As India is fast becoming a major pharma player on the global scene, the need to improve pharmacy practices on professional scales cannot be ignored nor delayed. This calls for innovative marketing dynamics in every industrial activity. In pharmaceuticals as a health care industry, India has already proved its technical competence and capabilities by producing basic drugs and formulations, in every therapeutic segment including preventive medicines for both domestic and global markets. By 2015 Indian drug manufacturers are expected to become major exporters to European countries and to the US in generics.
In India, pharmacists are not fully utilized in the health service. Pharmacists could be better used to help all patients who are taking long- term medication. With increasing healthcare demands, the pharmacy work environment as well as practising as community pharmacists is changing. Now-a-days with increasing health care demands, pharmacists should work in primary care as public health pharmacists, as primary care trust pharmaceutical advisers and also as practice -based pharmacists. The government should encourage the setting up of medicines management services. At present, community pharmacists are funded to dispense medicines but negotiations are underway to revise the national contract to provide funding for professional services other than dispensing.
The country should look forward to improve the quality in pharmacy practices. Otherwise it will be helplessly witnessing an impressive growth of pharmaceutical Industry vs outdated, unskilled medicine dealers defeating the very purpose of making the quality medicines available to the public with professional care and advice. These should be basic parameters on which we must introduce a practical approach to community pharmacy environment in India.
Community Pharmacy Division of IPA with All India Organization of Chemists & Druggists with state pharmacy councils as nodal centres can organize jointly, structured programmes to train practising pharmacists in every major town so that before 2015 we can bring a perceptible change in pharmacy practices in India. India is in strong need for better community pharmacy practitioners which can only be achieved by promoting the pharmacy practice education. Furthermore, such trained pharmacy practitioners are ideal for being groomed into drug information specialistsMerely comparing the pharmacy practices in developed countries and prevailing practices in India without considering certain realities will be a subjective assessment. We have to take an objective approach to change this situation.
Several suggestions which are feasible with the present realities of the country are-Good Pharmacy Practice
There is a need to accord legal status to Good Pharmacy Practice (GPP) concept and to create an accreditation authority for retail pharmacies to ensure high standards of pharmaceutical care.
Role of professional & trade associations
In this context it is crucial that we take bold initiative to educate the practising pharmacists, change their mind set and prepare them as Community Pharmacists by introducing refresher courses at state and district headquarters with a timeframe.* Advanced training programmes to update knowledge
In the ever growing OTC segments of products, lay press advertisements, self medication, drug abuse, non-compliance of dosage regimen, mixing of OTC medicines with prescription medicines,changing lifestyle and food habits, prevalence of diseases like asthma, tuberculosis, diabetes etc., there is a need to educate and advice the consumes on proper and safe use of medicines- and it requires regular refresher courses to prepare the community pharmacists in patient care and counselling.
Everyday, the pharmacist is asked by customers for advice about minor ailments. They may require advice on symptoms; may ask for a medicine by brand name; may require general health advice e.g. about dietary supplements, precautions etc.
The pharmacist's role in responding to symptoms and drug therapy requires a mix of knowledge and skills in the area of pathophysiology, pharmacogenetics, pharmacology, therapeutics or disease management, pharmaceutics and new drug delivery system, biochemistry, microbiology and biotechnology.
Pharmacists should be motivated for organizing various training programmes related to the health care field and should be flexible enough to implement the advancement for effective patient care.
Extending pharmacist’s role in patient care
Pharmacist’s suggested role in disease management which should also cover post treatment. Pharmacist interventions in health care system should include: providing education, training and resources; administering medication; formulating a treatment and/or follow-up plan; providing recommendations for disease prevention; and evaluating the patient’s knowledge of medication and willingness to implement recommendations.
Assessment of the patient should include: obtaining a patient medical and medication (e.g., prescription and non-prescription) history; determining appropriateness of medication therapy (supra- or sub- optimal), performing a review of relevant systems; evaluating pertinent lab data; assessing potential or existing drug-drug, drug-disease, and drug-nutrient interactions; establishing and/or obtaining such additional information (e.g., obtaining information from other medical records) as may be necessary; and development of a care plan including recommendations for optimizing medication therapy.
Pre- treatment service
Obtaining patient intake information, gathering or preparing materials that will be used during the patient encounter and co-ordination of other support staff.
