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The role of pharmacy in health care CHAPTER 1
Box 1.2
New Scottish community pharmacy contract, introduced incrementally from 2006
There are four services delivered by all community pharmacies:
Minor ailment service (MAS) (from mid-2006) The provision of a range of pharmacy and general sale list medicines
(e.g. to treat skin problems, pain, coughs and colds) from the community
pharmacy on the NHS to patients registered with that pharmacy and not
normally paying an NHS prescription charge
Public health service (PHS) (from end 2006) All interactions with patients should include provision of opportunistic healthy
living advice, take part in four national campaigns a year, e.g. flu,
vaccinations, meningitis by poster display and provision of health promotion
messages, and offer smoking cessation service, emergency hormonal
contraception supply and Chlamydia testing and treatment
Acute medication service (from July 2008) Dispensing prescribed medicines, plus advice. Electronic transmission of
prescriptions between GP and community pharmacy
Chronic medication service (anticipated mid-2009) The management of long-term conditions by monitoring, medications review,
adjustment of doses (by those with prescriber qualification), repeat
dispensing
There are also optional services:
National funded optional services E.g. palliative care, prescribing clinics
Locally negotiated services These will also continue, e.g. services for drug misusers (needle exchange
and supervised consumption), flu immunization and drugs as per the English
contract
(see Box 1.1)
and independent prescribing will greatly enhance this
role for pharmacy.
Responding to symptoms
Provision of advice to customers presenting in the
pharmacy for advice on self-care is now an accepted
part of the work of a pharmacist which, as described
earlier, has been enhanced by the increased armamentarium of pharmacy medicines. Advertising campaigns,
particularly those by the National Pharmaceutical Association (NPA), have brought to public attention the
advice which is available from the pharmacist, as have
the commercial adverts from the pharmaceutical industry for their deregulated products. The increased
emphasis on the provision of advice from community
pharmacies has also extended to the counter staff, who
require special training and must adhere to protocols.
Some of the principles of responding to symptoms are
dealt with in Chapter 22.
The full contribution of this advisory role to health
care has been limited, to some extent, to the more
advantaged sections of the population, particularly
since the deregulation of many potent medicines referred to earlier. Many of these newer P medicines are
relatively expensive, and those on lower incomes, and
particularly those who are exempt from prescription
charges, may in the past have attended their doctor
only for the purpose of obtaininga free prescription for
the drug. This has now been circumvented. Under the
new contract in Scotland, all patients who would not
normallypay for their prescriptioncan accessany medicine normally available without a prescription on the
NHS from their local community pharmacist. Patients
have to register with a community pharmacy to receive
the service and all records are maintained centrally and
electronically. Ultimately they will be able to be linked
to other patient information through a unique patient
identifier, known as the CHI (Community Health
Index). In England, similar schemes also exist under
the new contract but they are an enhanced, locally
negotiated service rather than an essential service. At
the time of writing, only about 25% of English community pharmacies provide this service.
9
SECTION ONE Pharmacy practice and society
Health promotion and health improvement
A large number of people pass through the nation’s
pharmacies in any one day; on the basis of prescription
numbers this is frequently said to be 6 million people
per day in the UK. Another way of looking at this is
that over 90% of the population visit a community
pharmacy in any single year. Thus the pharmacist is
one of the best placed healthcare professionals to
provide health promotion information and health education material to the general public. This has now
become part of the pharmacist’s NHS contract and
formalized as a core service to be delivered by all
pharmacies in England and Wales, and Scotland.
The service specification is generally limited to participation in healthy lifestyle campaigns and opportunistic intervention. More aspirational roles can also be
delivered and there are extensive opportunities for
proactive, targeted and specialist advice to be provided from community pharmacies. The development of
cancer and cardiovascular disease, major causes of
morbidity and mortality, are both closely linked to
lifestyle factors such as diet, exercise and smoking.
Pharmacists can give out patient information leaflets
on healthy nutrition, which may reduce the development of disease which would otherwise occur and
lead to the need for expensive treatment. Smoking
is considered to be the single biggest cause of preventable ill health. Pharmacists have a successful record in
supporting smoking cessation though tailored faceto-face advice and the supply of smoking cessation
products such as nicotine replacement therapies
(see Ch. 5), and the vast majority of pharmacies are
engaged in local smoking cessation schemes.
