Pamela Mason travelled to Denmark recently to find out about pharmacy education and pharmacy practice in that country
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The smallest and most southern of the Scandinavian countries, Denmark first came to the world's notice more than a 1,000 years ago when Danish Vikings raided large parts of Europe. A great deal has changed since then, and today this country of 5.3 million people is the epitome of civilised society, noted for its progressive policies, and also a liberal social welfare system where, helped by an average income tax of 52 per cent, more than half the national budget goes to providing extensive cradle-to-grave security. It is a land where, as the saying goes, "few have too much and even fewer have too little".
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The Little Mermaid, the famous landmark at Copenhagen's harbour |
Interestingly, electronic prescribing has been common in Denmark for about five years and started when general practitioners developed electronic links with hospitals for the purpose of receiving patient information. Today, about 75 per cent of prescriptions arrive at pharmacies electronically - not via e-mail, but through use of Edifact technology. All pharmacies are computerised (there are about four different systems used in community pharmacies and a single system in hospitals), but pharmacies do not usually keep patient medication records.
Such large pharmacies obviously require large numbers of staff, and, in addition to the owner, who must be a pharmacist, 15 to 20 employees, including two or three pharmacists and 10 to 12 pharmacy technicians, are not uncommon. Working as part of a large team brings many benefits, such as an avoidance of professional isolation. There is always someone available for discussion of clinical problems and weekly or monthly "team" meetings to exchange information gained through reading papers or attending continuing education seminars are common.
Pharmacists and pharmacy technicians often attend continuing education programmes together and, again, large staff numbers are an advantage, enabling continuing education events to be run during the working week rather than at weekends. Continuing education is organised by the college of pharmacy practice in Hilleroed, near Copenhagen, and, as in the UK, there is a growing emphasis on problem-based learning, rather than lectures, and on competency development, rather than passive participation.
The college of pharmacy practice is also responsible for the basic education of pharmacy technicians, who train on a three-year programme, some of which is based residentially at the college and some of which takes place in the pharmacy. Technicians are educated better in Denmark than in the UK and tend to have more responsibility, but the issues of skill mix and whether technicians should perform the final check on prescriptions are currently being considered.
Undergraduate education for pharmacists is provided by the school of pharmacy - there is just one in Denmark - but only about 20 per cent of graduates from the five-year programme currently go into practice. The rest pursue careers in industry, and this, quite naturally, continues to encourage a strong scientific, rather than clinical, bias in the course, and this has important implications for pharmacy practice. Danish pharmacies look extremely professional - they are not "shops" in the same sense as ours - and although they have a strong reputation for caring for patients, pharmacists' clinical skills still require a great deal of improvement.
Pharmaceutical care is high on the agenda in Denmark, and it is the classic definition of Hepler and Strand that has been promoted. According to Ms Hanne Herborg (head of research and development, college of pharmacy practice), it is important to be clear about what we mean by pharmaceutical care, simply because the concept is so new to pharmacists. The interpretation of pharmaceutical care varies widely throughout Europe, and indeed within the UK, but the broad approach used by some to describe pharmaceutical care as almost any pharmacy service that meets the health care needs of society is unhelpful, she thinks, because pharmacists are then tempted to think that they are doing it. In Denmark, she says, there has undoubtedly been an increase in the amount and quality of information given to patients at the time of dispensing, although ongoing monitoring of patients' therapy still does not happen to any significant extent.
Since 1991, several "pharmaceutical care" projects have been developed. Some are "disease based", for example, the therapeutic monitoring of patients with asthma, while others focus on specific patient groups, for example medication reviews in elderly patients. Opinions vary as to the value of a disease-based approach to pharmaceutical care, but in the Minnesota model, where the aim is to provide pharmaceutical care to all patients whatever their clinical condition, a disease-based approach is considered to be unethical. However, in defence of the disease-based approach, such as the Danish asthma project, Ms Herborg says that it represents a good starting point from which to move towards more advanced patient focused care. Gaining the knowledge and confidence to use a model for patient care in one disease area means that this can be more easily translated to every other area, and is a useful way to improve clinical skills, she thinks.
