International Perspective on the New Roles of Pharmacists Dr Luc Besançon
I declare that I have no financial relationships with any for-profit companies that are directly or indirectly related to the subject of my presentation 18/11/2017 2
What is it for me in this presentation? As a current / future leader of my profession: inspiration for development of programmes and policies As a community pharmacist: food for thoughts for revisiting the positioning of my community pharmacy, to update its business model, to further develop its business relevance, performance and personal satisfaction 18/11/2017 3
Context of the evolution of the new roles of community pharmacists 18/11/2017 4
Why there is a need for change? Trends affecting developed countries healthcare High-income countries: burden of chronic diseases (cancer, cardiovascular diseases, asthma, diabetes) and ageing population AMR raising: By 2050: more people will die from drug-resistant infections than from cancer (10 million per year) Risk of pandemics higher given globalisation Government budgetary constraints: cost containment measures, transfer from secondary to primary care, HTA also applied to care Shortage of healthcare professionals in most countries Increased focus on prevention of diseases and harm from care Increased expectations from patients and citizens Raise of new technologies 18/11/2017 5
Why there is a need for change? Inefficiencies associated with medicines According to WHO, among the 10 common causes of inefficiency of healthcare sector: - Spending too much on medicines and health technologies, using them inappropriately, using ineffective medicines and technologies; - Leakages and waste, again often for medicines; - Hospital inefficiency particularly over-capacity; - De-motivated health workers, sometimes workers with the wrong skills in the wrong places; - Inappropriate mix between prevention, promotion, treatment and rehabilitation, or between levels of care. All efficiency gains would effectively result in increasing the available funds for health by 20-40%. 18/11/2017 6
Why there is a need for change? Potential for responsible use of medicines 475 000 000 000 $ could be saved every year in healthcare costs at global level if responsible use of medicines was achieved Reference: Advancing the responsible use of medicines - Applying levers for change. Parsippany, NJ: IMS Institute for Healthcare Informatics, 2012. 18/11/2017 7
Policy guidance on the new roles of community pharmacists 18/11/2017 8
Main roles of pharmacists Joint FIP/WHO document Joint FIP/WHO guidelines on good pharmacy practice: standards for quality of pharmacy services (2011) Role 1: Prepare, obtain, store, secure, distribute, administer, dispense and dispose of medical products - A: Prepare extemporaneous medicine preparations and medical products - B: Obtain, store and secure medicine preparations and medical products - C: Distribute medicine preparations and medical products - D: Administration of medicines, vaccines and other injectable medications - E: Dispensing of medical products - F: Dispose of medicine preparations and medical products 18/11/2017 9
Main roles of pharmacists Joint FIP/WHO document Role 2: Provide effective medication therapy management - A: Assess patient health status and needs - B: Manage patient medication therapy - C: Monitor patient progress and outcomes - D: Provide information about medicines and health-related issues Role 3: Maintain and improve professional performance - A: Plan and implement continuing professional development strategies to improve current and future performance 18/11/2017 10
Main roles of pharmacists Joint FIP/WHO document Role 4: Contribute to improve effectiveness of the healthcare system and public health - A: Disseminate evaluated information about medicines and various aspects of self-care - B: Engage in preventive care activities and services - C: Comply with national professional obligations, guidelines and legislations - D: Advocate and support national policies that promote improved health outcomes 18/11/2017 11
7 (+1) star pharmacist To undertake these roles and functions, pharmacists must have the following characteristics: - Caregiver - Decision-maker - Communicator - Manager - Life-long-learner - Teacher - Leader - Researcher WHO and FIP. Developing pharmacy practice - A focus on patient care. Geneva and The Hague: WHO and FIP, 2006. 18/11/2017 12
How does this guidance translate at national level? 18/11/2017 13
