The Pharmaceutical
Journal Vol 267 No 7160 p199-201
28 July 2001
PDF file (50K)
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The Pharmaceutical
Journal Vol 267 No 7160 p199-201 |
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PDF file (50K) |
Seen but not often heard — proposals for enhancing the role of the community pharmacist |
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By the Adam Smith Institute |
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The Adam Smith Institute, one of the United Kingdom’s leading public policy think-tanks, is engaged in a major project to develop a blueprint for reform of health care in the UK. The goal is to move from monopoly to pluralism in the provision and funding of health care, delivering substantial improvements in health outcomes from a given resource and from the patients’ perspective. The better management of medicines has been central to a wide-ranging series of discussions and consultations and in this first article (compiled by Matthew Young, director of projects, Adam Smith Institute), the institute sets out proposals for extending the role of pharmacists. In a second article next week the focus will shift to the cost savings that can be achieved through smarter purchasing and distribution |
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Prescription drugs are expensive, but highly cost-effective in making inroads against a variety of acute and chronic illnesses. The current spend on pharmaceuticals within the National Health Service is around £7bn, or nearly 14 per cent of total NHS expenditure. That figure shows double-digit growth year on year and will probably double within five to seven years. The reasons? The costs of developing new medicines to combat a widening range of conditions, adding a continuous stream of new treatments to the balance sheet and expanding the range of people to be treated. Without doubt, the management of the prescription process within primary care and community pharmacy is central to the delivery of an effective and efficient service and to a better patient experience. This article examines the question of how best to improve NHS pharmaceutical services by extending the role of the community pharmacist. Are we getting value? Our system for prescribing, dispensing and monitoring the effects of medicines is not as cost-effective as it might be. Substantial anecdotal evidence suggests that inappropriate prescribing, poor patient compliance and system inefficiencies probably result in a waste of half the pharmacy budget — perhaps £3–4bn — an enormous loss to both patients and taxpayers. We cannot save it all but what is clear is that billions could be cut from the NHS drugs bill (or better spent) if the prescribing process were based on more rational principles. The blame for inappropriate prescribing lies squarely with the medical professions. They need to ask questions such as: Is this the right medicine for this condition? Does my choice reflect current thinking? Is this the most cost-effective way of treating this condition? But it is clear that GPs are not best qualified to give the correct answers to such questions; other health care professionals, such as pharmacists, are much better informed. This article also argues that it is the pharmacist who is better placed to help patients persist with their medicines. Harnessing the expertise The skills that already exist within the NHS need to be focused more effectively to deliver a better quality service with better health outcomes and better value for money. There is a plethora of tools that need to be brought more vigorously into play:
But to do this we need to change some key processes, and commit some professional turf wars to history. Steps to a better-managed prescribing process The public judges the high-street pharmaceutical service only on the ready availability of the prescribed medicine and the accuracy of dispensing and, seemingly, has few complaints. The broader question about the overall effectiveness of a system delivering 500 million prescriptions a year is seldom, if ever, raised. The prescribing process, like much of the NHS, is largely an “information-free zone” with no feedback loop to inform and guide decisions. What is missing is an essential level of interaction between diagnosis, prescription, compliance and measurement. There are six steps that need to be done, and done well:
This is a cyclical process with the first decision being influenced by the last: the feedback from outcomes measurements is used to refine further the cost-effectiveness of the treatment being provided. The introduction of this system can be achieved at low cost: it is a matter of relocating a proportion of the pharmacist workforce to work in the primary care organisation and providing them with the wherewithal for doing the work. If that is undertaken as a matter of routine, the savings will be achieved within a short time and will far outweigh the manpower and technology costs. Since these steps are not being followed on a routine basis in most GP practices, it is safe to conclude that prescribing is not being optimised in cost-effectiveness terms. In other words, the NHS medicines budget could be better managed, providing a better-quality service at lower cost and with less wastage. And the resource that is released by this greater efficiency could be used to extend prescribing to serious areas of illness where pharmaceutical treatment is not being provided as thoroughly as it might. If the increase in the length and quality of life is to be maintained, it is essential that patients affected by chronic conditions are diagnosed early and treated appropriately and effectively. We have already seen the gains achieved in the treatment of heart disease, diabetes, mental disorders, skeletal and muscular disorders such as osteoarthritis and rheumatoid arthritis along with hypertension and obesity. These will continue, and further significant therapeutic advances will be made, translating