Services to specific patient groups
Certain groups of patients have particular needs
which can be met by community pharmacists more
cost effectively than by any other healthcare professional. Such specific patient services often cause the
remit of a profession to change almost overnight in
response to an unexpected national issue. One such
example is drug misuse and the spread of blood
bornediseasessuchashepatitisandAIDS.Drug
misuse is an inc reasing problem in society today. It
is now generally accepted that drug misusers have a
right to treatment both to help them come off their
addiction a nd to reduce the harm they may do,
either to themselves or to society, until such time
as they are ready to undergo detoxification. The vast
majority of pharmacists will be involved to a greater
or lesser extent in a number of ways, as discussed in
Chapter 49. In particular, pharmacists have become
involved in needle exchange schemes and in instalment dispensing and supervised consumption of
methadone. Because of the urgent need for these
important services, and to some extent because of
the unwillingness of some community pharmacists
to become involved on the grounds of professional
responsibility alone, these services have unusually
been recognized by specific locally negotiated remuneration packages. These local arrangements continue within the new contracts.
Domiciliary visiting
Pharmacists have traditionally delivered oxygen to a
patient’s home, and many pharmacists will visit a
small number of patients in their own home to deliver
medicines and provide advice on their use. This will
now be extended to include other situations where
patients could benefit, such as on discharge from hospital, including highly specialized services (often
called the ‘hospital at home’) where patients may
be on palliative care, cytotoxic agents, intravenous
antibiotics or artificial nutrition. These topics are discussed in more detail in Chapters 40 and 41. As medicines management services for people on chronic
medication continue to evolve, and with more early
hospital discharge, this could mean more domiciliary
visits to housebound patients. There is also a separate
but related need for services to be provided in care
home settings, to include both advice on the storage
and administration of medicines as well as clinical
advice for individual patients (Ch. 48).
Personal control
One of the requirements of the current regulations is
that a pharmacist has to be in personal control/supervision of registered community pharmacy premises at
all times. The principle is that the pharmacist should
be aware of any transaction in which a medicine is
provided to a member of the public and be able to
intervene if deemed necessary. This requirement was
intended to protect the public but it has been a barrier
to innovative practice, and it has been interpreted as
the pharmacist needing to be physically present in the
pharmacy and aware of all transactions involving P and
POM medicines. For single-handed pharmacists this
has been difficult to combine with new roles undertaken outwith the pharmacy premises, such as domiciliary visits, or multi-professional meetings. A recent
consultation reviewed this stringent requirement
and recommended that the pharmacist can, under
10
The role of pharmacy in health care CHAPTER 1
exceptional circumstances, leave their premises for
professional reasons only, for short periods of time
during the working day. The current Code of Ethics
and Standards, released at the time of writing, promotes greater use of professional judgement, stating
principles and removing detailed technical requirements. It remains to be seen exactly how it will be
implemented.
A further challenge to established practice will also
come from the increasing use of the Internet for personal shopping; and the acquisition of medicines,
whether prescribed or purchased, will not be immune
to such developments. Already mail order pharmacy
and e-pharmacy are making small inroads into medicines distribution and supply, and challenge some of
the principles of the Code of Ethics and professional
practice points which encourage personal counselling
wherever possible. Again, the new Code of Ethics and
Standards has responded appropriately, with guidance
to professionals on how they can still deliver the same
standards of care as from face-to-face premises. Although online services are probably more developed
in North America, such changes to practice are inevitable and need to be managed professionally, remembering that best care of the patient, rather than
professional self-interest, must be the rationale of
any decision making.
Out of hours services
The NHS call centres NHS Direct (England and
Wales) and NHS 24 (Scotland) handle healthrelated telephone enquiries from the general public
and triage them on to appropriate services. Referral
to communi ty pharmacy is one of the formal dispositions included in the algorithms used by the call
handlers. It is intended, therefore, that the community pharmacist will not be bypassed by the new
telephone help lines. It should also serve to educate
the public about the role of the community pharmacist and to increase general awareness that the community pharmacy is just as m uch a part of the NHS
as is the general practice. Audits of calls have
revealed that a high proportion are linked to medicines and could have been handled directly by pharmacists. As a result pharmacists are now employed
directly to provide online advice from NHS 24/
NHS Direct phone lines, and there is also a recognized need to divert the public back to the community pharmacist as the port of call during normal
working hours. Finally there are moves to extend
accessibility to face-to-face out of hours pharmaceu-
tical advice through links between community pharmacies and out of hours centres.
