The Pharmaceutical Journal Vol 263 No 7066 p607-608
October 9, 1999 The Conference

Joint professional/science symposium

Medicines for the next millennium

In the closing symposium of the Conference on September 16, participants heard ideas of how both medicines and pharmacy practice might evolve in the next century

Challenges for pharmacy practice

The main challenge for practice will, I believe, come from new technologies," said Miss Ann Lewis, the Royal Pharmaceutical Society's Secretary and Registrar, opening the symposium with a discussion on "challenges for practice in the new millennium". Thirty years ago, when a piece of strategic thinking had landed a man on the moon, it had engendered a culture of belief, she said. This "one great leap for mankind" had led, she suggested, to technological advances that had had a considerable impact on many fields, for example, to the development of ultra-clean environments, low residue diets and microminiaturisation of computer chips. "We do not have problems any more, we have challenges," she said. The pace of life had accelerated dramatically in the past 10 to 20 years, said Miss Lewis. Just before the 1914-18 world war, male life expectancy had been 44 years. This had now extended to beyond 70 years, and to over 80 years among women. However, although they needed to look to the future, they should remain aware of the present, she cautioned.

Ann Lewis: dynamic strategy needed

But where would the impact of technological advances in health care be, Miss Lewis asked. Certainly effects would be felt by the individual in the guise of new treatments, the prediction of therapeutic outcomes and in terms of being better informed. For health care professionals, the availability of new diagnostic tools and medicines would be coupled with a move towards different roles and blurred boundaries. For society as a whole, knowledge and progress would create new dilemmas and concerns over values and affordability.
Priorities
With regard to priorities and challenges in health care, Miss Lewis said that the role of the pharmacist was a well recognised one and was likely to remain so in the future. From discovery to clinical action, medicines were pharmacists' business. They would be there, she suggested, to handle the newer and better medicines in development. For example, gene therapy was currently coming into use in a "corrective" sense and, in time, might present curative possibilities.
Pharmacists also knew about NHS priorities but should appreciate how other issues, such as housing and the environment, could have an impact on health. These issues were under discussion in the recent White Paper, "Saving lives". Health priorities for the next 10 years had been established in areas such as coronary heart disease, cancer and mental health. Pharmacy also had its priorities, including setting of standards and recognition. The profession had concerns too, she acknowledged, over remuneration and workload.
So how could the impact of such a diverse set of challenges now and in the future be assessed, asked Miss Lewis. It was important to develop a strategy that made the most of opportunities and which assessed risks, she said. The Society had such a strategy, but this must be dynamic and be constantly reviewed. In such a strategy, certain issues needed to be addressed and these included health care models, technology, resources, devolution, the "modern" NHS and professional accountability.
In terms of models of health care, these had changed significantly over the past 10 years, said Miss Lewis. In the 1990s, health care had been based on a "biochemical" model in which the emphasis for the pharmacist was still primarily on the handling of prescriptions and the supply of medicines. But by 2000, this emphasis would have shifted towards a role in the promotion of self care and in developing pharmaceutical care plans. Furthermore, by 2010, health care would be more likely to be based on a "molecular" model.
By this time, as a result of scientific advances, the emphasis of medicine would have evolved from a disease focus to one of prevention and prediction. The treatment of patients would become individualised and promote the pharmacist's role in managing facilitated and integrated care.
In general, there would be a move from a "diagnose and treat" culture to one of "predict and manage", said Miss Lewis. How fast this would happen was dependent only on the imagination of the scientist, she commented. In particular, the mapping of the human genome would have a wide impact on science, education and practice. Disease prediction would become reality and treatments more effective and specific. Moreover, it was a matter of when, and not if, gene-based pharmaceuticals would become available.
The pharmacist, she suggested, would assume a specialised role in the manipulation of such products, and a more general role of explaining to, and reassuring, patients receiving gene-based treatments. Drug regimes would become more tailor-made for each individual and, in the future, there would be a shift as to who selected medication and treatment.
E-commerce
There were also rapid developments in other aspects of technology, in particular the evolution of "e-commerce" and automation, said Miss Lewis. Automation had already been shown to have powerful effects in pharmacy, she suggested. E-commerce was here to stay but, although the implications for pharmacy required consideration, it was unlikely that it would displace the social importance of traditional shopping.
The "wired age" would also bring both opportunities and changes in the way health care was administered, said Miss Lewis. The NHS Direct system and telemedicine were just two examples. The opportunity to access information, share records and generate mutual referrals through health care systems such as NHS-net and PRODIGY would enhance doctor-pharmacist working relationships. Furthermore, patients were becoming better informed, with the world-wide web presenting a wealth of information which, increasingly, they would require to be sorted and explained by professionals.
It was also important to consider the adequacy of resources in terms of medicines, workforce and money in any strategic planning. Financial constraints must be recognised and addressed, in particular with regard to emerging medicines and technologies. The provision of an adequate workforce was a challenge in all countries, both in terms of money and competence.
With regard to the NHS, any strategic thinking must take account of the fact that the NHS was also a developing and evolving model, Miss Lewis said. The emphasis was moving towards local delivery of health care and improved service quality through clinical governance, professional self-regulation, life-long learning and continuing professional development. The Society was soon to publish a working document on clinical governance and would welcome feedback, she said. [This document has now been published, see PJ, September 25, p479.]
Concluding with a review of new opportunities, Miss Lewis said that pharmacists had to "forget introspection, leave the comfort zone and meet the challenges". The pharmacists of tomorrow, she said, were well prepared for the future. Miss Lewis referred to the words of two young pharmacists: "The only constant in life is change . . . pharmacy will evolve . . . the future is what we make it . . ." (Burton and Wicks, PJ, June 19, p880).

