Incentives within the reimbursement system will influence the behaviour of professionals. A senior Scottish pharmacy official is quoted as saying that: “medicine supply is the sacred cow of the community pharmacy sector. Technology will lead that approach to the abattoir”. Similarly, Adrian Price of Tesco also recognised that the potential of his “brilliant” pharmacists could be released through innovative approaches to remote dispensing.
These initiatives all mark a sea change in the direction of travel for pharmacy reimbursement, as commissioners look for ways to incentivise behaviours that are focused on interaction and counselling of the patient and integration into clinical teams, rather than the focus on mechanical dispensing activities. As is implied in the quote above, technology can be an enabler if it is seen as a means of freeing pharmacy professionals from the mundane tasks to focus on the value they uniquely bring as trained professionals.
Moving away from the mechanics of supervision
Because of the current incentives the profession has become unduly focussed on the mechanics of supervision and a narrow definition of the ‘clinical check’. Thus the concerns about supervision increasingly focussed on the process of authenticating that the dispensed items comply with the prescription, rather than direct interaction and consultation with patients and/ or care givers to assess the appropriateness of a prescription in the context of the patient’s full medicines and dietary history.
In the often cited case law – Pharmaceutical Society of Great Britain v Boots Cash Chemists 1953, the pharmacist’s power to intervene at the point of sale was deemed sufficient to meet the supervisory obligation under the law. The latest technologies allow a pharmacist to intervene in “real time” in many ways without being physically present. Hospitals and health centres enjoy the exemption from the supervision regulation for medicines dispensed in the “course of their business”.
What is absent in the supervision debate is the reality that the increasing complexity of medicines and the significant consequences of errors and failures continue to be a major cause of concern to the health system as a whole (see Impact of medicines below).
The logistics and commercial issues of getting prescriptions dispensed for patients at all times of day or night for all new prescriptions have encouraged new approaches that exempt pharmacists from any direct interaction with the patient. Examples include:
Out-of-hours – in hospitals, pre-labelled packs are handed out by nursing staff without any pharmacist involvement;
Systems where prescriptions are harvested from GPs’ offices, filled on an assembly line basis and returned to the GPs’ office for next day pick up, without any direct interaction between dispensing pharmacist and the patient.
As an industry, pharmacy has embraced technology where it appears to offer efficiency to complement existing systems. It has not however been seen as adopting new technologies that disrupt the status quo. Technology can ensure that prescriptions can be immediately dispensed at the point of care while also ensuring direct uninterrupted interaction with a pharmacist, in all cases and at all hours in a cost effective manner.
Various studies show that 15-20 per cent of unplanned admissions are due to some medicine failure and that less than 60 per cent of prescriptions do not achieve their goals because of medicine failures.
The discussion of the use of enabling technologies in remote supervision has pigeon-holed technology as somehow being ‘anti’ the pharmacy profession. As quoted, technology can release the pharmacist from the medicine supply treadmill and re-establish the primacy of the pharmacist’s role in effective medicines management and makes the pharmacist the most available primary care practitioner. To mix our metaphors we can take the sacred cow of medicine supply to the slaughter house and allow the pharmacist to emerge from the chrysalis as a fully formed butterfly and a major clinical player in the healthcare team.
Impact of Medicines Management on unplanned admissions and patient management (NICE Patient Safety Study)
- Medication errors are one of the leading causes of injury to hospital patients leading to increased morbidity, mortality and economic burden to health services;
- Over half of all hospital medication errors occur at the interfaces of care and most commonly at admission;
- The causes of the problem are multiple including, patient, practitioner and existing medicines management systems;
- With personal lead assessment there was a reduction in medicine discrepancies between home and hospital prescribed medications of 55.3% with the number of discrepancies per 100 patients falling from 43.6% to 19.5% following the intervention.
Impact of Medicines Management on unplanned admissions and patient management (Australian Government Study)
- Medication errors are implicated in 15-22% of unplanned hospital admissions;
- Medication errors are a leading factor in injuries sustained by hospitalised patients;
- Medications may be implicated in older patients presenting with falls, confusion and incontinence;
- Experience from organisations has shown that poor communication of medical information at transition points (interfaces) is responsible for more than 50% of all medication errors in the hospital and up to 20% of all adverse drug events.