Keywords: ?Clinical pharmacy, Evidence-based practice, Continuing Professional Development
The changes we see in our socio-economic environment are world-wide and unavoidable. They include a decreased deference to professions and a demand for high quality services that are equal to the current best.
Pharmacy must adjust its approach to practice and education in order to meet these challenges. Application of pharmacy to individuals (clinical pharmacy) in an evidence-based fashion is vital if our profession is to continue to have a high standing. This will be attained by continuing professional development rather than continuing education.
To consider how pharmacy may change in the light of a changing environment I will consider first of all what changes we may identify in our society, in technology, and in particular in healthcare, so that we can see what it is to which pharmacy has to respond in the coming years. ?I have talked on these subjects for some years in the United Kingdom and when I went to Kenya I sought the advice of professionals there to see if the same changes that I had observed in the UK, in Europe and at a distance in the U.S.A., had also occurred in Kenya. ?I expected that there would be major differences, but in reality I was assured that the same changes were occurring there and the differences were only in the details and speed of change. Having paid short visits to China in 1997 and in 2010 I can see many of the same changes and I believe these principles are probably universal.
Firstly, in society at large in the last couple of decades we have seen changes in people’s deference to professions. ?No longer, at least in Europe, is old age or seniority an automatic guarantee of respect. ?What matters now is competence and earned respect. ?No-one now believes something just because they were told it by someone in a white coat.
There is a much greater degree of education amongst the public, particularly in technical matters such as health and pharmacy. ?This has been fuelled by the development of the Internet and the proliferation of a wide range of resources, some good, some bad. ?Thus, a patient coming to see their doctor in the UK might well come with documents they have printed from the Internet. ?They expect their health professionals to be at least as up to date as they are! ?For health professionals, this is a major challenge and has led to completely different ways of working.
In parallel, there has been increasing demands for the very best in every area of society. ?Healthcare is no exception. ?Patients no longer accept delays, second rate options, or poor service. ?They demand good health and they demand it now.
Technology has become increasingly complex, leading to many new interventions in healthcare. ?There is high tech equipment and there are high tech drugs, and many diseases that were once untreatable are now responding to intervention. ?The obvious problem, however, is the cost and in every country in the world there is some form of rationing of Health Care, either a government led scheme, or rationing by affordability.
The information boom has extended such that we are now able to collect data on performance of doctors or hospitals or countries, and we can compare them very rapidly. ?In the past this was just not possible and so one doctor treated patients in one way and a different doctor in a different way, and no one would know and no one would be able to compare their results. ?These days, there are published league tables of hospital performance, and doctors’ performance, of surgical success and failure rates. ?A patient can see how well their surgeon has done in the past and how well the hospital is doing now. ?This has led to demands for standardisation, so that treatment in one part of the country is the same as treatment in another part of the country. ?It is widely agreed that this has indeed improved standards across those countries that use this system, although it can also be argued that this may stifle some innovation. ?Either way, these changes are here to stay and we have to live with them as a profession.
The emphasis on quality standards has also meant that it is no longer possible for any one profession to act in isolation. ?Interdisciplinary teamwork is the only solution for remedying deficiencies and for improving care. ?This has led to genuine changes in attitudes within Healthcare; no longer is the doctor king, and no longer do other professions including nursing and pharmacy have to bow down to the profession of medicine. ?This means that pharmacy has to take a new level of responsibility for what it does. ?No longer is it a profession that simply does what it is told but it is a profession that accepts responsibility for its actions and for its mistakes. ?This is very uncomfortable for some older colleagues but it is part and parcel of the brave new world in which we now live.
Specific changes in Pharmacy
Whenever I get to talk about change to a new group of students I usually ask them to list any drug that is of any importance for any reason. ?Then, I write them on the blackboard in three columns. ?There are very few drugs in the first column, a large number in the second column and an even larger number in the third column. ?Column one are the drugs with which I was familiar when I graduated. ?Column two are the drugs which I had heard of when I graduated, but which have changed their use dramatically since those days. ?Column three are drugs which were never even heard of when I graduated some 35 years ago. ?We have to learn continuously throughout our professional lives. ?
A professional response:
Education is about preparing for the future and it is increasingly obvious that today’s graduates will need a body of knowledge that is just not available now. As one person put it, half of what we teach today is wrong; the problem is that we don’t know which half!
