Clinical pharmacy in primary care.

Abstract

Clinical Pharmacy in the secondary care sector began to develop in the 1970s and has evolved into a service known as pharmaceutical care. The developments of such services in the primary care sector have not occurred at the same pace because of a remuneration structure which, to this day, largely depends on the speed and accuracy of dispensing a prescription. A complete examination and re-arrangement of the dual roles of the professional and trader is required in order to provide a more effective, efficient and easily accessible pharmaceutical care service within primary care. It has been suggested that up to 11.4% of hospital admissions [1–3] are related to the patient’s drug therapy and that if corrected at the dispensing stage would save considerable primary care costs [4]. An analysis of adverse drug reaction (ADRs) rates from 49 hospitals published in 36 articles stated that ADRs were responsible for 0.2–21.7% of hospital admissions [5]. Overall 71.5% of these were related to side effects, 16.8% were excessive effects, 11.3% were hypersensitivity reactions and 0.4% idiosyncratic. In 1989 Neville et al. [6], from a General Practitioner (GP) survey, stated that 1.06% of prescriptions had therapeutic errors but this may now be greater due to the inadequate control of a computerised repeat prescribing system [7]. This analysis of the prescribing in 50 GP surgeries revealed that 72% of repeat drugs had not been reviewed by a doctor for 15 months. Harris [8] reported that 75% of all prescribed items were repeats. These accounted for 81% of prescribing costs and 48.4% of patients obtained their next medicine supply by this method. Thus up to three quarters of all prescriptions may be generated by a patient initiating a repeat prescription. There is therefore a need for involvement by a clinical pharmacist at the prescribing and dispensing stages. This paper will focus on the limited reports of pharmaceutical care in the primary healthcare sector during the dispensing process. Pharmaceutical care The term ‘pharmaceutical care’ to replace clinical pharmacy was introduced by Brodie et al. [9] in 1980, when they suggested a complete change in the delivery of pharmaceutical services. Further developments of ‘pharmaceutical care’ were described by Hepler [10], as a covenantal relationship between a patient and a pharmacist, suggesting that pharmacists should accept more responsibility for drug use control. These concepts were further developed in 1989 by Hepler & Strand [11] who provided the now widely accepted definition of ‘pharmaceutical care’ as ‘the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life’. In 1986 the Nuffield Report [12] suggested that community pharmacists must be more patient-orientated. It also indicated that Pharmacy Practice (within the primary healthcare system) is an ‘area of health services research in which the greatest weaknesses are to be found. There is too little information available, relatively weak structures and very little funding’ [12]. The next dozen years have seen little change, and much of the Government funding has been spent on developing pilot services rather than their evaluation. Consequently when the funding has run out many of the services have ceased. Working party reports between 1986 and 1994 [13–16] have encouraged community pharmacy to assess its level of practice and research. Value for money and health outcomes will play a major role in the future and studies need to highlight the added value of community pharmaceutical services during the dispensing process. These studies should be based on the principles of pharmaceutical care especially the responsible provision of drug therapy, definite outcomes and quality of life issues. They also need to highlight the possible advantages for the development of multi-disciplinary teamwork amongst providers of care.