Pharmaceutical care: where we are now
Pharmaceutical care, what it is, as well as how and
in what setting it should be provided, has sparked an enormous amount
of debate around the world. There are differences in terminology, some
talking about pharmaceutical care, others about medicines management.
And even those who prefer to use one term rather than the other do not
always agree on what they mean by them and, more importantly, how they
work in practice. Hence there is no common understanding at either a national
or international level.
But does this matter? Are we not just different
countries divided by a common language? The argument is often put forward
that we should be getting on with “it” rather than arguing about semantics.
But what is the “it” with which we should be getting on? Some people believe
in the need for consistency in both terminology and approach across national
boundaries. That way we all know what we are talking about and research
results can be compared easily. More importantly, patients know exactly
what they are getting.
The other side of the argument is that differences
in health care systems and differences in pharmacy practice round the
world do matter, making any kind of consistency difficult, if not impossible,
and that pharmaceutical care or medicines management should be applied
differently in every country and culture. Interestingly, when these two
views were put to the test at the end of a debate at the conference last
week, roughly equal numbers of participants voted for and against establishing
a common understanding at an international level.
The scene had been set on the previous day when
speakers from five different countries gave their perspectives on pharmaceutical
care and/or medicines management, explaining what progress had been made
and why they or their country had taken a particular approach.
United States
Professor Linda Strand, University of Minnesota,
who, together with Professor Douglas Hepler, published the seminal paper
on pharmaceutical care in 1990, updated the delegates on developments
in Minnesota where pharmaceutical care is now being provided in nearly
50 practices. The word “practice” is important in the Minnesota model,
and it does not mean what pharmacists the world over mean when they say
“in my practice I do so and so.” Quite simply, it means having a practice
just like a doctor, a dentist or an optician. And there may not necessarily
be a tablet in sight on the practice premises.
This is because the pharmacist is there, not to
count and pour, but to prevent, identify and resolve a patient’s drug
therapy needs, just as a doctor is there to prevent, diagnose and treat
disease. Unlike several other models of pharmaceutical care round the
world, this one is not a “bolt on extra” to dispensing. It is quite separate
because Professor Strand and her colleagues firmly believe that you cannot
do both. In her opinion, you have to choose. So, in Minnesota, the pharmacists
operating according to this model see patients one at a time by appointment
in a consulting room.
To date, 45,000 pharmaceutical care encounters have
been documented for over 15,000 patients and over 19,000 drug therapy
problems identified, prevented and resolved. The financial impact has
been considerable with the ratio of savings to costs ranging between two
and 10 to one, Professor Strand says. Moreover, pharmacists are being
remunerated for the service by a variety of payers, such as insurance
companies and health maintenance organisations.
So, how has this been achieved? First by identifying
the unique contribution that pharmacists can make to patient care, that
is, preventing, identifying and resolving drug therapy problems, and nothing
else. Secondly by learning what it means to be a patient care provider
because, in the words of Professor Strand, “if you want to be paid for
providing care to patients, you have to know what being a patient care
provider entails. Pharmacists, unlike doctors and dentists, have never
been patient care providers, so have never learned the rules.” The rules,
she explains, are to provide care direct to patients, take responsibility
for a definable set of problems, document and evaluate the quality and
impact of the service and negotiate payment based on patient need. “You
will never be paid for patient care by providing services to GPs or drug
information to nurses,” she emphasises.
This is a significant statement, and one that is
easily misunderstood, because as we all know, pharmacists in the UK are
currently paid for providing services to doctors. But they are paid essentially
as prescribing advisers not as patient care providers. Of course, some
prescribing advisers do see individual patients, but some do not.
Professor Strand is quite clear on this — if you
want to look after patients and be paid for doing so, you must learn to
play by the rules of other patient care providers. These are rules, she
hastens to add, that were not written by her, but have been established
for hundreds of years all over the world. Hence a doctor in South Africa
can easily talk to a doctor in the US because they talk the same language.
It is this, in her view, which makes a standard, consistent approach to
pharmaceutical care world-wide essential. By this she means having one
philosophy of practice, one model of practice (patient care) and one standard
of practice. Above all, it means putting patients first. “Once we start
discussing patient care, we’ll know we’ve arrived,” she says. And, although
she would the first to admit that progress has been slow and involved
a lot of hard work, there is a steady growth in the number of pharmaceutical
care practices in Minnesota, all of which have paid practitioners.
New Zealand
The pharmaceutical care concept used in New Zealand
is essentially that of Hepler and Strand. It is a clearly defined patient
care process, separate from dispensing, provided only by specially accredited
pharmacists. According to John Dunlop, general manager, New Zealand College
of Pharmacy Practice, 28 per cent of community pharmacists and 16 per
cent of all pharmacists in New Zealand are now trained to provide pharmaceutical
care and, by August 2001, 183 were practising.
Prospective patients are identified by doctors,
nursing homes as well as pharmacists. The service is reimbursed partly
by third party payers and patients, but mainly by the government, which
pays NZ$160 for each pharmaceutical care plan submitted. By August this
year, 87 community pharmacists had claimed for a total of 4,123 care plans.
The government encourages pharmaceutical care and negotiations are currently
taking place for an expanded role in health care for pharmacists in New
Zealand.
Mr Dunlop believes that the future for pharmacists
lies in resolving drug therapy problems, and that the traditional dispensing
role could disappear to be replaced by delivery by mail order. Moreover,
he doubts whether community pharmacy as we know it is the right environment
to provide pharmaceutical care. Community pharmacy could easily develop
into two streams, he thinks — the supply side, which would increasingly
be dominated by the multiples, and the cognitive side, which would be
patient focused using a team approach. Many different models could develop,
and maybe even a new profession — pharmacotherapy — which could eventually
take over from the pharmacist.