Post treatment service
Documentation of the patient encounter; non face-to-face interventions and recommendations; referrals; communication with other healthcare professionals; administrative functions (including patient and family communications) relative to the patient’s care; and as appropriate scheduling of follow-up appointment
Need to maintain proper statutory records
It is in the interest of pharmacists that they buy the medicines from authorized sources with proper purchase records, maintain sales memos with patients name and address, batch number of the medicines sold, as a legal requirement and to safeguard themselves in the event of any drug found substandard or unsafe requiring recall etc. *Need to provide patient information brochures
Pharmaceutical associations, manufacturers can provide brochures to be distributed to patients at the counters on disease like asthma, diabetes, hypertension, epilepsy even common cold and cough, with dos and don't s etc,. * Provide information in national health care programmes
For immunization and if space permits, vaccination programmes can be organized with the help of manufacturers in the pharmacies.
Improvement in geriatric care
Elderly patients tend to get confused or forget to take medicines properly. Complementary packs for keeping each medication separately with dosage marked will help them to take medicines as prescribed.
Need to provide basic monitoring/test devices
In the counselling area , pharmacists can provide BP apparatus, devices are available to test blood sugar etc.
Improvement needed in storage of pharmaceuticals
All medicines are temperature sensitive and to retain their potency and efficacy, proper storage is essential, protected from sunlight and heat. While it is recommended that all Community Pharmacies are air conditioned, there is a proposal to amend D&C Rules to provide air conditioners compulsorily.
Prevent improper use of advertising and displays
No display material either on the premises, in the press or elsewhere should be used by a pharmacist in connection with the sale to the public of medicines or medical appliances which is undignified in style or which contains substandard drugs, or having false claims.
Regulations against clandestine arrangements
No pharmacist should enter into any secret arrangements or contract with a physician to offer him any commission or any advantage of any description in return for his favour of patronage by recommending his dispensary or drug store or even his self to patients*Access to advance technology and internet services
Pharmacist should have ready access to advanced technology in the field for efficient patient care. With the advent of IT, a wealth of information is available through web sites and drug information Centres on drugs, their actions, indications, side effects etc. Community pharmacists must provide a computer in their pharmacies for access to all these information through the internet and it’s most essential to maintain a patients' profile for their regular customers.
Good communication skill
To understand customer needs, a pharmacists should develop listening skills and questioning skills. Effective communication skill is necessary to develop a positive mindset for ethical pharmacy practices including all professional, legal and moral obligations to the society.* Specific journal for community pharmacy
As a supplementary activity, a journal dedicated to community pharmacy is necessary to constantly update their knowledge on new molecules, and this should reach all leading pharmacies in India. Such professional journals can be sponsored by manufacturers.
Non-dispensing roles for community pharmacist
Community pharmacists should also perform a number of health-related, non-dispensing services. A nation-wide survey of community pharmacists should be carried out which will indicate the preference of pharmacists for the work area amongst the various task available for them. If we consider the advanced and still growing health care system, the report of this survey would more inclined towards non-dispensing services. Theyy would prefer to spend more time in consultation with patients and prescribers, which will show potential changes in a current trend, and a new trend will be more inclined toward more disease state-focus whencounsellingg patients often under consent arrangements with prescribers.
The drug related problems needing the pharmacy practitioner’s intervention include any one or combination of the following:
Medicine management:
The profession is moving from purely product supply to “managing medicines”. Government should plan programmes for community pharmacy practice in near future and implementing those plans highlights the need for pharmacists to help patients get the best from their medicines. It encourages medicines management services, which involve identifying and addressing unmet pharmaceutical need—for e.g., through medication review. This requires the pharmacist to spend time with patients, Community pharmacists should be well placed to help patients who have cardiovascular disease, respiratory diseases, who are suffering from cancer or HIV or who are at risk of this. They should have an opportunity to identify at-risk patients, based on their knowledge of the families, what drug treatments are being taken, and information provided by patients. They can identify under treated patients at the point of dispensing and feed relevant information back to the surgery.
