Nick Barber travels to the future twice - once optimistically and once pessimistically - to see how community pharmacy fares in the next millennium
"Marvellous thing, technology," I muttered as I unwrapped the new time capsule in my office. It looked something like an upgraded Tardis, and the light glinted off its metal body. I climbed inside, opened the instruction manual and turned to the section on exploring the future. It seemed time travel had moved on: instead of assuming there was an unvarying, predetermined future that you would be propelled into, this machine would predict the future from your inputs.
I had ordered a machine to take me to community pharmacy's future, and it had surprisingly simple controls - a mere two dials. The first allowed me to enter our current position and future trends in four areas: society, technology, the health service, and the profession. These were all that were needed to construct the future. However, it seemed that there were uncertainties in the predictor mechanism and a range of futures were possible. To deal with this there was a second dial with two positions: optimistic and pessimistic. I set up the machine as follows:
Society Society has an ambivalent attitude to science and technology, questioning its former certainties, yet still depending on science and valuing its benefits. However, fear of the risks associated with science and technology is growing. Indeed, the whole area of the social construction of knowledge (ie, what we consider to be "true") is under strain.
Experts' opinions are increasingly taken as just one of many forms of advice, and are compared with those provided by others, such as the media (including the internet) and alternative practitioners. There is a growing belief in alternative medicine, some of which is seen as natural and less risky. Society is increasingly interested in health, and more informed than ever (if not always knowledgeable) about illness and treatment. The growth of patient autonomy, linked to consumerism, is leading to a society that seeks ever more individualisation.
Technology The march of technology continues apace. The unravelling of the human genome is beginning to yield benefits in terms of new therapies; this will continue to grow. What is more, the relationship between our genetic code and our predisposition to certain diseases and characteristics will mean a growth in individualised predictors of health risk and treatment tailored to the individual. More complicated drug delivery devices will be developed. Packaging, more there to meet the needs of manufacturers than customers at present, will be developed to add utility to the product.
Communications will be revolutionised and the long awaited benefits of computerisation and digital communications technology will converge into useful, usable systems to transfer information. The automated distribution of products, already present in simple forms in some hospitals in the United States, will spread.
Health service At present the National Health Service is wrestling with a crisis - can it survive as a utilitarian institution (one providing the greatest good for the greatest number) at a time when society increasingly values the autonomy of the individual? Growing demand for autonomy, linked with the greater autonomy that follows freely accessible information, will lead to services focused as much round the needs and aspirations of the individual as round their clinical condition.
The NHS will have an increased focus on monitoring, control and accountability of individuals, services and technologies. Drugs will continue to be a key issue as a result of their continued growth and success; services to influence their use by prescribers and patients will grow.
The profession The last 15 to 20 years of the 20th century have seen pharmacy as a whole expand and grow. The scope of community pharmacy activities is extending into new areas, such as primary care groups, in which community pharmacists may be involved on a sessional basis. Community pharmacies are growing in number, as is the proportion owned by large chains answerable to shareholders.
At present the acute number of unfilled pharmacist posts, the forthcoming shortage of new graduates as we move to a four-year degree, and the limits on undergraduate numbers, all conspire to hold back this expansion. The reimbursement of community pharmacists continues to be a source of dismay to many.
Having set the parameters I looked at the final dial and after a moment's reflection set it to "optimistic". I pressed the "time-shift" button and felt a strange sensation as I shot through the interstices of time towards the future.
Suddenly, the feeling went, then there was a hiss as the door slid open automatically. I was in my office in the year 2050. It looked pretty similar, except that the computer and telephone had gone, there appeared to be a large aquarium on the wall and the office was free of paper. "What, no Pharmaceutical Journal!" I said. The aquarium dissolved and there appeared a large image of The Journal, with a list of contents alongside. It seemed the computer screen was now on the wall and the system was voice activated. I browsed through The Journal; it was clear that pharmacy had changed.
I decided to see for myself and went out of my office to the community pharmacy nearby. It was much bigger; in the window were two giant screens with continuously changing displays, one advertising products and the other offering health advice. Inside some pharmacists were at consulting booths, others were at desks, some talked to patients on videophones. A large range of medical products was available for purchase and at the back of the pharmacy a robotic system was compiling prescriptions.
I talked to the chief pharmacist. It seemed that pharmacy had benefited from several factors. The continued growth and development of pharmaceuticals had meant more and more pharmacy input into the choice and control of medicines. The Medicines Act had finally given way under the strain and a new category of drugs had become introduced that pharmacists could prescribe and monitor. These were restricted to certain conditions diagnosed by a doctor - however, most drugs were in this category.
