The Pharmaceutical Journal
Vol 279 No 7479 p600-601
24 November 2007

This article
Reprint   Photocopy

PDF 50K, Acrobat Reader

Cracow

Take total responsibility for a patient’s drug therapy to ensure effective care

Accepting total responsibility for a patient’s drug therapy is the only way to deliver effective pharmaceutical care, according to Linda Strand, professor of pharmaceutical care at the University of Minnesota.

She told the conference that, in taking responsibility, pharmacists should be prepared to make decisions about pharmacotherapy that can make life and death changes.

“We should be delivering a service that is based on what the patient needs, not what is convenient for us. Medics and nurses always put patients first. They will recognise very quickly if you are putting yourself first, and they will not listen,” she said.

Patient care

Professor Strand has been instrumental in developing the practice of pharmaceutical care in the US. She spoke of the many mistakes she has made over the years that have led to the development of her model of complete pharmaceutical patient care.

The practice won funding in Minnesota in January 2006. Now, pharmacists there receive $90 for each pharmaceutical care consultation and patients generally return for follow-up consultations three times per year. This type of practice is now funded in around 20 states.

“There is only one rational decision-making process — problem-solving. You need to learn and execute this to provide pharmaceutical care. You need to know what the problems are [before you can solve them].” She said it is then essential that all problems are followed up personally by the pharmacist, another element of taking responsibility for patient care.

“Each medicine that the patient is taking needs to be evaluated to ensure that it is appropriate for the indication, the dose is effective and there are no unacceptable side effects,” she continued. “Patients do not take their medicines for good reasons. Before you encourage a patient to be compliant, don’t assume the drug is appropriate, safe or effective, just because the clinician has prescribed it.”

Alastair Buxton, head of NHS services at the Pharmaceutical Services Negotiating Committee, defended the importance of compliance monitoring — a component of England’s community pharmacy medicines use review process.

“You will not know if a patient’s hypertension medicine is working unless you know that they are taking it.” However, he agreed with Dr Strand that checking a medicine’s indication, effectiveness and side effects was equally important.

Isolate care from dispensing

Professor Strand told the audience that she could teach any pharmacist to deliver pharmaceutical care; however this practice had to remain separate from dispensing. Furthermore, once a pharmacist was practising pharmaceutical care, they would find the task of “traditional” dispensing challenging. This is because pharmaceutical care requires the pharmacist to consider other drugs and physiological markers, such as potassium level and blood pressure, when assessing a dose for appropriateness.

These factors are often not known in a dispensary, so a pharmacist who provides a pharmaceutical care service may find it difficult to dispense a prescription without that knowledge. Professor Strand estimated that only 10 per cent of the profession would want to deliver a pharmaceutical care service — that is full patient care — and that the remaining 90 per cent could concentrate on dispensing medicines correctly.

Karen Peachey, senior vice-president at the Pharmacy Guild of Australia, talked about the home medication review service that has been provided by pharmacists in Australia since 2001. Patients are flagged for a medication review by a GP, nurse or relative, and then choose the community pharmacy through which the review is conducted.

An accredited pharmacist conducts the review in the patient’s home, enabling the pharmacist to view all medicines that the patient owns, the technique used by the patient to remember to take medicines and his or her method of administration.

Dr Peachey agreed that it was important that this process was conducted away from the dispensary to allow the pharmacist to concentrate on the review without distractions. However, it was not a necessity that a pharmacist who did not also provide dispensing services undertake the review.

The nominated pharmacy receives AUS$180 for each medication review, which may be conducted by the pharmacist outside dispensary hours. Alternatively, it can be subcontracted at an agreed percentage payment to an external accredited pharmacist who returns the findings of the review to the patient’s GP via the nominated pharmacy.

Dr Peachey commented that the service was of particular use in Australia, where patients commonly see several medical specialists, and the GP is not always aware of the patient’s full list of medicines.

Mr Buxton agreed that pharmacists providing pharmaceutical care services required dedicated time to do so, without being distracted by dispensary issues, but he was confident that this was possible without the pharmacist leaving the pharmacy.

Single disease clinics

Professor Strand criticised the implementation of schemes that only aim to treat a single disease, such as pharmacist-led asthma clinics, because patients rarely suffer from a single disease. “You should solve a patient’s problems in order of the patient’s need, not in the order that you want to sort them. This does not look after the needs of the patient, but looks after the needs of the pharmacist.”

Alison Strath, principal pharmaceutical officer for the Scottish Government, gave backing to such schemes as a way of engaging community pharmacists in providing more patient-centred pharmaceutical services.

