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Pharmacy: the new frontline

Pharmacists have the chance to transform themselves into a new kind of frontline healthcare professsional - and pharma companies can benefit from new alliances, say Fawz Farhan and Paul Lowndes

Pharma companies have always had good links with prescribers, and GPs, as the traditional prescriber, have been the most obvious target for the industry, with face-to-face contact, meetings and continuing medical education. But things are changing, and GPs are no longer considered the only 'frontline' healthcare professionals. In particular, pharmacists, like nurses, are breaking out of their traditional 'backroom' roles and becoming more engaged in with patients and patient care.

Pharmacists - 'the scientists on the high street' - are now becoming more than dispensers of medicines and advice. Soon, community pharmacists will have a greater influence over disease management, prescribing and recommendations.

In the last few years, some 1800 pharmacists have become independent or supplementary prescribers. In addition, Pharmacists with Special Interests (PwSI) are fast developing new clinical services. By understanding pharmacists and supporting these new roles, pharma companies can develop new marketing approaches and strategies that can target this increasingly influential group of healthcare professionals.

Pharmacy Prescribers

The Department of Health introduced supplementary prescribing to certain healthcare professionals, including pharmacists, in April 2003, with the aim of providing patients with quicker and more efficient access to medicines, and to make the best use of the clinical skills of these professionals. Then independent prescribing was introduced in May 2006, as a means of improving patient care, increasing patient choice in accessing medicines and contributing to a more flexible team working across the NHS.

Supplementary prescribing is a voluntary prescribing partnership between the independent prescriber (doctor or dentist) and supplementary prescriber (eg pharmacist). Together they implement a patient-specific Clinical Management Plan (CMP), with the patient's agreement.

The supplementary pharmacist prescriber may then prescribe any medicine for the patient that is referred to in the plan, until the next review by the doctor or dentist. The pharmacist has discretion in the choice of dosage, frequency, product as specified by the CMP.

There is no formulary for supplementary prescribing, and no restrictions on the medical conditions that can be managed. The pharmacist can prescribe controlled drugs and unlicensed medicines in partnership with a doctor within a patient's CMP.

Supplementary prescribing is appropriate in specific situations:

* When working within a team where a doctor and the same common patient records are accessible.

* For specific long-term conditions which can be managed by a supplementary prescriber between reviews by the doctor.

* For mental health.

* For situations involving controlled drugs.

Independent prescribing

Pharmacist independent prescribing allows pharmacists to prescribe any licensed medicine for any medical condition that a pharmacist prescriber is accredited to treat. This includes most medicines in the British National Formulary (BNF) with the exception of Controlled Drugs (CDs) and unlicensed medicines.

The pharmacist must ensure that patients are aware that they are being treated by a non-medical practitioner and of the scope and limits of their prescribing.

Pharmacist independent prescribing is appropriate in the following situations:

* The pharmacist is competent to assess, diagnose and make treatment decisions for the patient.

* For conditions that the pharmacist independent prescriber is competent to treat independently.

* The pharmacist works remotely from a doctor, seeing patients independently.

A supplementary prescriber can undertake top-up training to become an independent prescriber.

Opportunities for pharma companies

Pharmacists' expanding clinical role gives them more patient contact and a bigger say with regard to over-prescribing and the use of prescription brands. Having sound understanding of diseases and drug treatments, pharmacists can, when properly trained, be in an ideal position to take on these prescribing roles, either independently or complementary to GPs. For pharma companies this means new opportunities to target pharmacists, taking a more "clinical" approach that is more similar to the way they currently communicate with GPs.

Supplementary and independent prescribing by pharmacists gives pharma companies the opportunity to help pharmacists deliver better patient care and build brand loyalty by providing their pharmacist customers with the right education, training and professional support.

Pharmacists with Special Interests

In 2006 a National Framework for implementing Pharmacists with Special Interests (PhwSIs) was published by the Department of Health and NHS Primary Care Contracting.

