The Pharmaceutical Journal Vol 264 No 7093 p627-632
April 22, 2000 Forum

Madrid Pharmacists Association/Peters Institute

Pharmaceutical care supporters meet in Spain

The goal of pharmaceutical care

Our goal is to introduce a new patient care provider - the pharmaceutical care practitioner - into the health care system. So said Professor Linda Strand of the College of Pharmacy, University of Minnesota in Madrid on March 22. Professor Strand declared: "We want to establish a permanent position for the pharmaceutical care practitioner right next to the physician, the nurse and the dentist as a primary care provider who will assume direct patient care responsibility for the patient's drug related needs. And we want that pharmaceutical care practitioner to be a pharmacist. This is our challenge." Professor Strand said that it was inevitable that there would be such a practitioner. The problem of drug related morbidity and mortality was now so great, and the cost of treatment failure and adverse reactions so staggering that someone would have to address these issues. There were so many new drug products that needed individualised attention and required follow-up evaluation. The new practitioner would provide the rational decision making processes for drug therapy that medicine, nursing, the pharmaceutical manufacturer and the patient were lacking. The pharmaceutical care practitioner would be a key component in primary health care in the near future. The challenge was to make sure that the practitioner was a pharmacist and not a nurse or physician.

Linda Strand: introducing new practitioners

To fulfil that role, pharmacists had to learn and abide by the same rules as all other patient care providers. Each pharmaceutical care practitioner must understand and commit to the same philosophy of practice as any other patient care professional. The commitment was to deliver the same high quality of care to each patient. In respect of pharmaceutical care, it was to make sure that all of a patient's drug therapy was appropriately indicated, the most effective possible, the safest available and the most convenient. This should be achieved by identifying and resolving drug therapy problems. It was a commitment to put the patient's needs before one's own, to act on behalf of the patient and to be an advocate for the patient each time the patient needed care.
This meant assessing each patient's drug related needs, bringing all available resources to meet those needs and following up to make certain that there had been a positive impact on the patient's wellbeing. Finally, it must be accepted that it was the social obligation of the practitioner to reduce and prevent drug-related morbidity "one patient at a time". This philosophy of practice must be in the heart and mind of each practitioner.
To be successful, pharmaceutical care practitioners would each need to subscribe to the same patient care process, just as did all physicians dentists and nurses. This process had three components:

• An assessment of the patient's needs
• A care plan to meet those needs
• And a follow-up evaluation to determine the progress the patient was making toward meeting the goals of therapy

A pharmaceutical care practitioner would have to organise his or her practice in the same way that physicians organised their practices. He or she should have his or her patients, document the care provided and systematically evaluate its quality. The practitioner would be recognised and reimbursed for the patient care provided.
What were the major milestones that could be used to measure progress in developing this role, Professor Strand asked.
The first milestone, she said, was to prepare qualified practitioners. There would have to be training programmes for practising pharmacists. The curricula of universities would have to be refocused. The training for practising pharmacists could be achieved through a course lasting approximately eight weeks. This would teach the patient care process and describe how to build a practice.
It would be necessary to prepare a critical mass of pharmacists who could provide the service to clients in any geographical area, thereby convincing a payer that the service was viable.
Secondly, qualified practitioners would have to document the patient care that they were providing, thereby generating practice data that could be used as a currency for all the collaborations required of a new practitioner. Data were the currency that all patient care practitioners used to collaborate with others. The unique data generated from pharmaceutical care would allow its practitioners to provide a high quality service to patients, contribute information to the pharmaceutical industry concerning new products and their effectiveness and would allow negotiation for reimbursement for the services provided.

The third milestone was reimbursement, coupled with public recognition of the role of the new practitioner. It would be necessary for the pharmaceutical care practitioner to be paid in the same manner as other patient care providers. This could not be achieved through payment for the product.
In the United States, the common system used to remunerate patient care providers used the "resource based relative value scale". This scale related payment to five different levels of patient need. In pharmaceutical care practice, the level of payment at those five levels would be determined by the complexity of the patient. Complexity was determined by the number of active medical conditions that the patient had, the number of active medications the patient was taking and the number of drug therapy problems.
Concluding, Professor Strand called for the creation of a series of pilot practices developing pharmaceutical care in various countries. There would need to be more than one practice in each country; Professor Strand suggested up to four in a particular location. A lot could be achieved by working together and sharing data. Such a development would strengthen the movement towards pharmaceutical care.
During discussion later in the meeting, Professor Strand said that pharmaceutical care was a patient care practice model. It was not another pharmaceutical service.

