The Pharmaceutical Journal Vol 264 No 7100 p884-887
June 10, 2000 Forum

Third International Symposium on Pharmaceutical Care

Antipodean review of developments

The third international symposium on developments in pharmaceutical care was held in Auckland, New Zealand, on May 19. Opening the symposium, Mrs Eleanor Hawthorn (president of the Pharmaceutical Society of New Zealand) said that pharmaceutical care must be considered to be the major focus for the future of pharmacy. The Pharmaceutical Society of New Zealand had embraced the concept and continued to work towards its implementation as a normal and practical application of pharmacists' skills and expertise. Internationally, there was a move towards collaborative health care. It was imperative that the positive contribution of the pharmacist was promoted as part of this in order that the patient received the best medicine-related outcome. The proceedings of the symposium are reported here

Eleanor Hawthorn: pharmacists' positive contribution

Government paying in New Zealand

Community pharmacists in New Zealand are being paid by the government for a limited form of pharmaceutical care. This was explained by Mr John Dunlop (general manager, New Zealand College of Pharmacists) when he described the scene in that country. The payments were made to pharmacies under what was called the Prescription Review Service (PRS). The service provided for one consultation per patient per year. Agreement was required by the prescriber before a review took place. Mr Dunlop was concerned that, under the service, the pharmacist had abrogated responsibility for the implementation of recommendations to the doctor. The pharmacist remained in a subordinate role. The one-year gap between reviews also raised concerns. What if the patient had more drug therapy problems than could be dealt with through what were only annual appointments? The good news, though, was that pharmacists were receiving payment from the government for professional services. Reviewing the development of pharmaceutical care in New Zealand, Mr Dunlop said that the country had adopted the American Pharmaceutical Association definition, namely, that pharmaceutical care was a "patient-centred, outcomes-orientated pharmacy practice that requires the pharmacist to work in concert with the patient and the patient's other health care providers to promote health, to prevent disease, and to assess, monitor, initiate and modify medication use to assure that drug therapy regimes are safe and effective".

John Dunlop: New Zealand adopted American model

It had also adapted the APhA's training programme, established a support service to peer review pharmacists' patient care plans, and registered "comprehensive pharmaceutical care" as a brand-named service offered by pharmacists. It had developed contractual obligations for pharmacists practising pharmaceutical care. These required pharmacists to send care plans to the Pharmaceutical Society of New Zealand for review. The society had developed an accreditation procedure requiring a certain standard of care plan before people were permitted to practise.
By May, 2000, a total of 320 pharmacists had been trained. Of these, 69 had been provisionally accredited and were able to make claims for PRS payments and 22 had been fully accredited, which meant they did not have to have their care plans reviewed by the society.
The PRS system had been in operation for nearly three years. Recent figures showed that the government had paid for 440 care plans under the PRS. These had come from 37 pharmacies.
Mr Dunlop was critical of this level of activity. Pharmacists had the opportunity for payment, but most of the 2,000 pharmacists practising in the community were not taking it up.
The reason for that could be found in a survey of New Zealand pharmacy that Mr Dunlop had conducted, the results of which he outlined to the symposium. Some 87 per cent of community pharmacists felt they had insufficient time for pharmaceutical care, 60 per cent felt they had insufficient finance, 54 per cent had inappropriate physical space, 50 per cent lacked motivated personnel and 51 per cent lacked appropriate management systems. Some 82 per cent felt there was no reimbursement system (despite the existence of PRS payments and the fact that some pharmacists were receiving payments from third parties and from patients), 64 per cent that there was a lack of patient demand, and 62 per cent that there was lack of access to patient medical records (a problem that CPC practitioners did not experience in reality).
Over two thirds (67.5 per cent) had fewer than one technician per site and 58 per cent did not have access to a private consultation area. Only some 6 per cent had a postgraduate diploma or better.