Thus we have to prepare professionals to learn for themselves and to keep doing so for the whole of their careers. ?At this point, young pharmacists ?have visions of many more lectures to come and many sleepless nights of study; things they had hoped were behind them.
In fact there are new ways to learn; the internet has opened many opportunities, and colleagues remain valuable sources of information; in almost all studies on the subject, colleagues are the most common source of information.
Nonetheless, most of this is not continuing professional development (CPD) but continuing education (CE), and the two are different. The key difference is that in continuing development I analyse my information and professional needs, and I then find a way to fulfil those needs. In continuing education, I just sign up for a conference, or look through a journal, and hope it will do me some good. The difference is the analysis and the planning. In UK, having been required to record CE for some years, pharmacists are now required to record CPD in a structured way that emphasises this difference.
The second response of the profession, and indeed the whole of healthcare, is to move along a path known as evidence-based practice.
This is a process which tackles any clinical or professional problem by the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. It involves framing the problem as explicit questions, searching for data to address those questions, and then applying the conclusions in a way that combines evidence with clinical expertise. Anecdotes and opinions of anyone, even of senior and distinguished colleagues, have to give way to evidence.
Evidence-based practice has been made possible by information technology but it has been made necessary by the changes in our society. It fits very well with continuing professional development and also with a style of learning known as problem-based learning (PBL). PBL was developed in several countries, including Canada, Netherlands and Sudan, and has been widely adopted in medicine, dentistry and nursing because those trained in these techniques are much better at keeping up to date after they graduate than those trained in traditional ways. Pharmacy has also incorporated some PBL techniques into undergraduate and postgraduate teaching, and the UK’s national curriculum emphasises integrated teaching instead of the traditional subject divisions.
Of course evidence-based medicine, problem-based learning and continuing professional development have their problems; the chief of these being a dependence on technology, but the necessary facilities are spreading rapidly and will be with us all in a very short time.
So, how does this fit with clinical pharmacy?
Pharmacy has changed, from a supply-based profession to an information-based profession. Supply of medicines remains a core task, but it is no longer sufficient. Customers want information on how to use the medicines, and they want it personalised to their own needs. When I graduated we had few potent medicines, we were using items that didn’t do a lot of good and didn’t do a lot of harm either. It was safe enough to give everyone the same drug in the same dose. Now that is not true; we have discarded much of the dross and we are left with very powerful drugs that must be used with discretion, tailored to individual need. That is the basis of clinical pharmacy and to meet that demand we use all the skills of continuing development and evidence-based practice.
Pharmacists in UK, USA, and many other countries no longer hide in the basement of a hospital or the back room of a shop. They have to be where the patients are, interacting with the patients, their carers and the other professions. Medicines are in pre-packaged forms dispensed by technologists or robots; the real skill is in applying those medicines to the patients.
Pharmacists have been successful in delivering services that have relevance to patients. The UK government was concerned about the increasing infection rates in hospital patients, and the problem of bacterial resistance, and so gave some money to pay for extra pharmacists to tackle the problem. What they actually did varied from place to place, as it must, but the outcomes were so successful that the money has been made permanent and expanded further. That was achieved because pharmacists took the trouble to plan what was done and to design and measure important outcomes of the new service.
Outcomes include the advice offered to prescribers and its acceptance. Typically we would record all suggestions for prescribing, all changes to prescriptions and all responses to questions. These would then be judged by a multi-disciplinary panel for importance and appropriateness. The results have generally been very favourable but it must be emphasised that the approach has to be a clinical one; understanding the role of drugs in the context of the whole patient1.
I firmly believe that the future for our profession lies in embracing clinical pharmacy, evidence-based practice and continuing professional development.
A. Prowse, D. Scott (2004)
An evaluation of a clinic-based pharmacist and a medicines home delivery service from a transplant outpatient department.
Pharmaceutical Journal ?2004; 272: 547-551
David Scott PhD MRPharmS.
Pharmacy, Oxford Radcliffe Hospital, Oxford, OX3 7EW, UK.
David Scott PhD MRPharmS.
Pharmacy, Oxford Radcliffe Hospital, Oxford, OX3 7EW, UK.
male,born in Britain in 1955
Registered Pharmacist(MRPharmS)in UK since 1977
PhD in pharmacokinetics 2001
Senior Pharmacist,John Radcliffe Hospital,Oxford since 1992
Professor of Clinical Pharmacy,University of Nairobi,Kenya 2007-2009
UK pharmaceutical Care award 2005