It had to be available to all. It was not appropriate to pick and choose diseases. The entire drug-related needs of a patient needed to be taken care of. It was acceptable to start building a practice by providing services to patients with a particular disease, say, diabetes, but it would be necessary to take care of all the drug related needs of such patients.
Professor Strand suggested that pharmaceutical care practitioners needed to organise themselves in groups of four or five, close to each other. They could then offer support and encouragement.
The fastest way to recruit patients was to have pharmaceutical care provided as a separate role in a pharmacy. Patients would see a new role being provided and ask about it.

German Society gives support

The German pharmaceutical society, ABDA, had changed its information technology systems to support pharmaceutical care, Professor Marion Schaefer (Humboldt university, Berlin) told the meeting. Pharmacists using the system were able to check for drug interactions, allergies and contraindications, Professor Schaefer said. This helped pharmacists detect patients' drug therapy problems.
Professor Schaefer advocated a data management system for pharmaceutical care. It was needed, she said, to standardise procedures, optimise the care process, provide equal opportunities for patients and pharmacists, and improve work routines in the pharmacy. It could also lead to comparability of systems and outcomes and facilitate evaluation of data.
Outlining German experience, Professor Schaefer listed barriers to pharmaceutical care. They included: time; workload; communication with and acceptance by physicians and patients; insufficient knowledge base; no remuneration for cognitive services; uncertain economic consequences; and motivation. Many of those barriers could be overcome by the use of modern information technology.

Suitable disease types
Indicating disease types that were suitable for pharmaceutical care, Professor Schaefer said that they included chronic disorders such as Parkinson's disease. Other suitable diseases included those where compliance with treatment was important, where combination therapy prevailed, where drug reactions were prevalent, or where dose adaptation was required.
On education, Professor Schaefer said that ABDA organised national conferences on pharmaceutical care. The fourth was being held in Hamburg that month. Various pharmaceutical care studies and projects had been run by Humboldt university and ABDA.
Workshops had been organised by the university and by software houses and the first seminars for pharmacy students had now taken place.

Here to stay in the Netherlands

Pharmaceutical care is "here to stay" in the Netherlands, according to Dr Johan de Gier (scientific consultant, Health Base Foundation). It was to be evaluated by the Ministry of Health and Welfare in about two or three years' time, he said.
Dr Gier said that pharmaceutical care had been introduced in the Netherlands in the 1990s as a means of providing patient-oriented care with pharmaceuticals. In 1995, the first electronic dossier had been introduced as a documentation tool.
At present, about 20 per cent of Dutch community pharmacists used that tool, whereas about a third had been involved in providing pharmaceutical care according to the philosophy developed by Hepler and Strand.
Dr Gier added that a unique situation existed in the Netherlands, in that general medical practitioners were linked to community pharmacies.
This was achieved through a health information network, allowing general medical practitioners to connect to a locally situated database where they could access patient medication histories. Recent changes in Dutch law would allow sharing of medical data in order to improve pharmaceutical care and pharmacists would be seen as health care providers. The Royal Dutch Society for the Advancement of Pharmacy would, therefore, be restructuring its policies on pharmaceutical care and would look for partnerships with existing organisations in pharmacy that supported the practice. Practice guidelines and protocols were being developed and research projects being established.

Government support in Spain

Pharmaceutical care has got official support in Spain. The country's Pharmaceutical and Health Products Authority has created a unit to support its introduction in the country. It has done so in response to demands from groups of pharmacists who want to promote the discipline. The legal basis for the introduction of pharmaceutical care in Spain had been provided by the Spanish Parliament in April, 1997 (law 16/1997). In this, the parliament included within the function of the pharmacist "monitoring of pharmacological treatments for patients" and "collaboration in the individualised use of medications with the aim of detecting potential side effects". The objective of the new unit is to contribute to the development of pharmaceutical care in Spain, co-ordinating the process, drawing together the interests involved and collaborating with the appropriate professional bodies.

