The Pharmaceutical Journal Vol 263 No 7067 p649-650
October 16, 1999 International

Pharmacy in Spain

During the recent World Congress of Pharmacy and Pharmaceutical Sciences in Barcelona, The Journal's correspondent, Pamela Mason, examined the state and status of pharmacy in Spain

Firmly part of Europe, and for 30 years the country with which British tourists have become more familiar than perhaps any other, Spain still retains many differences, and parts of its interior remain relatively unknown. Hidden beyond the Pyrenees, it has links not only with its near neighbours in Europe and North Africa, but also with the countries in South America with which it shares a common history and language.
Including the Balearic Islands and the Canaries, Spain has a population of about 39m, but currently the lowest birth rate in Europe.¹ With 19,222 community pharmacies, it has one of Europe's highest pharmacy densities, with one pharmacy per 2,049 inhabitants, compared with one per 4,900 in the United Kingdom. As a result, 98 per cent of the population have easy access to a pharmacy wherever they live, even in isolated rural areas. This is a characteristic of which the Spanish pharmacy profession is very proud.

Health care

Historically, the development of health care in Spain was patchy and inconsistent, but in 1978 the rights of all Spanish people to health care were declared in the Spanish constitution. As part of a process of profound political decentralisation, Spain was, at that time, divided into 17 autonomous regional governments, and in 1986, the General Health Law established a national health system with 17 autonomous health services mirroring the regional governments. The law's aim was to integrate and co-ordinate all the older health care delivery structures, devolve health care to the autonomous regions, provide health care finance through taxation and create a new model of primary care with multidiscplinary teams based in health centres.²
The law has yet to be be fully implemented, and the transfer of health care from the centre has taken place in seven of the autonomous regions, covering 62 per cent of the population. Spain spends 6-7 per cent of its national income on health services (a similar proportion to that in the UK), and the budget is divided between the seven regions, with the rest managed centrally by the central health insurance organisation, Insalud.
The health care budget does not seem to be distributed entirely according to need. For example, some drugs are paid for by some regions and not others, schedules for child immunisation vary between regions, and some regions offer dental care whereas others do not. Moreover, with some exceptions, a real change in primary care does not seem to have been achieved. Health services remain dominated by hospitals and, in contrast to the situation in Britain, general practitioners have not gained such significant control of access to hospital care and funding.³

Pharmacy organisation

Pharmacy is organised and co-ordinated by the General Council of Official Associations of Pharmacists in Madrid. This is made up of 52 official associations (one for each geographical region) which represent Spain's 46,761 pharmacists. To practise, pharmacists must register with the official association where they hope to work. The general council's role is to support and promote the profession, nationally and internationally, and it develops policy relating to pharmacy practice, including a code of ethics. Its work is divided between various "boards" representing the specialisations and interests, including community pharmacy, hospital pharmacy, industry, research and teaching, wholesaling, clinical analysis, dermatology and nutrition.
The general council produces a range of publications, including journals, books and drug databases, plans health campaigns, provides continuing education programmes and is involved in negotiating pharmacist fees and invoicing the social security system for community pharmacies' monthly drug payments. Like the Royal Pharmaceutical Society in Britain, it also works on research projects and produces reports on topics of importance to the future development of the profession. It has also developed an internet website.

Pharmacy practice

Pharmacy has a monopoly in Spain. No-one else can dispense or sell medicines. Moreover, all the 20,544 pharmacy owners are pharmacists. This is the law. And although a pharmacy can be jointly owned by more than one pharmacist, no pharmacist can own more than one pharmacy. This means, of course, that there are no chains, and all pharmacies are privately owned. A pharmacist must always be on the premises when the pharmacy is open. More than 27,000 pharmacists work in the community, and about half of pharmacies in Spain employ two pharmacists; this was the case in the pharmacy I visited. Owned by Ms Consol Estivill, it is one of 24 pharmacies in the town of Prat de Llobregat, which has a population of about 65,000 and is about three miles from Barcelona. The number of community pharmacies (19,222) is regulated by law, according to the number of inhabitants - there must be at least one pharmacy for every 2,800-4,000 inhabitants, although the average is one per 2,049 - and also the distance between pharmacies, which must be no less than 250m. Most people are covered by the national social security system and pay 40 per cent of the cost of their prescribed medication. Retired people get it free. Drugs for certain chronic conditions, such as hypertension and diabetes, are also exempt. Homoeopathic and herbal medicines are not obtainable through the social security system. As in other European countries, there is increasing membership of private health schemes. Each month pharmacists send their prescriptions for reimbursement to the National Institute for Health via their local pharmacy association and receive their money a month later. In Barcelona, however, an instance of financial fraud many years ago led to a bank offering to act as intermediary, and pharmacists there now take their prescriptions to the bank. Although 70 per cent of pharmacies are now computerised, few maintain patient medication records. Computers tend to be used for stock control, ordering and prescription pricing. However, most pharmacies keep the national drug data base on their computers, which gives ready access to information on drug interactions, adverse drug reactions, dosage, and points for patient counselling. Advising patients has long been a large part of the professional role in Spanish pharmacies, and there is a move toward greater participation in health promotion and management of both minor ailments and chronic disease. The general council, in collaboration with the regional associations, runs several health campaigns (similar to the UK Pharmacy Healthcare Scheme) each year, providing posters and leaflets. Examples of recent topics are AIDS, hypertension, menopause and anorexia nervosa. A survey by the regional council showed that one out of every four people visiting a pharmacy in Spain receives information without being sold anything. This is equivalent to 152 million non-sale health advice interactions each year.	Consol Estivill in her pharmacy in Prat de Llobregat
	A technician measures blood pressure in Consol Estivill's pharmacy
	Customers being served at the counter in Consol Estivill's pharmacy