Intellectually ready?
For the most part, community pharmacists appeared to feel that they were not intellectually ready for the role. Three quarters believed that pharmaceutical care required a major "upskilling" of knowledge, 56 per cent felt a lack of therapeutic knowledge and 55 per cent a lack of clinical problem-solving skills.
Put simply, more than half of community pharmacists felt they had no money, time, space or staff for pharmaceutical care.
However, as Mr Dunlop indicated, pharmaceutical care required time, money, skilled pharmacists and a private consultation area. It also needed patients, professional support and a collegial relationship with prescribers and between pharmacists. Mr Dunlop added that prescribers were happy to take pharmacists on as colleagues if they broke down the barriers.
Mr Dunlop said that the evidence suggested that community pharmacy practice in New Zealand might be not ideally situated to take advantage of innovative professional practice. It was going to have to change. The data suggested that pharmaceutical care was not going to flourish in this environment.

Payments under Medicare proposed

Pharmacists in the United States may soon be reimbursed for providing pharmaceutical care for the elderly. This was indicated by Professor Lyle Bootman (dean of the college of pharmacy, University of Arizona) when he delivered the symposium's keynote address. Professor Bootman said that various measures were under consideration in the United States for improving drug benefit for the elderly under Medicare, the federal health insurance programme for the over 65s. The most important of these - and the one supported by the president - required the provision of pharmaceutical care and for pharmacists to be reimbursed for providing it. If enacted, the legislation would be a major advance. It was already significant that 435 members of the house of representatives and 100 senators were beginning to think about pharmaceutical care. The recent report on the high level of medical error in the United States ["To err is human", BMJ, March 18; see PJ, March 25, p456] had caused pharmaceutical care to be included in the Medicare legislation. It had made public that patients were prone to significant error when they visited their physician. Opening his address, Professor Bootman said that he had been to many countries in the past five years talking about pharmaceutical care. There was universal interest, and that included among health ministers.

Lyle Bootman: drug-related problem gap

Major disease
Indicating the need for pharmaceutical care, Professor Bootman said that drug-related morbidity was a major disease. It was costing $100bn a year in the United States. This was on a par with cardiovascular disease ($117bn), cancer ($100bn), and diabetes ($98bn). It was the silent disease of America. In the US there was a national cancer institute and a national heart and lung institute. There was no such thing as a national institute for drug related morbidity. Yet here was an issue that was just as economically disastrous as cancer or heart disease. Little was spent on it.
Pharmacists would be key in influencing the cost-effective application of drug technology to address the problem. They would not be able to do it alone. It would require a tripartite relationship with consumers and physicians and other health care providers. The prime role would be that of the pharmacist.
Pharmaceutical care was starting to take hold throughout the world. But it would not necessarily have to be provided from a community pharmacy. More and more physicians were hiring pharmacists in their clinics to manage drug therapy. Community pharmacy chains were beginning to take on pharmacists to place then in physicians' rooms.
There would be re-engineering of the health professions. Interdisciplinary health care was on the horizon. Physicians were beginning to understand that they needed assistance in managing drug therapy technology.
Professor Bootman showed figures that suggested that pharmaceutical care would reduce drug-related morbidity and mortality by 60 per cent.
Professor Bootman said that the full value of pharmaceuticals was not being achieved. Phase 3 clinical trials of drugs identified how drugs behaved in ideal conditions. In clinical trials, everyone did the right thing in the right way according to protocol. If patients did not take their medication they were kicked out of the trial. But in actual use, non-compliance and inappropriate management led to diminished value. The difference between effectiveness in trials and effectiveness in practice was the "drug-related problem gap". Drug-related problems included improper drug selection, subtherapeutic doses and drug interactions.

Enhanced quality of life
Concluding, Professor Bootman said that pharmacists should have as their professional goal the achievement of enhanced quality of life. He said that he used to believe that they should seek to maximise the value of drug therapy. But he had been challenged on that when he had addressed an audience of consumers about pharmaceutical care. An elderly woman had said that she knew pharmacists could help her take her medication and lower her blood pressure, but it was quality of life that was important to her. If pharmacists could enhance that, she would guarantee that they would be reimbursed for pharmaceutical care.