Hospital pharmacy
Clinical pharmacy services have been established in
the hospital setting for some time; indeed many of the
innovations identified for community pharmacy come
from earlier experience in hospitals. In general there is
already a greater working together of the professions
in the hospital setting compared to primary care, including pharmacists’ involvement in medication history taking, active engagement in research, and for the
provision of 24-hour services. In 1988, the NHS circular Health Services Management: the Way Forward
for Hospital Pharmaceutical Services laid down the
government policy aim as ‘the achievement of better
patient care and financial savings, through the more
cost effective use of medicines, and improved use of
pharmaceutical expertise obtained through the implementation of a clinical pharmacy service’.Two
main components were identified. One is the overall
management of medicines on the hospital ward. This
is achieved through the provision of advice to medical
and nursing staff, formulary management and ensuring the safe handling of medicines. The other component is the development of individual patient care
plans. This is achieved through the provision of drug
information and assisting patients with problems
which may arise. In practice there are many stages
and activities involved in these processes. A working
group in Scotland published Clinical Pharmacy in the
Hospital Pharmaceutical Service: a Framework for
Practice in July 1996 (Clinical Resources Audit
Group 1996). The framework advocates a systematic
approach to enable the pharmacist to focus on the key
areas and optimize the pharmaceutical input to patient care. Some of the thinking behind this document
is discussed subsequently in Chapter 5.
There is a growing awareness of the problems
which arise at the interface between community (primary) and hospital (secondary) care. Patients move in
both directions. Their medical and pharmaceutical
problems also move with them. Over the next few
years it is hoped that a large proportion of these problems will have been resolved through the greater
involvement of pharmacists at admission and discharge with effective (ultimately electronic) transfer
of information, from hospital pharmacist to community pharmacist. As more patients are discharged early, and with more serious and specialized clinical
11
SECTION ONE Pharmacy practice and society
conditions, there will need to be greater communication at this interface and possibly hospital pharmacists operating outwith their traditional secondary
care base.
As in community pharmacy, technical skills for
local manufacturing of individual products is also
now greatly reduced and the skills of hospital pharmacists are more utilized in decisions about the costeffective and clinically effective selection of drugs,
and contributing to drug and therapeutic committees,
formulary groups and quality assurance procedures.
Issues of supply and efficient distribution of medicines are increasingly becoming automated.
Other NHS roles
Primary care pharmacy
During the 1990s there was increasing evidence of
close working between pharmacists and the rest of
the general practice based primary healthcare team.
Doctors realized that pharmacists had many possible
additional clinical roles in primary care, beyond their
traditionalcommunitypharmacy premises.Many pharmacists now provide doctors with adviceon GP formulary development (Ch. 18)andundertakepatient
medication reviews, either seeing patients face to
face or through review of patient records, either
globally or on an individual basis. They may also take
responsibility for specific clinics following agreed protocols, such as anticoagulant and Helicobacter pylori
assessment clinics. These pharmacists are known as
primary care pharmacists. However, as community
pharmacy develops along the lines described above,
and IT linksbecome the norm, itis envisagedthat many
of the tasks now done by primary care pharmacists
will ultimately be carried out from the community
pharmacy base.
Pharmaceutical advisers
As new NHS structures emerge in primary care, services are being delivered in an integrated way, involving the wider healthcare team as well as local
authority managed services such as social work, and
other community workers. In England these organizations are called primary care organizations, in Scotland community health partnerships, in Wales local
health boards, and in Northern Ireland health and
social services. Management teams for these organizations generally include a senior pharmacist who will
coordinate pharmaceutical care for the organization,
integrating community pharmacy into the delivery of
core health care, and coordinating the primary care
pharmacist workforce to achieve area wide goals in
prescribing.
Pharmaceutical public health
Strategic health authorities in England and NHS
boards in Scotland administer larger geographical
areas. Most of these also have a senior pharmacist,
operating at consultant level, as part of the public
health team. They have a specific responsibility for
local pharmacy strategy development, compliance
with statutes and the managed entry of new drugs,
as well as providing local professional leadership and
advice on professional governance alongside their senior pharmacy colleagues in the trusts. Increasingly as
professional boundaries begin to merge, they are also
seen as public healthcare professionals and take their
share of the generic public health workload. Many
are now gaining formal recognition as public health
practitioners through membership of the Faculty of
Public Health or the UK Voluntary Register for Public
Health Specialists.