Mr Poul Nissen, pharmacist owner of Apoteket Trianglen |
Practice researchThe facility to conduct practice research is another strength of large pharmacies, many of which have a constant turnover of students and preregistration trainees who need to complete projects to obtain their qualifications. Mr Poul Nissen, the owner of Apoteket Trianglen, the pharmacy I visited in Copenhagen, explained that several research projects were being conducted in the pharmacy. One pharmacist was looking at the influence of advice on the treatment and outcomes in patients with athlete's foot, and this had been presented at the World Congress of Pharmacy in Barcelona this year. Another project was investigating whether patients ask for specific analgesic products or simply a remedy for pain and the reasons for these differences. Yet another was looking at the effect on elderly people of substituting a generic or parallel-imported product for a branded product. |
The facade of Apoteket Trianglen, in Copenhagen |
Product substitution is an important issue because Denmark now has a reference pricing system for about 50 groups of drugs, such that, if a doctor prescribes a drug from a group which costs more than the fixed "reference price", the pharmacist has to substitute with a cheaper product. This is often a generic and generics now account for just over 50 per cent of prescription volume. Other cost containment measures include a system of patient co-payments. Until now, the level of reimbursement has been related to the type of medication on the prescription. For example, insulin is 100 per cent reimbursable, most cardiovascular medication is 75 per cent reimbursable, non-steroidal anti-inflammatory drugs and some antidepressants are 50 per cent reimbursable, while patients have to pay the full cost for items such as oral contraceptives and benzodiazepines. However, from March, 2000, this system will change to one based on the cost of the medicine. Patients will then have to pay the first DKr300 (£30) towards the cost of their medication, with the percentage reimbursed increasing in a stepwise fashion depending on the cost of the medicine. Several exemptions, for example, for the elderly and those on low incomes, will be built into the system. Many consider the current system, which has been in existence for 25 years, to be illogical, but it is arguable whether the new system is any more logical or any fairer to the patient, and it will in any case waste a great deal of pharmacist time in giving explanations to patients.
Whatever the benefits of large pharmacies in terms of the ability to pursue continuing education, provide pharmaceutical care and so on, there exist several drawbacks, the most important of which is that in some areas there is limited public access to pharmaceutical services. This gap is to some extent filled by various other outlets, including pharmacy branches, of which there are 45. Owned by pharmacist proprietors of main pharmacies, these outlets offer a similar service to that of the parent pharmacy. There are also pharmacy shops that hold a small stock of OTC medicines and other items carried by the parent pharmacy. These are run by pharmacy technicians, and prescriptions may be handed in to be sent to the main pharmacy for dispensing. Yet another variation is a unit within another retail outlet, such as baker's shop or a grocer's. Again, prescriptions can be handed in and sent to the main pharmacy, and the unit stocks a limited range of OTC medicines selected by the pharmacy proprietor. Finally, there are various collection and delivery points (eg, in petrol stations) for prescriptions and dispensed medicines.
All these "non-pharmacy outlets" currently represent quite a political problem. This is because the Danish government is currently considering liberalising pharmacy distribution and medicine sales. And, if OTC medicines can be bought in outlets that are not pharmacies, is it reasonable that pharmacy should continue to have a monopoly on medicines distribution? Denmark has not so far had a general sale list, but this is being discussed, and movements in the UK, such as the P-to-GSL transfer of nicotine chewing gum, are being keenly watched. Indeed, two journalists from the Danish pharmaceutical journal have recently been to Britain to investigate the implications of a GSL list.
Liberalisation of pharmacy and medicine distribution could have dramatic effects on a system that currently offers considerable protection for pharmacies. The Danish Pharmacy Association negotiates a "global figure" for pharmacist profits with the Ministry of Health, and drug prices are also linked to this global figure. This means that pharmacy profits remain fairly steady.
This situation means that Danish pharmacists have never seriously had to demonstrate their value either to patients or to government and this is something that the Danish pharmaceutical association is starting to address through consumer surveys, all of which are currently showing that patients are satisfied with the service they receive from pharmacies.
With the advent of supermarkets, the community pharmacy remains the one place where patients can experience personal service, Mr Nissen told me. Providing first-class service is certainly a high priority for him. "No one leaves this pharmacy with a problem," he says. However, if patients had the opportunity to buy medicines in a supermarket or a petrol station, who knows?
Pamela Mason is a pharmacist and freelance writer from Sydenham, South East London