evidence

Pharmacists. We’re the experts in medicines, right? But what does that mean in practice, and how does our conduct in the community (retail…) sector fit with the rest of the healthcare team and the direction in which it travels?

This is something spoken about on Twitter before, and a topic I’ve often pondered as both a locum and customer at community pharmacy.  To help frame this some more, it’s my absolute pleasure to be able to post an article by a crackin’-good pharmacist which was recently published in Medical Writing.  For you referencing geeks out there, it’s: Johnson, H. Selling Evidence over the counter: Do community pharmacists engage with evidence-based medicine? Medical Writing 2013; 22(4): 275-278.

Read it, consider it and let me know what you think with a comment or tweet as ever please.  But most of all – enjoy!

 

evidence

 

From the author:

“A while ago, I was asked to write an article by Adam Jacobs (@dianthusmed), who was guest editing an issue of Medical Writing. The theme for the issue was Good Pharma.

I had intended to write something about how different the sort of evidence base community pharmacists have access to differs to the sorts of evidence (or lack of) that accompanies complementary and alternative medicine. But, during my literature searches for the article, I was taken in a very different direction. I started wondering about how and why community pharmacists engage with evidence-based medicine (EBM). I often think that, in discussions about it, the practicalities of life as a busy front-line pharmacist can be forgotten. I wanted to see what the evidence had to say on the matter, and this is the resulting article.”

Selling evidence over the counter: Do community pharmacists engage with evidence-based medicine?

Traditionally, products sold over the counter (OTC) in a pharmacy may have been guided more by commercial gain than rational, evidence-based medicine (EBM). Even those products that are licensed may not have a robust evidence base for their effectiveness. Irrational combination products, cough medicines, and unproven complementary medicines line the shelves of most stores, leading some prominent promoters of good science to recently criticise pharmacy as a ‘quack trade’.1

As the role of the pharmacist evolves, it is becoming more and more imperative for the profession to distance itself from quackery and embrace EBM. This is particularly important in the face of deregulation of prescription-only medicines, the potential for self-selection of pharmacy medicines by patients, and a general public that is increasingly willing to take responsibility for its own healthcare.2

The cornerstone of EBM is the ability to locate, appraise, understand, and communicate clinical evidence. Pharmacists often act as the front-line interface between the patient and the healthcare service and as such require the skills to translate complex statistical health information into language which patients are likely to understand and engage with.3

Opportunities for EBM in the community pharmacy

An effective OTC encounter in a pharmacy is a stepwise, logical process of elimination, using good questioning and knowledge to narrow the available products suitable for an individual patient. The first step involves the use of careful, structured questions, usually following a mnemonic (see Table 1), to establish the symptoms and check the diagnosis. Symptoms which require referral are identified and patients directed to appropriate services where required. Once the diagnosis is identified, the range of OTC products available to treat it will be borne in mind by the pharmacist. Knowledge gained from questioning about the patient’s medical history and drug history is used to eliminate any products which are inappropriate for the individual patient due to cautions, contra-indications, or drug interactions. The pharmacist may then recommend a product based on a number of factors. Counselling points on how to use the product effectively and safely should then be conveyed to the patient.

table1

As some of the most easily accessible health care professionals, community pharmacists often deal with patients presenting with health- and medicines-related questions, which may be prompted by sensationalist media reporting or information gathered from friends, family, or the Internet. There are therefore clear opportunities within daily community pharmacy to utilise clinical trial evidence in accordance with the principles of EBM.

The evidence for a lack of evidence

A survey conducted in 2005 amongst pharmacists from all sectors in Illinois by Burkiewicz and Zgarrick found that 90% of 323 pharmacists held positive attitudes towards EBM.4 In a more recent survey of community pharmacists in Northern Ireland conducted by Hanna and Hughes, 88.3% of 205 community pharmacists stated that they were familiar with the concept of evidence-based practice.2 This is indicative of a profession that understands the underlying concepts of EBM.

In spite of these studies, there is an overall lack of robust evidence community pharmacists’ attitudes and uptake of EBM, and the currently published evidence is limited by small sample sizes and methodological flaws. However, the qualitative studies which do exist offer an interesting insight into the considerations when selecting an OTC preparation.