Federico Plaza with Maria del Val Díez (technical assessor for pharmaceutical care)

Mr Federico Plaza (general manager of the Pharmaceutical and Health Products Authority of the Spanish Ministry of Health) told the conference that the authority believed that pharmaceutical care could lead to a reduction in overall health costs.
There were difficulties in its implementation, however. These related to tensions with other professionals (including doctors), lack of awareness among patients, fears among pharmacists in relation to new responsibilities, availability of computer systems, suitability of premises for personal communication with patients, and the availability of specific training.
On the question of relations with professionals, the main barrier was at the corporate level. The authority would be willing to intervene here. It would be necessary to produce evidence to show that pharmaceutical care helped in the patient care process.
So far as patients were concerned, pharmaceutical care practitioners would have to provide a continuous, high quality service and guarantee that patients would always receive the drug therapy that they needed. Once patients had benefited from pharmaceutical care, they would become advocates of it.
Mr Plaza said that pharmaceutical care was feasible and desirable. There were professional and economic advantages. A reimbursement scheme was needed. That required a clear description of the service that was to be provided.
It would have to complement the existing pharmaceutical service, provide added value, be orientated to the patient and be documented.
From the government's point of view, the service would have to be homogenous in concept and have a basic methodology. The service would have to be available to the entire population. It must not be restricted to certain patients or certain illnesses. All pharmacists should be able to participate. Training, including continuing education, would have to be available for them. There would have to be evaluation systems in place to measure results in terms of impact on health, use of resources, satisfaction of patients and doctors, and economic impact.
Mr Plaza said that the profession was at a critical stage. They should not abandon what had been achieved so far. They now needed a critical mass of pharmacists to make pharmaceutical care a reality. They needed 2,000 to 4,000 practitioners to come on board.
The goal was that, eventually, pharmaceutical care should be available from all of Spain's 20,000 pharmacies.
Mr Plaza wanted a versatile practice model that would be open to all patients and that all concerned agreed on. The authority would not seek to impose one.
There would have to be a study of reimbursement systems. It was not to be introduced immediately. They needed to be clear about what pharmaceutical care was before they could settle reimbursement issues.
Ms Begoña Sánchez told the conference about how she provided a pharmaceutical care service from her Madrid pharmacy. She said that she had started the service in 1997 and had developed it little by little, which was the best way. After the hundredth patient it became easier. Pharmaceutical care was the specialty of the pharmacist. In Spain it was a viable reality.
Mr Pedro Capilla (president of the general council of Spanish Pharmacists Associations) said that pharmacists practising pharmaceutical care were performing a specific role in drug management. This was synergistic with the physician's role. His association was to create an intranet for pharmaceutical care in Spain.
Commenting, Professor Robert Cipolle (director of the Peters Institute of Pharmaceutical Care) complimented Spanish pharmacists for having support at the highest level from the beginning. That was a tremendous help.

Trial in Granada Mr Fernando Llimos (a community pharmacist and director of the journal Pharmaceutical Care Espana) indicated that many events had taken place in Spain in recent years to promote and develop pharmaceutical care, but very few pharmacists were practising it as yet and those that were were doing so on a small scale. Spain was still a long way from the 25 per cent level that would lead to public acceptance and recognition of the role officially. Barriers to pharmacists providing pharmaceutical care had been listed as lack of money, lack of time, the attitudes of other professionals, lack of communication skills, unhelpful health care structures, and lack of clinical knowledge. In essence, the barriers could be summarised as pharmacists saying that they did not know how to carry out pharmaceutical care, how to work appropriately with other professionals or to interact well with the health structure. Mr Llimos described a study into pharmaceutical care that had been set up by the University of Granada. A methodology had been developed to record the implementation of pharmaceutical care. Initial interviews had been conducted with patients and their health problems noted and pharmacotherapy assessed. The pilot phase had been completed and the project proper would begin in May. It was called the Dader project, after a pharmacist who had died from a drug-related problem. Mr Llimos emphasised that pharmaceutical care for patients needed calm evaluation. Hasty decisions could lead to mistakes. To intervene effectively, pharmacists needed training in therapeutics. Pharmacists did not need complex computer equipment. All they needed was sheets of paper and the desire to help.

Fernando Llimos: pilot completed

Computers needed in practice

A computer based practice system was needed to offer pharmaceutical care when patient numbers got beyond 500 to 1,000, Dr Michael Frakes (vice-president, Health Outcomes Management Inc, Minneapolis) told the meeting. Paper systems could be used for lower numbers. Dr Frakes, whose company develops IT systems for pharmaceutical care, said that computers offered organisation, communication, history, billing, analyses and reporting. Two systems were needed in a pharmacy offering pharmaceutical care: a system for the practitioner; and a central system for managing a network of practitioners and consolidating data. The practitioner system was needed to identify workload, schedule appointments and patient follow up, to maintain consistent documentation and to keep practice protocols and care plans. The practitioner system maintained an accurate record of medication used by patients. No one else was keeping such a record. The system could provide comments and recommendations in writing for the patient to refer to and provide information on conditions being treated. Data from the system could be used to provide physicians with written information about medication use by particular patients and provide recommendations and feedback. This could be given by the patient to the physician.

