Further information
Detailed proceedings from the “Pharmacy in the
far future” meeting will be available on the internet later
this week at www.pharmacyinthefuture.org.uk |
Predicting the future is impossible. But when a group of senior
pharmacists, academics and policy makers met recently to discuss what
pharmacy will
look like in 10 years’ time, the same themes came up again and
again. So it is a pretty safe bet that these themes will be central to
pharmacy’s future.
Supporting self-care and the development of chronic disease management
were top of the list. Better use of IT, more integration with other health
professionals and expansion in the use of diagnostics all featured. None
of these is a great surprise. So it is good news for pharmacy that the
groundwork for the future is already being done.
 The conference organiser Beth Taylor, member of the NHS Modernisation
Board, said that its aim was to paint a picture of future issues in health
care so that pharmacists are equipped to respond. “I don’t
think it is possible to say ‘this is what pharmacists will do’.
That was clear from discussion groups at the event, particularly around
IT where there is so much happening that we have to work with shorter
timescales. The idea was to give people a better feel of when things
might happen,” she explained.
Trends and expectations
In order to understand what might be required of pharmacy in the future,
participants at the meeting examined trends in health and patients’ expectations.
Life expectancy is increasing, and the population is ageing. The big
question is whether the elderly of the future will be fit and healthy
or frail and dependent, according to Candace Imison, head of whole
systems strategy at the NHS Modernisation Agency. “The burden
of disease is changing. There is a shift from acute to chronic disease,” she
said. Since 1991, prevalence of diabetes and osteoporosis has increased
and, by 2030, 50 per cent of the population will be suffering from
a long-term condition. This will place a significant burden on the
health service.
A serious problem is that current lifestyles are simply not healthy
and 60 per cent of the current burden of disease is linked to lifestyle
factors.
But the general public has yet to take this seriously. For example, only
13 per cent of the population eat the recommended five portions of fruit
and vegetables a day yet 40 per cent eat biscuits on a daily basis. Rates
of obesity have trebled in the past 20 years. And that is before mentioning
the effects of smoking, excessive alcohol intake and illicit drugs.
Despite risky behaviour, people have increasing expectations around their
health and what the health service will provide. “But will patients
accept responsibilities for their own health as well as expecting rights,” asked
Ms Imison. “In 10 years’ time we will start to reap the consequences
of the health risks people are taking now. We have a critical time in
the next five years to develop models of care to cope with the potential
increase in demand we will face in 10 years.”
People’s expectations about how care is delivered are also changing. “Young
people have a completely different attitude towards the way in which
technology is a part of their lives,” said Harry Cayton, director
for patients and the public, Department of Health. “So we absolutely
have to embrace what technology is doing.” He sees technology at
the centre of future health care: patients making appointments online,
downloading information from the internet and accessing their own health
records online. In pharmacies, he sees the introduction of electronic
transfer of prescriptions and monitoring of repeat prescriptions through
pharmacies as major technological advances. “This would add enormous
value for an increasingly mobile population who live and work in different
places,” he said. Roles for pharmacy
So what will the future of pharmacy hold? “There will be much closer
integration with the primary care team, better use of IT and a better
contribution to health improvement and public health,” according
to Jim Smith, chief pharmaceutical officer, Department of Health. “One
of my personal aims is for pharmacists’ public health role to be
anchored in the new pharmacy contract.” He added that he believes
pharmacists will be involved in supporting patients who are being treated
with highly technical diagnostics and treatments and, at the same time,
supporting other people through self-care. “As I see it, we will
see a pharmacy service which is more focused on health inequalities and
health improvement,” he said.
One of the biggest changes happening in health care now is a new
focus on chronic disease management (see PJ, 15 May, p601). “We are already
well into the shift from individual acute care to chronic disease management,” said
Dr Smith. “Pharmacists will play a major role in chronic care because,
let’s face it, lots of chronic disease management is around medicines.”
