The foundations of pharmaceutical care in the UK lie with the pharmacist as a healthcare practitioner in the community. Traditionally this role has required the pharmacist to provide medication for patients on an individual basis and to provide advice which meets the needs of patients. Over the past 15 years the advisory role of the pharmacist has developed in the community and in the hospital. Clinical pharmacy has become part of the mainstream of the pharmacist's contribution to patient care. There is now widespread recognition of this development not only within the Health Service but also by professional bodies and by Schools of Pharmacy. The term clinical pharmacy no longer implies any degree of exclusivity but has come to be used generally to describe the knowledge, skills and attitudes required by a pharmacist to contribute to patient care. As the delivery of healthcare becomes more dependent upon successful multidisciplinary co-operation, increasingly pharmacists see their contributions in terms of overall patient outcomes.
The UKCPA has already adopted the fostering of pharmaceutical care within its mission statement. This paper seeks to interpret the conceptsof pharmaceutical care based on the experience of clinical macists in the United Kingdom.
The Scope of Pharmaceutical Care
Pharmacy has evolved in such a way that the role of the pharmacist has adapted from product-oriented custodian to service-oriented technologist. The term pharmaceutical care enables pharmacists to describe their further evolution into patient-focused healthcare providers. Pharmaceutical care has been defined succinctly as;
"The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life." (Hepler & Strand 19901 )
The three key phrases are;
The responsible provision of drug therapy
In providing medicines, pharmacists inevitably share responsibility for the consequences to patients. The pharmacist has a legal responsibility to protect the patient from demonstrable harm, for example, personal injury arising from an overdose or from an incorrectly dispensed item. Pharmacists also have a moral responsibility to protect the patient from suboptimal drug therapy through their professional activity. The concept of pharmaceutical care seeks to codify this responsibility.
Definite (patient) outcomes
In order to protect against suboptimal drug therapy, desired patient outcomes must be made explicit and shared by doctors, patients and pharmacists. Such co-operation allows pharmacists to set their professional objectives in accordance with patients' needs. In order to discharge their responsibilities to patients, therefore, pharmacists must establish the exact purpose of drug treatment and the desired patient outcomes both before and during the provision of drug therapy. Since pharmaceutical care is delivered over a period of time and by a number of individuals, it follows that the desired patient outcomes should be documented and accessible to those individuals.
Quality of life
In order to be meaningful to patients, the outcomes should be expressed in terms of their own quality of life. In practice it is necessary for pharmacists to strive to improve that quality of life. In practice it is necessary for pharmacists to strive to improve that quality of life, whether it is guaged objectively or purely subjectively.
The emphasis on quality in healthcare focuses increasing
attention on the management processes required to provide
services to patients. Pharmaceutical care results from the
application of the principles of quality management to the use of
medicines. Quality management can be summarised as requiring;
Dialogue with consumers of care
Teamwork amongst providers of care
Process definition and assignment of responsibility
Measurement and recording of data to prompt continuous improvement of care
The delivery of pharmaceutical care therefore requires a quality system to be established for the individual treatment of patients with medicines. It is the function of the multidisciplinary team to implement a system for the overall management of the use of medicines in patients. It is the function of the pharmacist to take responsibility for that system of medicines usage which will provide the required level of quality assurance. The test of quality assurance in drug therapy is the demonstration that the usage of medicines accords with patients' needs. The patients' pharmaceutical care needs can be said to have been met when their drug treatment meets identified objectives in terms of clinical benefits, safety, efficiency of medicines usage and patient preferences.
Dialogue with consumers of care
Health professionals discharge their duty of care to patients through a process of individual assessment, usually through dialogue, to determine the patient's needs. Working within an integrated health care system, pharmacists have a duty to contribute to the assessment of patients' needs and the identification of potential as well as actual problems associated with drug therapy. Through dialogue with patients, pharmacists establish a suitable relationship to enable them to monitor drug therapy and to strive for continuous improvement.
Teamwork amongst providers of care
The implementation of a quality system for medicines usage requires that all members of the healthcare team be concerned with pharmaceutical care. The sharing of information on desired outcomes and on the consequences of drug therapy is necessary for the team to maintain quality systems. The commitment of the patient is a necessary part of this co-operation and is therefore a key objective to be secured. It follows from these considerations that the pharmacist has a responsibility to ensure that drug treatment and related care issues are fully documented.
Process definition and assignment of responsibility
To maintain and improve standards, care must be defined in terms of a series of processes each of which can be documented and assigned to individual responsibilities. The processes of care must be organised into a system designed to deliver defined patient benefits. Pharmacists should be instrumental in establishing and maintaining effective systems for the use of medicines in individual patients and in patient groups.
Measurement and recording of data to prompt continuous improvement of care
A quality system for managing drug therapy must be fully documented to allow sharing of information and continuity of pharmaceutical care. To achieve a focus on the outcomes of drug therapy, objective and subjective measures should be recorded, evaluated and collated so that improvements in care can be sought not only for individual patients but also for particular patient groups. For any patient group, the efficient use of medicines as a resource becomes an objective of the continuous improvement of pharmaceutical care.