The public’s view
Increasingly patient satisfaction with new services is
monitored in formal health services research projects, as part of innovative pilot schemes and for
ongoing routine quality control. Indeed one of the
requirements of the new contracts is that community pharmacists should ‘have in place a system to
enable patients to give feedback or evaluate services’. L arge surveys of the public’sopinionof
community pharmacy services have also been conducted. In general such surveys find that the public
are satisfied with the service they receive, and that
pharmacy is a trusted profession. Research also tells
us the public regard community pharmacy services
as an important resource for them to access when
managing symptoms of minor illness, and that they
prefer to seek such advice from a pharmacist rather
than a GP or one of the NHS online services. However, it is also shown that they are more wary of
hypothetical situations in which pharmacists become involved in the delivery of new roles which
have previously been delivered by GPs or nurses
working with GPs. In particular older people are less
open to new models of service, whereas younger
people are much more positive. Once new services
12
The role of pharmacy in health care CHAPTER 1
have been trialled, such as repeat dispensing, medicines ma nageme nt and prescrib ing, patient feedback i s highly positive. Nonetheless, when asked
whether or not they would prefer a doctor or pharmacist to provide the service, there is a status quo
bias in favour of the GP. This is not really surprising,
but the profession needs to be aware of this. New
services have to earn their place in the public’sesteem, building confidence in the quality of what
they offer and the advantages of pharmacy delivered
services. Th ere is also a need for other healthcare
professionals to value the pharmacist’snewroles
and to recognize their increasingly central place in
the NHS team.
Quality assured NHS
Some high profile examples of substandardhealth care,
most particularlythe investigationinto thestandardsof
children’s heart surgery at Bristol Royal Infirmary, have
focused attention on the need to identify and learn
from mistakes and to systematically assess and manage
risk. There is now an increasing understanding of the
components ofa qualityassured NHS, and the systems
that need to be in place to support this.
Clinical effectiveness
Clinical effectiveness is a term often used to describe
the extent to which clinical practice meets the highest
known standards of care. Clinical governance is a term
used to describe the accountability of an organizational grouping for ensuring that clinical effectiveness is
practised by all functions for which it is responsible.
Central to this is the use of evidence-based guidelines
and protocols, which have increased dramatically
in the past decade. (An overview is provided in Chap-
ter 8.) These guidelines are a way of increasing the
quality of service because they are developed after
systematic searches of the research evidence and
make recommendations for ‘best practice’ which
are easily understood and widely accepted.
The extent to which guidelines are actually applied
in particular situations should be measured by clinical
audit. Chapter 11 aims to give the background to the
need for audit and the different ways in which it may
be carried out. Audit is also an important tool in the
raising of standards of service delivery.
Training, research and development are also all important strands of clinical effectiveness, as are profes-
sional reflection and development. Structures
established to deliver this agenda for pharmacy are
described in more detail in the next section.
Continuing education and
continuing professional
development
In such a rapidly changing profession, there is a
need for continual updating of knowledge. The
RPSGB, through The Pharmaceutical Journal,has
established a regular pattern of continuing education ( CE) articles on a wide range of topics and has
introduced a formal portfolio-based continuous
professional development (CPD) i nitiative. The
council of the RPSGB, through the Code of Ethics,
requires that all pharmacists undertake at least
30 hours of continuing education each year. This
is now monitored more closely through an online
record which requires both details of activities undertaken and reflection on the values of the activities to practise. This approach is thus more about
tailored personal and professional development.
Continuing education is further supported by the
centres for postgraduate or post-qualification pharmaceutical education (CPPE). They are located in
Manchester (England), Cardiff (Wales) and Belfast
(Northern Ireland). The Scottish centre is amalgamated with sister organizations in medicine, dentistry,
psychology and nursing as a special health board, the
NHS Education for Scotland Board. This is an exciting
development, once again reflecting new approaches to
healthcare delivery and facilitating teamwork across
professional boundaries. Courses from all four centres
are provided free to pharmacists who are employed in
the provision of pharmaceutical services to the NHS.
There is, therefore, good provision for continuing
education, which pharmacists use to good effect. At
the moment there is no requirement for a further
assessment of competence once the pre-registration
year is successfully completed but it is unlikely that
this will remain the case for much longer.
