FIP 2008: The pace of change in pharmacy practice needs to be increased
The need for change in pharmacy practice was the topic of a symposiumorganised by the board of pharmaceutical practice, at the 2008 WorldCongress of Pharmacy and Pharmaceutical Sciences. Pamela Mason reports
The need for change in pharmacy practice was the topic of a symposium organised by the board of pharmaceutical practice, at the 2008 World Congress of Pharmacy and Pharmaceutical Sciences. Pamela Mason reports
Pharmacy practice must change at a faster pace than in the past, said Martin Schulz, head of the centre for drug information and pharmacy practice, Federal Union of German Associations of Pharmacists, in his introduction to the first FIP professional practice symposium.
Rising health care costs and the implications of the human genome project for use of medicines are just two of the many issues setting the stage for change in pharmacy practice, he said. History demonstrates, however, that change is not embraced rapidly.
He cited the example of lime juice, which was known to prevent scurvy by the early 1600s, but this knowledge was not put into practice by the British navy until 1795.
Pharmacists need personal vision
First is the need to help patients make best use of their medicines; and second is the long-term preservation of the pharmacy profession.
In free markets, economic imperatives mean that service provision is essential. The supply function can easily be provided by lesser trained personnel, so the need for pharmacists to perform a clinical function is clear.
However, pharmacists should not abandon the supply function, because it can co-exist with the clinical function, simply by “adding value to product”, he explained.
However, change is difficult and there is little evidence that pharmacists are changing. In most pharmacy practice sites around the world, pharmacists do not concern themselves with the best use of medicines.
Why does this matter? Mainly because of the risk of adverse drug reactions (ADRs), Mr Zellmer pointed out. About 25 per cent of ambulatory patients suffer from ADRs and at least 25 per cent of these are preventable.
Why do pharmacists not change their practice, he asked. Lack of motivation for change in the pharmacy profession lies in the pharmacist’s self-concept or vision. This is shaped by pharmacy education, practice patterns, public expectations, expectations of other health professionals and the legal scope of practice.
The pharmacist’s capacity for independent thought is a particularly important driver for change. Pharmacists have a deep knowledge of the truth — that their practice is not aligned with societal need, but both fear of change and lack of time conspire together to prevent the required change.
Yet change we must, said Mr Zellmer. We have a moral obligation to change and it will be worth the effort, not only from a broad societal perspective, but also for the sake of pharmacist fulfilment and self-esteem.
Describing the start of change as the “development of a moral compass”, he said that pharmacists need to have an inner dialogue such that they see their societal obligation to use their education and gifts wisely — and beyond their comfort zone — to encourage patients to use medicines properly.
This personal vision of the pharmacist must be addressed, he emphasised. The traditional paradigm will not sustain the profession and the idea that reform of structure deficiencies is enough to save pharmacy should be challenged.
“Make no mistake,” he said. “The supply function will be addressed by technology and economics. Pharmacy has a long-standing challenge — to put the needs of patients first.
If pharmacists do not find this moral compass, another professional to help people make the best use of medicines will be found. If pharmacists do not provide the solution, others will.”
Pharmacy organisations must change
It is not only pharmacists who need a moral compass, but also pharmacy organisations, associations and universities. Pharmacy organisations need structural change to reflect the importance of pharmacy services.
“Look at the amount pharmacy associations spend on advocacy and defending margins compared with pharmacy service development. Emphasising the role of the individual practitioner is not enough.”
The drivers for pharmacy change are clear and the same throughout the world: reduced profit margins, emphasis on safety and quality, increased healthcare costs, changes in remuneration agreements and changes in pharmacy education.
Innovative service development is important but this must be integrated with the pharmacy business and with product supply. Patients visiting a pharmacy expect to get a product, so although service delivery is important, it should not be separated from the product.
Accepting this need for change while sustaining business viability is one thing, but how do we achieve it, Professor Benrimoj asked. Although some pharmacists deliver cognitive services, the idea that others will follow the innovators has not born fruit, he said. To increase the speed of change requires organisations to change their structures and function.
Pharmacy organisations spend too much time buying into problems they cannot solve, such as margins and generics. Organisations are product-oriented not service-oriented. Too much time is spent on thinking about external stakeholders, such as governments, health insurers and doctors, while the problem is actually at an organisational level.
“Too often pharmacists are blamed for not changing, but it is a bit more complex than that. Change needs to take place throughout every structure in the profession.”
Professor Benrimoj went on to describe some research evaluating factors related to pharmacy practice change undertaken by his research group.
