Comment

More clarity, less dogma, in our approach to pharmacy practice

By Terry Maguire

In their “Broad Spectrum” article, “A pragamatic way forward” (PJ, March 3, p281), Duncan Jenkins and Hooman Ghalamkari add useful practical depth to a pharmacy-based model of pharmaceutical care, from handing out the medicine to advising the general practitioner. But they make a common mistake: pharmaceutical care is not simply care by pharmacists, it is care by medicines. Douglas Simpson started this discussion (PJ, February 3, p150) with his assertion that medicines management and pharmaceutical care are really one and the same thing. We are approaching a time in which it seems likely that pharmaceutical care, medicines management or an adpatation of each, might formally enter pharmacy practice in the United Kingdom. Medicines management services will be introduced as pilots and I suspect it will be up to the Department of Health and the Pharmaceutical Services Negotiating Committee project team to decide what form the service will take and what definition they will adhere to. My hope is that we look at the models proposed but do not become too dogmatic in their interpretation but pragmatic in our design.

Pharmaceutical care

We have been debating and envisioning the future role of the pharmacist for a long time, long before Hepler and Strand produced their seminal paper that made popular the term “pharmaceutical care” back in 1990 (Am J Hosp Pharm 1990;47:533–43). Then clinical pharmacy was flourishing in the hospital service and there was a strong political desire from within the profession to mimic these activities in community practice.

Hepler and Strand gave us a precise, useable and easy-to-remember definition of their model of practice that was attractive to national pharmaceutical organisations. They defined pharmaceutical care as “the responsible provision of drug therapy for the purpose of achieving definitate outcomes that improve a patient's quality of life”.

Moreover, their definition offered a possible solution to what was then, and still remains, a huge medical problem. The Hepler and Strand paper, like the Bible, is often quoted, but I suspect that few have read it, let alone studied it. It is a well-researched and balanced study of medicines use and concludes that a model of practice in which therapeutic outcome is central could solve many existing medicine problems. Pharmaceutical care, as I have stated above, is not care by pharmacists. It is care by medicines, and therefore should be multidisciplinary. But, politically, this has proved difficult to realise. Therefore, we will need to redefine pharmaceutical care from a UK perspective. Indeed, we should redefine the model to suit our needs as only then will it truly fit, and be adopted into, practice.

Being outcome-centered, the pharmaceutical care model seems to takes little cognisence of compliance in ensuring the effective use of medicines. It might be that in reviewing drug-related events, Hepler and Strand were convinced that compliance was too complex and issue to address.

It was left to the Royal Pharmaceutical Society to address the problems that stem from non-compliance and it produced a ducument outlining the useful concept of “concordance” as a satisfactory development of this model (From Compliance to Concordance, Royal Pharm Soc. 1997). Concordance has not been given a formal definition but it is a negotiation between equals (practitioner and patient); the aim, therefore, is a therapeutic alliance. The Society's document is an important piece of work providing practitioners with a clear model of how compliance can be improved through the process know as concordance, Yet it remains largely ignored and isolated which seems a great shame. I hope that its importance will be recognised, and perhaps incorporated within the definition of pharmaceutical care. This would represent a more holistic model of practice.

Recognising the limitation of the pharmaceutical care model, Strand, working in Minnesota, expanded the definition calling it “pharmaceutical care practice” and extending it to incorporate compliance issues.

Pharmaceutical care practice is “the practice in which the practitioner takes responsibility for a patient's drug-related needs and is held accountable for this commitment”. However, good as it is, this model is based on ensuring payment for US pharmacists actively providing the service within their health care system. This may be why it has proved difficult to implement the model in the UK.

Medicines management

In Northern Ireland, the four area health and social services boards have been rolling out a medicines management scheme and it is clear that few agree what it should be. Initially there was a limited expectation from the service with labeling, patient understanding and container appropriateness being key outcome measurements. Now a more cognitive approach has been adopted and the programme is focusing on coronary heart disease. This model attempts to incorporate pharmaceutical care, pharmaceutical care practice and concordance into a richer model of practice that really will improve the patient's lot.

Health promotion, and more specifically secondary disease prevention, are fundamental to improving a patient's quality of life as well as improving therapeutic outcome. Health promotion is absent from the models of pharmaceutical care and pharmaceutical care practice but is incorporated into the Northern Ireland medicines management programme.

The new model: primary care health promotion practice

To bring this together, a new model has been defined. “Primary care health promotion practice” might seem a recipe for further confusion but it has been carefully thought through and describes a more holistic model of pharmacy based care involving medicines. Primary care health promotion practice is the active and evidenced-based promotion of health, patient empowerment and the facilitation of lifestyle changes to ensure maintenance of good health, prevention of illness and assurance of disease management.

This is a multidisciplinary model of practice. It allows pharmacy to move away from a paternalistic medical model of health care based on medicine use only to a model of care that helps patients to make better use of their medicines and adopt healthy lifestyles. It is about empowering and helping patients. To many it will smack of motherhood and apple pie and clearly it provides a huge challenge; it will be uncomfortable for many practitioners who will view it as woolly and ineffective. It is, to paraphrase the government, “joined up practice”.

We are in so much need of a flexible, eclectic approach to the new pharmacy service. A lot of it is simple and practical and if implemented would bring considerable health gains. However, an effective training programme will be essential for successful implementation.

I hope that our definition will be at the core of the medicines management programmes in England, Scotland and Wales. However, we are keen to avoid the strict and absolute adherence to any model. What should be used is what works best so long as the key strands of lifestyle and medicine use are addressed. Above all let us not sacrifice the opportunity that medicines management offers in adherence to dogmatic definitions but let us use it to transform the way we practise.