Comment A pragmatic way forward By Duncan Jenkins and Hooman Ghalamkari

In his "Broad Spectrum" article (PJ, February 3, p150), Douglas Simpson stated: "Pharmaceutical care is a type of medicines management ... but the two terms are not synonymous. Pharmaceutical care is medicines management, but medicines management is not necessarily pharmaceutical care." We wholly agree with this analysis and would now contribute further to the debate by providing our opinion on how the two concepts relate to each other. We have thought long and hard about what constitutes the much used but less often defined term, "medicines management" and have produced a matrix of potential activities which could be provided in a community pharmacy setting (Figure 1). We do not claim to have provided a comprehensive analysis of the scope of community pharmacy services, but we have produced a conceptual framework which will aid the further development of medicines management nationally and locally.

Level	Prescription management	Concordance and adherence support	Prescribing policy support	Clinical pharmacy
I	Dispensing only	Counselling	Harmonisation of prescription quantities and rationalisation of strengths	Ensure clarity and safety of prescription
II	Collection of prescription from surgery, dispensing and delivery (at request of patient)	Monitoring of patient requests against patient medication records	Formulary support	Monitoring and couselling as per protocol, clinical guideline or integrated care pathway Clinics for medication review
III	Instalment dispensing	Provision of compliance aids	Empowerment to initiate and manage approved changes in medication

Figure 1: The medicines management matrix Levels are in increasing intensity, columns are in increasing integration with other services and level of skills required

An important feature of the matrix is that it consists of a number of different levels: level I relates to basic services and higher levels are more intensive in either resource, ability, or degree of integration with other services. From our experience, many pharmacists find the expectation to provide extended services daunting. But it has been shown that extended roles which have become established are those which are linked to traditional roles. The idea of pharmaceutical care and the concept of producing care plans will be beyond the scope of many pharmacists at the current time. The stratification of medicines management recognises these concerns and allows pharmacists to develop their services incrementally, to extend services comfortably and to aspire to provide other more advanced add-ons. With respect to integration, medicines management will only be successful if it is multidisciplinary and cuts across all relevant primary and secondary care services. Some of the content of the matrix is fairly basic. What we have termed "prescription management" is probably taken for granted by most pharmacists and will not be considered to be an extended role. We make no apologies for this: many pharmacists will be reassured that they are already some way along the road and patients value services which make it easier for them to get the medicines they need. While we can argue that needs and not wants should drive service provision, we must not lose sight of the fact that community pharmacy exists in a consumer environment. In addition, the Government's current philosophy is to provide services which not only strive to meet Government aims (such as reducing waiting lists and alleviating winter pressures) but also provide convenience for service consumers. This focus is important as it is one against which we will certainly be judged. Most people will be comfortable with services which support concordance and adherence, which at the very least consists of the opportunity for people to discuss their medicines. However, "prescribing policy support" is more controversial. We consider this to be an important component of medicines management which acknowledges one of the main needs of the primary care organisations: that of cost minimisation. The community pharmacist's role has thus far been limited in this respect, due mainly to the disincentives provided by an archaic contract. With these restrictions removed by placing the emphasis of remuneration away from dispensing and by the announcement of Local Pharmacy Services, community pharmacists could have a much more enhanced role by providing support for local formularies and managing changes in patients' medication in line with local policy. The fourth column of our matrix is headed "clinical pharmacy", a further concept which we do not consider to be contentious. Again, level I describes what all pharmacists should be doing as a duty of care, though the column culminates in the provision of pharmaceutical care and pharmacist prescribing. Because our matrix includes pharmaceutical care in only one of its 12 boxes, enthusiasts of the model will be quick to point out that many, if not all of the activities in the other 11 boxes could be included under the definition of pharmaceutical care. Of course this is true; patient assessment (the first step in the pharmaceutical care process) could, for example, identify the need for a collection and delivery service and the provision of a compliance aid. However, these things could also be provided without a comprehensive needs assessment, either because the patient does not need full blown pharmaceutical care or possibly because assessment is carried out by another professional. Indeed, most patients are likely to receive medicines management services without pharmaceutical care. This leads to a further dilemma. How do we target those that need full pharmaceutical care? We can all identify groups of patients whom we think need to be prioritised, and many of these will be evidence-based. For example, poor adherence results in worse outcomes for patients who have had a heart attack or have received a renal transplant. However, a basic and essential component of prioritisation is the application of a set of values against which to make an assessment. This is an important piece of work which needs to be carried out at a national level. We believe our matrix could help to define community pharmacy medicines management activities which will allow an incremental approach to service development. The matrix could also be used to support other aspects. For example, a "competency" matrix could be superimposed or pharmacists could use the matrix as a basis for a personal development plan. We believe we have clarified some of the tensions between medicines management and pharmaceutical care. In doing so we support Douglas Simpson in saying that we should not lose sight of pharmaceutical care, but should hold it up as the gold standard by which medicines management can be delivered in a rational, pragmatic and effective way.

Dr Jenkins and Dr Ghalamkari are directors of the MORPh consultancy, a provider of strategic advice to stakeholders in medicines management (e-mail morph@morphconsultancy.co.uk)

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