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Can pharmacists manage chronic disease?

Pharmacists are growing in their ambition and can play an important role in chronic disease management, says Professor David Taylor. But Dr Lal Mandal argues that moves to let pharmacists supply simvastatin and OTC antibiotics are all about profit rather than patient care

Pharmacists are growing in their ambition and can play an important role in chronic disease management, says Professor David Taylor. But Dr Lal Mandal argues that moves to let pharmacists supply simvastatin and OTC antibiotics are all about profit rather than patient care

Yes

Whatever politicians or managers may say, there is nothing new about having to live with long-term conditions - it's just that the sheer numbers are larger than ever.

Demographic and epidemiological transition had been in progress for over a century before the NHS was formed. Treating chronic conditions has always been a core task for the health service. It is just that now Britain has more people in later life, and the range of medicines and other therapies available is greater than ever before.

Public debate about the NHS often centres on hospital care. But it is in primary care, and especially GPs' surgeries, that

the majority of healthcare that is most valued by the public is delivered. Beyond that it is through the informed - and on occasions not so well informed - self-care efforts of people living with, or at risk of developing, potentially disabling and life-threatening diseases that individual and population health is most frequently determined.

During the lifetime of the NHS the image of community pharmacists has been that of sub-professionals - capable of supplying medicines correctly and advising about minor conditions, yet unable to provide sophisticated clinical care.

But historically British GPs and pharmacists share the common heritage

of the apothecaries. Looking forward, this can - and I believe should - be seen as

a foundation for redefining the partnerships between GPs and community pharmacists in a changing and in some respects increasingly hostile world.

Pharmacy is being driven to change by factors ranging from the impact of computer technology on dispensing to new public expectations and Government policies. As the education, employment and business opportunities of pharmacists have evolved, so too have their ambitions and values.

The recent white paper Pharmacy in England summed up progress towards pharmacy becoming a more clinically oriented profession. Its vision is that by 2020 the medicines supply role will be combined with patient-focused activities such as providing health checks and supporting appropriate medicine-taking.

As pharmacists' roles in areas such as the management of repeat dispensing continue to develop, they will - with appropriate medical support - take a more proactive role in defining therapeutic regimens.

Recent developments mean that there is an increasing range of over-the-counter medicines, such as low-dose simvastatin. Pharmacists can also directly supply prescription-only medicines via medically agreed patient group directions, and the first generation of pharmacists qualified to be independent prescribers is now beginning its work in the community.

There is no reason to doubt that pharmacists with the right information and skills can contribute extensively to managing chronic conditions such as diabetes and related metabolic syndrome problems - for instance, hypertension and hyperlipidaemia. But this is not to say they should or could attempt to totally replace the unique contributions of GPs.

As Professor Steve Field of the RCGP has stressed, 'pharmacists are not doctors'. They do not, for instance, have the skills good GPs have in differential diagnosis and the management of multiple pathologies.

So the answer to the question is Yes, in the right cases at the right time. The challenge for both the medical profession and pharmacy is whether they can work collaboratively to deliver the best possible care to the public. I hope the answer will again be Yes. But I don't underestimate the competitive and tribal barriers to further progress - including sharing records or even income - or the problems that ill-informed political and managerial interventions may yet create.

Professor David Taylor is professor of pharmaceutical and public health policy at the University of London's School of Pharmacy

No

Moves to let pharmacists supply simvastatin and OTC antibiotics are all about profit rather than patient care, argues Dr Lal Mandal

The Government is hell-bent on pleasing the pharmacist lobby by diverting more and more clinical work into their domain.

The recent news about pharmacists being able to supply statins under a patient group direction, the decision to make yet another NSAID (diclofenac) available over the counter and the possible OTC status

of trimethoprim are only the latest examples.

Do the people who make these decisions believe that, for instance, the key to reducing total cholesterol is as simple as doing a fasting lipid and shoving the patient on simvastatin?

I wish it was so easy. Don't they realise that patients need a holistic approach - of which prescribing is only a part? Before we start a statin our nurses will have given a lot of advice on diet, losing weight, giving up smoking and taking regular exercise.

It's not that patients don't already know this. But discussing these factors in the context of disease management and prescribing a statin only after that increases the chances of treatment success.

We're all aware of patients who don't take what they are prescribed but I've had quite a few patients coming in and telling me of pharmacists who have pulled them into a corner and frightened them about the side-effects of tablets they've been taking for years.

There are only a few common side-effects, so there's little or no point in frightening patients about the rarer ones. Our colleagues in pharmacy are doing us no favours in forcing patients back to us for an appointment to discuss side-effects they are very unlikely to experience.

Similarly, pharmacists claim they'd like to take over the monitoring of patients with hypertension, using automatic blood pressure machines. Again I can't help but feel the expertise of our practice nurses

is being overlooked and insulted. Again there is so much more to the management of this condition. Patients are counselled, advised holistically and regularly monitored perfectly well in the practice.

I have one patient who is on three different antihypertensives but can't afford the prescription fee. If the Government wants to help, surely it would be better to list hypertension as a condition for which a patient is exempt from prescription charges. This would be a much better way to ensure drug compliance and improve patient care.

Some years ago the pharmacists at our PCT advised that GPs should issue monthly prescriptions - meaning community pharmacists doubled their income from dispensing fees and increased their contact with the patient. They are now using this increased contact as a reason to take on more management. Personally I believe we should return to issuing two-monthly prescriptions to reduce our workload.

OTC antibiotics is another area of concern. Azithromycin is already available for chlamydia and it seems trimethoprim for cystitis is in the pipeline.

Do we want quick fixes or do we really want to treat the illness?

Any GUM clinician will tell you that chlamydia is only one STI a patient could have. What about the people who have another infection and need that treated too? And isn't making oral antibiotics available OTC just going to increase the problem of resistance?

Of course we all know that this is really about generating income for pharmacy. Pharmacists are shopkeepers and reap profits from sale of other products, and yet they seem to want a bigger bite of the NHS budget too.

My suggestion to pharmacists is that they continue to do what they do well - dispensing drugs from a prescription issued by a clinician. But the Government wants to cut the community health budget and pharmacists seem willing to offer a quick fix. It's our patients who will suffer in the long term - but by then our current health ministers will have long gone.

Dr Lal Mandal is a GP in Telscombe Cliffs, East Sussex

Can pharmacists manage chronic disease? Yes quote

Historically GPs and pharmacists share a common heritage

no quote

Patients need a holistic approach, and prescribing is only a part of that

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