Hanna and Hughes conducted a series of surveys into pharmacists’ attitudes to OTC sales.2 They found that the over-arching concern when selecting a product was patient safety, with 91.8% of pharmacists agreeing or strongly agreeing that safety was their main concern. Effectiveness of the product was of secondary interest. Pharmacists cited patient and colleague feedback, along with personal or family use, as the most common methods to determine a product’s effectiveness, with clinical trial data appearing to be a less important consideration. This would seem to be at odds with the principles of EBM, and suggests that while pharmacists are broadly in favour of EBM, their ability to use it in their everyday job is limited. Over 60% of respondents agreed that evidence-based practice is more difficult for community pharmacists compared to other healthcare professionals.2

In May 2013, the consumer magazine Which? performed an undercover investigation of the quality of advice given in a sample of 122 community pharmacies in the UK. The report found that unsatisfactory advice was given by pharmacy staff in 43% of visits.5 While this report has been widely criticised due to its small sample size,6 it may be indicative of a wider problem which may be improved by increased uptake of EBM. Which? also investigated the evidence for claims made for a variety of healthcare products, and has published a list of ten popular and widely available pharmacy products for which no good evidence of benefit exists. This includes well known brands such as Benylin and Covonia cough medicines, Bach’s Rescue Remedy, Bio-Oil, and Boots Cold and Flu Tablets.7

Reasons for the lack of EBM uptake

In the 2005 study by Burkiewicz and Zgarrick,4 45% of all pharmacists cited lack of time as the main factor limiting their ability to practice EBM. In a community pharmacy setting, the proportion is likely to be even greater, given the fast-paced, unpredictable nature of the retail environment.4 Constant interruptions and juggling many tasks whilst maintaining an open, appointment-free approach to healthcare can lead to a lack of time available for the pharmacist to read and interpret clinical data.

Community pharmacies can be under-resourced to effectively practice EBM, while trusted medical information resources such as Micromedex and Medicines Complete may be too expensive for the average community pharmacy to feasibly access, and can be difficult to navigate in the community pharmacy environment. With the delivery of advanced clinical services such as Medicines Use Reviews – an initiative to improve medicines adherence in the UK by providing support to patients with long-term conditions who are taking multiple medicines8 – along with an ever-increasing dispensing workload, the pressures on a community pharmacist’s time are vast and many.9

The availability of new OTC products and the deregulation of prescription-only medicines can lead to an overwhelming amount of extra training and research for a community pharmacist, on top of their usual daily workload. At present, OTC training tends to take the form of industry-sponsored training packs aimed at enabling community pharmacy staff to sell new products. In my experience, these training packs tend not to address any shortcomings in clinical evidence or proof of benefit, but instead focus more on practical selling points. Whilst they may be adequate to allow pharmacy staff to safely sell a product OTC, they do not always include enough information to allow a pharmacist to make an unbiased, evidence-based assessment of a new product. Moreover, in Hanna and Hughes’ study, only 38% of community pharmacists agreed that they knew how to perform a literature review and critically appraise research papers.2 This highlights a gap in the knowledge of community pharmacists and an important training need. Whilst critical appraisal is covered in pharmacy degree courses and pre-registration training, it may not be used often enough in everyday practice to allow community pharmacists to maintain and hone their skills sufficiently.

Patients appear more likely to rely on personal experience or anecdotal evidence than robust clinical trial evidence when choosing an OTC product, and seem on the whole ambivalent about the need for evidence of effectiveness.10 This, coupled with advertising and the policy in the retail environment that the ‘customer is always right’, means that patients may be unresponsive to messages about lack of evidence from the pharmacist. In an Australian qualitative study, pharmacists reported that advertisements for OTC medicines opposed their professional advice, leading to a sense of disempowerment.11 In the face of consistent rejection of scientific, evidence-based advice, it may be understandable that many pharmacists give up attempting to convey such information.

