Pharmaceutical care
To what extent has the concept of pharmaceutical care been taken up outside the
United States?
JUST before this year’s International Pharma-
ceutical Federation congress in Tokyo, the World
Health Organisation organised a seminar on the
role of the pharmacist in society, as a follow up to
the two previous WHO conferences in New Delhi
and Madrid. For the first time, pharmaceutical
care was discussed within the framework of
WHO, and in this way the concept gained interna-
tional recognition. Pharmaceutical care more and
more clearly manifests itself as a means to charac-
terise the competence of the pharmacist in rela-
tion to other health care professionals, and as the
area which will determine the development of
pharmacists in the years to come.
It was a coincidence that FIP’s section for
community pharmacists launched a continuing
education programme on pharmaceutical care at
the same time. This just showed more clearly the
importance of the concept to decision makers.
As so often before, we witness that America’s
competitive and innovative society is fertile soil
for new thoughts while at the same time providing
a milieu where these thoughts can be put into
practice.
I wonder to what extent Professors Linda
Strand and Charles Hepler anticipated the re-
sponse they received to their idea that the phar-
macist should share the responsibility of ensuring
that the patient’s quality of life be improved by
drug therapy. It is, however, a fact that the
concept has gained popularity. The explanation
for this is obvious. For some years, pharmacists
have been experiencing an identity crisis. Pari
passu with the fact that their role as the responsi-
ble party for drug quality faded considerably, the
need for pharmaceutical expertise as a guarantee
of safety and quality was watered down. This was
a result of the fact that the pharmaceutical
industry took over the role of production, and
ensuring product quality, thereby reducing the
need for careful pharmaceutical control in the
distribution link. At the same time, pressure from
the authorities for even greater efficiency and
productivity in all links of the health care system
increased. This of course also affected the phar-
macy sector.
Pharmacy technicians are better educated now-
adays and are able to assume more and more of
the pharmacist’s traditional functions. In spite of
this, pharmacists have not easily given up routine
tasks. What remains for the pharmacist is com-
munication of information and counselling, which
has now been emphasised as the most important
task. But this task is not one which belongs solely
to the pharmacist. Pharmacy technicians are also
able to provide information at a certain level, and
the pharmaceutical industry, doctors and nurses
also carry out important functions concerning the
communication of knowledge to patients/
consumers.
Nevertheless, because of the depth and breadth
of their knowledge, pharmacists should b e soci-
etv’s drug exDerts. And the Dressure from the
NOVEMBER
1993. THEINTERNATIONALJOURNAL OF PHARMACY
PRACTICE
authorities on health expenditure presents them
with a great opportunity. Seeking to implement
the pharmaceutical care concept could provide a
means of taking it.
This will require more deliberate customer
segmentation than has been the tradition in
pharmacies, so that individual needs, rather than
average solutions, are considered.
But society lacks documentation that such pro-
grammes seen as a whole save money. As long as
this documentation is insufficient, politicians will
hardly open the cash box and invest in offering
citizens a more comprehensive pharmaceutical
service. This deficiency will have to be addressed.
The Strand/Hepler definition of pharmaceutical
care - “the responsible provision of drug thera-
py to achieve definite outcomes intended to im-
prove a patient’s quality of life” - has not yet
been internationally codified, and it is probably
wise not to do so until the concept has been
subjected to debate at a national level so that any
necessary adjustments and interpretations can be
made on the basis of culture and tradition.
The very fact that the concept has been devel-
oped in the United States may make some coun-
tries resist it. The American drug store system,
mail-order pharmacy, and physician dispensing
do not appear ideal to European pharmacists
when we talk about professional development. In
Europe there is an invisible line between so-called
Anglo-Saxon Europe, comprising countries such
as England, Holland and the Scandinavian ones,
and Latin-Mediterranean Europe comprising
countries such as Belgium, France, Italy and
Spain. Ideas from one culture category are easily
rejected by the other, merely because of their
origin.
Pharmaceutical care has quickly become ac-
cepted by Anglo-Saxon Europe. That this has
been the case in Britain is not surprising given the
similarities between American and British drug
distribution. The smaller Northern European
countries tend to be open to new ideas because
their size makes them dependent on the develop-
ment in other markets. In Latin Europe, the
debate has begun on a very modest scale. Central
Europe (Germany, Austria and Switzerland) is
placed somewhere in between, with the last of
these furthest ahead with a positive attitude
towards implementing the pharmaceutical care
concept.
Pharmaceutical care has the drawback that it is
difficult to translate to other languages with
exactly the same meaning as in American/English.
