Pamela Mason travelled to the Netherlands to speak to two pharmaceutical care providers there
Pharmaceutical care means different things to different people, and there are several definitions internationally. Some take it to mean any professional activities over and above dispensing. Some think it is medication review; some, giving prescribing advice to doctors. Still others think it is counselling patients about their medicines. One person's pharmaceutical care is another person's medicines management, particularly in the United Kingdom, where we have tended to emphasise the latter term, and the diversity in both understanding and practice in different countries of the world is significant.
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Foppe van Mil: appropriate pharmacy design crucial for pharmaceutical care |
In addition, language differences mean that the term "pharmaceutical care" cannot be adequately translated. In some countries "care" has such emotional connotations that pharmacists prefer not to use the word at all and use terms such as "follow up". Other countries stick with the English expression. Images of pharmacies vary across the world, too, often depending on what they do or do not sell. The British pharmacy has long been a "shop" which exists mainly in the high street, while Dutch pharmacies are places where patients go to get their prescriptions dispensed and which are situated, like doctors' practices, mainly in residential areas. Moreover, the Dutch go to a drugstore to buy their cosmetics and over-the-counter medicines.
Such differences cannot be expected to disappear overnight, nor would we necessarily want them to do so. But, as Dr van Mil points out, different interpretations of pharmaceutical care sometimes prohibit the exchange of results from pharmaceutical care research, simply because we are not talking about the same thing.
Interpretation of terms such as "managed care" and "disease management" also leads to misunderstandings at an international level, although in Europe these terms tend to be used without much distinction, he adds. But there is a difference between pharmaceutical care, managed care and disease management, he says, and this is primarily related to who initiates and drives them. In the case of pharmaceutical care it is the pharmacist, with disease management it is the doctor, and with managed care, the health care insurer or payer. What is also important with pharmaceutical care is that the patient is at the centre, whereas with disease management and certainly with managed care the patient has less importance, Dr van Mil says.
Pharmaceutical care was defined and introduced into the Netherlands in the early 1990s. In the Dutch definition - as in others - the patient is at the centre and the philosophy is solely for the pharmacy profession, although a later definition by the Dutch Pharmaceutical Association embraces all pharmacy staff involved in the supply of medicines. The aim of pharmaceutical care, according to the Dutch definition, is to improve or maintain a patient's quality of life.
The influence of Professor Douglas Hepler (who during the early 1990s worked with Professor Linda Strand in the United States) was significant in influencing the introduction of pharmaceutical care into the Netherlands, but Dr van Mil maintains that it would have happened anyway, simply because the ground was fertile. Several factors encouraged the development of pharmaceutical care, including the size and structure of Dutch pharmacies, with their large numbers of "qualified" staff and the fact that they do not have the image of a shop. Few OTC medicines are sold, and most cosmetic items are sold in drugstores. Computerised prescription records in the pharmacy enable medication surveillance and patients tend to visit one pharmacy so allowing for continuity of care. In addition, pharmacists had, since the early 1990s, organised regular "therapeutic" meetings with doctors. All these factors helped.
But what was new for Dutch pharmacists at that time was taking responsibility for outcomes. Although some pharmacists had practised clinical pharmacy, with its emphasis on medication, no responsibility was taken for outcomes. In addition, Dutch pharmacists had never seen themselves as part of the health care team. This also had to change, Dr van Mil said.
Software has now been developed by several companies to encourage pharmaceutical care, and I saw this in operation in Dr van Mil's pharmacy in Zuidlaren, a small town in the northern Netherlands. The pharmacy computer programmes store two types of data - not just a medication history, but also what is known as a "patient care dossier" in which everything that has been discussed with the patient is noted. And when you open a patient's record, the patient care screen is the first thing you see.
One of the difficulties with the patient care dossier is that care can generate a lot of text, which can take a long time to read. Dr van Mil says that coding the various categories of care could help simplify the dossier and he is thinking about how this could be achieved. But he is opposed to the idea of using software from other countries, simply because he believes it is not translatable to the Dutch situation. The Dutch software is updated monthly and new information is added on the basis of the advice of a panel of pharmacists and the Dutch Pharmaceutical Association.
Appropriate pharmacy design is crucial for pharmaceutical care, according to Dr van Mil, and, in his own pharmacy, he has scrapped the long counter and replaced it with small "islands" each with a computer on the top. Interestingly, as soon as this design was implemented, patients, without being asked to do so, started to stand well back from the "islands" if a patient was consulting a member of the pharmacy team. Straight away, patients seemed to understand that this was a private consultation that involved more than just picking up a prescription.