Dr Smith said that IT is central to the changes in pharmacy. “We
are in the middle of an IT revolution. It is the first time the NHS has
tackled IT properly,” he said. “The introduction of the national
care record and ETP will revolutionise how we handle medicines. We are
proposing that pharmacists have read-write access to the national care
record dependent on their role and with patient consent. There will be
a consultation on this but it is our firm intention. There will also
be more automation in hospitals. Things have been slow around e-prescribing
in hospitals and I hope this can be accelerated.”
Other levers for change included the new community pharmacy contract,
increasing the variety of locations and roles in which pharmacists worked,
and the fact that more pharmacists are becoming prescribers. “There
is a massive range of developments already in place. We now need to accelerate
that and ensure that pharmacists do their bit around chronic disease
management too,” he said.
From a patient’s viewpoint, Mr Cayton’s prediction for the
future is that pharmacists’ main role will be in providing support
for self-care. Patients want more control of their health, especially
long-term conditions, he said. He advocated expert patient programmes
to empower people to make decisions in how to manage their health care. “As
patients take more control of their condition, they are more likely to
take their medicines properly.” But he said that patients need
better information about health and help to know what questions they
should ask about health. “Pharmacists are a group that patients
feel comfortable talking to,” he said. Another role for pharmacists
is in ensuring that patients are given information about medicines, particularly
risks associated with them, so they can make choices, he added.
Mentioning the POM to P switch of
simvastatin, Dr Smith said: “It is the first
medicine for a long-term condition and I’m pretty sure there will
be more. It has big implications for pharmacists. I won’t dwell
on the Which? report, as I have grave difficulties with it, but there
is no doubt that Which? did uncover some examples of bad practice that
we have to tackle as a profession.” Workforce
With the number of people aged over 65 years projected to be greater
than the number of people aged under 16 in less than 10 years’ time,
there are concerns that demands on the health service will be too great
for the number of people available to work in it. “These changing
demographics mean that we will have to draw on new workforce pools
and develop better models of care,” said Ms Imison. “The
current NHS model reflects the world of 1948 when doctors were doctors,
nurses were nurses, and there was a focus on acute rather than chronic
care.” New approaches could be to offer chronic care in group
appointments, make better use of remote care by e-mail or telephone,
and use non-traditional care settings.
Whatever future roles for pharmacists are proposed, they can only be
realised if there is a sufficient number of pharmacists to do the job.
A national pharmacy workforce review will be published later this year
and preliminary results were presented at a recent conference in London.
This coincided with the launch of this year’s pharmacy workforce
census by the Royal Pharmaceutical Society (see Panel below).
Pharmacy workforce issues: how the profession
will change in 10 years’ time
Later this year, the results of a national pharmacy
workforce review will be published. It is expected to reveal how
the workforce is
changing and what the long-term impact of these changes will be.
Part of the research has been the development of a model that will
enable more accurate prediction of the effect of proposed policies
on the workforce, explained lead author David Guest, professor of
human resource management, King’s College London, at a conference
in London on 26 May. The review is sponsored by the Royal Pharmaceutical
Society and the three national health departments.
Preliminary results from the review indicate that the greatest risk
to the profession is pharmacists cutting their working hours. “There
is no evidence of any significant planned exit of pharmacists from
the profession. There are modest levels of planned internal moves
within pharmacy but no dramatic shift from one sector to another,” Professor
Guest said. “However, there is some pressure to reduce hours,
notably among those who give a high priority to work-life balance.
This issue is perhaps the one about which we need to be most aware.”
The data show that in five years’ time, 80 per cent of those
currently working as pharmacists expect to remain in pharmacy. Thirteen
per cent of pharmacists expect to change sector in the next five
years, 38 per cent expect to change the organisation they work for
and 53 per cent expect to change job. “A majority would like
to extend their role upwards to do more interesting things but they
also believe they have limited opportunities to do so,” said
Professor Guest. Constraints cited include (in priority order) a
lack of time, workload, insufficient pay, lack of support from management
and lack of trained support staff.
The Society’s 2003 pharmacy workforce census revealed an increase
in the number of pharmacists who are working part-time, so perhaps
there is already a determination among pharmacists to cut their working
hours. The census also showed that the proportion of pharmacists
working in community pharmacy has decreased while hospital and primary
care pharmacy have gained numbers. Overall, the register grew by
2.4 per cent last year. See p750 (PDF 50K) for a more in-depth look at results
of the new census.