Michael Frakes: offering organisation

Patient history data kept on the system included demographics, care plans, medication, drug therapy problems and evaluation of progress.
Billing could be based on a resource based relative value scale, which identified the severity of illnesses and the needs of patients suffering from those illnesses.
The central system was needed to demonstrate the value of pharmaceutical care. Its functions included audit, quality assurance and analysis of clinical and billing data.

Responsibility
Concluding, Dr Frakes said that, in dispensing, the responsibility of the pharmacist for the outcome of treatment ended when the patient got to the pharmacy door. In pharmaceutical care, the responsibility of the pharmacist ended when the pharmacist stopped seeing the patient. Systems needed to be organised to take account of that. His company had developed 150 standard analysis reports based on, among other things, disease and drug therapy problems.
During discussion, when the question of relationships with physicians was raised, Dr Frakes said that they never tried to give a single recommendation to a physician. They offered two or three choices. When the relationship was more solid, the physician would ask for a single recommendation.
Professor Robert Cipolle (director of the Peters Institute of Pharmaceutical Care) said that, unless there was an emergency, information should be supplied to the physician in documentary form and should go with the patient. The pharmacist should ensure that the physician had all the information he needed to make a decision.
Professor Linda Strand (university of Minnesota) said that she told physicians that pharmacists practising pharmaceutical care looked for drug therapy problems in the same way that they looked for a diagnosis. Physicians understood the assessment, care plan, follow up process. As a group, they were the most supportive of pharmaceutical care. Then came patients and then pharmacists.
On the question of charging, Dr Frakes said that a service should never be provided free. Practitioners could, if they wished, give for a time a 100 per cent discount, but the principle of making a charge should always be adhered to.

Acceptance growing in Britain

Pharmaceutical care was not widely used as a practice model in Britain, though there were signs that it was gradually becoming accepted as a concept, Mr Douglas Simpson (editor of The Pharmaceutical Journal) said.
As evidence for this assertion, Mr Simpson cited support by the Royal Pharmaceutical Society for the statement on pharmaceutical care produced by the International Pharmaceutical Federation (PJ, September 12, 1998, p427) - though he acknowledged that the Society had not done much to put it into effect - and the planned project to test the concept of medicines management, which shared some of the characteristics of pharmaceutical care. He also said that support for the pharmaceutical care model was to be found within the document on clinical pharmacy in primary care produced by the Clinical Resource and Audit Group in Scotland (PJ, April 17, 1999, p527). He drew attention to pilot projects in pharmaceutical care planned for Scotland and changes in the way that pharmacy practice was being taught in some schools of pharmacy, particularly Aberdeen.
Mr Simpson said that second Crown report on prescribing (PJ, March 13, 1999, p347) could have a bearing on the subject. Its proposals for dependent and independent prescribers could have a substantial effect on the way that pharmaceutical care was pracised in Britain, should they be implemented.

Pilot trials
Referring to the community pharmacy pilot trials in Scotland, Mr Simpson said that they would deal with palliative care, the frail and elderly, and severe and enduring mental illness (PJ, November 13, 1999, p770). However, no details had been announced and it was not yet known what pharmacists would be required to do.
On education, Mr Simpson drew attention to the new pharmaceutical care centre at Aberdeen school of pharmacy (PJ, April 1, p515) and said that similar initiatives were being taken in Bath and Nottingham. Strathclyde was also strong in pharmaceutical care teaching.
Mr Simpson made it clear that the pharmaceutical press had a role to play in the development of pharmaceutical care. It could carry out the full range of journalistic activities, including publishing peer-reviewed research and reporting all developments. It could create awareness and an environment for change. It could also, where necessary, take a lead.
During discussion, Professor Robert Cipolle (director of the Peters Institute of Pharmaceutical Care) said that the future in a number of countries depended on trials like that on medicines management in Britain. It was essential that the profession got such trials right. It might not get another chance for many years.

