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Evolving Roles of Pharmacists in the UK and Medication Adherence

For our latest blog, CARE had the honour of speaking to Dilip Joshi, Superintendent Pharmacist and Visiting Senior Lecturer, KCL, about the evolving roles of pharmacists in the UK.

Dilip Joshi

How long have you been working as a community pharmacist in the UK, and can you briefly describe your experience?

I have been a practising pharmacist for nearly 40-years. During this time, I have seen and been involved in the changing landscape, particularly of community pharmacy. My belief has always been that the future of community pharmacy lies in moving beyond the supply model to embracing and providing services and we had one of the earliest consultation rooms, well before it was adopted more universally. I served on Lambeth, Southwark and Lewisham LPC and was involved in negotiating the first supervised consumption service and the earliest EHC provision in the country, both of which have subsequently been rolled-out nationally. We, through Pharmacy London on which I served as a committee member, also introduced the first in-pharmacy vaccination programme in the country which is now a national commissioned advance service. I was one of the earliest prescribing pharmacists in the country, having undertaken a Supplementary Prescribing course at King’s followed by an Independent Prescribing ‘top-up’ course and exam. I subsequently used this qualification to carry out a local surgery’s asthma reviews in our pharmacy changing their medications as necessary, but adding value by offering spirometry tests to screen for COPD and checking inhaler techniques. Our work was seen by a number of stakeholders including patient group representatives, All Party Pharmacy Group and other MPs and the Director General of ABPI. We also hosted visits of Dutch and Japanese healthcare journalists and were featured in their journals as well as in Asthma UK and the Health Service Journal. I also hosted two royal visits including one at my pharmacy by the late HRH The Duke of Edinburgh to raise awareness of what happens in community pharmacies and responsibilities of community pharmacists.

In recent years, how have you observed the role of community pharmacists evolving in the UK healthcare system? To what extent have community pharmacists in the UK taken on responsibilities related to prescribing medication? Would you like to provide examples of how this has changed your day-to-day work?

Pharmacy practise today, is unrecognisable from when I first started. Prescriptions and labels were hand-written! Pre-registration year was relatively unstructured. I believe the profession has evolved organically at least as much as it has in response to external drivers. IT has been a great enabler from computerised PMR systems to electronic prescription service. Better record-keeping and information-sharing have helped although with the latter, legacy systems and proprietorial behaviours remain significant challenges. We have seen better patient-facing roles with community pharmacists with the advent of more professional support members of the team such as registered technicians and accuracy-checking technicians allowing pharmacists to have more clinical interactions and medicine-management roles with patients including discussion of adherence. We have reinforced this in constantly adapting education of undergraduate trainee pharmacists.

Prescribing in primary care and in particular, in community pharmacies remains patchy. This is largely due to the inability to effectively link NHS budgets to pharmacist prescribing other than in GP surgeries. There are private clinics that have been successful because of pressures on obtaining timely GP appointments, but a more radical approach to NHS health-provision in community pharmacies would greatly benefit patients and reduce stress on GPs allowing them to carry out some secondary care procedures in their surgeries. The Pharmacy First initiative is a step in the right direction, however, in order to make best use of pharmacist prescriber graduates in community pharmacies, a more ‘joined-up’ approach is required.

Our asthma-review project as a prescriber in a community pharmacy consultation room provided tangible, cost-effective results. By ensuring better use of existing medication (for example, helping to improve inhaler technique), the need for more costly alternatives was reduced; at the same time, outcomes were optimised and screening picked-up possible previously-undiagnosed COPD patients that were referred for further investigation. This was fully funded by the PCT, however, despite it’s success, further funding for this service to continue was unavailable as there was no identifiable mechanism in place.

Since then, most of my prescribing experience has been for private patients in areas such as UTIs and vaccinations and these are well-appreciated by patients, however, not so readily available to those less able to pay for the service.