This framework is part of the ongoing implementation of 'A Vision for Pharmacy' in the new NHS, and sits alongside the wider development of the pharmacy workforce to create a better skill mix in primary care. This new system will allow accredited PhwSI to work more closely with GPs and other primary care professionals to deliver better care to patients as described in the White Paper "Our Health, Our Care, Our Say".

A PhwSI has to be individually accredited by the Primary Care Trust (PCT) to provide a specific specialist service. A PhwSI is a pharmacist who delivers a clinical service, normally through their pharmacy, beyond the scope of their normal professional role. For example a PhwSI in diabetes may offer a diabetes clinic that includes screening of undiagnosed diabetes, blood glucose monitoring and a Medicines Use Review (MUR) service. PhwSI are not required to qualify as prescribers, but some will be. They will normally practise across a locality or PCT or within a clinical network.

Examples of service areas for PhwSI

* Dermatology, eg follow up clinics for eczema.

* Sexual health, eg chlamydia testing and treatment, emergency hormonal contraception and monitoringsexually transmitted infections.

* Anticoagulation services, eg anticoagulation monitoring and management.

* Management of long-term conditions such as diabetes, eg monitoring and screening.

* Medicines management for the elderly, eg optimisation of therapy and reducing polypharmacy.

* Pain management, eg for rheumatoid arthritis or osteoarthritis and can include mobility aids and optimisation of therapy.

* Substance misuse, eg needle exchange clinics, supervised methadone supply.

Implementation and framework

'Special Interest' resources are governed by local PCTs. In order to get accredited, a pharmacist must first ascertain whether the PCT is supporting special interests for pharmacists in their particular area of interest. If this is the case, the PCT can commission and accredit the pharmacist.

Pharmacists have to first undergo extra competency-based training to become accredited as a PhwSI. This training can come from any source and the pharmacist can choose which route they take to meet their training needs. For accreditation, the pharmacist will have to demonstrate that they have the competencies required for their particular speciality.

Opportunities for pharma companies

In the PhwSIs launch meetings held in 2006 in London and Manchester, 150 pharmacists participated in a forum discussing the opportunities and threats of this new framework. One of the chief concerns was support and funding for pharmacist training.

At the meeting it was suggested that pharmacists could receive training and support from pharma companies. Indeed, the Association of Practitioners with Special Interests suggests that candidates should approach pharma companies for sponsorship.

A large number of companies already fund specialist training for pharmacist for POM to P switches and MUR support. By getting involved, pharma companies could align themselves with pharmacists who are playing a more significant role in recommendations and prescribing choices. By taking this approach, pharma companies can create a profile where their product becomes synonymous with a particular condition. Supporting emerging roles for pharmacists would open opportunities for increasing category and product awareness and support.

Patient Group Directions

Patient Group Directions (PGDs) are another vehicle by which access to medicines is widened. These documents allow medicines to be given to groups of patients without individual prescriptions having to be written for each patient. They can be put together to allow pharmacists to give out medicines without a prescription.

Each PGD must be written for a particular medicine and details specifics on when and how the medication can be given. It must also include exclusion criteria to ensure that the medication is given to the right type of person. PGDs can be conducted through the PCT with pharmacists given funding to participate, or privately where pharmacists charge patients directly for the service.

They can be written for Prescription Only (POM) and Pharmacy Only (P) medicines And are a useful way for patients to gain access to medication in a convenient fashion. Useful for trialing POM to P switches, PGDs can provide evidence to the Medicines Healthcare products Agency (MHRA) supporting the validity of supply of the medicine through the pharmacist.

By supporting pharmacists in developing PGDs, pharma companies can ensure that their brand is at the cutting edge of changes in pharmacy.

Current examples of PGDs include:

* Supply of sildenafil for erectile dysfunction.

* Supply of finasteride for male pattern baldness.

* Supply of orlistat for weight loss.

* Supply of azithromycin for treatment of chlamydia.

