World Congress of Pharmacy

Giving the patient's perspective, Mr ALBERT VAN DER ZEIJDEN (representing a motor neurone disease patient group in the Netherlands) emphasised the need for patient-centred health care and a shift in the attitudes of the different players in the process of drug therapy. "We have to move from a paternalistic system to a concerted action of equal partners," he said.
He believed that communication was the key to empower the patient and communication started with providing appropriate information. Doctors and pharmacists could contribute to this empowerment if they saw themselves as advisers to patients, who felt a responsibility for their own health.

People are different
Communication meant that account had to be taken of the fact that people were different from each other. No one should believe that it was possible to reach all patients with just one information leaflet. Several things had to be considered, including the background of the patient in terms of education, age, sex, mental stability, etc. The nature of the patient's disorder was also a consideration: whether the patient had a life-threatening disease or a common cold would make a world of difference for communication. Patient experience was also important: it had to make a difference to communication whether the health professional was seeing the patient for the first time or as an encounter in a long-term process.

Albert van der Zeijden: shift in attitides needed

Nursing and medicine
Dr ROSS TAYLOR (University of Aberdeen, Scotland), giving the nursing and medical perspective to the drug use process, said that 10 years ago there would have been little to talk about: doctors prescribed, pharmacists dispensed and nurses administered. But things had moved on. He mentioned the National Health Service plan for England, which extended roles for nurses and professionals other than doctors. The plan had indicated that, by 2004, over half of all nurses would be able to supply medicines.
Over the past 20 years, the role of the practice nurse had been developed. They were now increasingly involved in extensions of their traditional role, particularly in the running of various clinics, such as asthma clinics and obesity clinics.
It was also relatively recently that nursing had developed into an academic discipline. More rigorous training had led to a mainly graduate profession and, consequently, there had been demands for an appropriately increased status. Part of that development had arisen because of doctors being seen as maintaining their superior status through the monopolisation of the right to prescribe. Thus, primary legislation allowing nurses to be added to doctors and dentists as the only professions legally authorised to prescribe in the UK had been a great professional political success.
Consumerism had also played a part. Patients wanted better and quicker access to health care and a greater choice of whom they could consult. That favoured the development of nurse prescribing as it increased access and choice. However, for patients, there had been no great change in the way they received their medicines and few patients initiated contact with a nurse because of their new prescribing role. Of those who had, most requested items that they had previously had from their general practitioner.
Dr Taylor said that current nurse prescribing in the UK was very much about prescribing within their existing role. At the other end of the scale was the nurse practitioner movement, in which nurses were adopting new generalist and specialist roles. Training of graduate nurse practitioners was increasing, but the training programmes were variable and there were not yet that many qualified nurse practitioners in the UK.
Dr Taylor told the audience that GPs were relatively happy with "within role" prescribing for nurses. They were more concerned about the impact of nurse practitioners, and what they saw as competition for roles was the most problematic area. They were worried that nurses were not trained nearly well enough, that they might miss rare diagnoses, and that patient care would be fragmented.
Concluding, he said that co-operation, not competition, between the professions had to be engendered. The danger in the UK was that although there was certainly a need for radical change and modernisation of the NHS, care had to be taken so as not to damage the essential strengths of the existing system, particularly of general practice. "Don't throw the baby out with the bath water," he warned.