Magic bullets for the 21st century?

In the future, there would be a radical change in the technology and practice of human health care, said Dr Eric Tomlinson (director, The Scientific World Inc, Florida, US and visiting professor, school of pharmacy, University of London) in his lecture entitled, "High value medicines - the magic bullets for the 21st century". That view, he said, was based on the increasing availability of insightful biological information provided by recent advances in molecular medicine. Such biotechnological advances had been perceived by the press in various ways, from being hailed as a far reaching technology that would take health care into the next century to more cynical views suggesting that, so far, biotechnology had not "paid off". Nevertheless, Dr Tomlinson affirmed that, in his view, biotechnology would define the progress of the pharmaceutical industry and health care. But how could they gain from the amazing advances in biotechnology and cell science that were happening at the moment, questioned Dr Tomlinson. He proceeded to describe likely advances in the prediction, prevention, diagnosis and treatment of disease.

Eric Tomlinson: Individualised therapy likely

"Molecular profiling" of patients would lead to radical new methods for the prevention and treatment of disease, said Dr Tomlinson.
This profiling, or "genophenotyping", of patients would establish a record of both the genotype (ie, genetic make-up) and phenotype (ie, the observable result of the interaction of genotype and environment). Dr Tomlinson commented that he thought people would eventually carry "smart cards" which would contain this information. The data would be used to assess and examine overall health, disease risk and drug responsiveness and would become an integral part of an individual's health care plan, he suggested. The emphasis in medicine would move towards prediction and prevention. "Health is genetically defined and so treatment should be genetically defined," he said.
Molecular profiling
Molecular profiling would facilitate patient individualisation of therapy, said Dr Tomlinson. This would present a great opportunity for pharmacists and the pharmaceutical sciences. The pharmacist would move towards a predominantly information-based role, using pharmaceutical knowledge to provide and synthesise information for patients and other health care professionals. Furthermore, he commented, the advent of the internet would pave the way for the digital delivery of medicines. This would remove the yoke of the pharmacist from the "bunker mentality" and enable them to become health care advisers and to concentrate on the treatment of individuals.
On the changes that were shaping the environment for advances in biotechnology, Dr Tomlinson suggested that the pharmaceutical industry was now beginning to interact more productively with academia. Moreover, it had also started to collaborate closely with "tools" companies. These companies, usually originating as small, start-up enterprises, tended to have capabilities and expertise focused on highly specific areas, for example, in combinatorial chemistry or bioinformatics. Scientists taking risks were able to make money, he said.
There had also been major advances in the capacity to deal with information, Dr Tomlinson said.
The amount of data being created was awesome. Between now and the end of the year, the same amount of information would be generated as had been produced over the past five years. Bioinformatics, the science of archiving, analysing and annotating biological information, was a whole new science in itself.