into real patient benefits, but only if these resources are correctly managed. Getting the right management To ensure that more effective prescribing becomes the norm, we must make real changes in the way the NHS pharmaceutical service is provided. The simplest and most straightforward step will be to inject more expertise into the management of the service. This can best be done by recognising that pharmacists are trained to be medicines experts through their degrees and vocational experience, and that they should work in medical practices with doctors to participate actively in all stages beyond the initial diagnosis. Already, some GP practices are employing pharmacists to help them manage their NHS drug budgets, mainly from the point of view of cost. This being the case, some measurement of outcomes and optimisation of drug selection is taking place, but more on an ad hoc basis than as part of a national NHS programme. So the basis for a major reform of NHS pharmaceutical provision is in place and needs to be built on rather than initiated from scratch. The central proposition is that there is a distinction to be drawn between diagnosis and prescription, with all NHS general practitioner practices working directly with a pharmacist in the drug prescribing process. This would probably work best under the following conditions:
In addition to helping solve the problems, of inappropriate prescribing and the effects of non-compliance and associated drug wastage, the radical decision to move prescribing away from GPs and let them concentrate on their core competency of diagnosis would have two further benefits:
Wider benefits To capture the maximum benefits from this new specialisation, pharmacists should be empowered to manage medicines fully — adjusting drug dosages within recognised limits where they deem it sensible, authorising repeat prescriptions, monitoring outcomes, and counselling patients on the need to comply with the prescribed regimen. In turn, this would imply an increase in the skill set of the profession, and corresponding changes in today’s educational and regulatory regimes. Upgrading the pharmacist’s skill set and bringing them more centrally into the public health arena could improve health outcomes more generally. Routine diagnostic screening and health management programmes provided by the pharmacy service would encourage “well patients” to be more involved in their own health. There would be earlier detection of disease (which, of course, may cause an initial rise in the drugs budget, though the long-term savings in secondary care should be disproportionately large). The IT component ... and medical records Implicit in this extended role for the pharmacist is much better information management and exchange. An information technology infrastructure providing electronic prescription transfer between GPs, pharmacists and the Prescription Pricing Authority will facilitate repeat prescribing by pharmacists and help to reduce fraud and error. To achieve this level of IT connectivity does not require the establishment of some vast and expensive new network. It can be grown nationally on the back of local initiatives using internet protocols, and the early capital requirement can be contributed by the private sector on the basis of future income from its use. For example, one could imagine a system of web-based patient records, accessed through a code or smartcard, and containing each patient’s specific medical information, such as a record of their medicines, current and past. These records would be particularly useful if questions arose in the course of the dispensing process, and they could also include details of medicines (including over-the-counter medicines) sold by the pharmacy, thereby ensuring that medication records were complete and not restricted to medicines that had been prescribed, and so avoiding the possibility of incompatibilities. Different levels of access will be required to control which information is divulged to which health care professionals. The system would generate large improvements in patient management and medicines management, resulting in reduced admissions into secondary care and a reduction in medicines wastage. The role and status of pharmacy Currently, pharmacists are looking for a more professional role because their traditional role of dispenser in community, high-street pharmacies has changed dramatically with the adoption of standard manufacturers’ packs of medicines, each of which has a patient package insert giving dose and safety details. The only knowledge-based roles left for the pharmacist are to ensure that the prescribed dose is correct, that there are no incompatibilities between prescribed medicines, and that the whole dispensing process is undertaken correctly. Indeed, even the need for supervision is open to question since computer programmes aligned with bar codes on prescriptions and products can verify each of these points. There is a case for reviewing whether we need “fully qualified” pharmacists in community pharmacies now that the dispensing process has been simplified so considerably. This points logically to the development of a new qualification of “associate pharmacist” for those who undertake the community pharmacy dispensing service and also the sale of pharmaceutical products over the counter. This qualification would be examination- and experience-based, and administered by the Royal Pharmaceutical Society, which is responsible for the educational standards and the registration of pharmacists. The key benefit here would be the release of a considerable number of pharmacists to work more effectively in the NHS as medicines experts, or follow other careers in hospital, industry, information science, and so on. Education and standards To develop the pharmacist’s role as an in-practice medicines expert will require changes to the educational component of the undergraduate and postgraduate training. There are a number of ways to address this issue.