Factors encouraging change towards a service oriented model in this research included suitable pharmacy layout, good teamwork in the pharmacy and with other professionals, remuneration and generation of patient demand. Characteristics of “early adapters” included higher financial turnover, a larger staff and a desire to help people.
So, where are we now, he asked. Do pharmacists have the capability to change? Yes, if they have appropriate support in the form of remuneration for service delivery, funded support to address pharmacy infrastructure, service implementation and maintenance of service beyond any project period.
There are implications not only for pharmacists but for pharmacy educators and researchers as well as policy makers. “We need holistic change throughout every structure and organisation. The focus needs to move beyond practitioners. The foundations need to change otherwise pharmacy change will continue to be patchy and limited to innovators alone.”
How is change achieved?
Dr Maag based his presentation on the diffusion of innovation theory, which states that diffusion is the process by which an innovation is communicated over time, among members of a social system.
The study of diffusion innovation is the study of how, why, and at what rate new ideas and technology spread through cultures and can apply to changes in pharmacy practice and introduction of new medicines to market.
Several determinants drive the diffusion process, he said. These include communication channels of various types (eg, mass media, interactive and interpersonal channels), opinion leaders and social systems. The social context is important. All innovation must be compatible with the values, beliefs and past experiences of the social system concerned.
According to the diffusion of innovation theory, innovations are thought to spread through society in such a way that early adopters select the new innovation first, followed by the majority, until what was once an innovation is common. Diffusion is a social process so interpersonal networks are vital.
This theory can be used to describe the diffusion process for encouraging use of innovative drugs, Dr Maag said. Contextual factors influencing the use of a new treatment include health insurers and other health care payers, regulators, manufacturers, prescribers and information channels.
However, the balance of power among these participants is changing in that health technology assessments, physician groups and health insurers have increasing influence and increased cost is a major issue.
Contracts (including local listing of specific drugs, as occurs in the UK) can encourage uptake of innovative treatments, presenting a win-win situation for both patients and the healthcare system, he said. The decisions of authorities become crucial.
Given that pharmaceutical innovations increase life expectancy, survival rates and quality of life, it is important to understand the process of diffusion of innovation and work with it to speed up the uptake of innovative treatments and practice.
Applying lessons from the motor manufacturing industry to the delivery of healthcare
“Virginia Mason has a vision to be a quality leader in healthcare,which meant adopting a paradigm shift from thinking that defects are tobe expected to thinking and believing that zero defects in healthcaredelivery are not only possible but necessary.”
While healthcare technology and treatments have advanced considerablyin recent years, the business and management systems of healthcaredelivery have changed little since the 1950s and 1960s, he added.
The Virginia Mason production system (VMPS) is modelled on theToyota production system, a management method Toyota has used for morethan 50 years to produce its cars. VMPS uses Toyota principles toassess processes, eliminate waste and improve quality and patientsafety within the many processes involved in the healthcare system.This makes it possible for Virginia Mason staff to deliver the highestquality and safest patient care.
All too often services are designed around healthcare professionals,yet, as Toyota knows, services must be designed around the customer,or, in the healthcare context, the patient. By streamlining repetitiveand “low-touch” aspects of care delivery, staff members are freed tospend more time talking with, listening to and treating patients.
Explaining why car production was chosen as a model for healthcaredelivery, Dr Kaplan said that Toyota and Virginia mason share the samecore values: quality, safety, customer focus and a commitment to staff.Toyota has a rigorous system for involving front-line staff ineradicating mistakes and eliminating waste in its products.
Similar rigorous attention to all of the processes that surround thedelivery of patient care makes the Toyota system applicable tohealthcare delivery. Key to the VMPS are the staff who do the work andthey are encouraged to develop solutions to problems of error avoidanceand waste in the system (eg, waiting times and resources).
Benefits of the VMPS are that patients spend more time withhealthcare professionals, and VMPS tools and processes help providersto deliver the best possible care with zero defects. Patients benefitfrom greater safety, less delay in seeing physicians for care and moretimely results and treatments.
Virginia Mason staff benefit by havingless work to redo and greater opportunities to care for patients — oneof the primary reasons many choose health care as a profession. Theorganisation benefits because it operates more efficiently.
Ultimately,savings are reinvested to support the centre’s mission to improvepatient health and well-being.
Reports from the 68th World Congress of Pharmacy and Pharmaceutical Sciences
Citation: The Pharmaceutical Journal URI: 10038081
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