The role of the RPSGB
The RPSGB has historically undertaken an unusual
dual role as a professional body and a regulatory
body. For the latter function it is responsible for the
registration of pharmacists and premises, for the
13
SECTION ONE Pharmacy practice and society
maintenance of standards though a network of inspectors, and for disciplining those who do not meet the
required standard through the Statutory Committee.
With increasing public concerns about standards of
health care in general, the regulatory function is increasingly open to public scrutiny and the Council for
the Regulation of Healthcare Professionals was established. As part of a recent review of the regulation of
all healthcare professionals, arising from some high
profile cases of suboptimal care, a recommendation
has been made that the regulatory functions of the
RPSGB will be delivered by an independent body, the
General Pharmaceutical Council, and a new body for
pharmacy should be created to deliver the complementary professional role. Again at the time of writing, the exact shape of this new body is unknown but
it has been suggested it will be akin to that of a royal
college, such as is established for the medical specialities. See Chapter 10 for further information on CPD
and fitness to practice.
Pharmacy education
Undergraduate education
Teaching of pharmacy was traditionally under four
subject headings: pharmaceutical chemistry, pharmaceutics, pharmacology and pharmacognosy. This was
seen as a restraint on the development of new ideas of
teaching to make the course more relevant to the
profession. The course has to have a firm science base,
building on knowledge acquired in secondary school,
but be relevant to practice. Pharmacognosy is no longer a core part of the undergraduate curriculum. Pathology and therapeutics, law and ethics, and the
teaching of dispensing practice all have their place
alongside clinical pharmacy, which is now accepted
as a subject in its own right and one of the most
important parts of the course. The course also
includes social and behavioural science – a broad subject area which covers many sociological and psychological aspects of disease and patients – and
communication skills. Although communication cannot be learned solely by studying a book, it is still
useful to have an understanding of the underpinning
theoretical framework when learning to put good professional communication into practice. In this book,
chapters have been included dealing with social and
behavioural science (Chs 3 and 4), communication
skills (Ch. 13) and counselling skills (Ch. 44).
Most schools of pharmacy involve both primary
and secondary care pharmacy practitioners in undergraduate teaching. The aim of utilizing these teacher–
practitioners is to ensure that the university course is
relevant to current professional practice. This reflects
the situation in other healthcare professions such
as medicine. Other waysof learning fromcurrent practice as part of course provision are also used, such as
visiting lecturers, making GP practice and hospital visits, using part-time teaching staff, staff secondment to
practice and joint academic/practice research studies.
As a result of the need to harmonize the undergraduate courses across the EU as far as possible, all
UK courses are now of 4 years, and at master level,
with a further year of structured pre-registration
training in a practice situation (see below).
Pre-registration training
The purpose of the pre-registration year is for the
recent graduate to make the transition from student
to a person who can practise effectively and independently as a member of the pharmacy profession. At
the end of the year the pre-registration trainee has to
pass a formal registration exam prior to entry to the
register. Pre-registration training is carried out, in either hospital or community pharmacy practice, in a
structured way with a competency-based assessment
after 12 months. The recommendation to include
both hospital and community practice in the preregistration year has not yet been acted upon. Some
of the differences between community and hospital
practice are becoming less distinct as pharmacists in
the community take on roles which in the past have
been common in hospital practice, such as prescribing
advice to doctors. In the future, it may be that a
combined pre-registration year may be introduced
and interchange between the two areas of practice
will become easier to achieve than it is at present.
Higher degrees and research
As recently as the 1980s onlya few taught MSc degrees
were available. A wide range of such courses is now
offered. Some are relatively short; others offer a postgraduate diploma or a master of science. Subject matter may be veryspecialized or more general. Studymay
be full time or part time. There are also distance learning courses for those who have limited opportunity to
be away from their place of work. Additionally, taught
PharmD courses are gaining in popularity and are
14
The role of pharmacy in health care CHAPTER 1
providedfrom a small number ofinstitutions across the
UK. The programmes are intended to allow pharmacists to develop specialist skills in their chosen area,
through formal learning, together with the conduct of
either a substantive piece of research or work-based
project.