Solutions

Somewhat alarmingly, Hanna and Hughes2 found that only 23.9% of community pharmacists in their survey were familiar with the work of the Cochrane Collaboration, one of the world’s foremost independent organisations for the dissemination of information about the effects of healthcare interventions. Improving community pharmacists’ awareness of (and access to) reliable sources of medicines information is crucial to improving uptake of EBM in the sector. Pharmacists may not have the time or skills to interpret clinical trial data themselves, so need to have access to robust, concise resources from organisations skilled in the interpretation of evidence. Primary care guidelines such as the Clinical Knowledge Summaries provided by NICE (the National Institute for Health and Care Excellence) in the UK and the guidelines provided by Patient.co.uk can be helpful resources for dealing with minor ailments, but there is a lack of high-quality, independent guidelines for OTC medicines.

Greater collaboration between the pharmaceutical industry and accredited pharmacy training providers may be one solution. An independent review process similar to peer review, but tailored to OTC needs, could be implemented to ensure that any potential biases in industry-sponsored training packs for community pharmacy are reduced. The standardisation of such packs, and inclusion of information on clinical data and its limitations, may improve the ability of pharmacists to make evidence-based decisions.

Greater awareness and utilisation of medicines information services (see Figure 1) amongst community pharmacists may be helpful, as these provide a rapid and efficient evidence-based enquiry answering service, allowing community pharmacists to use their time to deliver other services. Staff in medicines information centres are specially trained in the retrieval, interpretation, and appraisal of evidence and can act as a go-between to interpret clinical trial data and apply it to a clinical situation.

There is a clear need for independent training on critical thinking and appraisal skills that is tailored specifically towards community pharmacists. The ability to disseminate complex safety and effectiveness data to patients is a valuable skill that the pharmacy profession could focus on. Questions remain about how best to close the gap between patients’ reliance on advertising and anecdotes and more reliable clinical trial evidence, and any future research in this area will be extremely valuable.

figure1

Selling honestly: a personal perspective

I worked as a community pharmacist for many years, and can identify with the use of patient feedback and personal use as the main means of informing OTC product selection. Bombardment with information about new products, along with the highly pressured and stressful job of managing a pharmacy day to day, can be so overwhelming that it can be virtually impossible to keep up with emerging evidence. It becomes easier to rely on more immediate, passive methods of differentiating between products than evidence appraisal.

After moving into a job in the medicines information field, I have improved my skills in finding, appraising, and communicating complex trial information. When undertaking locum shifts in community pharmacy, I have found that this in turn improves and informs my ability to advise OTC. Having more confidence to seek out and question evidence, as well as encouraging critical thinking and evidence communication, allows me to improve an engaged patient’s ability to make an informed choice. I have found patients to be variably receptive to this, with reactions ranging from gratitude, satisfaction, and engagement, through to impatience and, rarely, anger. For the most part, I have found that being honest about the lack of evidence for OTC products increases trust, as patients can see that I am not there primarily for commercial gain, but instead to provide them with good-quality health and medicines advice.

Conclusion

Community pharmacy has an inherent conflict of interest, given its situation as both a retail outlet and a professional healthcare service. Commercial interests may have traditionally outweighed the need for high-quality, evidence-based OTC advice, but a sea change is required to ensure the profession remains a respected part of the wider healthcare community. Other aspects of the healthcare system (and pharmacy) are adopting and implementing EBM, and there is an increased focus on the importance of clinical trial data in the health and popular media following the AllTrials petition (an initiative led by Ben Goldacre, and various other groups, which is calling for all past and present clinical trials to be registered and their results reported). This in turn is exposing the gap between reliable, robust evidence of benefit and how OTC products are currently being sold. Improving understanding of the importance of clinical trial data amongst community pharmacists will be a key step in converting pharmacy from a quack profession into what could more comfortably be considered ‘good pharma’.

 

References

1. @lecanardnoir 2013. ‘@bengoldacre the unspoken problem is that by any reasonable criteria, pharmacy is a quack trade. It pains me to say.’ Twitter; 2013 May 24 [cited 2013 Aug 19]. Available from: https://twitter.com/lecanardnoir/status/337872315666808832.

2. Hanna L, Hughes C. Pharmacists’ attitudes towards an evidence-based approach for over-the-counter medication. Int J Clin Pharm. 2012;34(1):63-71.

