The recent changes to health care delivery have promoted near-patient care and strengthened the primary care sector. There are clear national standards for services and treatments, through national service frameworks and the National Institute for Clinical Excellence, enforced through clinical governance, self-regulation and lifelong learning. There is now an established framework of assessing performance and a clear initiative to survey patient and user experience. Primary care is the central point of health care delivery, to overcome fragmentation and ensure the continuous care so desired for years.
Health authorities now have strategic leadership and the ability to assess local health needs through health improvement programmes (HImPs) and health action zones (HAZs). Primary care groups and primary care trusts are the vehicles through which these aims will be achieved, with unified budgets to link the care sectors, and full accountability for the professional services offered. The ideal model is one of motivation, where NHS trusts, PCGs and health authorities are in regular contact working together.
While developments in health technology have meant increased specialisation within secondary care, outcome and performance measures, such as waiting lists and waiting times, still remain unrefined. Additionally, secondary care now has to provide patient services with respect to the local HImPs, to agree long-term services with the local PCGs for particular care groups or disease groups, to set standards for and have statutory responsibility for quality, participate in planning and strategic decisions and to enter into partnerships. The move to empower primary care with responsive care facilities should ideally result in reduced visits to secondary care and allow specialisms to develop to their full potential, while increasing the value of the primary care sector. The increasing innovations in primary care will ideally make it easier for patients to access benefits from this deployment of health resource, while increasing emphasis on performance may mean they may choose where to access their health care.
Responsive changes require flexibility and professionalism. How will pharmacy react to such policy developments? Will pharmacists in both care sectors be able to inform quality drug choices based upon best evidence, to liaise with industry and to set measures of governance to ensure professional self-regulation is valid? Pharmacists need to be involved on all levels, to inform the research agenda, to drive the need for evidence and to inform evidence-based practice. The Government extols the ideal of the NHS with such phrases as "leading on performance", "commissioning specialist services", and "rebuilding public confidence". Can pharmacy contribute to these aims? Can pharmacy ensure appropriate health outcomes and health improvement, fair access to care, effective and efficient delivery of appropriate health care, all relating to the patient experience?
The discussion of how pharmacy needs to develop to meet these challenges in the new millennium should be preceded by an examination of how pharmacy has evolved and developed over recent decades. During the 1980s, education and training developed in line with the needs of the practitioners. At this time, service development was directly linked to the remit of education and training; masters degree and diploma qualifications in the practice of pharmacy and its clinical counterpart were developed. Ward pharmacy, satellite pharmacy, centralised intravenous additive services, pharmacy kinetic services, and pharmacy involvement in cardiac resusitation emerged. Specialisms in pharmacy developed as unique roles within the delivery of health care: in renal, liver, HIV, oncology, paediatrics and cardiology units, to name a few. The 1990s proved to be a decade of resource management focusing on evidence-based practice. Health care policy saw the emergence of seamless care, patient-centred care, discharge planning, cost containment, medicines management and empowerment. Pharmacy responded with an active move from a position of little research underpinning professional practice to founding a trust and 10 chairs of pharmacy practice.
The most recent changes in health care only hint at the potential for professional development while the ever-existent gap between resource management and efficiency targets and practitioners trying to respond to the needs of professionals and of patients has widened. Will pharmacy rise to the current and future unknown challenges? While consolidating professional services throughout recent decades, a loss of strategy has occurred and pharmacy is now threatened by direct competition for new roles. This is accompanied by loss of regional direction and of pharmacy at the centre of Department of Health strategic policy making. The increasing research culture has provided evidence for the benefits of developing pharmacy services, but has that been enough? Have we responded to the needs of the various skills within our profession? Have we identified our priorities to move both the professional and the profession forward? Has pharmacy spent its time protecting its own position within a market system that drives service delivery towards the cheapest denominator, unless there is irrefutable evidence to say that a more expensive provider should be used. Has the profession developed strategically in response to need based on evidence, or has it reinvented itself by reacting to professional intuitions?
The opportunities created by the recent health care reforms are ideal for pharmacy. They include:
Pharmacy has provided evidence of the value of increased and improved communication across the interface with measurable benefit to patient care and, with their central role in medicines management, can develop this further in line with governance issue for prescribing across the health care sectors. From the time of apothecaries, pharmacists have responded to symptoms and have been the first port of call in primary care. Independent prescribing is part of pharmaceutical care across the health care interface. Pharmacy needs to be involved in Department of Health initiatives from the start rather than realising too late the level of contribution that could have been made. In order to relate professional developments to wider policy, pharmacy has to:
Dr Duggan is teaching and research fellow and Dr Dhillon is director of taught postgraduate education in the centre for pharmacy practice at the School of Pharmacy, University of London