The
Pharmaceutical Journal Vol 266 No 7139 p364-366
What part pharmacists should play in providing medicines-related information |
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By Soraya Dhillon, PhD, MRPharmS, Catherine Duggan, PhD, MRPharmS, and Anne E. Joshua, MSc, MRPharmS |
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Is there a role for pharmacy-led ,medicines information services within the changing National Health Service? The inception of NHS Direct, an information service for patients, incorporates much of the information-provision role that pharmacy-based medicines information has, until now, met. The service is run by nurses, with only recent pharmacy input. Where is the place of medicines information in the evolving NHS? The pharmacy profession knows the value of medicines information but needs to demonstrate this with evidence to develop services in a multidisciplinary setting. It is an approach we need to adopt throughout the profession; the promotion of what we do backed up by the appropriate evidence. Let us take this opportunity to open the debate on developing pharmaceutical services, starting with medicines information. This article evaluates evidence for pharmacists' involvement in providing appropriate medicines-related information and suggests some of the ways the service can develop in order to maintain this role while describing the results of a study to explore the public demand for medicines information services |
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Is medicines information a pharmacy role? Communicating information related to medicines and illness is a major part of the role of a pharmacist. The use of medicines in society is widespread and information on their safety, appropriateness and efficacy is necessary. At any time, a third of the population is self-medicating and another third is taking prescribed medicines.1 The communication of medicines-related information lies at the heart of health care delivery and, to be effective, it must give patients the information that is appropriate to their needs. The information should enable patients to participate in the decision making process for their clinical management, to increase their empowerment and facilitate a concordant approach to medicines management. Communicating information in an individualised way is an essential part of pharmaceutical care provision. Studies have shown that satisfactory levels of communication between health care professionals result in increased adherence to medical instructions and prescribed medicines.2,3 However, the effect of additional information also depends on individual patient factors: increasing a patient's knowledge about their medicines can lead to anxiety about their prescribed treatment.4 There is additional evidence that patients' beliefs and behaviours, such as their use of health care and adherence to treatment, may have a stronger influence on behaviours than advice or instruction from health care practitioners.5,6 Information provision is only part of the process. Individualised programmes of pharmaceutical care, where the professional service is catered to the identified needs of the patient, are known to enhance medicines management.7 Why, then, should patients receive “standard” information regarding drugs and illness when the evidence shows that individualised care produces better medicines management and greater patient satisfaction? This emphasises the need for establishing partnerships between professionals and patients—the model of concordance, as it is termed — where the needs of individual are addressed and met through discussion by both parties. Recently, we have undergone an explosion in all areas of information and information technology. Sources of information available to the public about health and healthy lifestyles have risen exponentially over the past 10 years. The Government has launched initiatives to ensure that information is readily accessible to the public when they need it. The public can now access information regarding any issue at any time of day, often from the privacy of their own home via the internet. However, the quality of that information is not always regulated and issues such as professional responsibility surrounding appropriate information for the public and accountability of health care professionals for the information patients receive have subsequently arisen. For many years, medicines information centres in pharmacy departments throughout the United Kingdom have been offering evidence-based advice to health care professionals and, less often, to community-based practitioners and patients. More recently, NHS Direct has been set up for the public, where they can obtain information regarding drugs and illnesses, and nurses have been trained to follow protocols and “choose” the appropriate answer for the patient. Governments have stated their commitment to ensuring that care is co-ordinated through increased multiprofessional working “where services in which individuals' needs are co-ordinated and integrated across the health and social care system, including primary care and social care. In a seamless service, multiprofessional teams come together to provide high-quality services for patients that make the best use of the specialist skills and experience of staff involved and all staff are trained to work in multiprofessional teams.”8 Whereas service development should incorporate interprofessional working, individual roles should not be blurred; each health care professional has a unique role in the continuous