3. Davidson J, Valuck R, Moore G. Evidence-Based Medicine in the Pharmacy. Patient Safety and Quality Healthcare; 2006 [cited 2013 Aug 19]. Available from: http://www.psqh.com/marapr06/ebm.html

4. Burkiewicz J. Evidence-based practice by pharmacists: Utilization and barriers. Ann Pharmacother. 2005;39(7):1214-1219.

5. Can you trust your local pharmacy’s advice? London: Which.co.uk; 2013 May 20 [cited 2013 Aug 19]. Available from: http://www.which.co.uk/news/2013/05/can-you-trust-your-local-pharmacys-advice-319886/.

6. Gregory J. The Which? Scenarios: What would you have done? Chemist and Druggist; 2013 [cited 2013 Aug 19]. Available from: http://www.chemistanddruggist.co.uk/feature-content/-/article_display_list/15729377/the-which-scenarios-what-would-you-have-done.

7. 10 health products you don’t need. London: Which.co.uk; 2012 [cited 2013 Aug 19]. Available from: http://www.which.co.uk/home-and-garden/bathroom-and-personal-care/guides/10-health-products-you-dont-need/.

8. NHS Community Pharmacy Services – a summary. London: Pharmaceutical Services Negotiating Committee; 2013 Jul [Cited on 19/08/2013]. Available from: http://psnc.org.uk/wp-content/uploads/2013/08/CPCF-summary-July-2013.pdf.

9. Gregory J. Dispensing workload in England rockets 62 per cent over decade. Chemist and Druggist; 2013 [cited 2013 Aug 19] Available from: http://www.chemistanddruggist.co.uk/news-content/-/article_display_list/16053812/dispensing-workload-in-england-rockets-62-per-cent-over-decade.

10. Hanna L, Hughes C. Public’s views on making decisions about over-the-counter medication and their attitudes towards evidence of effectiveness: a cross-sectional questionnaire study. Patient Educ Couns. 2011;83(3):345-351.

11. Chaar B, Kwong K. Direct-to-consumer advertising: Australian pharmacists’ experiences with non-prescription medicines. Int J Pharm Pract. 2010;18(1):43-50.

12. ResourcePharm. Pharmacy Mnemonics: WWHAM, ASMETHOD, ENCORE, and SIT DOWN SIR. 4Pharm Ltd. [cited 2013 Aug 19]. Available from: http://www.resourcepharm.com/pre-reg-pharmacist/pharmacy-mnemonics.html.

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noted

notes2

It’s noted that we are officially in a heatwave and that expert advice is for people to regularly drink cold drinks like water or fruit juice, and to avoid alcohol.

Whilst I will give this important advice all due regard, it’s the third weekend of July and as such I will be attending the Kent Beer Festival for the thirteenth consecutive year, regularly drinking luke warm beer and avoiding cold drinks like water or fruit juice.

I’m back and will be responding to e-mails – dehydration permitting – on Tuesday 23rd July.

Thanks,

J

enforced

Image

I’m currently on ‘use it or lose it’ annual leave until Tuesday 2nd April, despite a pile of work to do and no real desire to be off when the weather forecast is so rubbish.

If you need a response before April please contact my PA Linda who will redirect your query accordingly.

Otherwise I’m probably going to do anything I can to avoid the DIY jobs the Mrs has lined up for me, so don’t be surprised if I get back in touch before my official return.

Cheers,

J

nomads

Nomads

I want to tell you about Mrs S. She’s a patient who has a significant drug burden and as time has progressed has found it harder to manage her regime. We’ve reviewed and rationalised, and what’s left is as simple a therapy as is possible without jeopardising her care. She’s cool with it all and wants to adhere but can’t as she finds it tricky to consistently remember exactly which medicine is taken when. Reminder charts have been useful but as another bit of paper, they’ve succumbed to the inherent risk of becoming inaccurate, lost or incomprehensible without anyone noticing until too late.

Unsurprisingly at this point the idea of a NOMAD was raised by a colleague. For those of you not in the pharmacy-know, NOMAD is one version of what are collectively termed “Multi-compartment Compliance Aids” or MCAs – these are those trays that people have their medicines popped into by a pharmacist, friend or relative such that each day of the week has morning, afternoon, tea-time and night-time medicines neatly separated. 

