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The Pharmaceutical Journal Vol 266 No 7148 p691-692
May 19, 2001

Forum

AAH Pharmaceuticals and Vantage Convention

The 2001 AAH Pharmaceuticals and Vantage Convention took place at the Bellagio hotel, Las Vegas on May 13-17. Clare Bellingham reports

Establishing pharmacy's future standards
Vantage silver award winner announced
Balancing the Government and business agendas
A changing world
What pharmacy will be like soon
Pharmacy in the US
Medicines management “not about rocket science”

Establishing pharmacy's future standards

Does pharmacy have a universal standard? This was an important question to answer because it was what defined pharmacy, said Professor BRUCE BERGER, professor of pharmacy care systems, Auburn University, Alabama.

If you go into a McDonald's anywhere in the world, you will always get the same standard of food and service. But what could pharmacists offer in terms of standards of care? “What can we promise?” he asked. In fact, all that pharmacists could guarantee was to provide the drug that the doctor had ordered. “This is the bare minimum that we are getting paid for,” he said. “We cannot guarantee to provide counselling or drug information.” Having this sole standard was a dangerous position for pharmacy to be in, particularly as technology was allowing the dispensing process to become more and more automated, he said. One of the major problems for the profession was that others tended to impose standards on it instead of the profession developing its own standards, he added.

The first step in developing standards was to look at what had to happen in order to achieve the desired outcome in pharmacy. This meant that the patient had to understand their diagnosis, be interested in their health, be able to assess the potential impact of their diagnosis, believe in the efficacy of the prescribed treatment, and find ways of using the medications that were not more trouble than the disease.

“We need to show that what we do as pharmacists produces the kind of outcomes that the health care system wants,” he said. “The ability to document this is our only hope for being compensated for providing health care services relative to pharmacotherapy. Rather than complaining about all the barriers in front of us we need to look at how to remove them,” he added.

Professor Berger stressed that there was a market need for pharmaceutical care. Last year, a quarter of a million deaths occurred in the United States that were directly attributed to inappropriate drug therapy. This had cost $125bn. Pharmacists had to demonstrate that they could lower this cost.

Pharmaceutical care was the responsible provision of drug therapy for the purpose of achieving definite outcomes that improved the patients' quality of life, said Professor Berger. This meant that pharmacists were going to have to be responsible for following up the patient, for example, measuring their peak flow rate or blood pressure.

Patients in the US had, on average, a four- and-a-half-minute visit with their physician, which was not sufficient to learn about their disease. “We may say that it is not our job to fill the gaps but if we do not then someone else will and those people will be nurses. Nursing is pharmacy's chief threat,” he said. “Physicians want help from pharmacists. They find it useful that pharmacists will take on some of the disease management education side of care,” he added.

The steps in pharmaceutical care that needed to be established were:

Listing any drug related problems
Establishing a plan for the patient
Determining feasible alternatives
Designing a monitoring plan
Following up to measure success and document outcome

As in the United Kingdom, there was a huge shortage of pharmacists in the US at present, one of the causes of which was a change in the degree course whereby in one year no pharmacists graduated. As a consequence, pharmacists were being offered $80–85,000 starting salaries. “We are challenging pharmacy students to ask chains for eight hours per week to do intensive patient care without dispensing any drugs. The chains are hiring them. There has never been a better time in US pharmacy for pharmacists to have the power to say to their employers this is the way I want to practise,” he said. “We need to dictate our standards rather than have corporations dictate their standards on us.”

The Eckerd Corporation is one of the four largest drug chains in the US. Professor Berger had been involved in a project with the company that was based on re-engineering the practice of pharmacy. Pharmacies are inefficiently designed, he said. Pharmacists and technicians spent 75 per cent of their day walking unnecessarily, he found. Even by curving the ends of the long, linear counter, the amount of walking would be much decreased. The project had also managed to reduce medication errors to zero, he said. When prescriptions were brought into the pharmacy, they were scanned using a barcode and an image was brought up on a screen showing what the drug should look like when it was checked. “Until we change the regulations that the pharmacist has to be the last check, we will still get a bottleneck at this stage. If technology can reduce medication errors to zero, why does the pharmacist need to be the last check?” he asked. The project used a robot that was about 2ft by 6ft and had 200 bins of drugs. The robot, which cost $110,000, fills the prescription and labelled items at a speed of 90 prescriptions per hour.

Professor Berger recommended two websites (www.aphanet.org and pharmacy.auburn.edu/pcs) that gave a list of over 500 US pharmacists who are providing specialist services such as asthma, diabetes and hypertension services.

Vantage silver award winner announced

Michael Guerin, proprietor, Eslers Pharmacy Group, Northern Ireland, is the winner of this year's AAH Pharmaceuticals Vantage Silver award. Mr Guerlin was presented with the award, a cheque for £5,000 and an engraved sliver timepiece, on May 15 during the convention.