At the start of the millennium, the NHS had finally realised the extent of wastage associated with non-compliance and had developed videophone support systems to maintain links with patients, to solve their problems and support them. After a pharmacist had personalised the dosage regimen for that patient's life style and preferences, medicines were dispensed in intelligent memory packs that interfaced with the patient's digital systems to remind them of dosing times.
Personalised pharmaceutical care packages were also big business. The pharmacy provided a diagnostic facility that included identification of genetic makeup to allow individualisation of dosing and a personal health protection plan, which offered a mixture of nutraceuticals and medicines designed to reduce the risk of the diseases to which you were prone. The growth of technology had extended over-the-counter advice and included fee-for-service videophone consultations, linked to couriered dispatch of the product.
The pharmacy, like most, was part of a large chain - the easiest way to provide the capital cost of set-up, and because some services offered economy of scale. The four-year degree and an increased throughput from the universities had allowed pharmacy to expand apace with the growth of medical technology. The pharmacy also provided a service to the local general medical practitioner syndicate, monitoring their prescribing and advising on medicines policy. The pharmacists looked rather prosperous.
I left the pharmacy, glowing with the success of it all. Medicines were helping individuals live a healthier and more fulfilling life and were also serving society as a whole. This was happening because pharmacists were using their expert knowledge to allow everyone to get the best out of their medicines.
There was no doubt about it, I thought as I slipped back into the time capsule, I would encourage my daughter to read pharmacy at university. I selected reverse and was whisked back to the present day.
It all seemed so logical - we had been saying for years that pharmacists had an important role in society that was not recognised; it was good to see that it had been. But there was a niggling doubt - what if I had selected the pessimistic option? Surely it could not be too bad? I decided to see for myself; I reset the dial and pressed the "time-shift" button again.
I had the same feeling as the capsule surged through time, then the door opened on to the same office. I decided to go straight out and see if the pharmacy was any different. But it was not there. No sign of it anywhere. An old man was sitting on a bench nearby, trimming his nails with a light sabre. I asked him about the pharmacy. He said it had closed in the early part of the century, together with many others. I walked slowly back to my office, where I called up past issues of The Pharmaceutical Journal and began piecing together the decline and fall of community pharmacy.
Several factors had led to the fall. A revision of the Medicines Act had done away with pharmacy medicines, as there was a general belief that pharmacists exerted no more control over pharmacy medicines than they did over tissues or hot water bottles. Medicines were now available through prescription, by a doctor or nurse, or freely available for sale at any retail outlet. The growth of alternative therapies had led to the movement of the associated products to specialist shops and drop-in holistic health centres, and patients went to those in favour of the pharmacy, or bought over the internet.
The growth in communications technology had been used, by an NHS fighting for its survival, to reduce the cost of supply of pharmaceuticals. An equivalent of mail order pharmacies (that had grown so rapidly in the US in the 1990s) had been approved.
These e-mail pharmacies supplied millions of patients and had the added advantages of new communication systems and automated dispensing; they now accounted for over 90 per cent of dispensed drugs. Doctors prescribed by computer and e-mailed the prescription to the company the patient chose. If drugs were needed urgently they were available from 24-hour druggists that were staffed by new super-technicians.
These changes had been exacerbated by the growth of pharmacies that were public limited companies in the early part of the century. Their shareholders had focused on immediate profitability instead of investment for the future. These companies now ran the country's e-mail pharmacies, although with much reduced profit on each item dispensed.
Minor ailments were treated by nurses at the end of videophones or by a nurse triage clinic in the GP surgery. The monitoring of therapies, and the encouragement of compliance, had also become the prerogative of nurses, sometimes paid for by the pharmaceutical company as part of an overall care and support package that went with the medicine. Although pharmacy still existed in other settings, its presence in the community and direct interface with the public had died out altogether.
I stepped rapidly back into the time capsule - I did not want to spend any longer in that future.
As I slipped back through time I began to reflect on the difference between the two futures, and to consider what factors had led to the different outcomes. The changes in society had been the same, as had the development of technology. The type of health service made no difference either. They were all under pressure to deliver more for less money. The difference was pharmacy itself; its actions had determined how well it was valued by society, industry and the government, and how well it had created and developed its opportunities.
It became clear that either future was possible. Which would happen in reality - continued rise or decline and fall? One thing was certain: it would be our own actions that would determine the future. The future is ours for the making.
Nick Barber is professor of the practice of pharmacy at the School of Pharmacy, University of London