and hyperlipidaemia. In North Carolina, in one city, pharmacists were being paid to provide pharmaceutical care for diabetics.
But of the lessons learnt from these projects, the most important was the one concerning capacity.
Dr Rovers said that in the United States, a lot of money for pharmaceutical care pilots had come from government sources. But he had heard on good authority that managed care [the main private health care provision system] would come on board soon. Managed care providers had cut costs so much they were finding it difficult to deliver. They needed help and pharmaceutical care could provide it.
But, in going into the market place, academic prejudice needed to be overcome. There was a belief in academia that there was one pure vision of pharmaceutical care. People who did not share it were shunned. But it was the market place that was defining pharmaceutical care. "People who are paying for it are determining what it is."
It was also crucial for pharmacists to work in partnership with physicians and important to find out what they wanted. Too many people developed such things as asthma programmes assuming that physicians wanted them.
Pharmacists would have to market their services. No-one was sitting at home waiting for pharmaceutical care to be invented.
Patients were increasingly being given responsibility for their own health care. They were being discharged from hospital faster. Pharmacists could help them.
Looking at academic barriers in the development of pharmaceutical care, Dr Rovers said that teaching philosophy had a long way to go: "Too many of us in pharmacy education don't have a clear idea of why we teach what we teach." And what students heard in the classroom had nothing to do with practice, once they had graduated. For teaching pharmaceutical care as a discipline there was "not much out there to help." Teaching sites offering realistic practice experience were needed. Pharmaceutical care should be integrated into the curriculum. Teachers should also bear in mind that they were teaching pharmacists, not doctors.
Looking at personal barriers to the development of pharmaceutical care, Dr Rovers suggested that many pharmacists did not see themselves as health care practitioners. Pharmaceutical care required a substantial change in how pharmacists regarded themselves. That kind of change was extraordinarily hard to achieve. "It is the hardest thing we have ever had to do as a profession."
Pharmacists had to develop support networks and co-operate rather than compete.
Concluding, Dr Rovers said that barriers to the development of pharmaceutical care could be overcome. He urged practitioners to seek out solutions for themselves and not to be too dependent on "experts".
Speaking later, Dr Rovers said that he had been very encouraged by what he had heard during the symposium. There had been great difficulty in getting pharmaceutical care started, but the snowball was now beginning to roll down hill.
"I have never heard of pharmaceutical care," an Australian general medical practitioner told the symposium. Dr Nick Carr (a GP practising in St Kilda, Victoria) said that none of the pharmacists he worked with had told him about pharmaceutical care or whether they were providing it.
Dr Carr went on: "I need to know that the pharmacists I am working with are embracing these ideas.
. . . I need to know what pharmacists are saying to my patients."
Dr Carr said that doctors did not know which pharmacists were doing a good job professionally and which were not. They did not easily get information about the way pharmacists practised. He added: "If you ask doctors about how pharmacists practise the answer is sometimes not very complimentary. . . . There is a perception that cosmetics promotions are what preoccupy them."
What was needed was for doctors and pharmacists to get together at the local level. There was no better way of doing this than through the carrying out of projects. In his area, pharmacists had been involved in projects on benzodiazepine use and on patients taking multiple medications. The projects had a clear primary purpose but the subtext had been doctors and pharmacists getting together. This was an aspect that the doctors and pharmacists involved greatly valued.
Reinforcing points made by Dr Carr, Dr LEIGH HAMMOND (medical director, Smithkline Beecham) said that pharmacists knew more about the practical aspects of medicines, such as packaging and palatability.
Patients would have problems with such matters if doctors and pharmacists continued to practise in isolation.
Opportunities already exist in Australia for providing pharmaceutical care and being paid for it. Pharmacists should take them and build on them for the future. If they did not, the development of pharmaceutical care practice would be slow and difficult. That was the essential message given to the symposium by Mr Grant Kardachi (a practising community pharmacist and president of the South Australian branch of the Pharmaceutical Society of Australia).
Mr Kardachi said that the existing opportunities arose because the federal government now paid a fee for medication review in residential care facilities and for "at risk" patients in the community. Mr Kardachi acknowledged that the existing payments were not large, but said that it was worth investing in the development of such services because of the potential for future growth. Pharmacists were quite happy to invest in "the front shop", so why not in the provision of professional services.
