Non-adherence to medications is a global challenge. In India, lack of concordance arises from multiple issues. Yet access to pharmaceutical care and medicines optimisation services are not considered essential.
A small percentage of the Indian population are aware of clinical pharmacy services and some pharmacists do work directly with patients in a few hospitals. But there largely exists a lack of willingness by doctors and management to develop these services in hospitals which do not already have an existing clinical pharmacy department. Human resources departments and appointment desks also act as barriers. To date, I have not come across any other pharmacists working with medical practitioners independently in community. Two years ago, I decided to take on the challenge of developing and pioneering an independent clinical pharmacy service in community.
Informal discussions with 55 healthcare professionals and students from a variety of disciplines showed support for both a direct access and referral based service. A survey of eight community pharmacies and six hospitals identified that development of consultation areas or clinics in community pharmacies and hospitals is unpopular. This led me to conclude that community pharmacists and pharmacy owners either did not realise the potential of this service and/or felt a clinical pharmacy initiative pose a threat to their revenue streams. Clinical heads or CEOs of hospitals were not willing to start a new service to avoid overheads. They either demonstrated a paternalistic view of medicine and/or believed that clinical pharmacists, like clinical pharmacologists, should only audit prescribing practices, services or processes; but audits are pointless if hospitals or doctors are not willing to make changes. Although some pharmacy chains and hospital pharmacy staff are competent in optimising treatment and supporting patients with appropriate information and medication use, it seemed to be the least of most pharmacy owners’ or doctors’ concerns.
I decided to set up base in a polyclinic and named it the ’Medicines Awareness & Optimisation Clinic’. I created leaflets which were displayed in the waiting areas of doctors’ clinics, hospital trusts, kids’ play areas, as well as consultant and GP clinics. I wanted to raise awareness of the service and increase understanding of the pharmacist’s role in providing a medication safety and optimisation service. I held face-to-face meetings and teleconferences to answer queries about the clinic. I also developed e-flyers and distributed these to healthcare professionals and other groups.
I later renamed the service ‘Medicines Optimisation Clinic’. This was important to increase patient acceptability and use.
I now have two clinics, one in Vadodara and the other in Mumbai. At one site I share a clinic space with a senior consultant rheumatologist who often refers her chronic rheumatology patients to me. At the other, I have more patients who access the clinic directly rather than through referral. I see patients on multiple medications including those diagnosed with diabetes, respiratory problems and / or minor ailments.
Examples of some interventions include:
- Dose adjustment of diabetes medications for patients who are overweight and have inadequate glucose control
- Advice and medicines information to a patient on warfarin post heart valve replacement. This involved discussion around appropriate dose adjustment and clarifying the patient’s understanding of potential interactions with certain vitamins and food.
During patient consultations I gather information relating to the individual’s allergies, medical and drug history, current problems and medicines. Each consultation is tailored to the individual patient, taking into account the patient’s and family’s beliefs, cultural views, awareness, adequate understanding of information on the internet and its interpretation, and social issues.
I inform the patient about appropriate use and administration of each medication and/or device, answer medicines information queries, counsel on dosing, interactions, generic medicines and brands (if relevant), self-medication and the need to check with a pharmacist or doctor rather than an untrained pharmacy attendant about any additional medications.
A major concern is patients having multiple prescribers. I review these medications comprehensively with a view to rationalising medication use. I communicate any concerns and recommendations to the patient’s primary prescriber. I also take into consideration the need for comprehensive drug cards, reminder cards and alert cards. The last of these is not used routinely in private practice. This led me to create the first of its kind in India.
Some consultations can be very time consuming. For example, a female patient with rheumatoid arthritis lacked knowledge of her condition as a result of her husband managing all her medications and speaking on her behalf during consultations. This was despite the patient wishing to do so for herself. Multiple consultations and follow up led to a significant difference in patient involvement, understanding and acceptance of her chronic condition, long-term treatment and concordance.
With the clinics set up, I am now faced with the bigger challenge of ongoing service and practice development. With the aim of improving health outcomes, I will continue to develop different areas of my practice including appropriate documentation, record keeping and development of standardised processes and practices.
N.D Patel, consultant rheumatologist; M.N Shah, physician; D.B Patel, consultant pulmonologist and B.P Udwadia, clinical pharmacologist for their professional acumen and guidance.
M.M Shah for financial training.
S.M Shah for improving my technical competence.
Andy Kostrewski and Soraya Dhillon and all members of the Pharmacy Practice Department for my clinical pharmacy training and leadership skills at The School of Pharmacy, University of London, and Guy’s & St Thomas’ Hospital, London.
My family for their continued support and encouragement, which has made this independent Medicines Optimisation Clinic a reality. My husband and children for supporting me with continuous travel between two cities and clinics.
About the author:
Mansi Shah completed her pharmacy studies at UCL School of Pharmacy and worked within the NHS before moving to India where she developed the ‘Medicines Optimisation Clinic’, an independent clinical community pharmacy service in Vadodara and Mumbai.