In Dr van Mil's pharmacy, pharmaceutical care is provided in several different ways. When patients are prescribed new medication, the pharmacist conducts a thorough consultation with them. This generally takes about three to five minutes but "you have to learn to be very focused", he says. In addition, pharmaceutical care is provided to patients with asthma and incontinence. The Dutch Pharmaceutical Association has produced care protocols for conditions such as asthma and hypertension, and although these act as useful guidance, it is important for pharmacies to develop their own protocols, Dr van Mil told me. Local ownership and involvement of the whole pharmacy team in protocol development make a huge difference to implementation, he adds. Ten years on from the introduction of the idea of pharmaceutical care, he reckons that about one third of Dutch pharmacists are involved in some pharmaceutical care, and that about 10 per cent are involved at a substantial level.
Payment for pharmaceutical care is an issue in the Netherlands as everywhere else. However, pharmacists are paid a fee of 11 guilders (about £4) for dispensing each item on a prescription - substantially more than the fee in Britain. The fee is calculated by the government and traditionally took into account only the cost of running a pharmacy in terms of staff, heating and lighting and so on. However, since October, 1999, the government has accepted that care is something that pharmacists should do and it now also considers the cost of the computer software in calculating the fee. Hence, the fee has increased recently and this helps a little towards providing pharmaceutical care.
However, wholesalers' discounts are increasingly being clawed back by the health insurance companies, the bodies responsible for remunerating pharmacists. Moreover, insurance companies are now insisting on contracts with pharmacies, and pharmacists will not get remunerated for prescriptions dispensed for patients who are with companies that have no contract with the pharmacy. Insurance companies will obviously shop round for the cheapest services, and now that pharmacies in the Netherlands no longer have to be owned by one pharmacist, there exists the possibility that insurance companies will start to own pharmacies themselves.
Indeed, in Zwolle, a town in the central Netherlands, this has already happened. A health insurance company threatened to open its own pharmacy, and quite naturally the local pharmacists were up in arms about it. So, in the end, the pharmacists got together with the insurance companies and jointly established a pharmacy. How much this will happen in the future is anyone's guess, but it certainly represents a move towards a form of managed care and companies are likely to dictate about the services they will and will not pay for.
As everywhere else, it is therefore becoming increasingly important for Dutch pharmacies to prove their worth and provide evidence of beneficial outcomes from pharmaceutical care.
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Dick van Tromp: pharmaceutical care now more widely understood |
They make a lively and enthusiastic team, and they told me about their work over a wonderful lunch. Their projects involve different numbers of pharmacies - anything from the 13 pharmacies which form a group in the locality to, say, 60 or so pharmacies across the country. Funding is obtained from various organisations, but the pharmaceutical care institute does not make a profit - just enough to pay salaries and running costs.
One project completed so far has been to investigate the numbers and types of drug interactions and other "alerts" identified by pharmacy computers during dispensing and, most importantly, what pharmacists did about them. Another project involves polypharmacy and 150 patients have been reviewed for possible changes to their medication. Of those 150 patients, 52 have had changes made to their prescriptions and, although results had not been totally analysed when I visited, there seemed to be about a 20 per cent reduction in prescription items among the 52 patients where changes were made.
The institute has recently submitted a proposal for funding for an asthma project to look at inhaler compliance and is looking to start projects to encourage the integration of pharmaceutical care into areas such as gastrointestinal medication, diabetes, angina and use of eye-drops. The aim of all the projects is about improving outcomes by pharmacist interventions, although the team is finding it difficult to measure the correlation between what is done and what is actually achieved in terms of quality of life for the patient.
Quality of life for the patient is the main aim of pharmaceutical care in the Netherlands and the last word must go to Professor Tromp's daughter Nelly, who is just about to qualify as a pharmacist. For her, providing pharmaceutical care is what being a pharmacist is really all about. As she says: "You cannot make patients better, but by providing pharmaceutical care can help give them the best possible quality of life." And this is what she intends to do during her professional life. Idealistic? Not really. Pharmacists in the Netherlands, as everywhere else, know that there is no long-term future in counting and pouring.
Dr Pamela Mason is a pharmacist and freelance writer from Sydenham, South London