Dr Mandeep Mudhar, AAH's marketing manager, said that Mr Guerlin's work in developing forward-thinking pharmacy solutions incorporating information technology and staff development had impressed the award scheme's judges. Each Eslers Group pharmacy has been equipped with computer software to analyse brand performance, to increase the efficiency of stock movement and to enhance communications between branches. “Management becomes a big issue when developing a group of shops. There is a great deal of information between the shops and a central point. Using IT removes the paper trail of faxes and the system becomes much more manageable,” Mr Guerlin explained.

Balancing the Government and business agendas

Community pharmacists are key players in United Kingdom health care, according to Professor NICK BOSANQUET, professor of health policy, Imperial College London. However, he warned that joint investment in both the Government's agenda and pharmacy's business agenda was needed or the former agenda would feel very heavy.

A massive period of challenge was opening up for health services worldwide, he said. “We need to grip this problem and start preventing and treating diseases more effectively or we are going to be faced with an ever growing problem of rationing and queuing within the health system,” he said.

Some of the new challenges in health care over the next 20 years were an ageing population, health inequalities between the social classes and lifestyle problems such as obesity. The wider context in which community pharmacists would develop businesses over the next 10 years had to consider services that would improve outcome, processes that were clear and user-friendly, partnerships with patients and carers, and access that would end and reduce postcode rationing.

The key challenge for community pharmacists was to develop a complementary strategy between the Government's agenda and pharmacy's business agenda. This included ideas such as giving advice on improving health problems, improving prescribing, starting new programmes relating to consumers (eg, weight reduction or smoking cessation), and developing websites.

The Government's agenda for pharmacy in the future was about medicines management, Professor Bosanquet said. This involved identifying high-risk groups and moving forward on improving prescribing for these groups. This was beginning to happen in some areas, he said, but the challenge was to get primary care trusts to fund this adequately.

The challenge for pharmacists was to repeal the law of halves, ie, for any given condition, only half were diagnosed, of those only half were being treated and of those only half were being treated effectively. A fuller agenda for medicines management was needed that would involve companies and patients as well as PCTs. The danger was that pharmacists would be left out and would not be adequately remunerated. The Government's agenda fitted in with the business agenda for community pharmacists by identifying special interests for customers. Pharmacists could then market more directly for customers on their special interests.

Pharmacists also had the scope for developing services in areas such as smoking cessation, and in the direct management of minor ailments, such as headache. Pharmacists could boost both over-the-counter sales as well as their patient and professional credibility in these areas. There were also new business opportunities, including the development of OTC products in response to new problems, such as the recent example of marketing compression stockings for preventing deep vein thrombosis, he said.

A changing world

Las Vegas had always been open to change in direct response to customer demand. Pharmacists had to reinvent themselves just as Las Vegas had done in response to the changing tide of consumer demand, said IAN BRAY, marketing director, AAH Pharmaceuticals. “We have to recognise that our world is changing, and changing fast,” he said. Independent pharmacists faced increasing competition from the high street and supermarkets, and internet prescription delivery.

One of the ways in which AAH was able to help its customers adapt in response to changing market conditions was by supplying information technology solutions. AAH Point is an extranet ordering and information service that connects pharmacists to the computer systems at AAH warehouses. “It gives immediate, real-time access to accurate, up-to-date information about the stock that is held in your local warehouse,” he said. AAH Point had financial information, such as facilities to check invoices, statements and sales figures. AAH also offered an internet site (www.pharmacy-point.co.uk) that could be accessed by the general public. It allowed people to search for their nearest Vantage pharmacy and each pharmacy had its own webpage where additional information about specific services the store offered could be added.

However, this was “just the beginning”, according to Mr Bray. Customers could buy items directly via the internet at Superdrug and Pharmacy2u and AAH would help pharmacists to build and develop this type of service. “Embracing the IT revolution and taking the fullest advantage of the potential it offers will be one of the keys to success in the coming years,” he said.

What pharmacy will be like soon

In a few years' time, pharmacists will earn half the current dispensing fee and the other half will go to those providing primary care professional services, predicted Dr MANDEEP MUDHAR, marketing manager, AAH.

The National Health Service pharmacy plan demanded that by 2004, every patient would get extra help from pharmacists in using medicines, reducing illness and in cutting drug wastage. Medicines management meant adding value to the dispensing process, said Dr Mudhar. This included leading repeat dispensing schemes, monitoring how and whether patients were taking medicines, reviewing medication for key illness groups, and providing advice and support on medicines.

Most of this pharmacists were doing every day, but were now being asked to do it formally because it was recognised that it would make a major impact on NHS drug costs and patient welfare, he said. Within the past year, AAH had set up a department to develop new primary care services for pharmacy. Dr Mudhar explained that some of the services had been developed in areas such as anticoagulation, blood pressure, blood glucose, weight and diabetes care management. Programmes were also available for medicines management (including repeat dispensing support, prescription and medication review training, and support in services to nursing and residential homes), inhaler technique assessment and smoking cessation.

Dr Mudhar said that AAH saw that pharmacists in the years to come would provide services either on their own or in combination with other pharmacists. The company would support pharmacists who wanted to drive other pharmacists in their locality to set up services such as medicines management for people with diabetes or drug compliance programmes, he added.

