The
Pharmaceutical Journal Vol 266 No 7132 p122
Pharmaceutical care is developing in several European countries, but perhaps most visibly in countries such as the Netherlands, Spain, Denmark, Germany and increasingly in the United Kingdom. In all countries, pharmaceutical care starts and progresses largely due to the enthusiasm and efforts of a few individuals and in Germany, the leader in this field is Professor Marion Schaefer. Pamela Mason travelled to Germany to speak to her
Professor Marion Schaefer works at the Pharmacy Institute, which is part of
the Humboldt university in Berlin. I went to see her at her office, which is
situated in the north east of the city, on the first floor of a large, white
house in a quiet, leafy street about five minutes’ walk from the nearest tram
stop. She studied pharmacy between 1969 and 1973 at the Martin-Luther university,
Halle, in the former German Democratic Republic, and at that time, prospective
students had to gain work experience in a pharmacy before starting at university
so that they knew what they were letting themselves in for. Then, following
the four-year diploma programme, came a 12-month internship - the equivalent
of the UK preregistration year - after which the student qualified as a pharmacist.
Professor Schaefer stayed on in Halle to complete her PhD studies before going
to work with an office of drug registration where she conducted research on
drug utilisation.
Finding out, among other things, that the use of drugs varied across different
countries, she realised the potential pharmacists had for making sure medicines
were appropriately prescribed and appropriately used. As she says: “Taking medicines
is easy; taking them properly is more difficult.” Her idea fell on fertile ground
in the former GDR where surprisingly - at least according to my preconceptions
- providing patients with information was an important issue. During the early
1980s, a few pharmacists were already starting to interview children about their
medicines.
By 1985, Professor Schaefer had accepted a teaching post in the school of pharmacy
at East Berlin’s Humboldt university, where her main interest was social pharmacy,
a subject that had formed part of the pharmacy curriculum in the GDR since at
least the end of 1960s. This post, together with an increasing enthusiasm for
what pharmacists could offer to patients, encouraged her to contribute to the
development of the concept and practice of patient care and counselling. Although,
as she explains: “We never called it pharmaceutical care, but the idea had been
around for some time.”
Following reunification of Germany in 1990, Professor Schaefer had a problem
in that social pharmacy had not been part of the pharmacy curriculum in West
Germany, and she almost found herself without a job. However, a succession of
fixed-term contracts has continued to secure her post until now. The East German
pharmacy curriculum had more in common with that in other western European countries
like Britain and the Netherlands than it did with its next door neighbour, she
added.
However, what German reunification did bring was the facility to travel, and
armed with her ideas on pharmaceutical care, Professor Schaefer soon made contacts
with other interested pharmacists in the rest of Europe and the United States.
This coincided roughly with the time when Professor Douglas Hepler (now at the
University of Florida) had been invited to various European countries to introduce
his ideas on pharmaceutical care. His definition of pharmaceutical care as “the
responsible provision of drug therapy for achieving definite outcomes which
improve a patient’s quality of life” is therefore used by many working in Europe,
both in hospital and community pharmacy. This definition focuses on outcomes
and is essentially process-oriented.
In Professor Linda Strand’s definition of pharmaceutical care, that is “a practice
for which the practitioner takes responsibility for a patient’s drug therapy
needs and is held accountable for that commitment”; the centrality of the patient
receives even more emphasis and her definition appears more humanistic. However,
the role of the patient and his or her drug-related needs are at the heart of
both definitions, and it is important to focus on the similarities rather than
the differences.
Hepler’s visit to Europe led, in 1992, to the initiation of an asthma therapeutic
outcome monitoring (TOM) project in Denmark and then, in 1994, to a pharmaceutical
care of the elderly project, in which Germany, Northern Ireland, the Netherlands,
Sweden and Portugal participated. One of the things that Professor Schaefer
and others learnt from these two projects was the difficulty that pharmacists
had in delivering pharmaceutical care without a focus on a single disease state.
In other words, pharmacists found the asthma project easier to manage than the
care of the elderly project where patients suffered from several different conditions.
Although Professor Schaefer agrees that Strand’s approach of providing pharmaceutical
care to every patient is the ideal, she thinks that pharmacists’ knowledge of
disease states needs to be built up first. So, projects that involve caring
for patients with, for example, diabetes or asthma, represent the easiest way
to improve a pharmacist’s skills and self confidence, she thinks. In her research
experience, the main problem with the more “all-embracing” projects is that
pharmacists do not find many drug-related problems, simply because they do not
know what to look for. Moreover, in Germany, it may be easier for pharmacists
to work with protocols and checklists so that, until they are experienced in
this type of work, they know exactly what to do.
As in every other country, persuading pharmacists in Germany to implement pharmaceutical
care is difficult. “It would be wrong to pretend that we have achieved that
- like most other places, we are only just starting,” Professor Schaefer says.
However, she has a growing number of PhD students working on pharmaceutical
care projects in community pharmacies, and the concept, although being implemented
in the pharmacies recruited into studies, is essentially being spread from academia.
Her PhD students, who are scattered all over Germany, not only conduct research,
but also lead pharmaceutical care workshops for other pharmacists.