The elderly are the target

The target population for pharmaceutical care is elderly people on multiple medications. So said Ms Linda Bryant (lecturer in clinical pharmacy, Otago university). She derived this information from a study of care plans prepared under New Zealand's comprehensive pharmaceutical care scheme. In all, she had peer reviewed 750 care plans. She took 170 of these for her study. Sixty-three per cent of the 170 had been for women and 37 per cent for men. The majority of patients, 74 per cent, had been over 60. The proportion of people with four or more medical conditions was 56 per cent. The average number of medicines being taken by them was five. Pharmacists had the potential to be effective in this area. Other health practitioners, such as nurse specialists, were skilled in the diseases they dealt with, such as asthma or diabetes, but they might not have the knowledge to deal with co-morbidity. Managing multiple medicines use in multiple disease states was a major role for pharmacists. The common diseases being treated presented no surprises, with cardiovascular disease at the top of the list. Drugs being used, again, presented no surprises, with diuretics and ACE inhibitors prominent.

Linda Bryant: multiple medicines in multiple diseases

So, according to the CPC care plans studied, the target group was elderly people with four or more medical conditions and an average of five different medicines.
Looking at the outcomes of 107 care plans, Ms Bryant said that the general practitioner had been contacted in relation to 63 per cent of them. The GP had agreed with recommended changes in 72 per cent of instances and partially agreed with 7 per cent. Further research was needed on the recommendations that were not accepted.
The number of medicines-related problems averaged four per patient. Eighty per cent of patients had two or more problems.
The types of problem were:

• Adverse reaction (27 per cent)
• Inappropriate compliance (21 per cent)
• Unnecessary drug therapy (17 per cent)
• Dosage too high (13 per cent)
• Dosage too low (10 per cent)
• Inappropriate medicine (7 per cent)
• Need for additional medicine (5 per cent)

Ms Bryant suggested that the Prescription Review Service, under which GPs nominated patients for medication review, was leading to a lesser rate of medicines-related problems being found than when pharmacists did the choosing. She thought this might be due to the fact that the agreement of the prescriber was needed for PRS review. Agreement might only be coming from "good" prescribers who did not feel threatened.
Another issue that required research was the allocation of clinical significance to interventions by pharmacists. In this connection, Ms Bryant said that a Pharmacy Intervention Day would be held on June 27 in New Zealand. All pharmacists would be asked to record their interventions.
Ms Bryant said that she had reviewed the list of pharmacists trained for CPC. Some 214 community pharmacists were included in the list. Eighty-nine had sent in at least one care plan, leaving 125 who had yet to do so. (Some had only recently completed their training.) Pharmacists pursuing postgraduate studies were more likely to be active in CPC. Of those who had completed more than 20 care plans, two-thirds were pursuing such studies, even though they were in the minority of all pharmacists who had completed CPC training.
Education also influenced perceptions. Those pursuing postgraduate studies were more likely to believe that pharmacists should increase their involvement in CPC and to be comfortable about being accountable for the medicines-related decisions required to fulfil a medicines management role.

Value-added
Ms Bryant said that she believed that postgraduate studies were required for CPC. This should cover how to find information relevant to the patient, how to evaluate this information and provide it in a value-added manner and how to solve complex problems encountered with use of multiple medicines in multiple diseases.
Pharmacists must be well prepared. There was information that pharmacists needed at the tip of the tongue so that when they got into discussions about medicines they did not have to dash off to look up information.
Ms Bryant said that when reviewing care plans or doing some herself she always took the attitude that she was the prescriber. She sought all the factors that she needed to know in order safely to prescribe the medicine at the time of review and in the long term.
Ms Bryant said that she had been at a recent meeting when a pharmacist had said to her that some published care plans that he had read had seemed pretty basic, involving such things as mouth rinsing after inhaled steroids, advice on suitable inhaler devices and so on. But, Ms Bryant said, no one else was providing this advice - not the general practitioner, the practice nurse, or the busy dispensing pharmacist. Pharmaceutical care did not have to be rocket science. Pharmacists, by using their specific skills during a CPC review, could have a big impact on patients' health-related outcomes. The seemingly small interventions did have an impact on a person's quality of health care.
Ms Bryant said that she had seen some very significant interventions in care plans, but they did not all have to be earth-shatteringly dramatic.

