United Kingdom Clinical Pharmacists' Association

Pharmacists should use health economics to make a case for new drugs and to implement change, rather than seeing it as a means to prevent innovation, said Dr ANDREW WALKER (head of health economics, Greater Glasgow health board).
Decisions as to whether to use new drugs and treatments were being made all over the UK and it was vital that all considerations, including financial ones, were taken into account before reaching a conclusion.
Using health economics when deciding whether a drug should be funded was the ethical thing to do, as it posed hard questions, making health care professionals question whether services that they were providing were of real benefit or were just a passing trend.
"Health economics should not be seen as just a means to stop treatment from being used on the grounds of cost; it gives health care professionals the power to make changes and decisions that are defensible through the legal system, should it become necessary," he said.
Dr Walker said that health economics was a good area for pharmacists to specialise in, as they were well placed to look for ways of improving or changing the current service.
For example, in the case of two drugs that cost the same as each other but where one was more effective than the other, it would be unethical to use the less effective of the two. However, if one cost 10 times more than the other, it might become unethical to use the more expensive one.
The important thing was to be systematic about health economics. When beginning an economic study, it was important to have a well-defined study question. The situation had to be one in which there were two or more options (including the status quo). There should be savings to be made, data available to measure each option and obvious benefits from the change.
Understanding the benefits of making a change was crucial, as this determined what outcomes and measures should be used. It was important that evaluations were timely and were completed before, rather than after, a decision had been made. It was important not to let "perfect" get in the way of "helpful and timely" and not to suffer from "quantophrenia", in which there was a neurotic need to quantify everything (including things that could not be quantified). Health economics took time and was rarely perfect but any other evaluation system would also be flawed.
There were a number of ways of measuring benefits. The first was the "balance sheet" approach, in which all costs and benefits were measured and listed. This was a transparent method but no recommendation was made at the end. The second method was cost-effectiveness analysis, which focused on a single measure, such as cost per unit reduction in cholesterol. This was a clear measure but was narrow and did not give the broader picture. The third method was the quality adjusted life year (QALY), which was a good method, as it allowed comparison of totally different interventions. The biggest weaknesses of the QALY were that the measurements made generally lacked sophistication and it was not immediately obvious what assumptions had been made when reaching a recommendation. The final method was conjoint analysis. This assumed that the process of care was more important than the health outcome. This was still in experimental stages.
Common problems with economic evaluation were that the options selected were too narrow, that important costs or benefits were missed out, that inappropriate data sources were used, that there was inaccurate interpretation of the data and that there was no allowance for uncertainty.
Dr Walker recommended that an economist be involved in any economic study from the start. One of his concerns about the National Institute for Clinical Excellence (NICE) was that its role implied that economic evaluation led to a definite, unambiguous answer, which was not always the case. It was not clear what the public expected from the NHS but the good of the many should not always outweigh that of the individual - did the public want an NHS that did not fund beta-interferon, or heart/lung transplants?
It was important to overcome the usual barriers of lack of time, experience and the perception that health economics was irrelevant in day-to-day practice.

Andrew Walker: health economics poses hard questions but is of benefit

Over 130 pharmacists attended the UKCPA spring symposium

Case conferences that involve all the health care professionals working in residential homes improve the overall management of patients and create a stronger team spirit, said Ms MICHELLE KING (postgraduate pharmacist, department of medicine, University of Queensland, Australia).
A study was carried out in three residential homes in Canberra, Australia, to see whether holding a weekly case conference for selected patients would help improve the management of patients and the communication between general practitioners (GPs) and pharmacists.
The researchers found that regular discussion of patients' cases improved communication between all health care professionals, and the GPs considered the meetings as a source of information and reassurance, as they learned a great deal from their peers.
"Although drug costs did not decrease by much, patients stood to benefit from all of the health care professionals responsible for their care working together as a more co-ordinated team," Ms King said.
Presenting the Pharmacia & Upjohn award 2000 lecture, she said that residential homes in Australia tended to be bigger than those in the UK and employed staff other than nurses and doctors. This was because the Australian government discouraged admissions to hospital for age-related health problems.
Pharmacists had traditionally provided just a simple supply service but they could now become accredited, which meant that they were allowed to review the prescriptions of residential home patients and make recommendations for changing treatment.
These reviews had caused considerable tension between pharmacists and general practitioners because there was a complete lack of communication between them about the reviews.
"It was often the case that the first a doctor knew about a review was when a list of recommendations from the pharmacist suddenly appeared in the patient's notes," she said.
The homes involved in the study housed a total of 245 patients, who were cared for by 83 GPs. A case conference was held each week during the study period and a total of 76 reviews were carried out. The case conference was attended by the relevant GPs, a clinical pharmacist, senior nursing staff, other relevant health care professionals (eg, physiotherapists) and sometimes the resident or resident's carer.
The GP described the patient's case and led a discussion of how best they should be managed. The pharmacist presented a review of the patient's drug treatment and made recommendations for any changes. Once all the patient's problems (not just the drug-related ones) had been discussed, a management plan was drawn up.
About half of the suggestions for change made by pharmacists were rejected either because relevant data had been missing or because there were aspects of the patient's case of which the pharmacist had been unaware. All of the recommendations accepted without modification were acted upon by the GP. Of these, 40 per cent were of obvious clinical benefit to the patient or carer and many others had no obvious effect but were not detrimental.
When asked if they would like to continue with the case conferences, 97 per cent of the GPs said that they would.

Michelle King: Weekly meetings were a source of information and reassurance to GPs

Role play using "simulated patients" makes undergraduate pharmacists more confident about giving advice on medicines, said Dr DELYTH JAMES (senior lecturer, school of pharmacy and biomedical sciences, University of Brighton).
Students who were asked to assess how good they were at giving patients advice about medicines both before and after training involving role play felt more confident and less intimidated afterwards.
The role play took place between students and "simulated patients", who were ordinary people off the street who had been asked to portray a number of situations.
"Consultation skills training improves students' confidence to undertake this activity," Dr James said.
Giving the Wyeth education and training award 2000 lecture, she said that good consultation skills were essential if the students, when qualified, were to be able to identify and meet patient's needs. In addition, it was important to encourage respect for patients and to have a professional approach to working as a pharmacist.
Initially, students had been trained using an actor but this had not been ideal as there were only so many roles that one person could play. So, the university had approached people recommended by the local postgraduate medical tutor, or by the charity Age Concern, or people who were postgraduates at the school of pharmacy.
The benefit of using real people was that they could bring their own experiences and perspectives to the role.
These individuals were assessed for common sense, flexibility, availability, a good memory for the scenarios that they were to enact, the ability to improvise and an understanding of how to give constructive criticism of the student's performance. They ranged in age from 22 to 73 years and were given any extra training that they required in order to carry out a successful role-play.
The idea behind the training was to help students plan and develop a structured, thorough consultation with patients, to establish a rapport with them, to decide what the patient's information needs were and to check that the patient had understood what they had been told. In addition, the students were encouraged to know their limits and not to be afraid to refer patients to their general practitioner, if appropriate.
It was important that students understood both the purpose of conducting an effective consultation and patients' attitudes and beliefs towards taking medicines.
A structured questionnaire was used to evaluate how well the students felt they had performed both before and after training. They had to assess their own level of confidence and the degree of difficulty encountered when counselling the patient. Feedback was given to the students from their peers, the group facilitator and the simulated patients. It focused on the things that the student had done well followed by those that could be improved.
Developing a structured approach to giving advice ensured that the patient was at the centre of care and made it easier to identify, prioritise and resolve drug-related problems.

Delyth James: Good consultation skills are essential