He urged pharmacists to become accredited for providing the services in question. Not all pharmacists currently working with residential facilities wanted to go through the accreditation process, so there was no shortage of work for those that did.
Mr Kardachi already practices in this field. In doing so, he uses the principles of pharmaceutical care, that is, collecting and assessing relevant data about patients and their medicines, developing a care plan and following up to find out if treatment is working. He made it clear that it was vital to establish close links with all other practitioners involved in the health care of home residents and "at risk" patients. He advocated face-to-face meetings with the medical practitioners concerned. They needed to understand what pharmacists would be doing and that pharmacists offered a value added service that complemented their own. Mr Kardachi made it clear that good relations with district nursing staff were also important. They were good at identifying people at risk.
Residential homes
In relation to residential homes, he recommended that they each have a medication advisory committee. Doctors and nurses as well as pharmacists should be represented on the committees. He also advocated that a formal letter be sent to doctors caring for patients in residential homes explaining the objectives of the service that pharmacists were offering. As part of the service, he recommended that all medicine reviews, as well as being carried out by an accredited pharmacist, should be peer reviewed by a clinical pharmacist. He, himself, employed a clinical pharmacist from a hospital in his area for this purpose. In addition to carrying out the peer-review function, the pharmacist also acted as a mentor to the pharmacists carrying out the reviews.
The medicines management initiative in England and Wales was presented to the conference as an example of pharmaceutical care by Dr D. K. ("THEO") Raynor (head of the division of academic pharmacy practice, University of Leeds).
In a joint presentation with Miss Ann Lewis (Secretary and Registrar of the Royal Pharmaceutical Society) and the Society's practice division, Dr Raynor said that the initiative would impact on the way that pharmaceutical care developed in Britain.
Dr Raynor said that the initiative was being co-ordinated by the Pharmaceutical Services Negotiating Committee, which negotiated remuneration with the government. The objective was to arrive at the most appropriate choice of medicines and therapeutic regimens for patients by a process of ongoing review. This would be achieved by structured discussion by the pharmacist with the patient, collaboration with the prescriber and other members of the health care team and recording interventions in an agreed format.
Both prescribed and over-the-counter medicines would be covered. The primary aim would be the management of chronic conditions.
Dr Raynor made it clear that the initiative involved a partnership of pharmacy bodies in England and Wales. The PSNC was handling political and professional communication and public relations, the Company Chemists Association and the Co-operative Pharmacy Technical Panel were developing premises changes needed for the new services, including future IT requirements, while the Society was responsible for education and training issues and research into new models of practice.
Dr Raynor went on to list a number of local pharmaceutical care initiatives in Britain. These included: work at the North Middlesex hospital on guidelines for prescribing lipid lowering drugs; a London scheme where housebound patients recently discharged from hospital were visited by a community pharmacist; a Sussex scheme where general medical practitioners and pharmacists worked together to improve care of asthma patients; a Leeds project where, by home visits, community pharmacists identified patients at risk of medicines management problems; a London scheme where practice nurses referred newly diagnosed patients with diabetes to a pharmacist for advice on diet, lifestyle and blood glucose monitoring techniques; an instalment dispensing scheme supervised by a pharmacist in Surrey; domiciliary visiting of psychiatric patients by a community pharmacist in Liverpool; and pharmacist run repeat prescription clinics in Leeds.
Dr Raynor also gave the National Pharmaceutical Association's repeat dispensing project as an example of pharmaceutical care.
He described how the pharmaceutical care changes were taking place against a background of the Pharmacy in a New Age initiative and reorganisation of primary care. He indicated that new opportunities for pharmacists would arise as a result of the Crown review of prescribing and the Health Secretary's round table discussions on an extended role for community pharmacists.
Criteria for care needed
The profession needs to more clearly lay out the criteria for when pharmaceutical care services should be provided for the consumer, according to Mr Warwick Plunkett (president of the Australian College of Pharmacy Practice). When drawing the symposium to a close, Mr Plunkett said that the criteria should involve the nature of the medication as well as the background of the consumer. When they were clearer about such issues, they would have more interest from third party payers, including government.
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An attempt to have pharmaceutical care accepted as the normal standard of practice in Australia by the year 2001 is foundering. The objective was set by the steering group of the Australian Pharmaceutical Care Project, on which is represented all the national pharmacy organisations.