The formula for the community pharmacy of the future Public health (prevention, entry gate to healthcare system ) Optimising medicines use for better health outcomes (adherence, medication review...) Product focus (dispensing, compounding ) Commercial (parapharmacy ) 18/11/2017 14
The formula for the community pharmacy of the future Public health (prevention, entry gate to Product focus (dispensing, healthcare system ) And the final active pharmaceutical ingredient: compounding ) Optimising medicines use for better health outcomes (adherence, medication review...) The Pharmacist Commercial (parapharmacy ) 18/11/2017 15
Public Health Public health (entry gate to healthcare system, prevention ) Optimising medicines use for better health outcomes (adherence, medication review...) Product focus (dispensing, compounding ) Commercial (parapharmacy ) 18/11/2017 16
Public health role As entry gate to healthcare system Foundation: high accessibility of competent pharmacists: - In EU: 46 million people visit a community pharmacy every day - Initiatives to support accessibility: IT-based solutions for locating the closest opened pharmacy (Sms and/or Website and/or App). Guidelines to make pharmacy accessible to lowmobility and handicapped persons (Spain) 18/11/2017 17
Public health role As entry gate to healthcare system Pharmaceutical triage (supported by protocols), which may include - Questionnaires; - Screening (via clinical tests): a community pharmacy can measure: blood pressure in 22 EU countries; body mass index in 23 EU countries; blood glucose levels in 20 EU countries; cholesterol in 20 EU countries. The pharmacist identifies the needs of the patient and determine if it is appropriate to deal with this case or refer it to another healthcare professional. 18/11/2017 18
Public health role Minor ailment scheme Scotland Patient register at the pharmacy of his choice (currently 900,000 patients registered out of 5,300,000 inhabitants) Dispensing of assured quality (through specific tools) around minor ailment scheme: acne, athlete's foot, back ache, cold sores, constipation, cough, diarrhoea, ear ache, eczema and allergies, haemorrhoids, hay fever, headache, head lice, indigestion, mouth ulcers, nasal congestion, pain, period pain, thrush, sore throat, threadworms, warts and verrucae. Results: 50,000 visits at the community pharmacy every month Decrease of the number of medical consultations Medicines are covered by NHS Scotland ( 400,000 for 190,000 units dispensed every month) 18/11/2017 19
Public health role Minor ailment netcare, Switzerland 18/11/2017 20
Public health role Pre-screening In the Philippines, India and Pakistan: pharmacists are trained to detect suspicious cases of tuberculosis and refer these individuals to the appropriate centres for diagnostics: - 30% to 40% of referred cases are confirmed. Pharmacies are then associated in the treatment for the Directly Observed Therapies (DOTs) Centres. 18/11/2017 21
Public health role Prevention through immunization Immunization made by pharmacists in a growing number of both developed and developing countries: USA, Portugal, Ireland, Switzerland, Philippines, Australia, France Some have a long history of immunization: Argentina (1958), Tunisia (1973), USA (90s) For more information: FIP. An overview of current pharmacy impact on immunization. The Hague: FIP; 2016. Available at: www.fip.org/publications 18/11/2017 22
Public health role Health Promotion Health promotion through active engagement of pharmacists - Through campaigns at the community pharmacies and/or in the (social) media - Through dedicated programmes in primary schools (Japan, Korea, Spain) or high-school (Germany) 23
Public health role Harm reduction Needle exchange programme - Example: Portugal Implemented on 1 st January 2015; national coverage reached by March 2015 56% of the Portuguese pharmacies involved in the programme In one year: 22,983 kits dispensed in pharmacies which corresponds to 45,966 syringes Compensation of 2.40 / kit dispensed paid by the Ministry of Health Methadone / opioid substitution therapy programme 24
Public health role Addiction Quitting tobacco programmes: - Run in community pharmacies - In Denmark: combination of personal coaching by pharmacists (individual interactions + group evening sessions) + an app which: Estimation of savings Community of support: videos, blogs When an urge for cigarette: tips to deal with it. 25
Product focus Public health (prevention, entry gate to healthcare system ) Optimising medicines use for better health outcomes (adherence, medication review...) Product focus (dispensing, compounding ) Commercial (parapharmacy ) 18/11/2017 26