Pharmacy in the US

Las Vegas is home to one of America's busiest Walgreens pharmacies. Pharmacist Marv Unell told The Journal that it is a tourist store with few regular patients. This meant that he had to register new patient details for a large number of prescriptions which was time consuming.

The biggest issue for pharmacy in the US was that there were not enough pharmacists. This led to work stress that was not helped by the fact that pharmacist were paid the same amount no matter what their level of experience, he added. Mr Unell believed that pharmacist prescribing will eventually happen in the US for a limited number of medicines.

A major difference to the UK was that US pharmacists had to deal with patient's medical insurance. Walgreens no longer dealt with some insurance companies where payment was not sufficient to cover costs, he said. In some cases, patients had to go from pharmacy to pharmacy in order to find a place where their insurance policy was accepted. However, Mr Unell felt that this was not a significant inconvenience for the patient because pharmacies were close together and there would always be a pharmacy that would accept the patient's business.

The three things that Mr Unell would like to change about US pharmacy, without inconveniencing the patient, were:

l Educate the patient so that they have an insurance policy that works. “This is not a job for the pharmacist to fix,” he said.

l Ensure that people who telephone prescriptions in to the pharmacy on behalf of doctors get the prescription details correct (in his experience, if people could not read prescriptions, they made the details up, often inaccurately).

l More money for technicians. “You cannot run a pharmacy without good technicians,” said Mr Unell.

For Mr Unell, job satisfaction was about being able to talk to patient and to try to make them feel better. Each pharmacist at Walgreens had a slogan under a picture of themselves which was displayed in the pharmacy. Mr Unell's slogan was: “If I can make the patient laugh that is the first sign of making them feel better.”

Walgreens was founded in 1901 and now has 3,401 stores across the US, Of these, 2,282 are “drive-thru” pharmacies and 784 are open 24 hours. In 2000, Walgreens pharmacies filled 288 million prescriptions. Walgreens also runs an online pharmacy (Walgreens.com). Patients can access the following services online: print their prescription history, find the nearest Walgreen store, ask a pharmacist questions (responses being given within one business day) and check for interactions with their medicines. Patient can also order medicines online and have e-mails sent as a reminder for repeat prescriptions.

Medicines management “not about rocket science”

Now is a time to “raise the alarm bells”. “We are only 30 months away from 2004 and the date set by the Government for a national roll-out of a medicines management programme,” said HEMANT PATEL, secretary of North East London Local Pharmaceutical Committees. That meant that everyone had to start doing something now in order to be ready in time.

Medicines management was about ensuring that people gained the maximum benefit from their medication to maintain or increase their quality and duration of life and did not suffer unnecessarily from illness caused by inappropriate or inadequate consumption of medicines. The rationale behind medicines management included the fact that many medicines were not taken, were underused or there was an inequivalence in prescribing leading to wastage.

“Medicines management is not rocket science but is about common sense,” he said. “You do not need to know everything in the BNF in order to start practising medicines management.” By reviewing just one patient a day, your knowledge multiplied rapidly. Mr Patel recommended concentrating on chapters one to four and 10 of the BNF because 80 per cent of drugs on prescriptions in primary care were listed in these chapters.

Older people were particularly prone to medicines management problems, he said. One patient he had seen recently had taken 63 medicines in the past two years and had not had a review of her medicines. Other people at risk who would benefit from medicines management were everyone taking more than four medicines, people taking specific medicines (such as NSAIDs, diuretics, warfarin), people who had been recently discharged from hospital, prescriptions with a mixture of generic and proprietary medicines, people with low levels of social support, people with some physical conditions (eg, visual impairment), people with poor mental state and people of certain ethnic minorities who believed that medicines did harm.

The consequences of poor medicines management were poor health, an increase in cost, avoidable suffering, stress to family and friends and an increase in workload in health care and social care.

The type of questions pharmacists need to ask in a medicines management review included:

What is the indication for the drug?
Is the drug needed?
Is there an evidence base for the drug?
Is the drug the best choice for the patient?
Are the dose and formulation correct?
Are there any interactions with other drugs or diseases?
Is the regimen as simple as possible when all medicines on the prescription are considered?
Does the patient know what the drug is for?
How long will the medicine have to be continued for?
Will monitoring be required?

Following a review, the pharmacists needed to suggest ways of moving forward. This included counselling about medicines, referring the patient back to the general practitioners, reporting adverse drug reactions, providing compliance aids, re-assessing current diagnoses, recommending tests and rationalising treatments.

Mr Patel gave an example of a pharmacist who found that for 96 items prescribed for 12 patients randomly selected from one surgery's records, 55 had some kind of error. Cheaper alternatives were available for seven drugs, there were seven cases of drug replication (eg, ranitidine and Zantac), six drug interactions, two inappropriate formulations (tables where the patient could not swallow tablets) and inequivalent quantities in seven cases. “Any pharmacist could identify these problems,” he said

After the session, which involved conducting a practice medicines management, Dipan Shah, pharmacist at St John's Pharmacy in Weymouth commented: “From what we have learned today, I feel empowered and motivated to be able to perform medicine management. Today's session highlighted our knowledge and ability to do medicines management without extra training,” he added.