Medicines Management
Issue no 1, pp7-8
January/February 2002

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How to get going in the community

What does any body know about medicines management? Every seminar I have been to on the subject, starts with this "What is medicines management?" question and usually answers it in terms of "pharmaceutical care" as defined by Heppler and Strand¹.

Apparently, even though the term pharmaceutical care defines a process not a profession, there are political sensitivities about how the use of these words imply the restriction of this role to pharmacists only. Not a good place to start. Surely it would have made more sense to have kept the original definition of pharmaceutical care and given examples of how health care professionals, including pharmacists, fit into the scheme of things.

So before starting medicines management I need to know what it means. Thus the launch of this new publication is particularly timely and Douglas Simpson's bibliography of some of the most important articles to be published in the PJ about the topic gives examples of good practice².

What is missing is a description of the means by which we, as a profession, can deliver this new role nationally or even within a primary care organisation. Marshall Davies, President of the Royal Pharmaceutical Society, has discussed this "reality gap" in terms of just how can we provide pharmaceutical care during a day that is already full. There are issues here to do with skill mix and funding that need to be addressed in order to start providing an infrastructure for the future (see Panel).

Assuming that these problems can be overcome, how are we going to organise our work? Any job where we can work independently, eg disease management clinics, domiciliary visits and brown bag reviews could be managed tomorrow given the right infrastructure and adequate training.

However complex medication review involving direct communication with the GP, to discuss clinical issues involving individual patients, is fraught with difficulty.

Our own experience is that GPs start out with good intentions towards any scheme of work that we have introduced, but quickly the conflicting demands on their time mean that only the most urgent reviews are dealt with. One of the biggest barriers to change is our own pharmacist mental barriers. In my own case, I was locked into a spiral of increasing levels of dispensing, leaving less time for other services and an unwillingness to do anything, (including training) for which I was not going to be paid.

What changed my mind?

The gradual realisation that my pharmaceutical knowledge base was out of date, persuaded me to take a part time Diploma in Clinical Pharmacy and, paradoxically, it was this that brought about a change in the way I thought about the way I ran my business.

At the time I thought that a day a week out of the dispensary, for training, was an indulgence but I gradually came to see it as an investment in the future. At about the same time I remember Sir John Harvey-Jones (former managing director of ICI) presenting a series of BBC programmes called "Troubleshooter". This successful businessman would go into failing companies and attempt to solve their problems by acting as a management consultant. One of his most consistent findings was that these companies failed to provide sufficient resources for research and design of new products/services, to secure future growth.

The diploma let me see that there were opportunities to increase the range of services I could offer from the pharmacy and, pretentiously, I thought about these in terms of John Harvey-Jones' advice.

Work with another pharmacist

The volume of work and the desire for change meant I needed another pharmacist to work in the same pharmacy and it is this one factor that has seen these changes implemented. I have been lucky to work with John Hall (in spite of his mistaken allegiance to Newcastle United) but I would strongly recommend any single-handed community pharmacist look at working with a second pharmacist. Give it a try, even if initially it is only half a day a week and limited for, say, 6-12 months. It will change your life.

The next stage is to decide what additional service you wish to provide, preferably something that interests you. It does not need to be high-powered, perhaps just selecting one or two nuisance patients and sorting out their problems. And it is not so much what you choose to do, as the way you do it. Away from the dispensing process, in protected time. Look at sources of funding — approach the PCG or drug companies. The expertise you develop grows out of your own interest and is firmly rooted in the needs and abilities of your own community.

Our interest in diabetes started as a simple query from a patient for quality control solutions, for a blood glucose meter. The local representative acted as a facilitator, introduced us to the local diabetes team and was then able to arrange some financial support for a study. Nothing to do with medicines management initially, but our developing involvement means we may have the opportunity to be involved in disease management in the future.

Impact on our business

When John joined us 10 years ago we did not envisage that the new roles we were developing would be such an important part of the business. This year, for example, our professional income from sources outside the global sum will exceed the income from our total over the counter sales. With hindsight it looks like strategic management but it was not that well organised. But we did have a vision and were prepared to invest time and money in making it happen.

We need strong leadership to deliver the infrastructure and income to make these changes happen across the profession. But as separate businesses, individuals and corporate bodies, we need to invest in our own future. Otherwise we present as the Arthur Daley's of the day with our flash cars and under-resourced premises³.

Finally I would appeal to our labelling software suppliers. We urgently need the tools to store additional data, to be able to identify and recall patients according to various criteria and to be able to manage repeat prescriptions in a structured way. We need to be thinking in terms of medicines management not just data transmission. I quote John Harvey-Jones: "The future lies in companies taking advantage of IT systems to do something new, rather than use IT systems to modernise and mechanise what they already do".