She acknowledged that Dr Strand’s model of pharmaceutical care fully addressed patient needs, but it was only being provided by a small percentage of pharmacists in the US, and therefore only available to a small number of patients.

In Scotland, she said, it was important that all patients were given equitable access to pharmaceutical care services.

The phased implementation of the new community pharmacy contract allowed pharmacists to develop a systematic approach to providing pharmaceutical care by breaking it up into smaller chunks, allowing the whole profession to move forward together.

“Developing the Scottish pharmacy contract involved many discussions with patient groups and care experts, such as Dr Strand, about what was needed. We then discussed this with pharmacists, to create a shared vision of how to move forward.”

Ms Strath suggested the pharmacist-patient relationship should be developed first, and this is being done in Scotland by building pharmaceutical care services on to a foundation dispensing service. This partnership is then extended to include the patient’s GP.

Professor Strand agreed that all patients should have equal access to services “However you can’t start by offering everything to everyone. You have to build practices one at a time,” she said.

Dutch pharmacy

Foppe van Mil, professional secretary of Pharmaceutical Care Network Europe, talked about how the structure of pharmacy services in the Netherlands has facilitated the integration of pharmaceutical care into community pharmacy practice.

In the Netherlands, a non-regulated medicine supplier known as a druggist provides the majority of over-the-counter sales. This allows the community pharmacist to focus on dispensing prescribed medicines, which contribute approximately 93 per cent of the turnover for a typical pharmacy.

In addition, customer loyalty is very high, with 95 per cent of patients routinely using the same pharmacy for getting prescriptions dispensed.

A secure broadband link has been set up between pharmacies and GP surgeries and also between all pharmacies in a region. This allows a pharmacist to check for interactions between the prescribed medicine and all medicines that have been dispensed for the patient in any other local pharmacy. This lets the pharmacist monitor the patient’s compliance with their medicine and provides the GP with information regarding the medicines that are dispensed.

The Netherlands has a large number of registered technicians who undertake extended services such as patient counselling and medicines use reviews, under the supervision of the pharmacist.

With a link to the GP computer system, pharmacies can obtain information on a patient’s medical diagnoses to provide the patient with personalised information leaflets that only contain the necessary information for the patient’s condition.

Other services being implemented in Dutch pharmacies include a cardiovascular risk assessment, and a questionnaire of all patients taking non-steroidal anti-inflammatory drugs to identify those who need gastro-protective therapy.

International communication

The conference was aimed at promoting the concept of pharmaceutical care to countries in Eastern Europe, however it concluded with all the key speakers agreeing that more collaboration was needed to develop the concept of pharmaceutical care worldwide, not just in Eastern Europe.

Mr van Mil called for more international collaboration between countries with regard to the success of various methods of pharmaceutical care. Although he acknowledged that different countries had different health care systems and different roles for pharmacists, “there was no point in everyone making the same mistakes at different times”.

International communication had to improve to drive the profession forward. In addition, pharmacists would need to be taught how to talk and touch patients. “If you are going to be discussing potentially difficult issues with patients, you may be required to at least hold their hand.”

Implementing new services

The cost of drug-related morbidity in the US is now higher than the cost of the drugs (Ms Strath and Mr Buxton confirmed that this may also be true in the UK). There is a big push to move patient care out into the community because hospital care is so expensive.

“In this practice [the model of pharmaceutical care developed by Professor Strand in US] we save $5 for the health care system for every $1 we spend delivering the service. This is the exact ratio of benefit to cost that is seen from vaccinations.”

In Professor Strand’s experience, it is not the government or physicians who hold back the implementation of pharmaceutical care. “Pharmacists are the rate-limiting step.” However, she warned that physicians behave differently in a political arena than they do in practice. She suggested that by changing things clinically first and politically second, the physicians will be a lot more supportive.

All key speakers agreed that this had been the case in their experience.

Dr Peachey recalled that the implementation of pharmacy innovations, such as the home medication review, involved first obtaining pilot data, then completing a literature review to confirm that data align with that in other countries. Legislation is the last stage of the process, once the cost savings and patient benefits have been presented to government.

Ms Strath recommended that new services require the patient to make the decision to improve their health, and the profession must then engage with them, to help them make the right decision.

Professor Strand believed that to provide a new patient care service, pharmacists have to understand what is happening in health care and fit the new service so that it augments existing care services. However, she reassured the audience that creating a pharmaceutical care service was not as difficult as it may appear.

“You are not required to fix all of a patient’s problems at once. Start with one patient and one problem. Find a solution and follow it up. Then move on to the next problem.”