Reporting on progress with the project, Mr AlIstair Lloyd (former registrar of the pharmacy board of Victoria and executive director of the Pharmaceutical Society of Victoria) said: "The early aspirations of a dedicated national programme to achieve the national vision is now regrettably at a standstill in Australia, where it will probably remain until more resources can be obtained to reinvigorate it.
"Unfortunately, I cannot observe any real attempt to gather these resources. I would hope that this is only a temporary lull, and that a national pharmaceutical care project will soon be the number one priority for the profession."
Shoe string
Mr Lloyd said that the project had always been run on a shoe string. He regretted the fact that the national society had not been able to continue with the employment of a national director for the programme. The Australian pharmaceutical care project had been inspired by addresses in Perth and Sydney by Professor Douglas Hepler and Professor Linda Strand, respectively (see also PJ, April 18, 1998, p567). In the early days, the Victorian branch of the Pharmaceutical Society of Australia had administered the project. It was supported financially by Glaxo Wellcome and the Pharmacy Board of Victoria. The management of the project was subsequently passed to the national office, and the (now discontinued) post of national director established.
Mr Lloyd made it clear that, while there was now no national programme to co-ordinate and support the development of pharmaceutical care, a considerable number of individual pharmacists were "battling on". There were places where "pharmaceutical care was alive and well" and there were self-help groups that were not prepared to wait for the profession to give support from the top but were applying their own energies and resources to develop their practices "from the bottom up". Mr Lloyd said that he, himself, was working with a group of Victorian pharmacists dealing with the practical difficulties of providing a pharmaceutical care service for a fee.
Mr Lloyd said that an American curriculum developed at the University of Iowa had been modified for use in Australia. Twelve courses had now been conducted in all states, with nearly 200 pharmacists receiving the training. In addition, over 1,000 pharmacists had been introduced to the pharmaceutical care concept at courses designed to lead up to formal training.
Australian software for pharmaceutical care was at the beta stage and needed some refinement before release as a commercial product.
Mr Lloyd likened pharmaceutical care in Australia to a bush fire. He declared: "The fire of pharmaceutical care has started in Australia. Much of the place is not affected, either because of apathy, complacency or ignorance.
. . . However, there are a significant number of places where the flames are burning vigorously. . . . Importantly, I believe the whole environment is dry and it will not take much for the bush fire of pharmaceutical care to begin again." What was desperately needed was committed leadership coupled with innovative practitioners.
One "warm coal" goes out quickly. If there are several together, then the fire stays alight. For "warm coal" read "pharmaceutical care practitioner".
This calorific metaphor was presented to the symposium by Mr Peter Hocking, a community pharmacy manager from South Australia. A dedicated practitioner working alone might, Mr Hocking said, be able to succeed in providing pharmaceutical care. But practitioners who were part of a group, working together and encouraging each other, were more likely to be successful.
Mr Hocking's pharmacy is part of a 15-practice group providing a pharmaceutical care service. He made it clear that, although pharmaceutical care was professionally rewarding, it was also hard work. None of the pharmacists in his practice who were capable of offering the service wanted to do it all the time. They preferred to stick to three four-hour sessions per week. Pharmaceutical care was extremely demanding and extremely draining in terms of the effort and work that went into it. Time needed to be allocated to providing the service. There was a separate line on staff rosters for it.
In Mr Hocking's pharmacy, much of the pharmaceutical care (or "medicines management", as he also called it) was provided for nursing home residents.
Mr Hocking, who works with Mr Kardachi (see p627), said that they had made a positive decision to invest in pharmaceutical care. The fact that they provided the service gave them a competitive edge and had enabled them to keep nursing home business that they might otherwise have lost. And they were now finding that there was real market for the service.
Proof of the effect of pharmaceutical care was still needed, Dr J. W. Foppe van Mil (chairman, Pharmaceutical Care Network
Europe, a research co-ordinating group) told the symposium. This was a barrier to its implementation.
There were many indications that pharmaceutical care satisfied patients and contributed to improved health status, but definite proof was still lacking. The core question was whether pharmaceutical care really helped to improve individual patient outcomes.
