Describing the training programme, Mr Rob Swallow (assistant director for education development, Centre for Pharmacy Postgraduate Education, England) said that he believed the programme would "make a real difference by generating local activists for pharmaceutical care".
Although the initiative was a national one delivered jointly by the CPPE and the Scottish Centre for Post-Qualification Education (SCPPE), the emphasis was on provision of training that facilitated development of pharmaceutical care expertise and practice at a local level. The programme involved a five-day residential course, divided into two parts with a five-week intervening period during which participants would complete practical assignments. These assignments involved practising pharmaceutical care - "actually doing it, doing it consistently and documenting it," he emphasised.
The training was case-based with development of structured pharmaceutical care plans to meet the needs of individual patients. The aim was to get participants to reflect on local opportunities for pharmaceutical care, to review how they practised pharmaceutical care and to consider ways in which they could reorganise their pharmacies to practise medicines-related patient care. Participants would be taken through all the stages of pharmaceutical care from assessing the patient's needs to developing a care plan and evaluating and monitoring the outcome.
Tutors on the programme would be practising clinical pharmacists with broad pharmaceutical experience and comfortable with a variety of therapeutic areas. Most importantly, tutors needed to be focused on pharmaceutical care and able to motivate others to do it.
The organisers were looking for a cohort of 20 pharmacists to participate in the programme, which was free with all expenses paid and a fee of £100 a day provided towards the costs of a locum. Application forms and information packs were available from the CPPE and the SCPPE and would also soon be available on line at www.cppe.man.ac.uk. Potential delegates needed enthusiasm and they had to be keen to change their practice, to be willing to give it a go. "We often think we're doing things right, but we often delude ourselves. With pharmaceutical care, pharmacists will say they can't help everybody, so they don't help anyone," Mr Swallow concluded.
Professor Douglas Hepler (University of Florida, and visiting professor at the University of Manchester), who has trained more than 100 pharmacists worldwide in pharmaceutical care and has contributed to the development of the UK programme, said that training was essential before embarking on pharmaceutical care. Why? Because the term pharmaceutical care was so widely used (and misused) that pharmacists often did not know what they were getting into and they needed to go on a training programme to find out.
Pharmaceutical care was, of course, about taking care of patients, and pharmacists needed to learn how to do this before they could go on to the next steps, one of which was to market the service. The problem was that when pharmacists were not dispensing, no one knew they were pharmacists. However, pharmaceutical care was a business. It needed to make money. Pharmacists would have to learn how to market this business to others, which in the first instance probably meant primary care groups. Pharmaceutical care was not something one could afford to do for a hobby or when one had a bit of spare time. It was about changing one's source of revenue from dispensing to patient care.
In addition, pharmacists needed to learn how to manage a practice - a pharmaceutical care practice, not a dispensing practice; the two were very different. Moreover, pharmaceutical care had to be practised consistently both by individual pharmacists and between pharmacists, otherwise there would be confusion. It was dangerous to have unpredictable pharmaceutical services where a patient could get pharmaceutical care from one pharmacist but not from another. In short, everyone had to be singing from the same hymn sheet.
There had never been a better time for starting pharmaceutical care, Professor Hepler said. Pharmaceutical care was fun and worth more money than dispensing. In the United States, managed care had forced down dispensing revenue and it was only a matter of time before the National Health Service would do the same thing. There had to be a better way of making a living and current conditions in the NHS were "excellent for pharmacists to increase their role in optimising medicines-related patient care."
One of these conditions was clinical governance, and there was a huge clinical governance interest in drug therapy. There was an increasing awareness of medication errors and, if general practitioners got involved in trying to solve these problems, they would soon find they needed community pharmacists. Practice pharmacists, nurses and GPs could not manage medication issues on their own: they needed the distributed network of community pharmacists. And community pharmacists needed to be trained and ready for when GPs asked them to get involved.
From international data, the estimated rate of preventable drug-related hospital admission in the UK might be approximately 5.4 per 1,000. This compared with 1.8 per 1,000 for diabetes mellitus, 1.8 for asthma, and 4.0 for myocardial infarction and about 5.0 for neoplastic disease. The admission rate to hospital could, therefore, be as high as that for myocardial infarction or for asthma and diabetes put together.
In economic terms, this translated in the US to $80 for every visit to a doctor and $57 for every filled prescription. The UK was probably spending more on preventable drug-related morbidity than the actual cost of the drugs themselves or the cost of the visit to the GP.
But pharmacists could prevent these morbidity costs. That was why pharmacists were worth so much. But they were not worth the £2 or so they got paid for dispensing a prescription. Why should the NHS pay for dispensing when there were cheaper ways to do it? Business conditions for community pharmacists who limited themselves to dispensing would not improve. And with the help of this new national initiative from the CPPE and the SCPPE, there would never be another time when pharmacists would have more resources at their disposal to learn to practice.
Essentially, pharmacists needed to learn to provide the service. Learning and doing the process were more important than gaining new knowledge. Pharmacists tended to be frightened of pharmaceutical care because they thought they did not know enough. But how much therapeutics did you need to track use of asthma inhalers? Or to track pulse rates and visual disturbances in patients on digoxin? Or to make sure that GPs were monitoring patients on warfarin? Pharmacology was important, but practising pharmaceutical care involved a disciplined mind and use of a consistent process.
So, what did pharmaceutical care look like? Basically, it involved assessing the patient and considering the therapeutic objectives by asking the patient - and often the doctor, too - what they expected from the therapy. That way you could assess whether the objectives would be met or not.
The next stage was to develop a monitoring plan - something that should be done before dispensing the medicines and advising the patient. But the plan also had to be implemented. And this could mean, for example, telephoning patients to see if they felt better. Everyone knew this, but no one did it. If the patient was no better, it could mean that the wrong drug had been prescribed, there had been a drug interaction or adverse reaction or that the patient was not taking the medicine.
Finally, any problems had to be assessed and dealt with. And, if pharmacists did this, they could prevent a lot of treatment failure. This would make the NHS happy because patients would not go back to the GP so often and there would be a reduction in hospital admissions and the drugs bill. It would make GPs happy because they would feel as if they were better GPs.
Pharmacists also needed to learn how to co-operate with GPs, patients, carers and other pharmacists; in short, how to be an active team member. They also needed to learn to be able to explain the service to others in terms of what pharmaceutical care could do for others and why they needed it.
"Get on the course," Professor Hepler said. "Learn what pharmaceutical care is about, learn the process and do it. Begin the practice on day one. Don't let other distractions put you off when you get back to the pharmacy. Network with others and share problems. And learn to appreciate the value of real case study-based assignments and evaluation. Nobody likes exams but there has to be a solid sense of what you've achieved on the course."
Too often pharmacists failed to see the big picture, he concluded. "It is time to enlarge our perspective. Things will not improve by themselves and time is running out."
Wishing the new initiative well, Dr Ambler said that 5.4 hospital admissions per 1,000 for adverse drug reactions was not a comfortable statistic. Moreover, it was clear that it did not take rocket science to solve the problem: it was having the confidence to start. The course would, hopefully, help people to gain that confidence. Although the Royal Pharmaceutical Society could offer leadership, pharmaceutical care had to come from the bottom up and there was a need to motivate individuals to do it. Describing the course as "very exciting", she hoped that the 20 or so participating pharmacists would be in charge of pharmacies where patients would experience a real difference.
