Pharm Science,technology and public health

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Pharmacists and Doctors collaboration and
competition? Evolving patterns of primary
care DDA Annual Conference Harrogate, November
1st 2008
David Taylor Professor of Pharmaceutical and
Public Health Policy, The School of Pharmacy,
University of London
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This contribution
This contribution seeks to place recent
developments in pharmacy in the wider context of
primary care development, and the evolving
relationship between GPs and community
pharmacists It outlines the concept of care
transition, and explores it in relation to the
changing relationships between health
professionals, managers and politicians involved
in twenty first century health care
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This presentation does not offer judgements
relating to any perceived financial or business
related conflicts of interest between dispensing
doctors and community pharmacists, or to make
partisan comments favouring either
side Rather, it attempts to identify areas of
common professional and public interest
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The direction of health care change
Helping healthy people to stay healthy and live
well

• In the UK, and more widely, modern pharmacists
  have important opportunities to extend further
  their roles as a clinical professionals. Key
  areas include enhanced medicines management, risk
  factor management, self care support and the
  direct provision of health care for common
  conditions.

Community pharmacys opportunity?
Recovering individuals
Community care, normal social roles
Institutional care, suspended social roles
Pharmaceutical care
The future of modernised primary medical care?
The traditional focus of medical power -
hospital care
Treating sick patients
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Assuming no extra patient costs, it would be a
good thing if community pharmacists could
prescribe a wide range of prescription only
medicines without people having to go to a doctor.
80
60
40
Percentage
20
0
France
Germany
Greece
Poland
UK
Sweden
Strongly agree
Agree
Based on samples of 1,000 patients in each
country, interviewed in late 2007
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Community pharmacies should be developed as
alternatives to doctors' clinics, so people have
more choice about getting advice and treatment
for common conditions
France
Germany
Greece
Poland
Sweden
UK
Strongly agree
Agree
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According to Eurobarometer data about 65 of
people in Belgium and France believe their health
system runs well, or is in need of only minor
changes. This compared (in 2002) with an EU
average of 44 and figures of around 30 in the
UK and Italy and 14 in Portugal.
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Health spending in the OECD, 2006
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Pharmaceutical spending in total health
spendingSource Pharmaceutical pricing in a
global market, OECD, 2008
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Stages of health development

• Demographic transition (Warren Thompson, 1929)
• Epidemiological transition (Abdel Omran, 1972)
• Care transition

King James 1 granting the British Apothecaries
their first Royal Charter in 1617
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Stage of epidemiologic transition
Pestilence and Famine
Receding Pandemics
Degenerative and Man-Made Diseases
Delayed Degenerative Diseases and Emerging
Infections
Crude birth rate
Vital rates
Natural Diseases
Crude death rate
Stage of demographic transition
Pre- Early
Late Post
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Dimensions of later stage care transition
include

• Increasingly assertive consumerism in health
  care, greater demands for both personal autonomy
  and (medicines) safety and effectiveness
• Decreased tolerance of health inequalities, and
  higher expectations of universal care access
  Decreased social distance between health
  professionals and service users
• Increased recognition of the role of self care in
  (educated public) health improvement
• A shift in responsibilities for care quality
  protection from professional to regulatory agency
  and managerial control
• Professional role merging and enhanced
  competition in managed health market places

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Change drivers include..

• Ongoing mortality and fertility reductions, and
  their psychological and social sequelae. Examples
  include the Flynn effect, Inglehart and
  consumerism, Sennett and the shift from rigidly
  structured hierarchical to flexible transactional
  production relationships, Salter and the new
  deal between the state and the health care
  professions
• Globalisation and diversity
• New communication and information technologies
• Governmental agendas relating to the NHS and
  political power retention in the UK

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Where does pharmacy fit in?

• As the profession which supplies medicines?
• As the profession which informs and improves
  medicines prescribing and use?
• As a profession which prescribes and provides
  health care?
• As a profession committed to improving the
  publics health via the widest possible range of
  means?

William Allen, 1770-1843
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Beyond dispensing adding value to community
pharmacy

• Medicines management
• Concordance and self management support
• Improved hospital and community co-ordination
• New repeat dispensing arrangements
• Pharmacist prescribing
• Extending the range of P medicines for example,
  EHC and statins
• Pharmaceutical public health eg, smoking
  cessation and vascular screening services

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Stages of health development

• Demographic transition changed population
  structures associated with industrialisation and
  increased income
• Epidemiological transition changed patterns of
  illness and risks to health
• Care transition changed relationships between
  the state and professional and other stakeholders
  in health care in an era of managed consumerism

• Improving sanitation and water supply macro
  environmental development
• Improving homes and child care micro
  environmental progress
• Improving lifestyles, and treating or alleviating
  common conditions
• Supporting health behaviour change more
  effectively, understanding genetically mediated
  risks and pathologies, and tailoring
  interventions to fit the requirements of specific
  phenotypes

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Threats, opportunities and questions

• Using medicines/drugs as instruments of
  population health improvement, with pharmacists
  as facilitators of their safe and effective
  public health use
• The weakness of the evidence base relating to
  pharmaceutical care outcomes, and pharmacists
  own doubts and limitations.
• Resistance to pharmacy based health care
  developments on the part of other stakeholders in
  health care
• Uncertainties as to the extent to which
  separating prescribing and dispensing at an
  institutional level protects public interests in
  modern health care settings

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Conclusions

• All professions need to be understood in, and are
  in large part defined by, their social and
  economic contexts
• Both general practice and community pharmacy are
  developing in environments which are increasingly
  regulated by external agencies
• The public could in some instances benefit from
  increased choice between alternative, competing,
  health care providers. In others, patient
  interests will be better served by closer
  inter-professional collaboration
• Community pharmacists and general practitioners
  have a common interest in defining a desirable
  balance of collaboration and competition between
  them, and working together to limit inappropriate
  external regulation and counter-productive
  managerialism

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david.taylor_at_pharmacy.ac.uk