New options for the pharmacist The concepts presented in this article envisage a radical reform of the role of the pharmacist into that of a medicines expert, becoming the manager of the prescribing process in primary care organisations and GP practices. The consequence of that shift in role will be for community pharmacy work — dispensing and OTC sales — to be undertaken by less qualified individuals. It must, however, be remembered that pharmacists, recognising that their dispensing role has become intellectually minimised, have sought a new role in treating minor illnesses through the provision of counselling and the sale of OTC medicines. This may have the benefit of reducing the workload of the GP and transferring drug provision from prescribed NHS medicines to OTC proprietary ones. But there are serious problems with this approach. First, patients already use pharmacies to a considerable extent for obtaining treatments for minor ailments. It is doubted whether considerably more patients could be persuaded to use pharmacies to a greater extent, because NHS medicines are free for many classes of patient and because patients prefer to consult their doctors. In many cases, the patient is fearful that the symptoms of illness are just the tip of an iceberg and that something more serious may be happening. At least the doctor can address this question; the pharmacist cannot. Also, pharmacists are not taught diagnostics, and unless this is included in their course, their advisory role is strictly limited to identifying the symptoms of common diseases, which patients can do for themselves in many cases. Where patients cannot do this they already go to the pharmacist for preliminary advice and the purchase of medicines. Pharmacists who wish to remain in community pharmacy because they enjoy the commercial aspects of the work will continue to operate along much the same lines as they do at present. However, the abolition of resale price maintenance on OTC medicines will lead to the closure of some smaller pharmacies and the concentration of pharmacy services in large multiples and supermarkets. And if lower-grade staff handle NHS dispensing, the remuneration for this activity will make dispensing by pharmacists uneconomical. One much-discussed option is that pharmacists could take on the work of providers of health care awareness programmes aimed at increasing the overall health of the population. Their high-street locations would ensure that there was good distribution of materials and spoken advice. They could be remunerated on an item-of-service basis, or there could be a contract with the NHS under which the community pharmacist would undertake to provide a range of services, including dispensing and other health care work, in return for a fixed amount of money related to the manpower needed to perform the work. Perhaps. But it seems likely that the role of the pharmacist as a medicines expert, managing the prescribing process in primary care organisations and GP practices, would be a more secure future. Pharmacists need to play a new role in the NHS to satisfy their professional ambitions; at the same time, there is a real need for far better management of the NHS prescribing services. Matching the pharmacist to this need would provide real therapeutic benefits for NHS patients, and significant savings for NHS managers. The reforms suggested can be implemented relatively easily at low risk and low cost. All that is needed now is the decision to make the change and draw up a programme for its implementation. Conclusions The changes proposed can probably be introduced within five years. The starting point would be the transfer of pharmacists to work in primary care organisations, accelerated through the introduction of prescribing standards and the allocation of funds for manpower and technology. The necessary standards could be established over two to three years. The development of a new pharmacist qualification would take around two years to negotiate and a further three to four years to start producing newly qualified individuals. The introduction of educational courses for qualified pharmacists and the modification of the existing syllabus for the MPharm degree could be achieved over two to three years, with new graduates and appropriately qualified individuals starting to emerge within five years or so. All in all, the changes that have been called for in this article can be achieved without recourse to new technology. Nor do they involve novel concepts. They build on existing trends. The need for better management of NHS medicines is apparent to all the professionals involved. Best of all, patients will get the best treatment at the most affordable cost. New medicines will be more rapidly taken up because the funding will be available, so patients will benefit sooner from advances in medical science. Wastage and over-treatment will be reduced significantly. What is now needed is the political will and commitment to change the status quo. |
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ACKNOWLEDGEMENTS |
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The views expressed in this article are those of the Adam Smith Institute and do not necessarily represent those of The Pharmaceutical Journal or of the Royal Pharmaceutical Society |
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