Elsevier

Health Policy

Volume 119, Issue 5, May 2015, Pages 628-639
Health Policy

From “retailers” to health care providers: Transforming the role of community pharmacists in chronic disease management

https://doi.org/10.1016/j.healthpol.2015.02.007Get rights and content

Highlights

  • As under-utilised providers, community pharmacists are not primarily rewarded for delivering health care.

  • Community pharmacists are increasingly responsible for effective, safe, and efficient use of medicines.

  • Progress in transforming the roles of community pharmacists in chronic disease management remains limited.

  • Countries are gradually introducing limited payment reforms encouraging patient-centered services.

  • Moving forward, challenges include integrating pharmacists into primary care; developing tiered pharmacist services; and adopting new remuneration mechanisms.

Abstract

Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs—particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes.

Introduction

Chronic conditions are the largest cause of death and disability in the world [1]. Across countries with advanced economies, an estimated one of five people have multiple chronic conditions—a situation that is expected to worsen as populations age. Management of chronic conditions is among the most pressing challenges of healthcare systems worldwide. There is a need for interventions, strategies, and policies that more effectively manage and treat the rising numbers of people with multiple chronic conditions, but considerable inertia remains in policymakers’ stewardship of the chronic disease crisis.

One reform that holds particular potential is the involvement of community pharmacists (pharmacists who work outside of a hospital setting). Concerns about the sustainability of healthcare expenditures have fuelled interest in expanding the patient-centered responsibilities of community pharmacists. Community pharmacists constitute a significant portion of the health care workforce. In the United States (US), there are approximately 110,000 practicing community pharmacists [2] as compared to roughly 250,000 primary care physicians [3]. Given the increasing demands on the time of primary care physicians and nurses, policymakers in a number of countries have started to tap into the potential of other professionals who can contribute to appropriate and cost-effective use of medicines.

Pharmacists are well suited to assume an expanded role in the healthcare system. Indeed, despite their current role as “retailers”, taking on patient-centered responsibilities is commensurate with the profession's extensive training and expertise. Although educational requirements vary by country, the total length of formal training is typically five to six years, with an additional two or three years required to specialize or obtain an advanced degree [4]. In addition, licensure is often required through a national or regional examination before the right to practice is granted. Unlike hospital pharmacists who are increasingly integrated into clinical care teams, and rewarded for caring for patients, community pharmacists have traditionally worked in isolation from the rest of the primary care workforce—predominantly responsible for retailing and dispensing medicines. Pharmacists are the only health professionals who are not primarily rewarded for delivering health care.

Recognizing this untapped potential [5], [6], a number of countries have recently implemented policies to expand the roles of community pharmacists in order to facilitate coordinated care delivery. While these reforms vary in their focus and scope, they are similar in their aim to benefit from pharmacists as primary health care professionals. A system-wide policy agenda is needed to align the roles, objectives, and incentives of health professionals and devise an expanded role for community pharmacists. Such approaches are emerging, albeit slowly. In this paper, we investigate recent reform efforts in Australia, Canada, England, the Netherlands, Scotland, and the US. These countries have recently undertaken a range of reforms with the objective of equipping community pharmacists with expanded roles and responsibilities when caring for people with multiple chronic conditions.

Our paper has three sections. The first section describes the analytic framework and methods used to collect country-level information on the current and future roles and responsibilities of community pharmacists. The second section sets out the results of the cross-country comparison and outlines the policy developments surrounding the key components for expanding the patient-centered responsibilities of community pharmacists. The final discussion section highlights opportunities and challenges ahead for the role of the community pharmacy profession in integrated primary care, and outlines the roadmap for overcoming important practical challenges when moving towards equipping community pharmacists with expanded roles.

Section snippets

Analytical framework

The analytical framework proposed by Mossialos and colleagues [7] guided our country selection and data collection. This framework builds upon and broadly parallels the domains of Pharmaceutical Care and Total Pharmaceutical Care models [8], [9]. Pharmaceutical care is often described as “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life” [8]. Total pharmaceutical care is “the delivery of a comprehensive range of

Results

We reviewed recent national policy developments with regards to the two dimensions of the framework in Australia, Canada, England, the Netherlands, Scotland, and the US. Community pharmacists in the six countries examined have made significant progress in achieving an expanded role in ensuring the effective, safe, and efficient use of medicines. However, developments in establishing a role within the prevention and management of chronic disease have been slow and piecemeal.

Discussion

This cross-country comparison of policy developments highlights the increasing appetite for reconfiguring the responsibilities of the pharmacist profession, better integrating pharmacists into the healthcare system, and equipping community pharmacists with patient-centered roles commensurate with their training and expertise in medications.

Fig. 1 summarizes where the six countries selected in this cross-country comparison stand with respect to three aspects which are crucial for the expansion

Conclusions

Community pharmacists are underutilized professionals: they have the skills and position in the healthcare system to engage further in the provision of care for people with multiple chronic diseases. The magnitude and range of reform efforts across the countries covered in this article demonstrate the enthusiasm and political will to equip community pharmacists with patient-centered roles. Integration of community pharmacists into primary care faces the following obstacles: lack of established

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