In your experience, how prevalent is medication non-adherence among patients in your community pharmacy practice? What are some common reasons you've encountered for medication non-adherence among patients?

Non-adherence has always been a challenge. From my early days of practise to present day, I don’t think we have adequately met this challenge. There are many reasons for poor adherence that I have encountered ranging from the NHS “wants to palm-me-off with cheap medicines”, to not feeling noticeably better to not liking taking medicines “too often”, so, for example, may take every-other-day instead of daily. There are also influences of friends or family or belief in alternative medicines being “more natural” as reasons for poor adherence. The appearance of certain medicines, perceived or real side-effects and preference for formulation-types also impact on adherence. For example, opening capsules to mix contents with water or crushing larger tablets and often this is not communicated to pharmacists unless a medicines-use review is carried out. This was regularly identified in the (now decommissioned) MUR service. Often inability to effectively use a device – as we encountered in checking inhaler-techniques during the asthma review project – or certain types of packaging has resulted in unintended poor adherence.

Do you collaborate with other healthcare professionals (e.g., GPs, nurses) to tackle medication non-adherence issues? How does this collaboration work in practice?

We have discussed this in local and national multidisciplinary meetings and there are a plethora of good ideas, however, implementation is far from uniform and very dependent on local arrangements and goodwill of practitioners involved. We have an informal arrangement with local GP practices to ensure medication changes are effectively communicated and hospital trust pharmacy departments have been encouraged to provide discharge information to pharmacies patients use as well as their GPs. Whenever possible, we try to address poor adherence with the patient in the first instance (for example, if we see returned weekly packs with some untaken medicines) and thereafter, if appropriate, advise GPs that they may wish to address this at a review. Sometimes, patients have confessed to having disposed of medication rather than tell their doctor that they are not taking them. I don’t think we have a good, systematic way to address adherence across the patch although many ad hoc local arrangements exist and initiatives like the New Medicines Service help in the disease areas for which they are commissioned. In many cases, there is a role for relatives and carers as well as healthcare personnel to contribute to effective medicines-taking and again, our contacts are ad hoc and largely informal. I believe a similar situation exists in other community pharmacies.

What challenges have you faced in addressing medication non-adherence, and what solutions or improvements do you think could be beneficial in this regard?

Challenges are multifactorial and not always easy to understand and some are mentioned above. We are aware of cultural barriers and beliefs, but fundamentally, I believe the barriers are a lack of understanding of acute and chronic conditions, not seeing or feeling a noticeable benefit and not valuing ‘free’ dispensed medicines. Often patients are looking for a long-term condition to be cured rather than managed. Discrimination of information is more challenging than ever with the advent of increasing channels of communication. This is not helped by misinformation received from friends and relatives as well as through social media and online sources. For example, patients will take paracetamol for pain-relief as their headache will go away. On the other hand, high blood pressure does not always manifest as symptoms and we often encounter patients that will vary their dosage regimen or not take them at all.

Improved patient-education at the time of collection including a brief discussion of side-effects and monitoring, as we teach undergraduates, can be really helpful. We have also found the New Medicines Service (NMS) where there are follow-up contacts with patients to check effectiveness and barriers to adherence has resulted in better medicines-taking or, identified issues at an early stage where interventions can be more successful. Good information systems accessible by all healthcare professionals involved in the care of the patient would also be really useful for early identification and management of adherence and other issues. More controversially, as medicines are largely ‘free’, there is less value placed on them and can contribute to hoarding. In a previous role, I had seen how a co-payment system operates in Jamaica. It is known as the Jamaica Drug for the Elderly Programme (JADEP) where a state co-payment (which can be up to one hundred per cent) is offered to patients over 60 for ten chronic illnesses. Whilst this would be politically difficult to introduce to the NHS in the UK, I believe there is merit in patients understanding the value of NHS medicines in some way. I have found disseminating information (such as in talks) to patients groups and expert patients improves communications and understanding of barriers to adherence as those in the same shoes are often felt to understand their condition better.

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