Posted by: Emmanuel Chisadza20 JUN 2018
Pharmacists make invaluable drug therapy interventions every day.
In recent weeks, I can think of three notable ones. On two occasions, I identified patients concurrently using a long-acting muscarinic antagonist (LAMA) and a short-acting muscarinic antagonist (SAMA), tiotropium and ipratropium, respectively. In both cases, the patients had been changed to tiotropium by their consultants and supporting documents were sent to the GP. The ipratropium had unfortunately not been removed from their repeat lists. They continued to order these at different times, and so they were inadvertently being overprescribed.
On another occasion, I intervened where an 11-year-old had been prescribed 100ml of clarithromycin 250mg/5ml at 5ml four times daily. The dose should obviously have been 5ml twice daily, and the GP agreed to change it, but just for five days and not the recommended seven days. I won’t bother divulging his reasoning — suffice it to say, it was something to do with his ego.
In all these instances, the interventions made had a positive impact on the clinical outcomes for the patients involved. For the tiotropium and ipratropium cases, there were also obvious savings for the NHS.
A 2015 PricewaterhouseCoopers report commissioned by the Pharmaceutical Services Negotiating Committee estimated that in managing prescribing errors, community pharmacy saved the NHS £498 per user transaction through avoided GP appointments and reduced pressure on the health system.
Yet, the pharmaceutical care that pharmacies provide receives little recognition and/or payment, despite the community pharmacist being the last health professional to interact with patients before they receive and take potentially life-altering (or life-threatening) drugs.
Community pharmacy has experienced a steady decline in drug reimbursement and professional fees, and some professional services like smoking cessation have experienced massive cutbacks and are available only in a selected number of outlets. The fact that these interventions are supposedly covered by the diminishing ‘essential services’ pot, is scandalous.
Essential service provision is supposed to ensure that all patients receive standardised care including dispensing, patient education and counselling, identification and resolution of drug therapy problems, ongoing patient drug therapy monitoring, and documentation of all clinical services performed by the pharmacists. Funding for this should ideally cover the cost of drug provision ‘and then some’.
The aim should be to provide patients with an outcomes-oriented service that requires pharmacists to work in concert with other healthcare providers to ensure that drug therapy regimens are safe and effective. This is technically defined as ‘pharmaceutical care’. When done well, it optimises the patient’s health-related quality of life, and achieves positive clinical outcomes, within realistic economic expenditures.
Imagine a community pharmacy-run medicines management service for long-term conditions like diabetes and asthma. This could ensure the provision of appropriate health coaching, motivational interviewing and lifestyle management in addition to drug therapy. Patient monitoring could be achieved through regular collaboration and communication with other healthcare providers.
Care for patients with comorbidities taking multiple medicines present another possible service delivery tier. This would enable community pharmacists to spend more time with high-risk patients to help them safely and effectively manage their therapies. They could provide consultations more clinically focused than the current medicines use review model, and (of course) the results would be entered into a shared patient record.
But the current reimbursement framework rewards quantity rather than quality and has led us to a deleterious race to the bottom. The dominant position of those who can extract the best buying margins from the supply chain is not good for the profession.
Faced with funding cuts and staff reductions, innovative services are stifled, and professional leadership is left to those who don’t necessarily have the profession’s future at heart.
The advent of online pharmacies like Pharmacy2U and the inevitable pending arrival of big players like Amazon may push us towards the commoditisation of the medicines supply chain. This push is short-sighted and should not be allowed to dominate and shape the community pharmacy market.
To achieve real progress in the many issues that have dogged the profession, we need entrepreneurial cadres who are prepared to model and roll out new ways of working that preserve our values and strengths. ‘Same old, same old’ will not cut it.
Yes, this may increase the labour costs on community pharmacy, and drug costs may also increase as adjustments are made to attain shared therapeutic goals set by national disease guidelines. But total healthcare spending should, however, decrease as hospital admissions and emergency call-outs are reduced. This will present a win-win-win situation for commissioners, contractors and, above all, patients.
To paraphrase wartime leader Winston Churchill to the powers that be: “Put your confidence in pharmacy. Give us the tools and we will finish the job”.
Emmanuel Chisadza is a locum pharmacist in Dorset and Hampshire.