Cognitive services
Many non-dispensing services are termed cognitive services, pharmaceutical care services, or medication therapy management services. Amongst these cognitive activities include medication reviews, resolution of drug-related problems, and pharmaceutical case management. But these programmes are neither widespread nor standard. Definitions of cognitive services differ, but all have a common focus on identifying potential or actual drug-related problems in patients. Various classifications of drug-related problems have been developed. In general, most include one or more of the following headings: questionable indication for drug (e.g., unnecessary drug, needs additional therapy), drug effectiveness (e.g., suboptimal dose or duration), drug safety issues (e.g., adverse effect, drug-drug interaction, excess dose or duration), or patient adherence (e.g. over- or under-use, poor administration or technique).
The impact of pharmacist’s effective participation in cognitive services proposed are improved clinical outcomes and reduce adverse reactions in conditions such as asthma, diabetes, hypertension and dyslipidemia and can be left to accurate monitoring of drug therapy by community pharmacists
Public health
Public health is another important area of the community pharmacist’s work and involves providing education and advice on lifestyle and diet. Pharmacists should also involve in smoking cessation services, rehabilitation programmes and should be able to support patients by providing structured advice and smoking cessation products. Government should also encourage pharmacist for participation in screening services—for example, measuring cholesterol and blood pressure. This can be useful provided that screening is undertaken in the context of global risk assessment and that services are discussed with local general practitioners to secure agreement on such matters as when patients should be referred for medical advice.
Active participation with patients
Patient partnership in medicine taking should be also high on the government’s as swell as the profession’s agenda. This means helping patients to reach decisions about treatments that they want to take, explaining the condition and treatment options and discussing risks and benefits of taking medicines. As a part of the concept of patient partnership, community pharmacists can be a source of education to patients about their treatments .They can explain the risks and benefits of treatment, side effects, drug–drug and drug–food interactions and can discuss the monitoring requirements and what action the patient should take if symptoms occur.
Patient partnership include-Education
● Risks and benefits of treatment
● Side effects
● Drug–drug and drug–food interactions. Requirements for monitoring & what to do if symptomatic at every step of treatment.
Ongoing support
● Re-emphasis of above factors
Encouraging compliance
Medication non-compliance is a pervasive problem resulting in significant morbidity and mortality. There are many terms used to describe medication-taking behaviour including compliance, adherence, intelligent compliance, and drug forgiveness. More recently, clinicians have focused on the need for a collaborative partnership with patients to attain medication adherence. Problems identified include the patient’s failing to initiate therapy, under using or overusing a drug, stopping a drug too soon, and mistiming or skipping doses. Adherence to medications is a complex health behaviour. There are many risk factors associated with decreased compliance and many strategies have been shown to improve drug-taking behaviour and patient outcomes. By careful assessment, the pharmacist can identify the high-risk patient, recommend an individualized care plan and provide the follow-up necessary to successfully change patient behaviour. Pharmacists should focus on improving their own application of behaviour modification principles and patient communication skills. Improved medication compliance results in improved humanistic, clinical and economic outcomes.
Issues can arise with both intentional non-compliance and non-intentional non-compliance. In intentional non-compliance, the patient has made a decision not to take a treatment. This may be an informed decision or it may be that the patient is misinformed or does not have the correct information. With education and advice, the pharmacist might be able to change the patient’s behaviour. Non-intentional non-compliance is a major problem and arises when, for example, the patient forgets to take medicine or becomes confused by their polypharmacy. Advice can be offered on making the medication regime simpler for patients. Some non-compliance relates to such basic issues as the patient not being able to open the medicine container. To help improve compliance, it is essential that pharmacists, like doctors and nurses, provide ongoing support and use every opportunity to re-emphasize the importance of taking prescribed treatment.
Compliance issues Intentional non-compliance
● Informed decision not to take medicine
● Informed or un-informed decision not to take medicine
Non-intentionalnon-compliance
● Cannot or forgets to order medicines
● Cannot open containers
● Gets confused with polypharmacy.
Practice -based pharmacists
A growing area of employment for pharmacists is work based on physician’s practices. One way in which practice - based pharmacists can support patients is through undertaking audit to identify under-treated or under -monitored patients. Searches can be made by read coding to identify specific groups of patients whose treatment can then be assessed. An example of this type of pharmacist audit would be to identify patients taking statins who have not reached target cholesterol concentration. The findings can be discussed at a practice meeting and agreement gained on corrective action. These meetings also have an educational function.
