Pharmaceutical public health: the end of pharmaceutical care?

The publication of “Better health, better Wales”¹ in May 1998, and the emerging strategic framework² along with their English^3,4 and Scottish⁵ counterparts have set clear aims and priorities for improving all aspects of health and reducing health inequalities. This new remit is much broader than the traditional, accepted role of the health service with its over-emphasis on physical health and under-emphasis on mental and social wellbeing. There is now a clear need to address this imbalance and develop a comprehensive, multidisciplinary programme for health care improvement that is for national and local action and contributes to preventing disease and improving the health and wellbeing of people and children in particular, bringing the level of those with the poorest health to the level of those with the best health, and encouraging individual responsibility for health.

Mental and social wellbeing are now integral components of the health care programme and they, in turn, are recognised as being intricately related to political, economic, social, environmental, genetic and institutional circumstances. It is therefore evident that to bring about the desired improvement in health status of the population a multidisciplinary, multiagency approach is required. This has brought about the shift to so called “joined up working” involving the integration of health and social services, local government and voluntary sectors. To play its part in this new agenda the pharmaceutical profession will have to rethink its own strategy.

Much of the profession’s current strategy is based on management of prescribed medicines, management of chronic conditions, management of common ailments, promotion of healthy lifestyles and provision of health advice.⁶ These embrace the core activities of the profession, but reflect a uniprofessional culture that focuses on the individual, pharmaceutical care and medicines management. With the new health agenda there is a clear need to minimise uniprofessional thinking and shift focus from the individual and the wants of those who are articulate and have resources, and place more emphasis on defining, addressing and monitoring the real health needs of the population.

If the profession wants to make a positive contribution to the new health agenda with its focus on the health of the population, it must identify its own public health role. The profession may choose to repackage existing services and claim this as their contribution to public health. Evidence from discussions with colleagues around the United Kingdom suggests that this is the chosen option. Typical examples of the cited public health roles are presented in Panel 1. While a number of these services can be correctly interpreted as public health roles, all are notable by the absence of ongoing, co-ordinated surveillance. Other roles, such as those associated with health promotion (Panel 2), have considerable public health potential but embrace issues that have a relatively poor evidence base of long-term benefit for society, are again associated with low levels of ongoing surveillance and provide limited, generalisible support for the value added role of pharmacy. To put it simply, continued involvement in health promotion at the level of leaflet distribution will not persuade those outside the profession that this is a role that can make a significant contribution to the public health agenda. This is somewhat ironic given that of the four categories of health determinants at a population level, health care provision is the least important. Heredity factors, environment, and lifestyle, the frequent target of health promotion campaigns, are all considered more important.⁷

The profession, however, should not despair. The plight of pharmacy is not unique as it wrestles with the concepts of the new National Health Service, public health, sustainable health and the need to reduce inequalities in health. A solution to problems that have been present in society for decades will not be found overnight. These problems will not be resolved by any single profession or the emergence of pharmaceutical public health, and will certainly not be addressed by the pharmaceutical profession if it continues to work in isolation or is disengaged from the health policy making process at either national or local level. Perhaps recent developments in the profession have left it ill-prepared for the new health agenda. The enthusiasm for pharmaceutical care with a focus on the individual has directed attention away from issues that affect the population. This balance needs to be redressed. Individual pharmacy practitioners and managers need to take responsibility for their contribution to a healthier population as do the profession’s politicians with their policies. There is also a need for a clear understanding of what constitutes pharmaceutical public health.

What is pharmaceutical public health?

The starting point for many recent definitions of public health has been that used in the Acheson report on public health in England.⁸ With appropriate amendment it may also be used as a starting point to define pharmaceutical public health:

The application of pharmaceutical knowledge, skills and resources to the science and art of preventing disease, prolonging life, promoting, protecting and improving health for all through organised efforts of society

This definition embraces a range of activities, implicitly acknowledges the need to work with patients, the public and other agencies, cuts across professional and non-professional boundaries and clearly indicates there is no single approach to pharmaceutical public health. As a consequence, pharmaceutical public health requires a core framework of activity analogous to that of public health. It must:

• Improve pharmaceutical surveillance of the health of the population centrally and locally
• Encourage policies and practice that promote and maintain health
• Ensure means are available to evaluate existing health services that have a pharmaceutical component

Barriers to the development of pharmaceutical public health include the low level of co-operation between sections of the profession, the uniprofessional culture that understates the value of partnerships, a poor knowledge of pharmaceutical needs and the absence of common data sets to monitor health and health related issues.
To progress the concept of pharmaceutical public health, pharmaceutical health needs will have to be identified and monitored in a standardised and sustainable format that is integrated with the services provided by pharmacy and other agencies. These common data sets could be utilised to monitor health needs, health patterns and health seeking behavior.
Any pharmaceutical health surveillance that has to be undertaken must be incidental to clinical and service activity and not an additional burden on the individual practitioner. For example, all community pharmacies could be required to collect specified data. Alternatively, a representative sample of contractors could be used. Independent reports on the status of pharmaceutical public health for a given population such as a locality or health authority should be compiled. These reports could then be collated to present the national picture. At the simplest level, pooled data of product sales could be used to indicate outbreaks of headlice infection, allergic rhinitis, diarrhoea or the use and abuse of over-the-counter medicines. Prescription records could be better used to monitor the therapeutic management of patients in nursing homes and residential homes at locality, health authority or national level. Likewise, prescription records could be used to provide more timely feedback on prescribing patterns, the incidence of common drug interactions, the uptake of new drugs in specific patient groups, variations of dosage regimens prescribed or the issue of private prescriptions for given products.

Pharmacy in secondary care also has a key role to play in pharmaceutical health surveillance although it, too, needs to ensure it has embraced a culture of collaborative working. Areas for potential surveillance include discharge medication, utilisation of telephone helpline services, discharge of patients to care homes, provision of packages of complex care, hospital at home and palliative care services.

The National Health Service deserves an integrated service from a pharmaceutical profession that operates to its full capability, works with others, contributes to and defines health policy and plays its part in monitoring, promoting, protecting and improving the health of the population. Society will not benefit from a pharmaceutical service that is fragmented and pitches multiple against independent, multiple against multiple or primary care against secondary care. Similarly, every effort must be made to ensure everyone has ready access to pharmaceutical services. Deprived areas with the most to gain from a comprehensive pharmaceutical service are still among those most likely to be denied this service.

The need to collaborate and undertake pharmaceutical public health surveillance and utilise anonymised data is desirable and achievable. The emergence of pharmaceutical public health will not mark the end of pharmaceutical care and medicines management. Rather it will serve to refocus on the individual in the context of his or her physical, social and mental wellbeing within society. An active pharmaceutical public health policy, had it been in place, may have helped avoid problems associated with the inappropriate use of antibiotics or the high use of antipsychotics in nursing homes. If put in place it could highlight inequalities in prescribing with drugs such as the statins or hormone replacement therapy. The collection of additional data from prescriptions, prescriptions dispensed out of hours and OTC sales data could be used to provide indicators to monitor the impact of deprivation, poor housing or redevelopment schemes on health and the health of children in particular. Likewise proxy markers, such as the prescription of inhalers, could be used to indicate environmental pollution.
Both pharmaceutical care and pharmaceutical public health can help the profession highlight that it can do more than provide a supply and cost control service. Pharmaceutical public health is a real value added role that the profession has, to date, chosen not to exploit. As part of the big picture of health determinants, it may be able to make a more significant contribution to the health of the population than more traditional aspects of pharmacy. Can we afford not to support its development?

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