Australia
Pharmaceutical care is also growing in Australia
where pharmacists are paid for providing it to patients in nursing homes,
domiciliary settings and at the hospital/community interface. According
to Professor Andrew Gilbert, Quality Use of Medicines and Pharmacy Research
Centre, University of South Australia, the main driver in Australia is
a national policy on the quality use of medicines (QUM). This policy was
formulated in the early 1990s in response to the growing data on overuse,
underuse, inappropriate use and adverse health consequences of medicines,
particularly in older people, in whom illness caused by medication was
considered to be the most significant health problem amenable to treatment.
Interestingly, however, there was also a strong pressure from the consumer
lobby.
QUM is defined as “the selection of treatment options
between medicine, non-medicine and no medicine, and when medication is
required, appropriate choice across drug categories, together with safe
and efficacious use of the chosen medicine.” In common with the Minnesota
model it focuses on the burden of medication-related problems and aims
to ensure that medicines are used appropriately, safely, effectively and
conveniently. However, medication related problems are seen as problems
with the system rather than with the individual, and the focus is therefore
on system change.
Nonetheless, national data on drug related problems
have generated a range of medication management services in older patients,
at the primary/secondary care interface and in residential care homes.
Services are patient focused and multidisciplinary in approach, and according
to Professor Gilbert, the QUM policy has “created the environment in which
ideas consistent with pharmaceutical care can flourish.”
The Netherlands
Dr Foppe van Mil, community pharmacist and researcher,
University of Groningen, the Netherlands, uses the term pharmaceutical
care to apply to the services he and colleagues in the Netherlands provide.
However, he disagrees with having a uniform approach world-wide, arguing
that perspectives in the US, Australia and New Zealand are essentially
Anglo-Saxon in approach and therefore have a different basis from those
in much of the rest of the world. He believes that differences in health
care systems, and differences in pharmacy practice, such as size of pharmacies,
dispensing workload, staff numbers and so on, do have an impact on the
provision of pharmaceutical care.
The definition of pharmaceutical care used in the
Netherlands emphasises the role of the whole pharmacy team — not just
the pharmacist — in caring for the individual patient in the field of
pharmacotherapy, and aims to improving the patient’s quality of life.
However, the pharmacy team in the Netherlands includes pharmacy assistants
who are trained for three years beyond secondary school, and therefore
well qualified to be able to participate in the care process.
The ground has long been fertile for pharmaceutical
care in the Netherlands for several reasons. Dutch pharmacies only provide
medicines and medical aids, so they do not look like shops and have a
strong professional image. Patients are loyal, with 95 per cent using
one pharmacy only, and pharmacists have a well established role in advising
patients on their medicines. All pharmacies have a private room for consultations.
Working relationships with doctors are good and pharmacists regularly
meet doctors (6–8 times a year) to discuss pharmacotherapeutics, thus
raising awareness of pharmacists as experts on medication, and all pharmacies
have conducted automated medication surveillance for more than 10 years.
The provision of pharmaceutical care is therefore
not such a culture shock for Dutch pharmacists, although such services
are not universal across the Netherlands. Pharmacists are not paid for
pharmaceutical care but their income from dispensing is good and pharmacies
are large, usually employing two pharmacists.
The pharmaceutical care process itself involves
detection of drug therapy problems, discussion with the patient and monitoring
compliance. There are protocols for providing care to patients with specific
diseases (eg, asthma, diabetes, hypertension) and those on specific medication.
One of the big strengths in the Netherlands is that part of the patient’s
medical record can be viewed remotely by the pharmacist, because most
pharmacy and GP systems are compatible.
Moreover, the pharmacy software allows the pharmacist
to document drug therapy problems and record any action taken. A new development
in the Netherlands is that doctors will have to write down the indication
for each medicine on the prescription. This is expected to happen from
next month and will as Dr van Mil recognises, be of enormous help in pharmaceutical
care.
England
England is in the process of developing medicines
management services, which are in line with current well-known Government
policy for the NHS, particularly the target identified in the NHS plan
for all general practices to have medicine management services in place
by 2004. Clive Jackson, director, National Prescribing Centre, Liverpool,
explained that the development of medicines management services is also
linked to other initiatives such as local pharmaceutical services, repeat
dispensing schemes, patient partnerships in medicine taking, new prescribing
responsibilities for professions other than medicines and new structures
and responsibilities for NHS organisations.
Medicines management services therefore fit in well
with the current NHS agenda in England, and although they seem to find
little parallel with pharmaceutical care developments in other countries,
there is the same focus on medication related problems as being an important
driver for change. Of significance is the fact that services include all
aspects relating to the supply and therapeutic use of medicines from the
individual patient level to the organisational level.
Conclusion
The five speakers made it clear that different countries
are continuing to approach pharmaceutical care in the primary care setting
in a variety of ways, although the burden of drug-related morbidity and
mortality is a common focus. The model started in Minnesota is the most
distinctive — at least for pharmacists — with its emphasis on the pharmaceutical
care provider having a practice in the same way as a doctor or dentist.
A similar approach is also being adopted by some
pharmacists in Australia and New Zealand. Pharmaceutical care in the Netherlands
is provided as part of the dispensing service and is not perceived as
something that has to be separated, partly because Dutch pharmacies are
large with plenty of staff. In England, medicines management services,
as they are being called, are being provided in both pharmacies and GP
surgeries, covering the whole medication process from prescribing to supply,
identification and resolution of medication-related problems and follow-up.
What will be interesting in the future is to see
whether pharmacists split into two streams — the supply side and
the pharmacotherapy side — and whether indeed we shall see a new
breed of practitioner, the pharmacotherapist, or whatever title is deemed
to be most appropriate.
— Contributed by Dr Pam Mason
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