The role of pharmacists in primary care

The National Health Service recently launched Choosing health through pharmacy,1 an initiative aimed at enhancing the contribution of pharmacists to improving the public's health and reducing health inequalities. The initiative assumes that, on the basis of their knowledge, skills, and proximity to the public, pharmacists are an untapped resource for health in the United Kingdom. However, evidence that pharmacists' involvement with the public improves health outcomes is mixed.2 3

This week's BMJ includes two studies about the role of community pharmacists in primary health care.4 5 In the first, Salter and colleagues explore the role of pharmacists in giving advice to older patients during medication review.4 They find that although many opportunities were available for pharmacists to offer advice, information, and instructions to patients, this was often resisted or rejected. This caused “interactional difficulties” during consultations between pharmacists and patients. In the second study, Holland and colleagues report a randomised controlled trial assessing whether medication review and advice by community pharmacists reduced hospital admissions or mortality in patients with heart failure, compared with usual care.5 It found no significant difference in hospital readmissions at six months (134 v 112 in controls; rate ratio 1.15, 95% confidence interval 0.89 to 1.48), quality of life, or mortality. The fact that both studies using different research methods produced unfavourable findings raises important questions about the role of pharmacists in primary health care.

Holland and colleagues' findings may have been negative because their trial assessed the global impact of the intervention rather than outcomes related to specific aspects of the interaction between the pharmacist and the patient. This would mean that the relative, and potentially positive, contribution of these different aspects could not be ascertained.

Salter and colleagues are clearer about the negative impact of pharmacists giving advice, and emphasise the potential harm of (unsolicited) advice on patients' sense of competence and self governance. By analysing the discourse between pharmacists and patients they highlight the problems with medication review where advice giving is didactic and controlled by professionals. Their conclusions support the growing body of literature in which the relationship between the “expert” and the lay person is deconstructed,6 7 8 and where “concordance” around the goals of treatment is prioritised.9 This literature suggests that healthcare professionals have the greatest impact when they give serious consideration to patients' agendas for health and how they rationalise decisions.

Although the overall findings of the studies are negative, there are positive aspects that the authors do not consider. Salter and colleagues do not elaborate on their assertion that pharmacists found many opportunities to offer advice, information, and instruction (presumably because of problems with elderly patients' drug regimens). Holland and colleagues look at this aspect in more detail. They report that pharmacists' home visits to patients with heart failure resulted in 384 recommendations to general practitioners. These recommendations were made despite patients having unusually high levels of adherence to their drug regimens. In other words, the recommendations to doctors were not related to non-adherence.

The recommendations reported by Holland and colleagues resulted in visits to doctors, drug reviews, and sometimes (re)admission to hospital. Holland and colleagues interpret the outcome of increasing hospital admissions as negative (assuming that intervention by a pharmacist should reduce admissions). However, any responses to pharmacists' advice, including readmission to hospital, may have reduced iatrogenic illness and possibly saved lives. The study design did not include assessing these specific actions.

Pharmacy as a profession has reoriented its practice from a clinical service model to a pharmaceutical care model10—a practice philosophy with parallels to the concept and goals of the patient centred care model adopted by medicine.11 Both models proclaim a commitment and responsibility to enhance outcomes for patients through developing an alliance between the professional and the patient. Pharmaceutical care is uniquely focused on the pharmacists' responsibility for the patient's drug related needs. Those needs are not limited to specific clinical problems and goals but to all of the patient's medications, medical conditions, and outcome parameters.10

Yet, public recognition of the potential role of pharmacists in reducing the medical and economic costs of inappropriate drug use is lacking. This might be because any positive impact that pharmacists' may have is not captured by the appropriate study designs. It might also be due to patients' perceptions of the status of the pharmacist in the health professional hierarchy. This is shown by Salter and colleagues with reference to many examples where patients “call on the higher authority of the doctor” as a means to challenge the advice given by the pharmacist.

If the Department of Health is to provide pharmacists with a more expansive role in public health in the UK, a campaign is needed to educate the public and the medical community about the harms of inappropriate use of medication and how pharmacists can be a potential resource for patients who take medicines. A strategy to increase the public's exposure to pharmacists working in primary care, separate from the dispensing of products—the new pharmaceutical care practitioner model10—may help. Finally, the agenda for research into the impact of pharmacists on health should be refined. A good start would be to explore the nature of the drug related problems in elderly people highlighted by Salter and colleagues,4 and what specific recommendations were made to the doctors of patients with heart disease in Holland and colleagues' study.5