standard of care patients receive. Pharmacists must promote themselves, at this stage, as health care professionals who ensure safe and appropriate medicines management. Otherwise, if pharmacists fail to capitalise on their unique medicines knowledge, their professional status may be threatened. Perhaps this threat already exists. If pharmacists are recognised as experts in medicines management, with demonstrable experience in delivering medicines-related information, why are they not actively involved in all new policies surrounding medicines management and information regarding medicines? Perhaps pharmaceutical services are not effectively publicised to the public. Perhaps pharmacy is not equipped to deliver medicines information to the public. Perhaps the public do not want to obtain their medicines-related information from pharmacists. Furthermore, if pharmacy is the profession to deliver medicines-related information, are there appropriate measures of clinical governance in place to ensure appropriate medicines information is given at all times? Demands for medicines information? Members of the public accessing medicines information (MI) were interviewed during a study to assess public demand for pharmacy medicines information as described in this article. The results provide valuable information on the evolution of these services within the profession and may be used to inform measures of clinical governance in service development. They are summarised here and discussed with respect to other work in the area. The study aimed to describe the characteristics of the clients using pharmacy MI services, compare pharmacy MI services delivered locally and regionally, evaluate the appropriateness of pharmacy MI services for patients and clients and explore the ways in which pharmacy MI services can develop. The study sites included regional medicines information centres for the then South Thames region (based at Guy's hospital, London), the North Thames region (based at Northwick Park hospital, London), together with five local MI centres in the then South Thames regional health authority. During the three-month data collection period, the NHS health information service help-line for South Thames, Health Direct, was contacted to identify those calls referred to the MI services. The MI centres interviewed all the clients who telephoned, using a piloted, semi-structured questionnaire. The client was asked where they usually accessed medicines-related information, how they found out about the MI service, whether they had used the service before, and if they had a medical background. During the three-month study period, the participating MI centres received 109 inquiries from members of the public, which constituted approximately 3 per cent of the total workload for both regional and local MI services. There were no differences between the types of inquiry (as defined by the UK Drug Information Pharmacists Group), the gender of the caller or the status of the MI centre (regional or local). The characteristics of the callers are summarised in Table 1. |
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In this study, information and advice was sought for over 100 different medical products in the 109 inquiries (91.7 per cent). Cardiovascular drugs are the most frequently prescribed group nationally1 and were related to 11 inquiries (10.1 per cent) here, but antibiotics generated the most calls (23, 21.1 per cent) about prescribed drugs. Inquiries about over-the-counter medicines accounted for 20 calls (18.3 per cent) and were most commonly related to analgesics. This was not surprising since analgesia is the most common form of self-medication with OTC products. Continued deregulation of new medicine categories from POM to P could alter the information needs of clients and possibly generate new types of inquiries to MI centres. Clients also made inquiries about adverse effects of drugs and, again, these were most frequently related to the adverse effects of analgesics. Patients tended to request specific information about prescription only drugs. The information tended to be supplementary to their existing knowledge or for reassurance about their drug treatment. Inquiries included those generated by “bad medicines” from clients with real clinical problems, and those generated by anxious individuals seeking validation information from several sources before being satisfied, calling their GP or the NHS health help-line services before telephoning the MI centre. It seems that patients like to receive information from a variety of sources, probably to increase their confidence and autonomy. It is, therefore, essential that more than one source of information regarding drugs is available to the public and pharmacy MI fulfils this need. Other evidence Studies in the 1980s found that 62 per cent of patients feel that doctors and pharmacists give insufficient explanations about prescribed medicines.9,10 When asked which information was essential, 92 per cent of the respondents had felt that “when and how to take it” was essential, and 88 per cent that “side effects and what to do about them” was essential. Although the NHS health help-line (Health Direct) referred 39 callers to the regional MI centre at Guy's hospital during the study period, only 21 (53.8 per cent) subsequently made that contact. Reasons why contact was not made were not explored in this study, but it was generally believed that this could be due to costs of calls and worries about confidentiality. A limitation of this study was the lack of data regarding