Pharmaceutical care laboratory The faculty of pharmacy at the University of Minnesota had a pharmaceutical care laboratory that was the faculty's pride and joy. So said Dr Raquel Rodríguez (a lecturer in pharmacy at the faculty). In the laboratory, students were taught to deal with patients. Emphasis was placed on skills needed to communicate with patients. Real patients came to the laboratory. Dr Rodríguez said that the school set out to be a leader in theimplementation of pharmaceutical care practices. It offered courses to students, postgraduates and practising pharmacists. Dr RodrÍguez said that what was needed in any country was an integrated programme to introduce pharmaceutical care in which professional associations and schools of pharmacy worked together. Raquel Rodríguez: pride and joy Professor Stephen Schondelmeyer (faculty of pharmacy, University of Minnesota) said that no charges were made for patients treated in the laboratory, but some had wanted to pay. They had been invited to pay what they felt was appropriate. One had sent a cheque for $100; another, $150. If pharmacists delivered this kind of service, patients would recognise the value. If pharmacists met patients' needs, the reimbursement would follow. They would not know what patients needs were if they did not ask. First, pharmacists must seek to solve patients' drug therapy problems. Second, they should seek to address government's problems by reducing inappropriate drug use and costs. Pharmacy's problems would only be addressed by doing the first two. It all started with the patient. The value of the pharmacist was not in knowing what to do, but doing what he or she knew. Professor Schondelmeyer said that drugs were the most widely used form of health care. Sixty-four per cent of the United States population used one or more drugs in a year. The proportion rose to 83 per cent in the elde

The industry should help

In an address on the relationship between the pharmaceutical industry and practitioners, Mr José Carlos Mantilla (technical manager of Lilly, Spain) said that the industry should give more information to pharmacists in order to facilitate pharmaceutical care, which would help ensure that the industry's products were used more effectively.

Reshaped Toronto course needs new type of student The faculty of pharmacy at the University of Toronto has reorganised its curriculum to focus on pharmaceutical care, Professor Donald Perrier, former dean of the faculty, told the meeting. The clear goal of the course was now to produce professionals who were patient orientated and could practise pharmaceutical care. They would do this "by indentifying, solving and preventing drug-related problems and by assuming responsibility for decisions associated with this care". Graduates would also have a broad background in the pharmaceutical, managerial and related sciences and humanities and be committed to life long learning. Information became old very quickly. Professor Perrier, who is still on the staff of the faculty, also made it clear that selection criteria for pharmacy students had also now changed. Students were now selected on the basis that they would be likely to be successful on the programme, when previously those with the highest grades had been admitted. Students must be able to read, write and think. They were set a writing exercise before selection. Now, selection depended 60 per cent on grades and 40 per cent on other criteria. This had had a significant impact on the type of student chosen. Forty per cent would not have got in before. Forty to 50 per cent of those who would have got in before, did not do so now. Specific outcomes had been developed for the professional practice component of the course, Professor Perrier said. The most dominant of these was meeting patients' drug-related needs. As part of that, students must know how to develop a professional relationship with the patient, to determine patients' needs and desired outcomes, to identify and prioritise a patient's drug-related problems, to develop a therapeutic and monitoring plan, and to refer to another practitioner when appropriate. Students also needed to know how to document the process. Practitioners were employed to teach pharmaceutical care. The course used real patients. Teaching methods in this part of the course leant heavily on problem-based learning. Students were taught how to identify and solve problems. This was the best way of teaching professional practice. Donald Perrier: clear goals Eight weeks of the course in the final year was spent in practice. This was a co-operative process between practitioners and academia. The faculty had sought the most progressive practitioners in Ontario. It had spent over three years developing pharmacists and pharmacy practices to the point where they could take on students. Practitioners were helped to move to patient focused care and were taught how to assess student performance. Practitioners attended for four sessions of two days each and were given assignments in pharmaceutical care. They received an honorarium for each student taken. Over 200 practitioners had been through the process and now served as practice based instructors. By June, three sets of graduates would have completed the new type of course, Professor Perrier said. The problem was that pharmacy practice was slow to change and the environment for the practice of pharmaceutical care was not general yet. The reimbursement system in Canada was based on dispensing of prescriptions and not on taking care of patients. Summarising, Professor Perrier said that what was needed was practitioners who wanted to change and academic institutions willing to assist the profession to change. On the question of selecting students or pharmacists for pharmaceutical care training, Professor Robert Cipolle (director of the Peters Institute of Pharmaceutical Care) said that what practitioners had to remember was that they were selecting their future colleagues. They should do so on the basis of whom they would trust with their patients or their family members. Asked how to get academia to change, Professor Perrier said that an enthusiast was needed in each faculty. He or she needed to persuade colleagues that they were seeking to educate practitioners, rather than scientists. If licensing and course accreditation bodies were working in the same direction, that helped. Professor Linda Strand (University of Minnesota) urged academic institutions to work together because there was so much to do. In a presentation on progress on pharmaceutical care in Canada, Professor Perrier said that there had been some success at the organisational level in getting bodies to work together and some success at the academic level. At the practice level, success had been limited. There were some excellent pharmaceutical care practitioners in the community, but they represented a small percentage of the total number. Hospital pharmacists were developing the practice. Licensing bodies were raising standards, but more needed to be done.

