The Pharmaceutical Journal Vol 265 No 7112 p3375-336
September 2, 2000 Forum

Pharmacy World Congress

The environment of practice

How do pharmacists use evidence?

Opening the session, Dr LINDSEY DAVIES (a doctor with responsibility for public health in the National Heath Service Executive's Trent region, United Kingdom) gave a broad view of current trends in health systems that were likely to influence the way pharmacists used evidence. Pharmacists needed evidence to maximise effect and to minimise risk, she said, and professional practice in health care had always been based on evidence. "I think it is the essential duty of every professional pharmacist, nurse and doctor to make a judgment about each patient or issue and then to advise the patient and take action themselves on the basis of that judgment," she said. Evidence included a range of things - what the patient was complaining about, previous experience, knowledge, clinical trial data, etc - and it was a professional's job to integrate all the different evidence to make a judgment. It was important to draw on potential sources of evidence properly, so that judgments were as well informed as they could be. "We are all doing this every day, to a greater or lesser extent; but are we doing it right?" Dr Davies asked.

Lindsey Davies: not enough use of evidence in pharmacy practice

Use of evidence
Dr Davies went on to say that there was some evidence about the use of evidence. She had recently chaired a Royal Pharmaceutical Society working party on getting research into pharmacy practice, and it had transpired that pharmacists in England were not using enough evidence in their practice. Pharmacists in general were not bringing enough evidence from clinical trials, from systematic reviews of their own activity or from advances in basic science into their daily work.
There were various reasons for this, including lack of time, cultural issues (such as the tradition that pharmacists were generally deferent to doctors), professional isolation, financial disincentives (inasmuch as in England community pharmacists were paid according to how much they dispensed), and a lack of research evidence in the practical aspects of the use of drugs.
But did it matter whether pharmacists got it right in the balance of the evidence they used? Dr Davies believed that it did. Health systems were constantly changing and these were likely to have an effect on every single pharmacist sooner or later, and they all had implications for the way evidence was used.
One issue was the rise of consumerism, which represented a significant change in the relationship between the patient and the professional. Patients' demands and needs had to be recognised.
Patients were also more aware of different treatments available, thanks to the internet and telephone health advice lines, but they were often not so aware of the scientific evident to support these options. Also, there was a high level of media interest in health issues.
"The pressures here for using evidence in practice are clear," said Dr Davies. "The public increasingly, quite reasonably, expects professionals to perform to the highest possible modern standards.
. . . A quick skim of the latest journal in the hope that something will stay in your head will not be enough any more."
A second issue was regulation. The UK Government had asked professional organisations to start reviewing their members' competence formally and regularly. This process of revalidation was likely to be required every five years or so for every doctor, initially - but it was coming for other professions, too, she warned.
Organisations, too, were increasingly being expected to undergo external evaluation to prove that their systems conformed to the best modern standards. This "accreditation" required organisations to demonstrate that evidence was being applied in practice.

Universalism
A third issue was universalism. Dr Davies explained that universalism was the idea that everyone should have access to high quality, essential care. In this context, high quality was usually defined in terms of effectiveness, cost and social acceptability, while "essential" implied that the highest priority basic health needs were met within the resources available. This led straight to the fourth issue, of prioritisation.
Prioritisation meant that doctors had to balance the rescue principle ("save my dying child") against the public health principle of the best value for the population. It was this which, in England, had led to so-called "post-code prescribing", where the treatment received depended on which health district one lived in.
Post-code prescribing had arisen largely because the Government had delegated decision making at a local level a long way from the Government itself. "This has the advantage for the Government that difficult decisions are clearly local ones and not the Government's fault. But is also means the Government risks losing control of what is going on. This is a continuing trend in some countries today," said Dr Davies. In England, however, the Government had acted in a more "universalist" way by producing evidence-based national service frameworks, which set clear expectations and targets for service quality.

Team working
Team working was important. At last, in many health systems, there was a positive movement towards a real team approach in the care of individual patients, where everyone's contribution was respected and valued. "The doctor who thinks he or she is the only one who really ‘knows' and who therefore has the right to tell everyone else what to do is increasingly becoming, thank goodness, a thing of the past," Dr Davies said. Individual members of a health care team had to trust each other and respect each other. "But it is difficult to gain that respect if you do not have a clear grasp of all the evidence."
Concluding, Dr Davies said that pharmacists could not possibly know everything all the time. But they needed to be selective and practical. "It is essential to keep up to date with the really important changes in what drugs are available and what they can do, and with the relevant aspects of pharmacy practice."
Pharmacists needed to know how to find evidence and how to assess it. They needed the basic facilities to do this - eg, libraries and a personal computer - and they needed the time and the inclination to use them.

What do consumers demand?