Royal Pharmaceutical Society's lack of drive

The Royal Pharmaceutical Society is not driving pharmaceutical care hard enough. That was suggested by Miss Sheena Macgregor (senior prescribing adviser, Borders primary care trust) during the course of a presentation to the symposium. There was, she said, little action being taken by the Society. In her presentation, Miss Macgregor described the work of practice pharmacists - pharmacists who worked closely with general practitioners, often in their surgeries - and explained their role in pharmaceutical care. Her comment about the Society was made when she outlined the support mechanisms available to practice pharmacists. Those support mechanisms included the "prescribing management scheme", which was a Scottish initiative, enabling Government money to be made available to health boards to manage prescribing. This had been used to employ practice pharmacists in some areas. Also in Scotland, the Health Department was making money available for pharmaceutical care initiatives in palliative care, and services for the frail elderly and patients with severe and enduring mental illness. In England, a medicines management system was to be piloted, though this did not amount to a complete pharmaceutical care package. The Royal Pharmaceutical Society had recently accepted that practice pharmacists had different needs in terms of professional support and education and a committee was to be set up to look at their role. Two journals geared to primary care pharmacists had recently been launched.

Sheena Macgregor: new branch of the profession created

Opening her address, Ms Macgregor said that the emergence of practice pharmacists [also called primary care pharmacists] had created a new branch of the profession. They worked with medical practitioners in medical centres, but not in the traditional dispensing role. They were integrated into the health care team to contribute to the pharmaceutical care of the practice population.
There were various models, from the full-time pharmacist working in a GP's surgery, to pharmacists working on a sessional basis undertaking specific projects.
It was the introduction of GP fundholding - which had given individual GP practices a prescribing budget - that had given most primary care pharmacists their first opportunities. Subsequently, National Health Service changes resulting in the establishment of primary care groups (in England), local health care co-operatives (in Scotland) and local health groups (in Wales) had resulted in a large increase in demand for pharmacy input into general medical practice, though this was often at a more strategic level. PCGs, in particular, had been very cost-saving driven.
Practice pharmacists performed a variety of roles. The initial pharmacy input usually involved reviewing how a practice managed the prescribing process and setting up systems to improve it. There was no point looking at repeat prescribing unless future prescribing was optimised first.
Formulary development was a good place to start. It rationalised future prescribing.
Managing the drugs budget was another role. This included ensuring that high-cost drugs were used appropriately, providing non-promotional information on new drugs and improving repeat prescribing systems to eliminate waste.
Among clinical roles for practice pharmacists listed by Miss Macgregor were implementation of national disease management guidelines, audit of current practice, medication review, identifying and addressing pharmaceutical care issues, running disease management clinics and prescribing from within local guidelines.
Practice pharmacists also performed a liaison role with hospital and community pharmacists.
On the issue of management of care, Miss Macgrogor said that this could be carried out by many of the health care professions. Nurses could manage specific disease states using agreed protocols. However, diseases seldom occurred in isolation and patients frequently took several medicines on a long-term basis. Co-existing disease could significantly affect treatment decisions and, other than the doctor, it was the clinical pharmacist who was best trained to evaluate risks and benefits. That essentially was the function of pharmaceutical care.
Many disease management clinics were pharmacist-led. There were particular advantages for this being so where compliance with medication, dosage titration or monitoring was important or where side effects might be unpleasant.