Research has also developed, and research articles
appear regularly in the Pharmaceutical Journal and
the International Journal of Pharmacy Practice as well
as other academic journals from medicine and primary care. There are practice research sessions at the
British Pharmaceutical Conference each year, and
there is an annual dedicated Health Service and Pharmacy Practice Research Conference. Many students
are now graduating with a doctorate for studies undertaken in aspects of pharmacy practice, and,
reflecting the integrated multidisciplinary delivery
of care, many pharmacists are carrying out research
in multidisciplinary research teams. The development
of the discipline of pharmacy practice research has a
lot to be proud of. The generation of research evidence of the clinical and cost-effective contribution
which pharmacists can make to health care has had a
key part to play in the innovations in professional
practice we have seen in the past decade, and which
have been summarized in this introductory chapter.
extending to the general public regarding pharmacists as a source of information and advice about
their prescribed medicines and seeking help from
pharmacists with any medication problems which
they may encounter. This process is likely to develop further as society moves into the 21st century.
We are also likely to see further changes reflecting
the merging of professional boundaries and competency based delivery of health care. Thus generic
healthcare professionals may emerge, and many
may undertake tasks traditionally undertaken by
one profession. In addition, in order to free up
professional time, we can expect to see pharmacy
technicians taking on greater responsibility for the
technical aspects of the pharmacist’srolewhile
qualified pharmacists concentrate on cognitive
functions and interact directly with the patient.
Pharmacists need to have the knowledge and
adaptability to take a lead in these processes, so that
they can have a key role in ensuring that the health
care of the public can be delivered as efficiently as
possible. The undergraduate pharmacy courses must
reflect these changes to ensure that their graduates
meet the demands of the future NHS workforce.
KEY POINTS
Conclusion
During the 20th century, pharmacy has undergone
major changes. This process has accelerated since
the introduction o f the NHS in 1948, the Nuffield
Report in 1986 and, most recently, the new plans
for the NHS published at the turn of the century.
As will be evident from reading this chapter, many
changes are still ongoing , demonstrating the vibrant
and dynamic nature of both the health service and
of our profession. Pharmacists now deal with more
potent and sophisticated medicines, requiring a different type of knowledge and a different skill set
than was previously t he case. At the same time, the
public has become more aware of the services
which are available from pharmacists. People are
making increasing use of the pharmacist as a s ource
of information and advice about minor conditions
and non-prescription medicines. This is now
*
The UK NHS came into being in 1948
*
Early developments in the NHS were in hospital
services, but this has gradually changed to focus
on community practice
*
Publication of the Nuffield Report in 1986 marked a
watershed for pharmacy in the UK. It made nearly
100 radical recommendations for change, most of
which have been implemented in community
pharmacy; use of IT, links with GPs, responding to
symptoms, health education, meeting patients’
needs, re-regulation of POM to P medicines have
all developed
*
New community pharmacy contracts in the UK are
delivering the vision together with regulatory
changes such as patient group directions and
supplementary and independent prescribing
*
Education at undergraduate and postgraduate
levels reflects these changes and pharmacy
graduates are well trained for their new roles
*
The public values the pharmacist but still has some
reservations about too much care being delegated
from doctors
15
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Chapter Two
Models of pharmacy practice within
healthcare systems
Judith A. Rees
2
STUDY POINTS
*
Some of the influences on pharmacy worldwide
*
Private and public healthcare systems
*
Classification of medicines, availability and
advertising of medicines
*
Different educational pathways for pharmacists
*
Registration and regulation of pharmacists and
pharmacies
*
Types of community pharmacy organization
*
Different types of hospital pharmacy
Introduction
The development and role of pharmacy practice in the
UK was detailed in Chapter 1. It can be seen that the
role of, and demands on, the pharmacist has come a
long way from being an apothecary or simply a
dispenser of medicines. Chapter 6 describes the types
of patient charges for prescriptions and their impact.
What becomes clear from these two chapters is that
there are many methods used by healthcare systems
in different countries to charge patients for their
medicines. Also, lists of medicines have to be drawn
up in less well developed or economically poorer
countries to assist them provide basic essential medicines for their populations (see Ch. 7). Thus it
becomes apparent that different countries, depending
on their economic circumstances and their values
(political or otherwise), have developed numerous
different methods to provide and distribute medicines to their communities.
Most countries of the world have some system of
healthcare provision and involve a range of healthcare
providers. The latter may range from very basically
trained lay support or outreach workers to highly
skilled, university-graduated, regulated and registered
healthcare professionals. The skills and range of
healthcare workers available in a country will depend
mainly on the economic development of that country.
