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Allan Karr, pharmacy business service manager at
University College London Hospitals NHS Trust
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What do patients want from pharmacy now? Do they just want an efficient
medicines supply service or do they also want accessible clinical advice
about their medicines and their treatment. The answer must be both.
The NHS is in the middle of developing a complex range of financial,
technical and professional changes to health care systems that will alter — beyond
recognition — the manner in which the pharmacy profession practises.
These drivers for change appear to be refocusing the key elements of
our profession and moving them slowly from a traditional “medicines/product” base
to a newer “service/medicines management”-based role. The
change from a focus on product to one that focuses on service has critical
implications for all those involved.
This fundamental repositioning of our role cannot be ignored, especially
if we are to manage the process effectively. Important strategic and
operational processes such as performance management and standards,
education and training, pharmacy practice and reimbursement need to be
carefully considered in the context of this evolutionary transformation.
Pharmacists are experts in the manufacturing and supply of medicines.
We have spent many years being trained to formulate and dispense medicines.
Extemporaneous dispensing of a wide range of formulations has, until
a few years ago, been a significant part of the pharmacist’s role.
The continued development of convenient and ready-made medicines provided
in patient packs by the industry appears to be reducing the need for
some of our existing range of skills. Also, the impending introduction
of automated
dispensing technology will most probably
reduce the need for pharmacists to provide significant input to handling
the product and supply in the future. This increase in efficiency in
the provision of a medicine supply will potentially release the pharmacist
to look at expanding their skills into other critical roles. These roles
may not be traditional product-oriented ones, but rather service-focused
ones.
There is significant awareness now that patients continue to have problems
with taking their medicines despite our existing attempts to improve
their pharmaceutical care. For example, the wastage found from ad hoc
medicines “dump” campaigns and the high incidence of hospital
admissions due to iatrogenic disease are worrying features of this problem.
Many patients may not be receiving the optimum preventive health care
support that they require from a modern health care service. The significant
resources now invested must deliver tangible improvements in this direction.
Patients clearly desire and need more information about their diseases
and the medicines that they take. The information they require is more
than what is available from a patient information leaflet. Patients would
prefer easily accessible clinical advice about the medicines they have
been asked to take. Pharmacists, because of their expertise, now have
an opportunity to provide a medicines management service to patients.
The medicines management service-based role will inevitably expand. The
role may, however, require a slightly different set of skills from that
of managing the traditional product/medicine-based dispensing or extemporaneous
preparation service
The management of services is different from that management of products.
Although many may regard the differences as small, the variations could
have a major impact on the way we do things. Pharmacy services, as for
other services, are intangible. So unlike medicinal products, they cannot
be made on a production line nor can they be seen or touched before they
are used. The pharmacy service will be consumed at the time that it is
given and so cannot be put on a shelf like medicinal products. Services
will inevitably be variable and will be dependent upon the skills and
expertise of the individual pharmacist involved. The effectiveness of
the pharmacy service provided will also be dependent upon the person
receiving the service.
Services are therefore characteristically more difficult to manage than
products and will present pharmacists and their managers with a new set
of challenges.
Evolution or revolution?
Evolutionary changes from a medicine/ product focus to a service/medicines
management focus has already become well established in the hospital
pharmacy sector. The growing demand for a wide range of
pharmaceutical services which are not just supply oriented has changed
hospital pharmacy from a dispensary-based service to a more clinical
service, eg, patient counselling, anticoagulant clinics, formulary management,
product evaluation, clinical audits and protocol development.
This service transition has taken approximately three decades. Understanding
the evolutionary process may be helpful in formulating practices to manage
today’s changing world.
Hospital ward pharmacy services started in the 1970s. Before then, prescriptions
were routinely brought from wards to pharmacy departments by nurses.
It was recognised that there was a more efficient way to monitor ward
prescriptions than wasting nurses’ time by frequently visiting
hospital dispensaries.
At that time hospital pharmacists generally did not review patients’ notes.
In the 1980s, following the expansion of ward pharmacy, the development
of clinical pharmacy occurred. Here, pharmacists took a greater interest
in the clinical needs of individual patients. There was insufficient
clinical information on the prescription chart alone to enable safe dispensing
to occur. Ward pharmacists were ideally positioned to review patients’ notes,
including laboratory results. Complex clinical interventions were made
possible which improved patients’ clinical outcomes. Extensive
clinical pharmacy training courses were introduced to assist in supporting
this new role and these are still widespread.
The clinical role was expanded further as directorate structures developed
within trusts. Each directorate was given its own drug budget to manage.
The role of clinical pharmacist now required additional services in order
to support the financial needs of the directorates. The new clinical
directorate pharmacists were asked to assist the health care team in
controlling their ever-increasing expenditure on medicines.
A few trusts have now introduced consultant pharmacists. Much of this
latest role will resemble that of an independent practitioner and so
will include prescribing, research and clinical governance issues. Pharmacists
in these roles will tend not to be involved in supply functions, such
as dispensing or extemporaneous manufacturing. They will,
perhaps, not even see these particular pharmacy services as their responsibility.
These pharmacists have moved on: they have evolved into becoming experts
and providers of pure services.
The primary care sector is now beginning to show similar patterns of
change owing to the demands of patients and budget holders. The introduction
of primary care trust advisers, medicines management projects and clinical
governance initiatives is perhaps the beginning of this evolutionary
process. The new pharmacy contract will look at reimbursement for a wider
range of services than ever before, eg, cholesterol management and anticoagulant
services. I suspect that soon there will be little difference in the
level of service provision between these health care sectors.
The only difference between the sectors will be that the hospital sector
has had three decades to evolve while the primary care sector has considerably
less time to adjust to the new service demands. Despite the short time
scales, there are positive signs that the revolution is occurring. |
The
Pharmaceutical Journal