Ross Taylor: strengths of general practice

Pharmacy
The pharmacist's perspective was outlined by Dr JEFF POSTON (Canadian Pharmacists Association). He said there were many forces for change at work. These included rising health care costs, which was causing governments to assess the level and cost of health care professional needed to provide a particular service, hence the emergence of nurse practitioners. There had also been a rise in consumer demand for autonomy, which had resulted in an erosion of professional autonomy. There was a complex mix of social, scientific, economic and cultural factors that would influence changes in who prescribed, dispensed and administered medicines.
A key issue would be the balance struck between consumers' demand for responsibility for health outcomes and the responsibility given to health care practitioners. Pharmacy was fortunate that the concept of pharmaceutical care had emphasised the importance of the covenantal relationship with the patient as the focus for decision making and care. "This is an important foundation for future development in this area," said Dr Poston.
Developing a greater role for pharmacists in the initiation and modification of drug therapy was based on a number of important opportunities and challenges. There was a growing body of evidence that supported the expanded role of the pharmacist in improving health care, the cost-effectiveness of health care and drug use. But challenges were that pharmacists had to have the necessary competencies to prescribe, and legislation and health care systems needed to be significantly changed. Pharmacists needed to improve the documentation of their care.
Competencies required included patient interviewing, record keeping, patient monitoring and evaluation, patient assessment and self-audit skills.
Pharmacists had already developed these to a certain extent. But keeping up to date would become even more important and concepts such as self-audit would have to become everyday practice.
A fundamental question was whether pharmacists who had authority to prescribe would need some sort of advanced academic qualification. This had been the case in some countries with respect to nurse practitioners. The extent to which it would be needed for pharmacists would depend on the degree of autonomy and the types of drugs that pharmacists were allowed to prescribe.
There were political obstacles to pharmacist prescribing. First was the debate with the medical and nursing professions on respective roles and responsibilities. But could pharmacists have a rational debate with other professions? Dr Poston suspected that it might only be possible within the context of a much broader debate on health reform, which might have to be government-led. There was also the question of payment systems, and whether patients were ready to accept pharmacists in a prescribing role. Indeed, would pharmacists themselves want to accept a greater prescribing role?
As a starting point for the debate in Canada, the Canadian Pharmacists Association had produced a discussion paper on the options with respect to expanding pharmacists' authority to initiate or modify drug treatment. In it, three options had been described: (i) dependent prescribing by protocol, (ii) independent prescribing, and (iii) expansion of the pharmacist-only drug list. Canadian pharmacists were being asked for their opinions.
Dr Poston went on to consider the impact of technology. Consumers had unprecedented access to health information via the internet and other media and this was already beginning to change the relationship between them and health care professionals. Systems already existed for patients to keep their medical records online via the internet.
Dr Poston said that advances in technology might lead to a future where patients would prescribe, automated technologies would dispense with the minimum of supervision, patients supported by technology would monitor their response to treatment, and the role of the health care professional would be to enable rather than directly to provide care. The great accessibility of community pharmacists, their relationship with their patients and their proven ability to develop new competencies would put them in a strong position to capitalise on the changes technology might bring, Dr Poston concluded.

Jeff Poston: pharmacists in strong position

To conclude the session, Professor CHARLIE BENRIMOJ (dean and professor of pharmacy, University of Sydney, Australia) said that over the past decade there had been tremendous advances in conceptual models for the practice of community pharmacy. These models could be categorised under three broad headings: competency based, pharmaceutical care and pharmaceutical services.
In the competency-based model, the basic assumption was that if pharmacists were trained to be competent in performing certain skills, they would apply them to delivering a professional service. But in Professor Benrimoj's view, that model was naive, because it did not fully address the practical realities, barriers and pressures of everyday practice.
The second model of pharmaceutical care had had great acceptance philosophically by national professional organisations. But most countries had experienced much difficulty in its practical application. The reasons were complex and varied. "In my view," said Professor Benrimoj, "the associated implementation strategies are not sufficiently elegant or practical to take into account the massive changes needed to accomplish the totality of this esoteric professional behaviour change."

Charlie Benrimoj: no more unsustainable, esoteric models

Next year in Singapore

The next international meeting of the International Pharmaceutical Federation will take the form of a "pharmacy and pharmaceutical sciences world congress" in Singapore from September 1 to 6, 2001.
The main theme of the congress will be "Combining practice and science to extend horizons" and it will have the usual mix of symposia and sectional meetings with the added feature of joint meetings of pharmacy practitioners and pharmaceutical scientists.
A full programme of events is being arranged for participants by the Singapore host committee.
Further details about the congress are available from FIP Congress and Conferences, Andries Bickerweg 5, PO Box 84200, 2508 AE The Hague, The Netherlands.
The 2002 congress will take place in Nice, France.