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Barriers to the development of modern pharmaceutical care

Jiri Vlcek
European Society of Clinical Pharmacy

Healthcare is a service made up of interdisciplinary teams dedicated to patient care. Patients have to profit from the knowledge, skills and empathy of healthcare workers to get better. However, pharmacists are not formally considered as healthcare workers by law in many countries. Similar postgraduate education for pharmacists and physicians has been developed in a restricted number of European countries, even though in many others no postgraduate education system controls the quality of work or increases knowledge and skills. Consequently, pharmacists are evaluated according to the volume of drugs they sell and not according to the quality of care they provide.

The pharmacy profession is closely linked to industry and many pharmacists sell drugs as their main activity, which does not require much clinical pharmacy knowledge. As a result, pharmacists fluctuate between being a salesperson and a genuine healthcare worker, which confuses their relationship with patients.

Pharmacy in flux
The European Society of Clinical Pharmacy (ESCP) aims to support the healthcare side of pharmaceutical practice, in view of the fact that there is not a satisfactory level of pharmaceutical care in old EU countries, while the situation is even worse in new EU countries. Sadly, new EU countries did not protect the good level of pharmaceutical care developed during the socialist era (when pharmaceutical care was managed centrally together with medical care). Today, the pharmacy network is not regulated in new EU countries and pharmacists have started to compete on price alone. Some industry figures see this as an advantage as they can concentrate their marketing activities on the physicians who make the clinical decisions, without having to deal with pharmacists.

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What’s more, politicians and patients don’t see any added value in the pharmaceutical service and believe that reducing cost in this area can help to solve more general financial problems in healthcare. Drug prices are not fixed, so patients travel between pharmacies to find the cheapest drug. However, they are confused as to why reimbursements vary. Industry can cause fluctuations in drug prices to occur by selecting a few pharmacies to reduce reimbursements. In addition, physicians can increase their income if they dispense drugs and they, together with politicians, don’t think enough about the risks related to patient safety.

The modern face of pharmacy?
Hospital pharmacists may think they are in a better position because of their closer links with other healthcare workers, but the reality is different. Many hospital managers do not expect hospital pharmacies to provide tasks other than patient safety support, controlling medication errors, carrying out pharmacoeconomical analyses and cooperating in pharmacotherapy.
Some hospital pharmacies have outpatient drug dispensing units, which increase hospital income. There are clever hospital managers who allow part of this money to be used for developing hospital pharmacy services, but if the margin goes down then it is immediately seen as the “wrong” policy.
Hospitals, insurance companies and governments are often not used to accepting the pharmacy as a valid element of healthcare. When they do discuss this topic, reducing margins and implementing more market economics are often the focus. Of course, this is not the picture everywhere in the EU, but in general Europeans are not as successful at transforming pharmaceutical activities as they are in the US, Australia or some Asian countries. What are the reasons for this? Many think that it is a communication problem between pharmacists and pharmaceutical associations with the public and physicians, between pharmacists themselves, and between experienced pharmacies and graduates. Many older colleagues and pharmacy owners have got different expectations and do not support clinical pharmacy activities as a general concept, which does not allow hospitals to develop the modern face of pharmacy.

Cooperation and communication
European studies that could help to provide evidence about today’s activities and differentiate the pharmacy practice with a focus on patients are, unfortunately, not available. Such examples do exist in the US, but we think the advantage of the European healthcare system is the number of well-educated general practitioners and community pharmacists. These two main key professions cooperate well in the Netherlands and reason is simple: the Dutch government supported communication between the two professions and put them on the same collegiate level.

We have to base improved cooperation and communication on the development of clinical pharmacy. The ESCP is trying to stimulate debate to find out how best to achieve this; we are looking for strategic partners, such as the European Association of Hospital Pharmacists (EAHP), the Pharmaceutical Group of the European Union (PGEU), the World Health Organization and some physician associations, with the aim of providing better care for patients. The EAHP agrees that clinical pharmacy should become a specialisation in hospital pharmacy. All professionals involved in pharmacy should be focused on clinical pharmacy, improving praxis on the ward and participating in training the rest of the pharmacy team and pharmaceutical students. In the future hospital pharmacies should become training centres for community pharmacy.
We are also in discussion with PGEU representatives. We need to accept that only when pharmacists are united can they show that they are a valuable part of the healthcare team and a good partner for all patients, physicians, managers and payers. The ESCP has ambitions as a society of individuals who wish to develop clinical pharmacy in both settings, joining hospital and community pharmacies under one umbrella. We hope that effective care for patients is the basis for this.

Effective care
But, what does effective care mean? Pharmacists can support pharmacotherapy by encouraging optimal self-medication and by the rational use and choice of prescription drugs. Pharmacists are able to maximise benefit, minimise risk, control compliance and control cost. These are main areas for protecting rational pharmacotherapy and we need to know how and what are our barriers are, and what we as pharmacists can improve on in terms of reducing medical errors that occur during prescribing, transcribing and dispensing. We have to be proud of it and use complementary knowledge about pharmacotherapy, which is missing from the curricula of medical faculties.The ESCP offers its services to all pharmacists. It is our hope that the hospital and community pharmacists on the ESCP board cooperate and develop clinical pharmacy together. Clinical pharmacy is one of the keys to improve the image of pharmacy around to Europe. Physicians and patients need this service.