The PCNE had recognised that outcomes were poorly defined and so had organised a conference on outcome measurement in pharmaceutical care. This had taken place in Hillerod, Denmark, in January (see also p632). The meeting had looked at the issue under six headings: satisfaction and health status; knowledge and attitudes towards medicines; behaviour and coping strategies; use of medical resources and economic impact; assessing drug-related problems; appropriateness and change in drug therapy. Fourteen-hour workshops had been held on each. The only workshop to complete its work had been the one on drug-related problems. The workshops were to continue their work.
Dr van Mil said that it was essential that professional organisations actively supported the concept of pharmaceutical care in their own countries.
A pharmacist from Ulverstone, Tasmania, is using the principles of pharmaceutical care in offering a travel service to his clients. He is also making money out of the service.
Explaining his approach, Mr David Wools-Cobb, a community pharmacist, said that he had undergone pharmaceutical care training two years ago. But he had found the prospect of putting it into practice daunting. He had, therefore, decided to tackle one area where he felt confident, and that was travel health. In doing so, he applied the principles of pharmaceutical care, namely collecting and evaluating data about the client, preparing a care plan and then implementing the plan and monitoring the results. This approach could be applied to any area of the business. He had just chosen travel.
He had prepared for his new service by assembling a full set of travel references, including judicious use of the internet.
Opportunities to offer the service presented themselves, for example, when prescriptions were brought in for the vaccines needed by travellers or when customers talked to staff about their holidays. If customers agreed to receive the service, he sat them down at his counselling desk where he took a history using a proforma that he had prepared. The history covered basic patient details, current medication, health problems, immunisation status and destination and duration of the forthcoming trip. A further appointment was booked, by which time the needs of the client would have been assessed. The client at the first interview would also be given a travel check-list setting out items that a traveller might need. This was brought back at the second appointment, when a staff member would collect the requirements together for sale to the client.
At the second appointment, a list would be supplied of requirements that would need to be fulfilled by the client's doctor. A card offering self-care advice was also provided.
Mr Wools-Cobb said that pharmacists could also supply vouchers for developing and printing and pick up extra business that way.
The counselling desk was not physically separate from the pharmacy. Other clients could see it being used. Mr Wools-Cobb suggested that that arrangement improved the perception of the services offered in the pharmacy.
Mr Wools-Cobb made it clear that his travel service made money. His average sale to a travelling client before offering the new service had been $65-$85 (about £26-£34). Now it was over $250 (about £100). In the first year of the service, he had achieved $25,000 (about £10,000) in extra sales.
He had found the service so profitable that he did not need to charge a fee for it.
The service could be marketed by normal advertising and by liaising with local travel agents and companies sending their staff abroad. Doctors referred clients to him for the service.
Concluding, Mr Wools-Cobb said that pharmacists could greatly enhance their businesses by using the pharmaceutical care formula for various professional services. Other areas could include smoking cessation and wound care.
Insurer shows interest
An Australian private health insurer is preparing to pay for the provision of pharmaceutical care in the community. Ms Sue Brown (pharmacy manager, provider relations, Medical Benefits Fund of Australia Ltd) told the symposium that her company would like to shift the emphasis from paying for drug supply to recognition of high quality clinical pharmacy services within community pharmacy.
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Consumer view
Consumers want to build a relationship with their pharmacist, not just have a prescription dispensed. So said Mr Mitch Messer (chairman, pharmaceuticals project steering committee, Consumers' Health Forum of Australia). He added: "When a pharmacist, or any other health professional for that matter, takes an active interest in their customers or patients they are beginning to develop that bond."
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Press controversy followed the decision by a New Zealand pharmacist to start charging for pharmaceutical care.
Mr Bernard McKone (vice-president of the Pharmaceutical Society of New Zealand), who owns a pharmacy in Gore, a small town north of Invercargill on South Island, said that reports of his decision to start charging had appeared on national television and radio. There had been huge interest in the matter. There had even been cartoons in national newspapers. What resulted had been an unprecedented focus on pharmacy practice.
Mr McKone went on: "Many of us were not ready for the scrutiny that occurred. It resulted from a lack of understanding by the media, the public and other health professionals about comprehensive pharmaceutical care [the term used in New Zealand]. Not only that, but some professional colleagues had been at odds with the decision to make charges.