The same difficulty existed when clinical pharma-
cy was internationalised. It created problems
because “clinical” was interpreted by doctors as
something in which they had a monopoly. The
word “care” contains some of the same problems
and a tactical/strategical responsibility lies with
pharmaceutical organisations when they have to
convert pharmaceutical care to non-American
cultures.
125
 The interpretations of the term pharmaceutical
care range from an ordinary, good distribution
service, a smile and some friendly advice, to being
a scientifically organised monitoring programme.
The first interpretation is too narrow because it
does not distinguish the pharmacy from any other
specialty business and thereby does not offer a
professional challenge to the pharmacist. The
second one falls within the meaning, but such a
restricted interpretation does not do the concept
justice either.
In spite of cultural differences, the attention
paid by various leaders of pharmaceutical organi-
sations does indicate that pharmaceutical care is a
sort of life line which will lead pharmacists into a
development process, resulting in added value for
both patient and society.
Both in the Central and Latin part of Europe,
the traditional, independently-owned pharmacy
fights to survive, pressed by the authorities and
by large retail chains that want to have a share of
the lucrative health care market. Pharmaceutical
care may well prove to give pharmacy a competi-
tive lead, although it is obviously not a panacea.
Is pharmaceutical care exclusively something to
secure the survival of the pharmacist in the highly
technological part of the world?
The answer to this question is easy when you
read the Strand/Hepler definition of the concept
closely, but the fundamental health care problems
in the developing countries are still of such
dimensions that simple access to a pharmacist is a
luxury reserved for a small percentage of the
population. The road leading to pharmaceutical
Raising pharmacy standards
Health service purchasers are looking for value for money from community
pharmacists
AS the cost of providing health services escalates,
governments and other health service purchasers
are looking for value for money from community
pharmacists. At the same time, the implementa-
tion of pharmaceutical care is expanding the
community pharmacist’s role. Against such a
background of change, pharmacists will need to
examine their effectiveness. Health service pur-
chasers will increasingly want to be assured that
their money is well spent.
It is thus important that the quality of the
service offered is not only maintained but also
improved. Pharmacists across the world are
looking at the best ways of raising standards of
practice. The International Pharmaceutical Fed-
eration recently approved guidelines for good
pharmacy practice.’ Its document sets guidelines
for a quality of service that patients can demand,
and FIP suggests that national standards based
on these guidelines should be laid down by each
national pharmaceutical association.
In Great Britain, the standards for pharmacy
practice are contained in the Royal Pharmaceuti-
cal Society’s code of ethics,‘ which sets out the
standards which are exvected of the vrofession by
126
care is longer and solutions must be found which
are different to those being discussed in the
United States and Europe today.
However, the Tokyo WHO seminar and FIP
congress clearly showed that pharmacists in the
developing countries are also interested in partici-
pating. A responsibility lies with colleagues in the
well-to-do parts of the world that the programmes
taken up by FIP also make due allowance for the
conditions prevailing in developing countries. A
sponsored pilot project might be appropriate
here.
In spite of the interest shown by the pharmaceu-
tical organisations with regard to having pharma-
ceutical care incorporated in national develop-
ment programmes, there is reason to pause and
reflect. It will not be an easy “turnaround” to give
the pharmacist a new profile. Both internally in
the profession, as well as externally with authori-
ties and other health care professionals, there will
be scepticism and resistance to overcome. The
justification for pharmaceutical care is the phar-
macist’s competence, not to mention the fact that
nobody else is doing it. There will, however, be
barriers and pitfalls and solving these problems
should take place in co-operation with others, not
by monopolising the task.
PETER J. KIELGAST
Director General,
Danmarks Apotekerforening,
Bredgade 54,
PO Box 2181,
DK-1017 Copenhagen K,
Denmark
the profession. Failure to meet the standards
might lead to disciplinary action and could result
in a pharmacist’s right to practise being removed.
To be effective, standards must be adopted by
pharmacists as a whole and must be monitored.
Their adoption will be dependent both on how the
profession is made aware of their existence and
how the reasoning behind them is presented.
Before pharmacists will change their practice,
they must be convinced of the need for change.
Monitoring is generally seen as a role for the
professional body, although often the major pur-
chasers of the service (eg, government or health
insurer) will also want to ensure that standards
are being complied with. In Great Britain, a team
of inspectors is employed by the Royal Pharma-
ceutical Society to monitor compliance with pro-
fessional standards. However, inspections will
generally be infrequent and it will be difficult to
gain more than a snapshot picture of compliance
with the standards. It will be easier to measure
how well the premises comply with the standards
laid down in the code of ethics than to inspect the
standard of other professional duties, eg, patient
counselling. Furthermore. this tvDe of inmection
THEINTERNATIONAL
JOURNAL OF PHARMACY
PRACTICE,
NOVEMBER
1993