Product focus Unit dose dispensing: prepared centrally or at community pharmacy level Generic substitution and coming up biosimilars Appointment based model - Synchronising all prescriptions of a chronic patient and dispensing at a fixed time improve adherence + better efficiency of pharmacy operations Authentication of medicines dispensed (falsified medicines) 18/11/2017 27
Optimising medicines use for better health outcomes Public health (prevention, entry gate to healthcare system ) Optimising medicines use for better health outcomes (adherence, medication review...) Product focus (dispensing, compounding ) Commercial (parapharmacy ) 18/11/2017 28
Optimising medicines use for better health outcomes New medicines service (usually for chronic patients) - Example: Medisinstart Service (Norway) - Two follow-up consultations for patients receiving for the first time a chronic treatment (anticoagulants, statins, ACE inhibitors / ATII antagonists, calcium channel blockers or betablockers) - Results: Patients experienced fewer medication-related problems after the 2nd consultation, fewer experienced sideeffects, less worried about the treatment and side effects - New medicine services also available in UK and a few other countries Teaching inhaler technique (asthma patients); Denmark (since 2005) 18/11/2017 29
Optimising medicines use for better health outcomes Optimising medicines use and prescription - Overview of medicines currently taken by a patient (Medicines Use Review) It may be called Medicine Use Review, Entretien de Polymédication or Home Medicines Review; Covered by health insurance e.g. UK, Australia, Switzerland; Comprehensive review of current medication (both prescribed and OTC medicines) run at the pharmacy (or at the patient s home); Detection of issues and recommendations to medical doctors to improve medication treatment. - Improving prescribing: quality circle in Switzerland and the Netherlands (gathering doctors and pharmacists) 18/11/2017 30
Optimising medicines use for better health outcomes Monitoring of the effect of treatment: - Example: AVK treatment service in France If authorised by the law, pharmacists may then adjust the dose to meet the therapeutic objectives defined by the medical doctor (e.g. in Canada) Also making visible the effect of adherence on health parameters (e.g. a medical electronic device and an app) 31
Optimising medicines use for better health outcomes Improving adherence - Example: Australia: Identification through dispensing software scoring called MedsIndex (based on the renewal of prescriptions) When issue detected, a series of 3-5 minute consultation at the community pharmacy every twelve weeks: structured discussions with prompt for pharmacists via a web-based platform; followed by a print-out of compliance improvement. 18/11/2017 32
Commercial Public health (entry gate to healthcare system, prevention ) Optimising medicines use for better health outcomes (adherence, medication review...) Product focus (dispensing, compounding ) Commercial (parapharmacy ) 18/11/2017 33
Towards the future of community pharmacy 18/11/2017 34
More and more services 18/11/2017 35
Development of community pharmacists services: for whom? Primarily patients and/or their family But also the healthcare system: - Other healthcare professionals: training and improvement of prescription - Healthcare settings (e.g. medicines budget management of medicines in nursing homes in Switzerland) - Funders of healthcare systems (e.g. generic substitution ) - Administrators of healthcare system (pharmacovigilance ) How do we measure and make visible the intellectual contribution of pharmacists to each recipient? And who should pay for these services? 18/11/2017 36
Funding concerns Number 20 18 16 14 12 10 8 6 4 2 0 Service is mandatory Third party payment of service Source: FIP. Sustainability of pharmacy services: advancing global health - International Overview of Remuneration Models for Community and Hospital Pharmacy. The Hague, the Netherlands: FIP; 2015. 37
Towards a change of the remuneration models for community pharmacy Fixed assets Stock Structure - Space -Licence - Software Activities -Staff -Consumables Investments Productbased -Margin - Add-on per product, per prescription Structure - Fee on duty - Capitation fee - Fee for structure (rural pharmacies) Activities - Fee for services Performance Based on economic, health or other objectives Costs Remuneration components Adapted from: FIP. Sustainability of pharmacy services: advancing global health - International Overview of Remuneration Models for Community and Hospital Pharmacy. The Hague, the Netherlands: FIP; 2015. 18/11/2017 38
