What is medicines management?
It is clear that there is confusion among pharmacists as to what is meant by "medicines management". Is it the same as pharmaceutical care and, if so, what exactly is that? Is it therapeutics or medication review, or what?
Medicines management is a fully enshrined concept in official Government documents and holds the key to repositioning community pharmacy in primary care. The community pharmacist will move into a clinically focused role, more closely engaging patients, doctors and other health care professionals, where appropriate. Government commitment to this new role is reinforced by a minimum investment of £30m over three years, starting this year, to develop the process to secure "better use of medicines" and "partnership in medicines taking".1
From an original description of medicines management some seven years ago,2 further definitions of the concept have emerged, and in a recent "Broad Spectrum" article by Douglas Simpson3 its inter-relationship with pharmaceutical care has been explored. The Government document "Pharmacy in the future" uses both terms, the latter possibly in a general sense such that any pharmacist service could be described as pharmaceutical care. However, as the medicines management initiative gathers momentum, it is inevitable that new aspects will emerge and lead to further definitions. These will, it is to be hoped, assist in refining both the concept and the process. The definition of medicines management offered here is:
"The systematic provision of medicines therapy through a partnership of effort between patients and professionals to deliver best patient outcome at minimised cost".
There are four key dimensions implicit in the concept: clinical excellence, collaboration of participants, cost control and concordance.
The expression "best patient outcome" has been used to cater for those situations where maximum improvement in the clinical condition is not the only consideration. Health economics evaluation studies have shown, for example, that patients can rate some life states as worse than death.4 If maximum control of the disease is only achievable at the expense of severe side effects, some patients might prefer less effective drugs to allow a better quality of life. This may also be a factor in better family support for the patient and in better quality of life for the family, too. Cost-effectiveness comparisons may thus be inappropriate in some circumstances, and cost-benefit analysis may be necessary to help compute the best overall outcome for the patient, the family and society.
The words "minimised cost" in the definition partly address this consideration. It may be, for example, that an effective generic drug is being taken by a patient to control an illness. Severe side effects might compel the use of another branded drug which is more expensive and which has no generic equivalent. However, the cost of the new drug may be "minimised" by adjusting dosage form and frequency among other means.
The cost is therefore minimised, but is not necessarily minimal unless the more comprehensive consequent benefits, as described above, really do produce a net overall saving, which is quite possible.
So far as the dispensing community pharmacist is concerned, the word "medicines" in the definition encompasses over-the-counter treatments as well as those from the National Health Service. Conflict of effect between them, through drug interaction or synergy, could damage a patient's response to both. A fully developed medicines management service will therefore include pharmacist intervention in patient self-medication, using IT facilities and country-wide cross checks, where necessary, with distant patient medication records.
Pooling of knowledge
Medicines management is a pooling of medical, pharmaceutical and patient knowledge for the benefit of the patient, accessing other professionals' expertise where appropriate. In this context, the FP10, electronic or otherwise, becomes a contract of patient care and not simply a medicines order. Conceptually, this contract will involve a four-phase structured intervention:
Phase 1 Review of the therapeutics and economics of the medication to indicate areas of potential improvement or rationalisation
Phase 2 A pharmacist-patient dialogue to identify or assess problems and opportunities for more closely matching medication to patient needs and encouraging commitment to therapy
Phase 3 A discussion (at some stage) between pharmacist and doctor to merge medical and pharmaceutical knowledge for patient benefit and at minimised cost for any revised medication plan
Phase 4 Implementation of an agreed change plan and review of outcomes, thus completing the cyclical process ready for further adjustment, as necessary
In our concept of medicines managamen, the doctor becomes the director of an expanded primary health care team the lead clinician giving direction and pace to the care effort in consultation with professional colleagues. The partnership relationship between health care professionals and patients should add another dimension of care through the motivational, synergistic and support aspects of the process and patient ownership of the effort.
However, it is clear that the impetus for medicines management must now begin to come from individual pharmacists on a local as well as a national basis. Because of issues of professional demarcation and the need to dissolve traditional barriers, such initiatives may take time to develop. Pharmacists must, then, have determination, resilience and excellent communication skills in addition to a commitment to continual clinical knowledge development. Pharmacists who have kept abreast of clinical drug development and modern therapeutics are in a good position. But even those who have yet to make an unequivocal commitment to continuing education can catch up and quickly.
There is no better time than now to pursue medicines management. The Government wants it and leaders of the medical profession are supportive of it. If pharmacists do not take this initiative, particularly those in the independent contractor sector, other professionals will move in even if they do not know as much as pharmacists about medicines.
Clearly, there is much to do in order to deliver a full medicines management service. Pharmacist supervision will require revisiting in the pursuit of freeing pharmacist resources to accommodate new responsibilities. Part and parcel of this will be an enhanced role for the certificated pharmacy technician. Pharmacists must be prepared to spend less time in the dispensary while still taking responsibility for the dispensing process through quality assurance.
The implementation of medicines management could mean "change or perish". The choice will be for individual pharmacy contractors to decide.
|Professor Jones is professor of pharmacy practice at the University of Portsmouth. Mr Tweedie is chairman of the strategy committee of the Pharmaceutical Services Negotiating Committee and is chairman of the Leadership Group on Medicines Management|
Citation: The Salvadore URI: 20004090
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