Richer countries generally have more healthcare
workers with more of them highly trained and skilled.
Healthcare provision throughout the world is not
equitable. Although economically rich countries often
help poorer countries with financial aid, medicines,
medical equipment,advice and somehealthcareprofessionals, etc., there is still inequality between countries.
This can be demonstrated by comparing the average
overall life expectancy between countries (Ta b le 2 . 1 ).
Discussion of how equitable health care can be
provided worldwide is outside the scope of this
chapter. The chapter describes some of the actual
healthcare systems to illustrate their diversity and,
in particular, emphasizes the role of pharmacists, their
education, regulation and registration, and the supply
and distribution of medicines to a country’s inhabitants. Rather than describing the healthcare provision
and the role of pharmacists in every country in the
world, the aim has been to look at trends, similarities
and differences between countries.
Healthcare systems
No one healthcare system is perfect for all situations
and equally no system will be totally static. Countries
do look at other healthcare systems and often copy,
emulate and subsume the perceived ‘good ideas’ into
their own systems. Healthcare systems will change
SECTION ONE Pharmacy practice and society
Table 2.1 Life expectancy in years at birth for different countries
Country Life expectancy at birth (years)
World average 67.2
Japan 82.6
Australia 81.2
Singapore 80.0
UK 79.4
USA 78.2
Lithuania 73.0
Saudi Arabia 72.8
India 64.7
Gambia 59.4
Kenya 54.1
Nigeria 46.9
Swaziland 39.6
depending on the economic stability, growth of the
country and political or governmental changes. Other
factors include changing demographics of the population, development of new medicines and medical technologies, the emergence of new diseases (e.g. HIVand
AIDS) or the eradication of old diseases (e.g. smallpox). Most countries with the lowest life expectancies
are those in which there are high incidence rates of
HIV/AIDS, such as Swaziland, Botswana, Zimbabwe
and Zambia. These countries also lack the finance to
provide the population with antiretroviral drugs.
Pharmacists and/or pharmacy technicians (the
names may vary in different countries) are present
in most countries. Their roles may be widely different; for example in some countries the concept of
pharmaceutical care or medicines management may
not be accepted or well developed, so there will not be
roles for pharmacists in those specialist areas. However, because of the increased availability of modern
medicines of greater potency and cost, it becomes
imperative that someone is responsible for their
distribution and supply to the population, either via
dispensed prescriptions or by sale over the counter.
Due to their efficacy and side-effects, medicines are
both potent and potentially dangerous. A rational dis-
tribution system safeguards the population by controlling the supply of medicines to the general
public. In most countries pharmacists are normally
given the authority to be the guardians of medicines.
Thus they are the healthcare professionals with the
responsibility for the safe, effective, rational and economic use of medicines. However, the extent of these
responsibilities will be dependent on the healthcare
system in the individual country and the legal controls
placed on medicines, their supply and the healthcare
professionals involved. Pharmacists will be employed
in the pharmaceutical industry (if there is one in the
country) as the developer and producer of manufactured medicines. Alternatively pharmacists will be
engaged in controlling the importation of medicines,
checking their authenticity and safety. Pharmacists or
pharmacy technicians will be involved in the extemporaneous production or small-scale supply and distribution of medicines, whether in hospitals, in
healthcare centres such as district clinics in remoter
areas, or in pharmacies in the community.
Each country tends to develop its own system to
accommodate its own particular needs and in line
with its economic ability. Clearly the provision of
pharmaceutical services and medicines will be different in a small economically rich country with good
transportation and communication links when compared to that of a much poorer, geographically large
country with remote areas and limited transportation
and communication links.
The legal structure within a country will influence
both the distribution of medicines and the place of the
pharmacist in that distribution system. Laws may
strictly regulate the production, distribution, marketing and supply of medicines, e.g. the UK Medicines
Act 1968 and its subsequent amendments and subsuming of EU law. Other countries may have much
less tight regulation of their medicines. The legislation
in place will control, for example:
*
Which medicines are available for purchase
directly by the public
*
Which medicines are only available on prescription
*
Whether and which medicines can be advertised
directly to the public
*
Who can prescribe and who can dispense
medicines.
Furtherlegislation may regulatethe educationof potential pharmacistsand whether they need to register with
a stateor professional body beforebeingableto practise.
Forexample, the PharmacistandPharmacyTechnicians
Order 2007 in the UKdetails theeducation, registration
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