client satisfaction with the information they received from MI centres. They may have sought information from further sources after contacting the MI centre. Clients do not necessarily see the local pharmacy as a point of contact with a health professional for advice on their treatment. Studies have found that most people use their community pharmacy primarily as a source of advice, but are more likely to buy medicines and receive prescriptions without actively seeking advice.11 At present community pharmacists have open access to their local MI centre but awareness of the various services available is limited. In this study, clients contacted the MI centres to seek reassurance, to boost their confidence, and to increase their knowledge. In order to develop pharmacy-based medicines information services further, a needs assessment and cost analysis, together with risk management and litigation assessment, would have to be undertaken. The MI centres would have to invest in promotional activities to inform patients and health care professionals of this service. These could form the basis of national clinical governance measures. Most recently, an evaluation of the MI service set up to provide support for pharmaceutical and prescribing advisers from a user's perspective was undertaken.12 There was a wide range variation in the use of service from zero to 13 times (an average 1.5 inquiries) per month. The interviews revealed the service was frequently used for inquiry answering, literature searches, drug evaluations and bulletins, and the major benefit to individuals was “access to resources not otherwise readily available”. There were other benefits relating to saving or maximising time. Accessibility, availability and the empathy of the service provider and their insight into primary care were frequently quoted strengths, and the reliability and confidence in the quality of information provided were also mentioned. Frequent weaknesses identified were concerns over cover when MI pharmacists were not available and that the service might become overwhelmed in time. The study concluded that the service was well used by advisers and facilitators and found that users' opinions and perceptions of the service were uniformly high and positive. Conclusions In the past, MI centres have been a focus for supporting secondary care personnel. A direct-access service to clients would be a predominantly primary care activity and, as such, would require working in a team with other health care providers, such as GPs and community pharmacists. Primary care groups could commission these services for their own patients, especially if issues of quality and accountability were ensured. It would be interesting to undertake a similar audit of NHS Direct and to compare clients' satisfaction with both services, together with the satisfaction of the referrer. As previously mentioned, it may be that MI centre services to the public act to augment those of NHS Direct. Initial queries would be dealt with by NHS Direct, following protocols, and, if the problem could not be resolved or required a more extensive search for appropriate information, the client would be referred to a MI centre. In this way, the workload would remain manageable, pharmacists and nurses would continue to build interprofessional working relationships, and issues surrounding individualised care would be addressed. The professional role of pharmacists as medicines experts is maintained within a joint working environment and issues of clinical governance are resolved. MI centres could be involved in developing the training and education of nurses to ensure the appropriate handling of information and inquiries. This function could then be used as the basis of multidisciplinary measures of governance. The potential for MI centres to develop an inquiry answering and advisory service for direct public access already exists if units wish to take up the challenge. Experience from other countries providing client access medicines information would indicate that such services are well used. The service could be developed further to provide an active educational and health promotion service as an integral part of the service.13–16 Based on existing services, there are several models that could be developed and offered as packages of services to the purchasers. For example:
Pharmacists have the skills and abilities to develop such services, but have to decide if this is the route they wish to follow when the present workload and demands on the existing MI service are already large. The study described here suggests there is a need for quality advice on medicines via the telephone for clients, and purchasers may ask for the service despite medicines information pharmacists' reluctance to provide it. Pharmacists must take the opportunity to extend their role as experts on medicines further, and work as part of the health care team in order to do it, otherwise they risk being side-lined for roles that they are eminently suited to undertake as part of pharmaceutical care provision. |
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Dr Dhillon is director of taught postgraduate education and Dr Duggan was teaching and research fellow at the centre for practice and policy, University of London School of Pharmacy. Ms Joshua is a pharmacy consultant at Cerberus Healthcare Ltd, Guildford, Surrey. Correspondence to Dr Duggan at the Academic Department of Pharmacy, Barts and the London NHS Trust, St Bartholomew's Hospital. West Smithfield, London EC1A 7BE (e-mail duggan@ulsop.ac.uk) |