But some governments are already keen to fund substantially these new services Example of Australia: Sixth Community Pharmacy Agreement (2015-2020): - A new Administration, Handling and Infrastructure (AHI) Fee: less susceptible to the ongoing impact of price disclosure. Dispensing remuneration indexed to Consumer Price Index - Nearly double the previous Agreement investment in community pharmacy programs and services: $1.26 billion - $50 million over the Agreement for a Pharmacy Trial Program to trial new and expanded community pharmacy programs seeking to improve clinical outcomes for consumers and extend the role of pharmacists in the delivery of healthcare services through community pharmacy, especially for underserved areas or populations. 18/11/2017 39
Conclusions 18/11/2017 40
What future for community pharmacy? Community pharmacy as a local (community-based) healthcare centre / hub, based on its strengths: - Proximity and accessibility to patients - Integration in healthcare system - Trust of patients - Providers of tailored solutions to prevent and treat diseases or to empower patients and carers with dealing with diseases and symptoms: Primarily through medicines (which efficacy is assured through associated services) Education of patients as well (health promotion) 18/11/2017 41
Community Pharmacy - an integrated community health hub Other healthcare professionals Medical doctor Pharmaceutical triage Pharmacy Referral / transfer Diagnostic (and if needed, prescription; medical care ) Medical follow-up Validation of prescription Short-term treatment Monitoring and support to optimal outcomes (including adherence) Preventative measures and health education Pharmacy and Consulting 42
Conditions for achieving this future Patients and payers want reliable systems with demonstrated and guaranteed added value and safety: - Developing evidence of the added value of community pharmacists (for current and future activities) foundation for remuneration - Reproducibility of the good health outcomes: Quality assurance and/or implementation of Good Pharmacy Practice (as recommended by WHO and FIP) like in many countries (developed and developing countries) And/or compulsory accreditation of community pharmacies (e.g. Vietnam) Professional associations play a key role in the development of our profession 43
Key factors for success of these new functions and roles Competences (usually services are associated with additional training) Grounded on pharmacists expertise in medicines and their responsible use science-based approach Collaborative practice with other healthcare professionals and full integration in the healthcare system Remuneration of pharmacists activities reflect new services and functions (by health insurance, governments, patients ) 18/11/2017 44
At community pharmacy level Selection of the new services based on: - Legal framework (what is allowed and what should be changed) - Needs and characteristics of the population served: targeted approach, differentiation between pharmacies Implementation: step-wise approach, based on existing experience, potential support by professional bodies Evidence from Australia (through their health destination pharmacy programme): increased professionalism leads to: - Better health outcomes and satisfaction from patients loyalty - Higher job satisfaction -. And better financial results for the pharmacy (+9%) 18/11/2017 45
7 (+1) star pharmacist Applying the 7 (+1) star pharmacist concept to implementation of new services: Characteristics Care giver Decision-making Communicator Manager Life-long learner Teacher Leader Researcher 18/11/2017 46
7 (+1) star pharmacist Applying the 7 (+1) star pharmacist concept to implementation of new services: Characteristics Care giver Decision-making Communicator Manager Life-long learner Teacher Leader Researcher Example with immunization by pharmacists Characteristics used when Being an immunizer Inclusion / exclusion criteria Promoting the services Developing processes; business model developed Acquiring skills and knowledge Implementing the processes; advocating for immunization Developing support in the community Collect data and assessing 18/11/2017 47
Thank you for your attention Any questions? 18/11/2017 48