Experiences in pharmaceutical care

Results of practising pharmaceutical care in the United States were presented to the meeting by Professor Robert Cipolle (director of the Peters Institute of Pharmaceutical Care). Professor Cipolle said that the Minnesota pharmaceutical care project had been carried out several years ago [see PJ, June 28, 1997, p901]. Since then, pharmacists providing pharmaceutical care had seen 14,357 patients. Those pharmacists practised in community pharmacies (independent or chain) and some were employed by physician groups to provide pharmaceutical care. There had been 45,165 recorded patient encounters. Fifty-nine per cent of the patients had been female. Problems increased with age. The average number of medical conditions per encounter was 1.7. The average number of drug therapies per encounter was 2.6 and the average number of drug therapy problems per encounter was 0.4; the average number per patient was 1.3. Professor Cipolle said that, in a generalist practice like pharmaceutical care, the practitioner encountered patients with common disorders, common drug therapy needs and common drug therapy problems. In the 45,165 documented encounters, the most frequent indications for drug therapy had been:

Robert Cipolle: three phases

• Hypertension
• Pain
• Bronchitis
• Sinusitis
• Peptic ulcer disease
• Otitis media
• Hyperlipidaemia
• Osteoporosis
• Allergic rhinitis
• Diabetes

Those conditions had represented 44 per cent of all indications for drug therapy.
Pharmacists had identified, prevented or resolved 19,140 drug therapy problems (see table).
Professor Cipolle speculated that if 1 per cent of drug therapy problems were lethal, pharmaceutical care was saving one life a week.
Professor Cipolle said that when a practitioner started pharmaceutical care they might seem unprepared. But essentially, they would see the same problems over and over again. When they provided such care, more therapies would be used than if they did not. Drug therapy was the primary tool of the pharmaceutical care practitioner's trade.
And they increased doses more often than they reduced them. Prescribers mostly started treatment at the lowest end if there was a range, but rarely checked to see if it was effective.
With no pharmaceutical care, nobody was primarily responsible for identifying drug therapy problems.
Professor Cipolle presented financial data to suggest that, for every $1 invested in pharmaceutical care, $2 was saved in terms of avoiding visits to the physician or casualty department, unnecessary drugs costs, and unnecessary home visits or hospital admissions. He emphasised that what he was talking about were the results of practice and not a research study.

Follow-up
The practitioners concerned had been following the process of assessment, developing a care plan and follow up. In doing so, they assessed the patient's drug related needs in terms of "indication" (did the patient need additional drug therapy or was the therapy unnecessary?), "effectiveness" (was the wrong drug being used or was the dose too low?), "safety" (were there adverse drug reactions or was the dose too high?), and "convenience" (could the patient comply with the treatment?).
The practitioner did this over and over again in that order, and, in doing so, became good at it.

Building practices and finding patients

The future of pharmaceutical care depended on the building of practices, Professor Robert Cipolle (director of the Peters Institute) told the meeting. Its progress would be measured in terms of the numbers of practices that had been built and the numbers of patients receiving pharmaceutical care. There were three phases to building a practice. In the first, phase, the practitioner learnt his craft, that is, the provision of pharmaceutical care. This could be achieved in eight weeks. Pharmacists needed to see and document two new patients each day during this time. And they needed to separate themselves from the dispensing process. It was not possible to dodge pharmaceutical care to dispensing. And pharmacists needed to work together so that they could support each other and practitioner meetings where they could talk about patients.
The second phase was the building phase. This required six to 18 months, depending on how busy the pharmacy was. At least four new patients were needed each day, and a minimum of 250-500.
Finally, there was the practice phase, which would last for two or three years. This was when the practitioner became established and good at what he or she was doing. One or two new patients a day were required, building up to between 1,000 and 2,000.
The aim should be the provision of pharmaceutical care for all patients in a country. The physicians provided care for all patients, so why not pharmacists.
During the practice phase, pharmacists would need to improve their skills continually.
Winding up the conference, Professor Cipolle said that the practice of pharmaceutical care required change in many aspects of the profession. They included education, regulation, reimbursement, policy and economics. But, the most important change required was in the day to day practice of pharmacists.