Funding for the research is largely provided by the German Pharmaceutical Society
(ABDA), which, Professor Schaefer says, is “very supportive and actually founded
the financial initiative for pharmaceutical care”. The ABDA obtains funding
through members’ fees and outside sponsors.
Pharmaceutical care is taught in the pharmacy curriculum at Humboldt university
in Berlin and has also been introduced by the universities in Bonn and Marburg.
In Marburg a group of students tries to get preregistration trainees to recruit
two or three patients during their training year and provide care for them,
reporting back their findings in the form of case studies. This, of course,
also helps the pharmacists with whom the students are working to gain an understanding
of pharmaceutical care.
Payment for pharmaceutical care in Germany is, like everywhere else, a problem.
“It doesn’t happen yet.” The fee-for-service model is commonly applied to health
care. Doctors working in the community, for example, are paid on this basis,
and the more services they provide - at least in theory - the more they earn.
However, this type of system is open to fraud, as the sickness funds, which
pay for health care, have found out, and there may be some reluctance to pay
pharmacists for providing pharmaceutical care on this basis.
Professor Schaefer favours a model whereby pharmacists have to meet an agreed
standard, according to various criteria, such as an agreed number of patient
contacts, documented drug-related problems and the number of patients in a pharmaceutical
care programme. “But this is a vision for the future - not the present reality,”
she emphasises. In the meantime, “we have to provide evidence for the value
of pharmaceutical care, and the various projects are helping us to do this.”
Documentation is, of course, a vital part of pharmaceutical care, not only
for keeping a record of care, but also for providing evidence of its value.
Nine pharmacy software companies in Germany are now producing some sort of program
for supporting pharmaceutical care based on the steps of the pharmaceutical
care process which were developed and standardised by Professor Schaefer. In
the main, these come as a bolt-on package, which is fully integrated with the
existing pharmacy software. They vary in cost from about £100 to £300, with
one company providing its package free of charge. To some extent, the programs
are similar to those already in existence for keeping patient medication records
in the UK, with provision for the entry of patient demographic and disease data
and maintenance of a medication history. However, a useful feature in one program
I saw was a visual calendar to show how long each prescribed medicine should
last. Provided the patient returns to the same pharmacy for all his or her prescriptions,
this calendar can be used to identify possible compliance problems. In addition,
the software is now starting to provide the facility for detection and documentation
of drug-related problems. This includes a description of the problem, what was
done about it, including any contact with the patient’s doctor, and what the
final outcome was.
Such software, when it is used more widely than at present, will be useful not
only for providing pharmaceutical care, but also for the collection of pharmacoepidemiological
data. Prescribing data in Germany are not collected centrally. This is because
patients pay into different health insurance companies, of which there are about
450 in Germany, and prescriptions have to be sent to each of these in order
for the pharmacist to be paid. Even though far fewer companies than this would
be represented by one pharmacy’s prescriptions, it is considered to be a huge
administrative headache to allocate each month’s prescriptions for payment.
Pharmacists, therefore, send their prescriptions to a central organisation which,
at a cost of 1 per cent of the prescription profit, does the job for them. But
there is no single source of prescribing data that can easily be used to provide
an indication of doctors’ prescribing habits in a locality. There is certainly
nothing like the Prescribing Analysis and Cost data in England and its equivalents
in Scotland and Wales.
However, German doctors have not, so far, had the prescribing cost constraints
experienced by their colleagues in the UK. And there has been little incentive
to improve prescribing quality. Germany spends 11 per cent of its gross domestic
product on health care compared with the 7 per cent spent in the UK, and it
is only recently that Germany has started to look at cost containment policies
for health care. Germany is a federal state with 16 counties (Länder), and health
care is decentralised, being delivered at the level of the Länder.
Overall prescribing budgets have now been set by the Länder, but, surprisingly,
doctors do not know what the budgets are. Remunerated on a fee for service basis,
doctors have traditionally been paid more for prescribing more. However, the
health insurance companies now fix a fee for each type of service and, if some
doctors prescribe a lot, the overall fee for prescribing goes down. This means
that heavy prescribers can reduce the income of their more economical colleagues.
However, doctors only know what the particular fee for prescribing (or any other
service) will be at the end of the year, ie, retrospectively. So they have no
idea how much they will be paid. This can be likened to driving a car in a 40
miles an hour speed zone, without knowing what speed the car is going. As Professor
Schaefer says, this is one of the best arguments for pharmacists to work with
doctors. The pharmacy software could be used to generate prescribing data for
individual doctors and therefore help them on a more regular basis to “know
what speed they are driving at”.
In Germany, as in other European countries and indeed in the United States, pharmaceutical care is in its infancy. Contrary to what many people think, no one country has got all the answers and no one country is doing it in every pharmacy - or even in a large number of pharmacies. But this makes it a good time to learn from each other and advance the practice of pharmaceutical care on a worldwide basis to make sure that patients not only take the appropriate medicines, but also take them appropriately.
Pamela Mason is a pharmacist and freelance writer from Sydenham, South London