So what of the future? The new model cannot predict the future but
it can be used to assess whether supply of and demand for pharmacists
match, or if there is a risk of under- or over-supply. It incorporates
data on demand, for example in community pharmacy this is based on
prescription numbers and in hospital pharmacy on patient numbers.
Supply information comes mainly from surveys and higher education
statistics. Data are then fed into the model and scenarios tested
by altering the assumptions made. For instance, based on a scenario
of an increase in the number of whole-time equivalent pharmacists
from 27,000 now to 45,000 in 2013, if 10 per cent of the workforce
reduced their working week by four hours, the number of whole-time
equivalent pharmacists would drop to around 40,000 in 2013.
The research has highlighted particular questions around the supply
of pharmacists. “The assumption from our work is that we have
got to be fairly pessimistic about the possibility of pharmacists
considered ‘permanently lost’ to return to the fold.
So other sources of supply have to be found or there is a need to
think more carefully about job redesign and skill mix,” said
Professor Guest. Perhaps pharmacists should be discouraged from quitting
in the first place, he suggested. “Quite a lot could be done
with human resource policies in organisations to increase pharmacists’ commitment
to the organisation and profession, particularly around improving
work-life balance,” he said.
The team has identified a number of propensities that pharmacists
who leave the profession are likely to have, along with others for
those who are more likely to reduce their hours or have a career
break. These will be published in the report later this year. |
New medicines
Developments within the pharmaceutical industry will change the medicines
that pharmacists work with in future. One of the most talked about of
these is genomics, but there are plenty of other advances too.
Bill Dawson, research and development committee, Association of the British
Pharmaceutical Industry, said that the next 10 years will be about making
better use of existing medicines. The introduction of novel medicines
to the market will increase in five to 15 years but it will not be until
10 to 20 years’ time that genomic medicines really come good.
The delivery of genetic material into the body has been the big hold-up.
Finding a good vector is key to the future of genomics. Although viruses
work, they give side effects, so alternatives are being sought. Professor
Dawson said that it is easier to get proteins into the body than DNA
but that the science of proteomics is behind that of genomics.
What will make a difference in the near future is that pharmacogenetics
will be applied to existing therapies, he said. It could be used to identify
a genetic basis as to why people do or do not respond to a particular
drug. “By genetically typing patients, you can tell them if a medicine
will work for them in advance which is better than them trying it and
discovering that it doesn’t work,” he explained. “This
is a low-hanging fruit in research terms; something we can get at quickly,” he
said. Examples of drugs where genetic reasons for variations in response
have already been identified are leukotriene antagonists and pravastatin.
He expected that more new drugs will be targeted for patients using diagnostics
in a similar way to that used for trastuzumab. It is only effective in
the 25 per cent of women who over-express a certain gene and this must
be tested for before treatment is started. Without the test, it is unlikely
that the drug would have been marketed since identifying the 75 per cent
of people for whom it is ineffective would have been impossible.
A Government organisation that spends its time looking into the far future
is Foresight. It aims to produce challenging visions of the future drawing
on the experts in science, business and Government. One of Foresight’s
current projects that is relevant to pharmacy is the “Brain science,
addiction and drugs” project. It is examining the medical and social
effects of increased knowledge about the brain and how it can be influenced,
including using legal and illegal drugs. Some of the questions it aims
to address are: What are the psychoactive substances of the future? What
else will be used to treat the brain in the future? Should drugs be used
as cognitive enhancers to alter a healthy brain as well as to treat illness?
Can a body be made to make its own drugs? Further information about Foresight
is available at www.foresight.gov.uk Pace of change
Dr Smith concluded that nothing that had been talked about at the meeting
was incompatible with the direction that had already been set in last
year’s Vision for Pharmacy. Whether or not the predictions are
correct, one thing is for sure: the pace of change
remains uncertain. |
The
Pharmaceutical Journal