The response from the public had varied. One of his regular customers had telephoned to say that he would never pay for advice. Others, including many who did not use the pharmacy, had called to inquire about the service. Many customers now purchased the CPC service but did not obtain their medicines from the pharmacy.
Mr McKone said that he had recently refitted his pharmacy to improve his consultation services. As well as a consultation room, he had a "healthy advice" room. The latter was used, he said, for occasions when customers asked questions on personal matters. No appointment was necessary to use the room and no charge was made for consultations in it. Mr McKone said that his customers had told him that they did not want to feel that every time they asked for a pharmacist's advice they would have to pay.
Many of the conversations in the "healthy advice" room led to formal appointments for pharmaceutical care, which were undertaken in a consultation room.
He employed a member of staff to keep the appointments diary and to administer the charging system. He preferred to devote his time to pharmaceutical care issues.
Mr McKone said that the new arrangement met customers' wishes about be able to speak informally to the pharmacist without incurring a fee. And it also allowed a fee to be charged for in-depth consultations that were required for some customers.
Describing other services available at his pharmacy, Mr McKone said that he was offering an asthma management service in partnership with the school of pharmacy at the University of Otago and the Health Funding Agency (HFA), the payer for pharmacy services. One typical patient had shown reduction in medicines usage and savings in drug costs. The pharmacy also provided a diabetes monitoring service, offering analysis of blood glucose levels for patient and doctor, computerised spirometry for chronic obstructive pulmonary disease and medication review for at risk patients,with a view to preventing hospitalisation.
Mr McKone said that introducing pharmaceutical care services in the pharmacy had required a restructuring process among the staff. New roles and responsibilities had been, and were still being, defined.
So far as general medical practitioners were concerned, Mr McKone had been able to break down some of the misconceptions about pharmaceutical care. He referred about one patient in two to the GP and got written feedback on some of the referrals. A simple form was used for this.
His pharmacy had been providing pharmaceutical care for over two years. He was now earning more from it than from selling Revlon cosmetics.
Mr McKone said that obtaining HFA funding was essential in the strategy to develop pharmaceutical care practice. This would complement the fees paid by patients. All the relationships were in place with other health professionals to maximise patient outcomes, should the HFA agree.
Concluding, Mr McKone said: "I have enjoyed business growth, an increase in the market share of prescriptions, a closer relationship with other health professionals, but, most importantly, immense satisfaction as a pharmacist ."
Mr McKone's refitted premises were opened by the Minister of Health last November.
Asthma package launchedDuring the course of the symposium, the Pharmaceutical Society of Australia launched an asthma package designed to equip pharmacists and their staff with resources to deliver high-quality asthma care. The package contains a distance education module developed by the PSA and the Australian College of Pharmacy Practice, a pharmacy assistants' course, asthma management resources, including symptom monitoring forms and forms for referring a patient from a pharmacy to a general practitioner, a management handbook and asthma information. Also included are asthma fact cards for use by patients, and materials for marketing an asthma service. The package, which is sponsored by Zeneca Pharmaceuticals, is available from the PSA (PO Box 21, Curtin ACT 2605) for a minimum fee of $250 (about £100). Mr Tony Nunan (president of PSA) said that it was appropriate that the package be launched at the symposium because it was a wonderful example of how pharmaceutical care could be applied. Two million Australians suffered from asthma. As the most accessible health professional, the pharmacist had a unique role to play in reducing asthma's impact in the country. |
Two pharmacists in a pharmacy at the same time are conducive to providing good pharmaceutical care. That is one of the findings of the Alberta pharmaceutical care project (see also PJ, April 18, 1998, p565). Outlining some of the results of the project to the symposium, Dr Karen Farris (associate professor, faculty of pharmacy and pharmaceutical sciences, University of Alberta, Canada) said that the pharmacies which had been the most successful in providing pharmaceutical care had had "overlapping pharmacists". This had allowed one pharmacist to continue to work in the prescription filling process while the other worked with patients providing pharmaceutical care.
Dr Farris conceded that the overlapping pharmacist model had higher wage costs than single pharmacist establishments.
For the Alberta project, 16 pharmacies had been recruited by the University of Alberta to trial pharmaceutical care. Half were for a control group. By the end of the project 10 pharmacies remained. Fieldwork had now been completed.