Progress in Pharmaceutical Care in the UK
The essential skills for the delivery of pharmaceutical care are
already taught and practised within the profession. There is
however a need to broaden the availability of this training and
to extend pharmaceutical care. Emphasis must be placed on both
interpersonal and clinical skills training to develop the desired
attitudes. In practice, the co-operation of other healthcare
professionals has been widely secured, although there is a need
to increase understanding of the concept of pharmaceutical care.
A healthcare environment which supports the general implementation of quality management systems and audit programmes is entirely compatible with the development of pharmaceutical care. The speed of this development depends on pharmacists adopting those quality assurance techniques and applying them to their own discrete areas of practice. The implications of the development of pharmaceutical care for the organisation and practice of pharmacy in the UK can be considered under the following headings;
Meeting patients' needs
Prescribers' needs for pharmaceutical care
Models of pharmaceutical care
Pharmaceutical care and public health
Research and development of pharmaceutical care
Meeting patients' needs
The increasing complexity of healthcare is presenting professionals and patients with a wider range of choices. As patients are encouraged to participate more in these choices, the assessment of an individual patient's needs requires negotiation to achieve a blend of expectations between those which are technically possible and those which are desired by the patient. As a pre-requisite, the quality of pharmacist-patient contact in the community and in hospital needs to be improved.
This improvement requires the pharmacist not only to adopt a
systematic approach to the screening of patients, but also to
have the skills and knowledge to take into account each patient's
individual circumstances. The professional requirement is to
identify a patient's needs while securing the patient's
commitment to participate fully in the therapeutic process. As
patients transfer across clinical settings and from the
responsibility of one clinical team to another, the achievement
of continuity of pharmaceutical care offers real benefits to
patients and carers and must be seen as a priority.
Prescribers' needs for pharmaceutical care
Pharmaceutical care potentially offers the prescriber a means for the quality assurance of therapy with medicines. A commitment to pharmaceutical care requires the prescriber to ensure that treatment objectives are properly negotiated and fully communicated before and during drug therapy. In hospitals, effective personal communication is achievable through the inclusion of pharmacists at the point of therapeutic decision-making. In primary care, working systems are needed which allow free, rapid and reciprocal communications between prescribers and pharmacists. There is also a need for close co-operation between pharmacists and prescribers in order for prescribers to realise the full advantages of pharmaceutical responsibility for the attainment of specific therapeutic objectives.
Models of pharmaceutical care
The design of suitable models should define the structure of services and the processes of practice. In order to test the ability of a particular model to deliver pharmaceutical care, the capacity to measure patient outcomes is required. A combination of imaginative solutions and a multidisciplinary approach to research and development is required. Different models may suit different clinical contexts and different patient groups. Research into the evaluation of models of pharmaceutical care should focus on particular patient groups with defined needs. Only once a choice of models of pharmaceutical care is available will it be possible for pharmacists to tailor pharmaceutical service specifications to suit particular clinical environments.
Pharmaceutical care and public health
In order to contribute to health gains in defined patient populations within limited resources, particular forms of pharmaceutical care must be targeted to particular patient groups. There is a need for pharmacists to use public health information from the health needs assessments of patient populations to help set local goals for pharmaceutical care. Equally, pharmacists have the opportunity to generate information about medication usage which is valuable in the public health domain and which can inform public health policy.
Research and development
The political and managerial priorities of the Health Service offer broad scope for research into pharmaceutical care. Formal evidence of the results of interventions is increasingly necessary to inform clinical decisions. The need for reliable and meaningful outcome measures for therapeutic interventions is shaping the context in which pharmacists are practising. To make their contribution, pharmacists require to continue to develop the research skills to undertake those types of research which are conducted outside the laboratory with patients as well as with medicines. Although the key components for expanding the implementation of pharmaceutical care are available, more research is required into working systems.
In practice, quality research effort in the NHS1,2 is required to:
be relevant to the NHS
follow a clear protocol
have had the protocol peer reviewed
be appropriately managed
aim to report findings
be
designed so that the results are generalisable
Conclusion
UKCPA continues to aim to help pharmacists to refine their skills and their levels of practice in order to create new and effective working relationships with other disciplines. Through aprogramme of conferences, workshops, practice interest groups and publications, UKCPA provides facilities for pharmacists to develop, share and exchange ideas, research findings and practical experiences. The Association intends to contribute to pharmaceutical care by encouraging the development and evaluation of new services to patients. The Association offers a supportive network to help pharmacists to engage with the demand for better health care and to meet public health needs.
1. Hepler CD & Strand LM. Opportunities and responsibilities in pharmaceutical care. American Journal of Health Systems Pharmacy 1990; 47: 533-543
2. Supporting
Research and Development in the NHS. (Culyer Report). A
report to the Minister for Health by a Research and Development
Task Force. HMSO September 1994: London