By Ray Sturgess
It may be a cliché, but it is nevertheless true that at the present
time pharmacy stands at a crossroads. Never before have members of the Royal
Pharmaceutical Society been so unsure of the future direction of the profession,
or felt less confident that the Council has the knowledge or unity to lead them
along a more secure and well-lit road.
Pharmacy’s predicament mainly stems from the realisation by pharmacists
that their days as the passive dispensers of drugs prescribed by their betters,
the doctors, are over, while at the same time they are unclear as to their future
function. Nurses, always well-led and with a positive public image, have effortlessly
made the move to becoming prescribers, while pharmacists, with a more comprehensive
knowledge of drugs, have had to be content with the consolation prize of supplying
medicines demoted from POM to pharmacy status.
The greatest unifying factor for any profession is a well-defined and worthwhile
goal, by which is meant an aim that is seen equally by the membership and the
public as wholly desirable. There is an aim staring pharmacists in the face,
if only they realised it. It is to ensure that medicines are, as far as possible,
used to make patients better. If that sounds too obvious, try answering the
following two questions.
Earlier this year, the annual cost of treating drug-related morbidity in the
United States was calculated. Was the cost $1m, $10m or $100m? The annual number
of fatalities ascribed to mistakes with medication and treatment was also calculated.
Was the number of mistakes 5,000, 10,000 or 30,000? The questions are unfair,
because the answers are none of the figures mentioned. The annual cost of treating
illness caused by prescription drugs in the US is $100bn. The number of deaths
due to mistakes with treatment and medication is estimated at 120,000. This
means that the misuse of prescription drugs, and the results of their side effects,
constitute a major disease category, alongside the leading illnesses such as
cardiovascular disease and cancer.
Better to act
To those who would argue that the problem is an American one, the response must
be that what happens in the United States today manifests itself in the rest
of the world tomorrow and that, in any case, it is better to act before the
problem here assumes greater proportions than it has already. Drug-
related diseases fall into three main categories: those caused by side effects
of drugs, those due to inappropriate dosage, and those caused by interactions
between prescribed drugs. Classification cannot be hard and fast because some
factors overlap others. Non-compliance, for example, can be classed as inappropriate
dosage. The point is, however, that pharmacists have sufficient knowledge in
these areas to enable them to make the appropriate corrective interventions.
It used to be assumed that doctors were aware of the side effects of the drugs
they prescribed and would advise and monitor their patients in this regard,
until experience showed that, in practice, doctors have little awareness of
or control over what goes on outside their surgeries. In the days when most
community pharmacists owned their pharmacies and knew their customers, they
were able to help patients with advice in this area because their customers
would often discuss side effects with them rather then “bother” their
doctors. This happens less now that most pharmacies are owned by chains and
run by less-than-permanent managers or a rota of floating locums. In any case,
the problem cannot be solved by dispensary-bound pharmacists. Pharmaceutical
care must extend beyond the pharmacy, into people’s homes and into residential
homes and hospitals.
Until very recently the problem of disease caused by prescription drugs has
been seen as a minor one and government funding for pharmacists engaged on medicines
management has been reluctant and patchy. Now that drug-inflicted morbidity
could end up costing almost as much as cancer and cardiovascular disease, budget-conscious
health ministers are taking note, and in January, 2000, it was announced that
in England a major nationwide trial of medicines management involving pharmacists
was to be undertaken (PJ, January 29, p187). But from “Pharmacy in the
future — implementing the NHS plan” and its references to the Action
(sic) Team — “the Government wishes to support a national pilot trial
of a structured medicines management service based exclusively in community
pharmacies” and “the Department of Health will be starting discussions
with the PSNC very shortly [sic], with a view to a trial staring next year”
— it is clear that bureaucratic inertia has allowed wishing to supplant
action, and not only the Pharmaceutical Services Negotiating Committee but all
sectors of the profession’s leadership should be demanding that a sense
of urgency be introduced into the process. If pharmacists want to take their
place at the forefront of medicines management, they will need to recognise
and seize the opportunity, and not leave initiatives solely to the slowly grinding
wheels of government.
Although it has long been recognised that prescribers have a part to play in
ensuring that drugs are used as little and as effectively as possible, measures
to encourage this approach have not been conspicuously successful, probably
because the prescription is still seen by doctors and patients alike as the
expected outcome of a consultation. That apart, doctors tend to stick to their
favourite medicines regardless of their relative effectiveness or safety, and
the results of attempts to introduce evidence-based medicine have been disappointing.
Dr Darren McGuire, the spokesman for an eminent American team assessing the
adoption of evidence-based medicine, concludes that doctors “continue to
believe what they are doing is right, even in the face of evidence to the contrary”
(PJ, March 25, p461). This
may be regrettable, but it reinforces the proposition that pharmacists are the
ones to review and monitor the administration of prescribed drugs.
Beneficial results
It has been suggested that the target population for pharmaceutical care should
be the elderly on multiple medication (PJ, June 10, p885). It is clear that
domestic supervision of medicine taking by the elderly by pharmacists would
produce marked and beneficial results and should be implemented at the earliest.
However, the evidence points to a more pressing need in hospitals, since it
is here that the majority of medication fatalities occur. Research into the
extent of medication errors and their consequences in the UK has begun only
relatively recently, but the evidence reviewed by Dr Charles Vincent of the
University of Central London suggests that the number of deaths due to mistakes
in treatment in hospitals in the UK is around 20,000 annually, the majority
being drug-related and involving injections. With such a death toll there is
an incontrovertible case for the checking by a pharmacist — except in the
direst emergencies — of all hospital injection procedures where a potentially
lethal drug is to be administered.
To take up the challenge of effecting a marked reduction in drug-related disease,
pharmacists will need to rise above their present preoccupation with petty in-fighting.
In the weeks following the revelation that drug-related disease in the US costs
$100bn annually (PJ, June 10, p885),
I looked in vain through the letters pages of The Journal for some reaction.
Instead, its columns were devoted to debates about the underlying philosophy
behind pharmaceutical care, the in-fighting within Council, and the pros and
cons of working as a locum. Pharmacy as a profession needs to stop looking inward,
and to prepare to take action where it is most needed, out in the world. Above
all, pharmacists need a vision. Here, in the huge challenge presented by combating
drug-related disease, the profession has surely found a worthwhile goal?
Ray Sturgess, of Knaresborough, North Yorkshire, retired early from pharmacy to write, and has published articles on a wide variety of health-related topics