Dr Farris identified four barriers to implementation of pharmaceutical care: pharmacists' capabilities and attitudes; the quality of information available to pharmacists; the time that pharmacists had to perform their various functions; and the quality of their relationships with patients and physicians.
Discussing pharmacists' capabilities, Dr Farris said that the main thing that they had wanted to accomplish in their project had been to raise the level of problem identification among pharmacists. They had put together a training programme to achieve that. This had involved theoretical cases and practical cases with volunteer patients. As part of the process, pharmacists would make a detailed study of the pathology and treatment of diseases that they came across in patients. Tests of pharmacists' capabilities midway through the programme and at the end of it had shown that their skills in this field had improved.
Pharmacists had identified 158 drug-related problems in the volunteer patients. They had made 57 recommendations to physicians, of which 35 (61 per cent) had been accepted. The pharmacists had been very surprised how little they knew about their patients before the study.
On the question of information, Dr Farris said that a lot could be learned by interviewing patients. Interviews with 123 patients during the project had found 244 drug therapy problems. The most common finding was "requires drug therapy" (50 per cent). Seventy-eight per cent of pharmacists' recommendations had been accepted by the patient and 39 per cent by the physician.
On the issue of time, Dr Farris made it clear that provision of pharmaceutical care was time consuming. The initial interview with a patient could take 45 minutes and studying a disease state with which the pharmacist was not familiar could take eight to 10 hours. Completing the assessment and plan could take another two. It was not a 10-minute process. But pharmacists still felt they had to give their traditional duties precedence. They were most comfortable with those duties, hence the success of the two-pharmacist model.
On relationships with patients, Dr Farris said that they had had some encouraging results on patient satisfaction. This particularly applied in the area of drug therapy and trust of the pharmacist. Furthermore, patients receiving pharmaceutical care had been found to have a higher expectation that their pharmacist would communicate with their physician about their drug therapy.
An agreed model for pharmacy practice is needed, according to Ms Leone Coper (manager, professional liaison, Health Insurance Commission, Australia). Ms Coper, who is a pharmacist, told the conference, that all the talented people in pharmacy should contribute to the agreed model, which should take account of the unique and valuable pharmacy environment. The practice model should be described and be understandable. It should be seamless across different environments and be delivered consistently to all who needed it. It must be demonstrated to be effective and cost-effective and capable of being implemented at the national level.
The pharmacy profession was too small, and health needs so great, that pharmacy could not sustain the present fragmentation and territory protection.
Ms Coper said that she had been authorised to offer the funding of a forum to discuss how the best features in all the individually admirable models and systems of practice could be integrated to maximise pharmacy's contribution to primary health care, to have that practice taken on by all the pharmacists in Australia and to ensure that that contribution was accepted, valued and recognised.
Earlier in her address, she said that the value of pharmaceutical care type services was not widely apparent to the people who needed to be impressed - health policy makers. She also said that most general practitioners with prescription writing software believed that they had all their patient medication needs covered. Pharmacy would have to work hard to persuade them otherwise.
Mr WARWICK PLUNKETT (president of the Australian College of Pharmacy Practice), who was in the chair, said that the forum offer should be taken up.
The Health Insurance Commission is a federal authority administering a number of Australian government programmes in the health area, including the pharmaceutical benefits scheme.
A pool of quality pharmaceutical care practitioners needs to be developed, according to Dr Andrew GilberT (associate professor, school of pharmacy and medical sciences, University of South Australia). It was no good, he said, having a few individuals working in isolated areas. "We have to have," he said, "a consistency of service across the profession."
The quality pool should also seek to work alongside the organisational structure for general medical practitioners to help doctors achieve their goals. Individual personal relationships between pharmacists and doctors should be developed. Arms length relationships conducted by post could lead to misunderstanding.
The kind of quality service that the practitioners concerned offered should be readily differentiated from the type of pharmacy practice with which most consumers were familiar.
Dr Gilbert indicated that pharmaceutical care projects carried out in South Australia had helped define the practice of pharmacy. They had demonstrated a community need for such services and had built better interprofessional relationships by demonstrating the added value to the patient and practitioner of pharmacist input. The services had also been shown to be cost effective. For example, with respect to older people at risk of medication misadventure, possibly leading to hospitalisation, net savings to the health system per patient ranging from $40 (about £16) to $311 (about £124) a year had been demonstrated.