There has also been a national dietary project, with pharmacists trained to give nutritional advice. Involving 2,954 pharmacists, the first phase of the project targeted housewives and the second phase, running currently, is aimed at schoolchildren aged 10-11 years. More than 3,800 pharmacists are involved in the second phase, which includes going into schools giving appropriate dietary message to encourage healthy eating.
Pharmacists are also increasingly involved in follow-up of patients with chronic conditions, although this is opposed by doctors' organisations. A pilot study in Madrid, which started last year, has produced positive results in patients with hypertension, and may be extended formally to conditions such as asthma and diabetes mellitus.
Interestingly, antibiotic resistance does not yet seem to be an issue of practical concern in Spain. Health professionals are aware of it, but antibiotics are frequently prescribed by doctors and frequently given out by pharmacists, almost as emergency supplies.
Several pharmacies measure blood pressure, glucose, cholesterol and haemoglobin levels. In the pharmacy I visited, about 300 blood pressure measurements and 50 blood analyses (glucose, cholesterol, haemoglobin) are performed each month. The patient is charged 200 pesetas (about 80p) for a blood pressure measurement and 500 pesetas (£2) for a cholesterol or glucose analysis.

Drugs bill

Sharing many of the cost containment problems common to other European countries, Spain's Ministry of Health is keen to contain the drugs bill, which has increased rapidly in recent years. In 1998, prescription drugs accounted for £4.3bn. This is equivalent to 23 per cent of Spain's public health care expenditure (the UK figure is 10 per cent), representing the highest proportion in Europe.⁴
At the end of 1998, prescribing details started for the first time to be recorded on a central computer network. Launched in the 10 regions whose health care is still managed centrally, this initiative covers half the population of Spain and aims to identify those doctors who are high prescribers and which patients are the biggest consumers.
More recently, the Spanish Ministry of Health has announced two main measures which it hopes will help to reduce the annual rise in drug spending, the first of which is a nationwide campaign to explain to the public the importance of generic drugs. The second is a reference pricing system to be launched later this year, under which pharmacists will substitute a generic drug for a branded product if the branded product exceeds a certain price laid down by the Ministry. If patients want a specific brand which costs more they will have to pay the difference.
Currently the situation is that pharmacists are allowed to substitute brands, but this is normally done on the basis of what they have in stock rather than from a cost point of view. Doctors in Spain are being encouraged to prescribe generically, although relative to branded preparations, generics are not quite so cheap in Spain as in the UK, varying between 10 and 50 per cent of the cost of their branded equivalents. Generics accounted for just 1.3 per cent of total drug sales in 1998, although this will obviously rise when the reference pricing system is applied.

Education and training

Students can study pharmacy at any of 12 faculties of pharmacy in Spain. Currently, some 2,000-2,500 pharmacy students graduate each year. The degree programme is five years long with a period of six months supervised work in a community or hospital pharmacy. There are both national and regional regulations for the degree programme. In 1990, a royal decree made certain subjects compulsory for all regions, but the rest is left to the regional colleges to decide. After qualifying, the pharmacist can work anywhere in Spain. Hospital pharmacists, however, undergo several more years training before they can be in charge of a pharmacy. After qualifying, pharmacists sometimes specialise in different areas, such as environmental and public health, microbiology, clinical analysis, nutrition and dietetics, and food technology and hygiene. The food industry employs many pharmacists, with responsibility for chemical and microbiological testing of food and drink.

The faculty of pharmacy at Barcelona university

Continuing education is not mandatory. It is provided partly by the general council in collaboration with the local pharmacy associations, and also by the university faculties and the pharmaceutical industry. Eight thousand pharmacists are currently registered on the national continuing education training plan, which consists of eight modules on various pharmacotherapy topics, each providing 30 hours of work, including distance learning material and workshops. More recently, a course on phytotherapy has been developed. Participants also have access to a telephone consultation helpline. Evening workshops tend not to start until 9pm, finishing at 11pm or midnight. But as anyone who has been to Spain knows, the day tends to end very late or carry on into the early hours. Clearly, pharmacists are no exception, but many community pharmacies still seem to enjoy the traditional siesta, closing from 1 to 4.30pm.

Future challenges

With so many pharmacies, Spanish pharmacy has not surprisingly often been criticised, if not envied, for maintaining a position of relative privilege, a position it is keen to keep. The general council's recent survey showed that pharmacists are respected by the public. Although the government does not question this, it thinks pharmacists play a part in maintaining the high cost of the drugs bill, encouraging too much spending on medicines.
In defence of this, the general council's survey also demonstrated that pharmacists' health advice saves at least £750,000 each year and, according to its president, Pedro Capilla, the council is willing to encourage pharmacists to participate in activities to rationalise health expenditure. Like pharmacists throughout Europe, pharmacists want to become better integrated into the health care team and better recognised for what they do, but how long the present model, with its dense network of community pharmacies, can last is anyone's guess.

Pamela Mason is a pharmacist and freelance writer from Sydenham, South East London

References