For Mrs S, it seemed like a good idea: none of her medicines were excluded from being in a MCA and she clearly needed something more to support her.  A call was put into her usual pharmacy to discuss, but was met by an almost instant refusal.  There was no capacity to do any more I was told. It was unsafe to accept another patient onto the system was the explanation. There was nothing more that could be done for Mrs S was the closing statement.

 

It’s not that often that I get so pissed off with my pharmacist colleagues that I bad-mouth them to my GPs, but I’ll admit to losing it over this phone call.  It’s not that I don’t understand the risks of these devices – as a locum, nothing in the world worries me more than arriving to find a note telling me there’s eight MCA to complete that day – but I’m angry that a patient who would likely benefit from one is being denied it because the system is already at capacity.  Is this position unfair of me? I think not for the following reasons:

  1. Making ‘reasonable adjustments’ to dispensed medicines is a requirement of the Equality Act (EA) (previously Disability Discrimination Act) and is an essential part of the retail pharmacy contract.  To this end, all pharmacies get a monthly payment from the NHS to help them provide such adjustments (up to 6.6p for each item they dispense regardless whether the item requires ‘reasonable adjustment’).  Of course an argument exists whether a MCA is ‘reasonable’ in this case, but this wasn’t part of the pharmacy’s reasoning or conversation.  At the least the pharmacist was under obligation to assess the patient themselves or discuss alternate solutions with me.
  2. Now more than ever pharmacy should be demonstrating its worth as the best support option for patients unable to take their prescribed medicines. You can term it the shiny new ‘medicines optimisation’ or call it good old-fashioned good pharmaceutical care, but if it’s not being done for those most at need why will I turn to the sector for help in the future? Why wouldn’t I just commission a more responsive nurse-led service?
  3. The large multiples – mostly Boots – have pushed these devices as a free service for years, as a way of getting what they term ‘lock in’; that is, once a patient is hooked on a MCA they won’t take their medicines in any other way and therefore will be locked in to taking their prescriptions to Boots until the day they pass on.
  4. I know that this store in particular, because of point 3) above, provides MCA to a chap on just two medicines (one once daily, one twice daily) who whilst seeming useless at taking these two drugs is quite able to run his own, successful, painting & decorating company: hardly a suitable candidate under EA?

I’ll admit early that I’m not the biggest fan of these devices, and after years providing a domiciliary medication review service you can count the number of MCA’s I’ve initiated on the fingers of one head.  But my experience suggests that the people that benefit are those like Mrs S – unintentionally non-adherent to their medicines, orientated in time and space, able to manipulate the packaging and capable of remembering that they need to take their medicines and whether they’ve already done so. Yet I’m now in a position whereby a suitable candidate is geared up for it but is being denied because the system is full of patients who either aren’t benefiting from them, who get them simply out of their own laziness, or because the pharmacy had a target to reach and have ‘sold’ them to unnecessarily straightforward patients.

I know there’s no formal funding for this service, I’ve previously spoken to the LPC at length about 7-day prescriptions and remuneration (the argument doesn’t wash for me– see point 3) and so I appreciate pharmacies are caught between a rock and a hard place. But ultimately Mrs S needs help and can’t get it from her usual pharmacy because they’ve put targets before service and maxed themselves out.

 

So my next steps? Easy – Mrs S has switched pharmacies to one that has capacity and will be locked in to another pharmacy for the foreseeable future. She’s doing well, reports no problems and despite a few teething problems getting prescriptions ready and redirected, it looks like it was the right solution for her.  It still leaves the issue with the near-by maxed-out pharmacy, and with an ever increasing population of complex elderly patients in the community, I can see them losing out time and again. 

 

So why the blog? Because I want pharmacists to think about their MCA service.  If you recognise your store in this scenario perhaps it’s time to re-assess your MCA patients:  do they really need it or are they’re a case in point of targets before care?

 

isolated

Isolated

This is an impromptu blog: I’ve been meaning to do a few recently but haven’t managed it, but I wanted to share these thoughts before they drift away.  They’re not directly pharmacy related but have some lessons for us nonetheless.