Opportunities for pharma companies

PGDs give pharma companies an opportunity to increase access to their medicine, and could involve a wider group of pharmacists who are not necessarily qualified as prescribers. A good relationship with PCTs and Local Pharmaceutical Committees (LPCs) is required to get PGDs off the ground and an awareness of local disease area priorities can help better target PGDs and address a genuine healthcare need.

Industry-led initiatives

Compliance is a major issue in the UK. It can have a negative impact on disease prevention, control and treatment. Unused drugs account for a significant amount of wastage on the NHS.

'Making the Most of your Medicines' (MMM) is a new initiative by AstraZeneca that aims address this and help bring pharmacists and pharma companies closer together. It recognises pharmacists' new clinical roles and their contribution to medicines optimisation and rewards them for it, and the scheme seems to have been well received by the Pharmaceutical Services Negotiating Committee (PSNC) which has said "it was quite good value for money".

Under the MMM scheme, four of the company's products have been highlighted (Arimidex, Crestor, Nexium and Symbicort) as being eligible for paid consultations in community pharmacies. Pharmacists are remunerated £10 for a 10 minute session. Initial responses from pharmacists are favourable, particularly since they only involve a small number of products in a distinct setting. They are seen to be more manageable for busy pharmacists who do not have time to conduct extensive MURs. Patients may also benefit from a scheme, in which they are not overwhelmed by information.

By training pharmacists to conduct these short, structured interviews, pharmacists will be able to deal with patient concerns, difficulties and lifestyle issues in order to increase compliance and strengthen pharmacist and patient relations.

Patient education programmes are another area where pharmacists can have influence in getting patients signed up. Their role in compliance, offering ongoing advice at the point of prescription collection and sign-posting (a requirement under the pharmacy contract) can help bolster these patient education programmes.

By getting involved in other industry-led initiatives, pharma companies can not only increase brand compliance, but also build better relationships with pharmacists. Valuing pharmacists and the services and expertise they provide, will strengthen brand loyalty.

Targeting pharmacists at every level

Pharmacists can influence medicines usage at a number of levels, from simple interventions that all pharmacists can get involved in, such as screening and MURs, right through to independent prescribing.

The rapidly changing roles of pharmacists mean that there are greater opportunities for pharma companies to get involved, in supporting pharmacists and promoting brand loyalty. Pharma companies can offer support to pharmacists at every level of clinical expertise.

Summary

There are many ways for pharma companies to get involved. A large number of companies already fund specialist training for pharmacist for POM to P switches and MUR support.

By supporting pharmacist training as independent or supplementary prescribers, pharmaceutical companies can align themselves with clinical pharmacists who are now playing a more significant role in recommendations and prescribing choices.

At a different level, pharma can get involved by providing information leaflets, testing devices and sponsoring services. This too can increase brand visibility, brand confidence and awareness.

Box 1: Case Study - Diabetes Care

In the UK, 2.3 million people have been diagnosed with diabetes ¿ up to 4% of the total population. An estimated additional 500,000 people have the condition but have not yet been diagnosed.

The need to monitor this chronic disease and to provide support to people living with the condition provides many opportunities for pharmacists to play a more active role in patient care.

Research shows that there is a lack of patient-centred services in many parts of the country. A recent report by patient organisation Diabetes UK underlined the current shortcomings in diabetes care in the country. It cited findings from the the Healthcare Commission that in 55% of PCTs, 10% of people or fewer had attended an education course on how to manage their diabetes.

Starting from the bottom up, pharmacists can implement a number of new services, many of which would benefit from advice and support from pharma companies.

Screening

* Testing services for patients to find out whether they have diabetes.

* Providing training and set up support, advertisements of service and glucose testing equipment.

Monitoring

* Regular testing to already diagnosed diabetics to ensure that they are keeping their blood sugar well controlled.

* Providing training and set up support, advertisements of service and glucose testing equipment.

Medicine Use Reviews (MURs)

* Reviewing medications and lifestyle issues with diabetics and making recommendations to be taken to the GP.

* Supporting pharmacists with specific training on MUR for diabetes.