In the future, pharmacists would have to develop schemes which allowed improved relationship building with their customers, in other words, relationship marketing. So said Professor PETER SCHNEDLITZ (professor of retailing and marketing, Vienna University of Marketing and Business Administration), when he addressed the congress. Relationship marketing included sticking with core competencies, focusing on customer retention and repeat sales (perhaps offering loyalty schemes), providing trust and service for customers, ensuring quality and value, and offering modern shop concepts through integrating new information and communication technology into their businesses. There would always be a place for traditional pharmacies in the future because pharmaceutical products were more than just ordinary products. Pharmacists were concerned with people's health. Professional knowledge would always be necessary because "a fool with a tool is still a fool," he said. Professor Schnedlitz suggested that marketing and pharmacy professionals had a very similar ideology. Like pharmacists, marketing professionals always started with the question of how people really thought and felt. Marketing focused on the needs of the consumer. It was preoccupied with the idea of satisfying the needs of the customer by means of a product and the whole cluster of things associated with creating, delivering and finally consuming that product. The pharmaceutical profession had changed over the years. In the past, the pharmacist was considered by the man in the streets as a wise man because of his knowledge of pharmaceutics, botany and Latin. Also, he prepared his compounds himself, from a limited number of substances and powders in his mysterious laboratory, said Professor Schnedlitz. Nowadays, European pharmacists had to cope with the internet. The preparations he used to make himself had now been replaced by industrially manufactured medicines. But pharmacists were still perceived as professionally qualified persons with an outstanding image, in Austria at least, as a general health adviser. He reminded the audience that a pharmacist was still the only professionally qualified person who ran a business in the high street and who received clients without an appointment.

Peter Schnedlitz: marketing and pharmacy have similar ideology

How does pharmacy set priorities in health care?

How pharmacy decides to set priorities will largely be a function of its desire to place the needs of the patient before the needs of the profession, said Professor BRUCE CARLETON (faculty of pharmaceutical sciences, University of British Columbia, Vancouver, Canada). But there was no easy answer. Without the profession, there was no pharmacy-driven patient advocacy; without patients there was no need for the profession. Professor Carleton was convinced that patient advocacy was the way forward for pharmacy. However, that was likely to require the relinquishment of some professional turf, for example, some dispensing, because, he said, "we must no longer concentrate on what pharmacy can do for patients, but on what patients' health care needs we can best address". It was clear that the profession of pharmacy was developing a larger role in the care of patients in the form of medication monitoring and management activities and many studies had demonstrated the utility of pharmacists in improving health care efficiency and effectiveness. Less well developed was the quantification of this impact. "Health care decision makers need to be provided with evidence of programme benefit in terms they understand and to which they can relate," said Professor Carleton. "With health care budgets already overburdened with requests for additional services, why should expanded clinical pharmacy services take precedence over other obviously needed services?" The challenge was to provide decision makers with information that would allow them to see clearly the costs and consequences of not providing clinical pharmacy services.

Bruce Carleton: patient advocacy is the way forward for pharmacy

To that end, he proposed four principles which would assure pharmacists of a place at the patient health care table.
His first principle was: "Convert professional constraints into professional resources." Some of pharmacy's professional functions could be viewed as a professional restraint or a professional resource, for example, dispensing. The pharmacist's position in the linear drug use process put him or her in a powerful position to influence drug therapy decision making. Because pharmacists were so close to drug use, professionally speaking, they had wonderful opportunities for achieving meaningful clinical impacts while monitoring and managing drug therapy.
How should they best take advantage of these opportunities? Training pharmacists to be "better trouble-shooters and patient-specific, drug therapy problem-solvers" was an obvious solution, but it had been shown to be only marginally successful. Improvements in practice due to training were generally transient and modest at best. What was needed was simulated practice through case-based instruction methods. Improvements in drug therapy decision making would occur if practice was influenced while it was actively occurring.
The second principle was: "Develop cognitive apprenticeships." This meant "link, lurk and learn": if one was to "link" up to the internet, one could "lurk" in, say, a group of clinical drug therapy decision makers and then "learn" by picking up the genre of that community. "And you can move from the periphery to the centre, safely asking a question, sometimes more safely virtually than physically, and then back out again," Professor Carleton suggested. He believed that this type of internet learning had provided a platform for what would be the most successful form of learning ever seen.
The third principle was: "Decision making needs to be done as if consumers are family members". Who made clinical decision about the use of drugs without first asking, "would I recommend this for my own child, parent or grandparent?" Such thoughts needed to be integral subconscious thoughts at the initial stages of every drug therapy decision.
The fourth principle was: "Professional strategies need to shape research strategies". Perhaps too much time had been spent trying to show the value of pharmacists in patient care rather than what would happen if comprehensive pharmacy services were not provided. For example, in the United States, pharmacists reported 14 times more adverse drug reactions than physicians did. More needed to be made of such statistics.
Pharmacist researchers were fond of talking to other pharmacy researchers. What they needed to do was to shape their research strategy to encourage a large amount of information exchange between researchers and clinical decision makers.
Concluding, Professor Carleton said that pharmacists were clearly viable candidates for the job of patient advocacy and that patients would not forget to whom the credit for that advocacy belonged.