We moved house a year ago to Yateley which although has a population leaning towards the older side, has some awesome schools for Little’un.  After moving we went round the seven other properties in our close and introduced ourselves, but aimed to get everyone round to us for a BBQ once we’d settled. The weather never let us, so we said that New Year drinks would be good, but then chicken pox got in the way. So today we finally had the neighbours round for drinks and nibbles; eight people (youngest >60) from five of the seven households showed up and a couple of things really struck me that I want to share.

  • They didn’t eat much, despite the huge spread, but after 45 minutes I had to pop to the shop to buy much more wine
  • The oldest frail guy, who lives alone, was the wittiest
  • The dour Scottish chap who talks little outside had the best stories
  • Three households had at least one person who was effectively houseboud through illness or age, and their lives run on the help from unpaid carers (mostly family)
  • When one chap starts drawing his pension next year he automatically loses the carers allowance he currently recieves: he reckons they’ll be financially worse off from this despite nothing in their life actually changing apart from the date on the calendar

But the most stricking thing? Social isolation is a killer for these people.  Few of them go out much, and when they do it’s not far and locally there’s no longer much for them to access despite the population demographic.  What really hammered this home was that two of the households had not even spoken to each other properly in the seven years they’d lived on the same 200 metre strip of road.

So what’s this got to do with pharmacy? Well it wasn’t easy hiding my profession and so I’m now versed on all their ailments and therapies, and this is key: they all get their medicines delivered from the local pharmacy and none of them have spoken to a pharmacist since this service was started. 

It’s known that these patients may have higher needs and there’s already ideas around how pharmacists can support their care; what I’d ask is that if you’re a pharmacist who provides a medicines delivery service to housebound patients, please reflect on how long it’s been since you last saw these people or even simply spoke to them (and remember from above that they are people, not just ‘patients’); maybe it’s time to pick up the phone?

 

 

exposition

Ptms

Pharmacy in the UK, along with much else, is in a period of serious change, to some extent serious jeopardy and of course serious seriousness, and so it was with immense relief that I read Mr Dispenser’s first – and with luck, not last – entertaining book “Pills, Thrills and Methadone Spills”.   An eclectic compilation of blogs, stories and witticisms, it jogged me to remember that no matter how serious things are in the world of pharmacy, it’s a world that will always be able to put a smile on your face.

Personally I wouldn’t know where to start in writing a book, but if a serious drinking session disrupted my thought processes such that I made an attempt, I can’t imagine how I’d make pharmacy  the theme.   As such I had little idea of what to expect; in the back of my mind I did have memories of the excellent read by Drug Monkey ready to compare it to, but I need not have worried. 

I’ve followed Mr Dispenser on twitter pretty much since I joined it eighteen months ago and thought I’d have seen most of the book’s content through this, but thankfully I was wrong.  A wonderfully informal and original piece of work, if somewhat a little unstructured in parts,  I read it in one go, not out of a need to tick another job off the list, but because even at 1am when the Mrs was seriously pissed off I still had the bedside light on, it was compellingly difficult to stop.   Immensely reflective of my past experiences and gloriously enlightening on the experiences of others, funny in most places and sincere in parts, it’s a genuinely worthwhile read.  

The New Year will invariably make people reflect on their previous twelve months, and as usual, hearing “If I only knew then, what I know now” won’t be uncommon.  Similarly if I’d only read this book before I qualified I’d have been so much better prepared for the wonderful world of pharmacy.  I would have never ruined my favourite cream and pink striped tie had I been pre-warned that checking the lid is secure before shaking was the most critical part of antibiotic reconstitution.  If I’d only read the patient attempts to pronounce medicine names I wouldn’t have had my own infamous “ferocious sulphate” incident.   And although I read @weeneldo’s account of his pre-reg and wept with laughter, I do wonder that had I read it before qualification whether I’d have switched to another course… 

But that’s not to say this book is only suitable for students – far from it.  I almost wept with relief after reading the ‘Locums Deserve Respect’ section: here was someone who understood my woes, my fears, my wishes.  And the wise words within Candy Sartan’s genius “Badges” should now be the theme-tune for all pharmacists, though I do worry which of her ‘male pharmacist’ breeds I fit in.  On the serious(-ish) side there’s also the excellent contribution from @OptForOptimism – even after a decade of being a pharmacist it was good to be reminded how we, and our services, may look to patients .

