The Pharmaceutical Journal
Vol 268 No 7198 p682
18 May 2002

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Why we need to demonstrate that compulsory CPD offers value for money

By John Wilson

One of the features of modern life is the apparent need to "modernise". Now, modernising tends to start with the doubtful premise that what has gone before is necessarily bad, inefficient, too expensive, or just plain old-fashioned. Modernised functions therefore must be good, more efficient, more cost-effective and eye-catching.

The last quality is probably the most important to modernisers since it is one of the few qualities of a modernised system that is immediately visible and produces instant, or near instant, kudos for the instigator of the modernisation. Other attributes and qualities, such as whether the modernisation actually improved anything, are more difficult to measure. At least, that is how it might seem.

One problem is that modernisations tend to be circular. Take, for example, fundholding for general practices. This was launched in the early 1990s with much flourish and a few doubters. As far as I am aware, no pilot studies were carried out before the launch, although a number of papers subsequently appeared showing, among other things, some short-term improvements in cost and quality of prescribing. Fundholding was abolished by the present Government, to be replaced by primary care trusts, which seem to be not dissimilar to the fundholding multifunds of a few years ago. No doubt reputations, not to mention careers, hinge on the success of the PCTs, but the benefits to the patient remain to be seen.

"Producer capture" can be defined as when a system has effectively been taken over by the "producers" of the service to serve their own ends and not those of the "consumers" of the service. Rural policing is a good example of producer capture. At one time every village had its policeman who lived in a police house in the village and was a visible presence and deterrent to petty crime. Now it is deemed more "modern" and presumably more exciting to rush about in little white cars with blue lights and nee-naws going, but this may actually be less effective in preventing crime than the old system. To my knowledge, there have been no studies on this subject, but ask a colleague who lives in a rural area about their concerns over local crime.

There are other examples of producer capture, from nearer home. The concept of educating the patient by means of leaflets is common within the health care system. Every community pharmacy has its collection of health promotion leaflets, hopefully kept up to date and displayed prominently. Go into a GP surgery and the reception area is littered with leaflets and plastered with posters, covering every imaginable health issue and a few more besides. We all "know" that it is valuable, indeed essential, to have up-to-date information leaflets available for the patients, and not just in pharmacies. However, has anyone attempted to measure the effectiveness of these? Of two recent studies of evidence-based leaflets about informed choice in maternity care, one concluded that in everyday practice, evidence-based leaflets were not effective in promoting informed choice in women using maternity services.¹ The other considered that the way in which the leaflets were disseminated affected promotion of informed choice, but that the culture into which the leaflets were introduced supported the existing patterns of care and so resulted in informed compliance rather than informed choice.²

Take EHC, for example ...

One topic which has occupied the minds of pharmacists in recent years has been the supply of emergency hormonal contraception (EHC). I attended a training course on supplying EHC under a group protocol, at which the supply principle was lauded to us as one of the issues that would save the pharmacy profession from extinction, or at least allow us to offer another service to our clients, patients, or customers. The UK has the dubious honour of topping the European league table for unwanted teenage pregnancies, and it is hoped that EHC supply from pharmacies will assist in reducing the level of such pregnancies. A recent paper³ looked at whether improved access to family planning services for under-16s was likely to help in achieving the aim of reducing under-age conceptions. The author concluded that there was no evidence to show that the provision of family planning services reduces either under-age conception or abortion rates. However, socioeconomic variables, such as rates of children in care and rates of participation in post-compulsory education, were significant predictors of the extent of under-age pregnancy.

As soon as this paper was announced, it made headlines in the press and was immediately condemned as misleading or worse by people involved in the provision of family planning services. However, I doubt that they could have read the paper before commenting as it is in a specialised journal and I had some difficulty in locating a copy. Not only that, but it is full of impenetrable mathematics. The conclusion drawn in the paper is clear enough, though. Again, we seem to have an example of producer capture, in which a service is provided because it seems like a good idea but without examining the evidence.

As a final example of possible producer capture, let us examine one of our own most sacrosanct proposals — that of continuing professional development (CPD). Yes, it seems like an excellent idea — who could doubt it? But, has anyone set out to measure the benefits of CPD in any way? Not until now. A recent paper⁴ gave a critical review of the evidence for the cost-effectiveness of continuing professional development in health care. The discussion was "generic" in that it covered all health care professions, not just medicine. The authors state that CPD for health care professionals must be cost-effective to avoid waste of resources. However, they found that only nine economic studies, of varying quality, have been carried out in this area and that the evidence base so far does not allow any conclusions to be drawn about the economic value of CPD. But surely, you might say, something as important, nay essential, as CPD cannot be reduced to mere economics? Well, if we need to pay pharmacists to carry out CPD, to say nothing of paying for locum cover (as seems to be being mooted at present) then the economics of CPD matter very much.

The NHS always claims that it is strapped for cash, and we have just seen a massive tax rise put in place to reverse this. However, pharmacy CPD will be just one of many areas in which the additional money could be spent. We have, therefore, an obligation to demonstrate that a proposal such as that for compulsory CPD is good value for money and will not simply take up resources without any evidence that it is worthwhile. Within pharmacy, we must be careful always to demonstrate the value of what we do, or plan to do, both to the patients and to the wider community. We must not think just in terms of what it will do for us: of such is the essence of producer capture.

John Wilson is a semi-retired pharmacist based in Arnold, Nottinghamshire, who works part-time as a writer and locum pharmacist