Practice - based pharmacists also have the opportunity to improve patient care through individual medication review clinics. Such clinics can cover several areas of drug treatment.
They can for example:
● identify suboptimal treatment and monitoring
● identify problems patients have with medicine taking
● provide education on disease and the treatment
● explain reasons for changes that are being made to treatment.
Pharmacist’s role in improved patient’s adherence to chronic medication:
Government should emphasis on effectiveness of community pharmacist’s role to improve patient adherence to chronic medication like in the treatment of respiratory disorders , cardiovascular disorders and in the treatment of depression like psychological abnormalities. Pharmacists may be well placed to take up a role in depression care, complementing the role of general practitioners. However, depression care is a relatively new role for pharmacists, and little is known of their attitudes, current practices, and barriers toward it. For pharmacists to effectively take up depression care, perceived barriers need to be addressed through specific training programs and increased cooperation with general practitioners.
Pharmacist’s suggested involvement in HIV/AIDS therapy:
To prepare and implement a set of guiding principles on how pharmacists in India can be involved in the fight against HIV/AIDS. Pharmacists are given training in prevention and information, counsellingg, perils of injectable drug use, blood and blood products, diagnostic tests, safe use of anti-retrovirals (ARVs), their doses, quality control, storage and therapy cost.
The services of community pharmacists should be utilized in referring, counselling and participation in DOTS strategy of the Revised National Tuberculosis Control Programme (RNTCP).
Pharmacists should be encouraged to educate the public in the thrust areas in Reproductive Child Health (RCH II) by scaling up contraceptive acceptance and playing an meaningful role in family planning by displaying contraceptives at a prominent place in pharmacies with appropriate signages for helping the patient in choice of contraceptives; distributing family planning literature freely; being counsellors next door; and spreading the message of small family norm and its advantages.
Pharmacists need to be actively involved in the surveillance of drug safety issues within the context of their practices. Greater participation by pharmacists in all practice settings would be an important tool to increase the reporting of ADRs and other drug-related problems in pharmacovigilance.
Advanced planning for research projects that prove impact of pharmaceutical services in community & ambulatory care settings Health ministry should plan research projects and implement the same to review and evaluate research on pharmaceutical services in community and ambulatory care pharmacy settings, specifically study designs and patient outcome measures, and to provide recommendations to improve future research on pharmaceutical services in community and ambulatory care pharmacy settings.
Relevant study should be conducted in following areas:
Pharmacist services, pharmacist interventions, community pharmacy, ambulatory care, primary care, and patient outcomes. From each relevant study, researcher should extract the study objectives, sample size, study period, study design, major tasks performed by pharmacists, and economic, clinical, and humanistic outcomes (ECHO)
On the basis of the report of such studies necessary steps for improvement should imply promptly in current practice of Community Pharmacy.
Further research should be conducted in Community Pharmacy’s improved settings and measure the impact of improvement in pharmaceutical services on patient outcomes.
Electronic transmission of prescriptions and automated dispensing systems
By adapting Electronic Transmission of Prescription and Automated Dispensing System, India will put one more effort in the advancement and growth in the health care field. This will help in minimizing all potential error and speed up the process of dispensing of drugs, which in terms save the precious time of community pharmacist so that the community pharmacist can contribute more effectively in other non-dispensing task related to health care management.
Encourage and regulatecommunity pharmacy
Policy makers should view pharmacies as part of the health care sector and pharmacists as health care professionals providing health care services and focus on them as they do with other health care professionals.
Some other areas for action at both organizational &
professional level suggested are-
● Requirement for appropriate consumer access to pharmacy services
● Demand for increased convenience of service provision
● Consumer awareness of service portfolio offered in community pharmacy
● Increase of overall service delivery capacity within community pharmacy
● Extended functional role for and counter staff in community pharmacy
● Development of appropriate regulatory and organizational structures
● Support for professionals in reshaping of the community pharmacy function
● Development of new organizational forms and approaches to working
● Increasing feminization of workforce and the growth of part-time employment u
Prof. Dr. G. Vidya Sagar is Professor & Principal & Nipa H. Thacker is lecturer, Veerayatan Institute of Pharmacy, Jakhania, Gujarat