So in these austere times do I recommend that you spend your hard-earned pounds on this book? Yes I do, regardless of whether you’re in pharmacy, planning to join it, come in to contact with it regularly, or have no idea what it actually entails.  You’ll love the ‘Pharmacy Films’, laugh at our Gangster similarities, be amazed at the lengths we go to when supporting and helping our patients, and come away with the feeling that whilst we sometimes get  unfair flack when trying to keep people well with their medicines, we’re also always able to see the funny side of it all.

 

The e-book is available for download from Amazon and I’m happy to report that 5% of sales will be donated to Pharmacists Support a charity that offers a helping hand to pharmacy colleagues who find themselves in difficult circumstances.  There really is no excuse not to buy a copy.

 

predictions

The end is nigh (of 2012) so I thought I’d get in early with some pharmacy predictions for 2013, and given how much uncertainty the NHS will be in from April I’m expecting to be as good as the Mayans in getting this right. 

 

Starting from April the biggest changes will obviously affect our colleagues currently in primary care: the lucky ones will end up being part of a Commissioning Support Unit (CSU), the really lucky ones will be in a Clinical Commissioning Group (CCG). Many won’t be lucky and there’s a real risk that some great talent that may be lost from pharmacy altogether: at a certain level in PCT-land you’re not clinical enough to keep your banding in a hospital, and you’re earning too much to go straight into retail.  Pharma is one option, but they’re not a safe bet if your mortgage depends on it.

For the lucky ones their work will be dependent on how focussed and forward thinking their CCGs are: there are some real opportunities to make a difference to patients and their medicines, but I fear that most of their work in 2013 will be nickel & diming.

 

Sticking with the NHS, let’s consider our hospital colleagues. Again money dominates: acute trust funding, FT or not, is going to get a kicking especially when CCGs try to squeeze tariffs or pull activity via referral reduction or re-commissioning work into the community. In this instance, retention will be about specialisation – focus on a speciality disease area, be super clinical on it and prove you make a difference; my money’ll be on cardiovascular and endocrine.  Other opportunities will exist though for those in trusts who hold vertically integrated community services….

 

Community services pharmacy is, I think, where the exciting stuff will start to happen: whether CFT, FT or independently based these services are being seen as the answer (wrongly) to the NHS’s ‘troubles’ and will need to really innovate to deliver outcomes on restricted budgets.  Where better to show the value of pharmacists? If Medicines Optimisation has a natural home then this will be it.  Hand in hand with this are our colleagues in mental health services: the new Health Secretary’s focus on dementia will play well here as funding will follow – again another good place for medicines optimisation to thrive.

 

Retail pharmacy: my roots and love in all of pharmacy.  I think 2013 will be a holding year for retail with little changing, but I suspect that it’ll be the calm before the storm of self-selection and remote supervision in 2014.  The difficulty will come from a lack of proven outcomes for what is done already, a squeezed budget from central NHS coffers and a lack of a cohesive plan for more commissioned clinical services.  An influx of pharmacists from PCT-land may also add pressure to the workforce, and staff may find (as locums are now) that remuneration and T&Cs are adversely affected.  And if that’s not bad enough you’ll all still be selling homeopathy.

 

Academia: I have no idea! You’ll have to speak to Messer’s Bush and Cox (no seriously, they’re called that, and they aren’t a late-night Channel 5 comedy duo: go follow @josephbush and @drarcox  to find out)

 

Industry – err. Dunno?!

 

Overall? 

There will be opportunities to do some innovative things in 2012 but it’ll be small-scale, patchy and uncoordinated; if experienced pharmacists have the balls then they’ll start up their own provider company (no CQC registration needed remember) and approach CCGs with ideas on what they can do to makes medicines count for patients.

In retail, the opportunities will be outside the NHS and with Local Authorities, using their key geographical positions, extended opening hours and enviable reach and footfall to place themselves at the forefront of what’s left of public health. But if anything, pharmacists are the most business-minded of healthcare professionals and in this current climate that is a huge strength.

 

But then again the best laid plans of mice and men and all that…

Roll on the New Year

Employment