Comment

What is medicines management and what is pharmaceutical care?

By Douglas Simpson

The development of community pharmacy in England, at least so far as the National Health Service is concerned, is heavily focused on medicines management. So, under the circumstances, it would be as well to know exactly what “medicines management” is.

Fortunately there are good clues to be found in the Department of Health’s recently announced programme for pharmacy within the NHS plan. The document setting out the programme¹ uses the phrase “Helping patients get the best from their medicines” as a heading for the section which outlines the Government’s aspirations in this area. And, in the introduction to that section, the words “medicines management services” are followed by (separated only be a hyphen) “targeted support for patients”. Thus the latter phrase appears to prescribe a definition of the former.

Clearly then, medicines management, at least so far as the Department is concerned, involves patients. But more than that the services must be targeted at patients. What kinds of services might these be?

According to the Department’s document, these are medication review, support for patients with particular medication needs, and structured medicines management services based exclusively in community pharmacies.

Explaining the need for such services, the document says: “There are many people receiving less than optimal care because they find their medicines difficult to take or hard to remember, because they don’t have anyone to talk to about their medicines or because they have complicated regimes involving several different drugs which are not being reviewed often or well enough.” It adds that, by 2004, every primary care group is to have “schemes” so that “people get more help from pharmacists in using their medicines”.

The structured medicines management services in community pharmacies that the Department has in mind follow those that the Pharmaceutical Services Negotiating Committee has agreed with the Department to trial for patients with coronary heart disease. In the PSNC trial, pharmacists with premises fitted out for private discussion will interview selected patients about their medication so as to identify any problems that might have arisen. The pharmacist will make a structured assessment of the patient’s prescribed medicines with a view to discussing the matter with the patient’s general practitioner. The topics for discussion with the GP may include such matters as drug interactions, side effects, polymedicine and whether a more effective drug regimen could be implemented. Discussions between the patient and the pharmacist will take place at regular intervals for the purpose of reviewing treatment. Patients will be advised on how to use their medicines and other steps they can take to cope with their condition.

In reality, what the PSNC is seeking to try out is a process that has been developed in the United States and is now being adopted in New Zealand, Australia, the Netherlands, Spain, South Africa and elsewhere. It goes under the name of “pharmaceutical care”. Pharmaceutical care has been variously and often confusingly defined. It is perhaps safest to identify it through its process components. These are:²

• Assessment - to ensure that all drug therapy for a patient is indicated, effective, safe and convenient and to identify drug therapy problems
• Development of a care plan - to resolve and prevent drug therapy problems and to achieve therapeutic goals
• Evaluation - to record patient outcomes, to evaluate progress in meeting therapeutic goals and to reassess for new problems

All these steps are identifiable in the proposed PSNC trial. Since it is pharmaceutical care, as is generally accepted throughout the English-speaking world, that is to be trialed it might be as well to say so. It would mean that England was not out of step terminologically. This would help the practice to develop since it would reduce muddle in the literature and, by clearly showing that developments in England were in line with desired developments elsewhere, would build up the momentum for change.

In reality, pharmaceutical care is a type of medicines management. It falls within its ambit, but the two terms are not synonymous. Pharmaceutical care is medicines management, but medicines management is not necessarily pharmaceutical care. In this respect pharmaceutical care is on a par with formulary development or the operation by pharmacists of clinics dealing with the drug treatment of single diseases, such as asthma. To give all the same term would only lead to confusion.

Support for the contention that medicines management should be viewed as an umbrella term can be drawn from the definition adopted by the department of medicines management at Keele university: “Medicines management seeks to maximise health gain through the optimum use of medicines. It encompasses all aspects of medicines use, from the prescribing of medicines through the ways in which medicines are taken or not taken by patients.”

This would seem to cover just about everything. As an umbrella term it is excellent. But, like the Department’s paper, it allows for a variety of practices and processes to fall within it.

Paradoxically, a senior member of the faculty at Keele, Professor Stephen Chapman, avers that the NHS plan refers to “medicines management” rather than pharmaceutical care because the former involves all health care professionals and patients in the proper use and management of medicines.³ But, in reality, pharmaceutical care does the same² - so, no reason for different terms there.

It may be that the Department prefers the term “medicines management” because of the sensitivities of doctors. Pharmaceutical care, as defined by Cippole et al² would have the practitioner (hopefully, the pharmacist) taking responsibility for a patient’s drug-related needs and being held accountable for that commitment, which might be regarded as invasion of territory by the medical profession. But Chapman³ still has pharmacists taking the lead in medicines management, and so does the Department for that matter. In my book, taking the lead means taking responsibility and being accountable for outcomes.

Without a good reason for not using the term pharmaceutical care, we in England would do best to march in step with the rest of the world. And in this context, the rest of the world includes Scotland. While Wales is following England in the use of the term medicines management, Scotland is not — its NHS plan refers to model schemes for “pharmaceutical care” being set up in community pharmacies.⁴

Incidentally, when doctors see the benefit that pharmaceutical care brings to their patients they come to appreciate it.⁵ Medical sensitivity should not be a problem.