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Health Services Research and Pharmacy Practice

Are you a hero, a villain or just a practising pharmacist?

Will pharmacists want to rise to the challenges set by the government's plans for the NHS? Angela Alexander reports from the seventh Health Services Research and Pharmacy Practice Conference, held at the University of Nottingham from April 19 to 20

Single-handed and small group contractors face particular difficulties in implementing the Government's plans for the NHS, according to Professor Robert Dingwall, director of genetics and society unit, school of sociology and social policy, University of Nottingham. He described “Pharmacy in the future — delivering the NHS plan”, as a “ragbag of ideas” and explained how the sociology of professions identified solo practitioners as both heroes and villains. As heroes they provided a personal service, were able to develop relationships within the community they served and had autonomy to develop individual initiatives. But as villains they were often marginal practitioners serving marginal groups, and economic pressures led them to practise away from the norm.

Research conducted by Professor Dingwall and Pam Watson had shown that within pharmacy there was a price to be paid for the freedom of being a sole practitioner. This was the need to work long hours, to suffer professional isolation and to be put under considerable economic pressures, which, he said, prompted ethical temptation. He said that it was easy for those working office hours at the Department of Health to lose sight of the incredible hard work that sole pharmacists were doing.

In addition, many pharmacies were being maintained at an economic level that was not able to sustain a sole income. The Government was able to take advantage of the fact that more women were becoming sole proprietors who often only needed to provide a second income. This feminisation of the profession was subsidising the NHS.

The conclusion of this situation was that there was neglect of the economic basis of professional work, a lack of collegiality and a reluctance to accept imposed change. But pharmacy was at the dawn of a new age. There were technological changes to contend with as well as a professional shift from craft to counselling. Pharmacists were becoming mediators in the appropriate use of medication.

Professor Dingwall suggested that solo pharmacists would not be able to carry the increased regulatory overhead of a modern profession. In future there would be a shift to employed practice, pointing to a new kind of patient services pharmacist in the community as part of the NHS team, such as was happening to general practitioners, but it was doubtful whether or not all pharmacists would make that shift. He was unsure how interested the big multiples were in the Government agenda. As large organisations they could not be bullied as much and there were likely to be struggles ahead.

If there was a future for solo practitioners as patient services pharmacists within the community, it was not clear how to get from here to there, and it was not clear if there was to be a compassionate exit for those who did not wish to change. He said that, in this context, his view of the Council of the Royal Pharmaceutical Society was of people shuffling deckchairs on the Titanic. Pharmacy was peering into the twilight and the dawn was a long way off.

Poster presentations

More than a glimmer of dawn was seen, however, in the 48 oral and poster presentations at the conference. Many of the research topics provided evidence of forward thinking, in line with the governments plans for the NHS and the future of pharmacy.

Particularly timely were those which had implications for pharmacy input into the National Service Framework for Older People. Recognising that resources were limited, a team from the division of academic pharmacy practice at the University of Leeds sought factors that could be used to target medication review in older people. Duncan Petty reported that age, sex and the need for a home visit did not predict the need for pharmacist review, whereas being on multiple medication and having no evidence of a doctor review in the past 12 months was of value in targeting a review. These findings added further weight to the argument that all patients needed to be considered for a review and there was no justification for having an age cut-off.

The value of a pharmacist taking part in joint domiciliary visits to older people with mental health problems was presented by Diane Harris, University of Nottingham. Key workers, who could be community psychiatric nurses, occupational therapists or social workers, liked the increased contact with the pharmacists and valued the assistance that they could provide. Integration of pharmacists into mental health care teams for the elderly had now been accepted as a service development.

The need to identify outcomes of domiciliary pharmaceutical care for the elderly patients in relation to medication costs had been investigated by the pharmacy practice research group at Queen's University Belfast. Eileen Scott reported that although it was possible to simplify prescribed drug regimens, and achieve cost savings through reducing the number of unused medicines, the total costs of medicines that the patients were taking was not reduced, despite a significant increase in the prescribing of generic medicines.

These three presentations represent only one aspect of the conference. Other research was presented on prescribing, patients' information needs, compliance and concordance, education, the pharmacists' public health role and research methods.

The conference concluded with a debate: “This house believes that pharmaceutical care does not require pharmacists.” Proposing the motion, Professor Nick Barber, School of Pharmacy, University of London, pointed out that pharmaceutical care was an area of specialised knowledge and that since knowledge did not have professional boundaries it could not be corralled within the profession and was not exclusively the domain of pharmacists.

Opposing the motion, Professor Frank Wilkinson, University of Cambridge, argued that pharmaceutical care made the best use of the expertise of the pharmacist; it was neither possible nor desirable to eliminate pharmacists from pharmaceutical care. It made no more sense than to remove the doctors from medical care or the nurses from nursing care.

Seconding the motion, Dr Foppe van Mil, a pharmacy practice consultant from the Netherlands, said that from a society perspective it did not matter who provided pharmaceutical care as long as the outcomes for the patient were improved. Pharmacists might have the superior knowledge, but what was the value of knowledge without the other skills required?

Seconding opposition of the motion, Helen Remington, Addenbrookes Hospital Cambridge, said that in Blair's new NHS the delivery of care and the definitions around it were changing. Pharmaceutical care was a term commonly used by pharmacists, but outside the profession it was only occasionally used. She thought the Government had been astute in coining the term “medicines management”, a more embracing term which was a strategic concept with many stakeholders. Doctors and nurses, however, did not have sufficient depth of information to provide pharmaceutical care.

Details of all the abstracts for papers and posters, together with those from last year's conference, can be found on the conference website (www.hsrpp.org.uk).