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Pharmaceuticalpublichealth:theendofpharmaceuticalcare?|News|PharmaceuticalJournal

Pharmaceuticalpublichealth:theendofpharmaceutical
care?
ThePharmaceuticalJournal26FEB2000

ThePharmaceuticalJournalVol264No7085p340341
February26,2000Articles

Pharmaceuticalpublichealth:theendofpharmaceuticalcare?

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toPJ
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ByRogerWalker,PhD,MRPharmS
Pharmacyhastoidentifyitsownpublichealthroleifitwantstomakeapositivecontributiontothe
newhealthagendawithitsfocusonthehealthofthepopulation
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Thepublicationof"Betterhealth,betterWales"1inMay,1998,andtheemergingstrategic
framework2alongwiththeirEnglish3,4andScottish5counterpartshavesetclearaimsandpriorities
forimprovingallaspectsofhealthandreducinghealthinequalities.Thisnewremitismuchbroader
thanthetraditional,acceptedroleofthehealthservicewithitsoveremphasisonphysicalhealthand
underemphasisonmentalandsocialwellbeing.Thereisnowaclearneedtoaddressthisimbalance
anddevelopacomprehensive,multidisciplinaryprogrammeforhealthcareimprovementthatisfor
nationalandlocalactionandcontributestopreventingdiseaseandimprovingthehealthand
wellbeingofpeopleandchildreninparticular,bringingthelevelofthosewiththepooresthealthto
thelevelofthosewiththebesthealth,andencouragingindividualresponsibilityforhealth.
Mentalandsocialwellbeingarenowintegralcomponentsofthehealthcareprogrammeandthey,in
turn,arerecognisedasbeingintricatelyrelatedtopolitical,economic,social,environmental,genetic
andinstitutionalcircumstances.Itisthereforeevidentthattobringaboutthedesiredimprovementin
healthstatusofthepopulationamultidisciplinary,multiagencyapproachisrequired.Thishas
broughtabouttheshifttosocalled"joinedupworking"involvingtheintegrationofhealthandsocial
services,localgovernmentandvoluntarysectors.Toplayitspartinthisnewagendathe
pharmaceuticalprofessionwillhavetorethinkitsownstrategy.
Muchoftheprofession'scurrentstrategyisbasedonmanagementofprescribedmedicines,
managementofchronicconditions,managementofcommonailments,promotionofhealthy
lifestylesandprovisionofhealthadvice.6Theseembracethecoreactivitiesoftheprofession,but
reflectauniprofessionalculturethatfocusesontheindividual,pharmaceuticalcareandmedicines
management.Withthenewhealthagendathereisaclearneedtominimiseuniprofessionalthinking
andshiftfocusfromtheindividualandthewantsofthosewhoarearticulateandhaveresources,and
placemoreemphasisondefining,addressingandmonitoringtherealhealthneedsofthepopulation.
Panel1:Possiblepharmaceutical
publichealthroles
Providehealthadviceonself
care
Providehealthadvicetoyoung
mothers
Providesupporttodevelop
effectiveparentingskills
Participateinhealthpromotion
campaigns
Participateinhealthyliving
centres
Promotedrugmisuseawareness
Participateinneedleandsyringe
exchangeschemes
Promotehealthyschools
ImproveAIDSawareness
Providesexualhealthsupport
Provideunplannedteenage
pregnancysupport
Supportpatientswithchronic
illness

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Iftheprofessionwantstomakeapositivecontributionto
thenewhealthagendawithitsfocusonthehealthofthe
population,itmustidentifyitsownpublichealthrole.The
professionmaychoosetorepackageexistingservicesand
claimthisastheircontributiontopublichealth.Evidence
fromdiscussionswithcolleaguesaroundtheUnited
Kingdomsuggeststhatthisisthechosenoption.Typical
examplesofthecitedpublichealthrolesarepresentedin
Panel1.Whileanumberoftheseservicescanbecorrectly
interpretedaspublichealthroles,allarenotablebythe
absenceofongoing,coordinatedsurveillance.Otherroles,
suchasthoseassociatedwithhealthpromotion(Panel2),
haveconsiderablepublichealthpotentialbutembrace
issuesthathavearelativelypoorevidencebaseoflong
termbenefitforsociety,areagainassociatedwithlow
levelsofongoingsurveillanceandprovidelimited,
generalisiblesupportforthevalueaddedroleofpharmacy.
Toputitsimply,continuedinvolvementinhealth
promotionatthelevelofleafletdistributionwillnot
persuadethoseoutsidetheprofessionthatthisisarolethat
canmakeasignificantcontributiontothepublichealth
agenda.Thisissomewhatironicgiventhatofthefour
categoriesofhealthdeterminantsatapopulationlevel,
healthcareprovisionistheleastimportant.Heredity
factors,environment,andlifestyle,thefrequenttargetof
healthpromotioncampaigns,areallconsideredmore
important.7
Theprofession,however,shouldnotdespair.Theplightof
pharmacyisnotuniqueasitwrestleswiththeconceptsof
thenewNationalHealthService,publichealth,sustainable
healthandtheneedtoreduceinequalitiesinhealth.A
solutiontoproblemsthathavebeenpresentinsocietyfor
decadeswillnotbefoundovernight.Theseproblemswill
notberesolvedbyanysingleprofessionortheemergence
ofpharmaceuticalpublichealth,andwillcertainlynotbe
addressedbythepharmaceuticalprofessionifitcontinues
toworkinisolationorisdisengagedfromthehealthpolicy
makingprocessateithernationalorlocallevel.Perhaps
recentdevelopmentsintheprofessionhaveleftitill
preparedforthenewhealthagenda.Theenthusiasmfor
pharmaceuticalcarewithafocusontheindividualhas
directedattentionawayfromissuesthataffectthe
population.Thisbalanceneedstoberedressed.Individual
pharmacypractitionersandmanagersneedtotake
responsibilityfortheircontributiontoahealthier
populationasdotheprofession'spoliticianswiththeir

Provideadviceonhow
medicineswork
Adviseoncomplimentary
medicine
Maintainpatientmedication
records
Providemonitoreddosage
systems
Promotepatientmedication
adherence
Provideoutofhoursservices
Providecollectionanddelivery
services
Undertakedomiciliaryvisits
Dealwithpharmaceuticalhazard
alerts
Facilitatedisposalofwaste
medicines

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policies.Thereisalsoaneedforaclearunderstandingof
whatconstitutespharmaceuticalpublichealth.
Whatispharmaceuticalpublichealth?
Thestartingpointformanyrecentdefinitionsofpublic
healthhasbeenthatusedintheAchesonreportonpublic
healthinEngland.8Withappropriateamendmentitmay
alsobeusedasastartingpointtodefinepharmaceutical
publichealth:
Theapplicationofpharmaceutical
knowledge,skillsandresourcestothe
scienceandartofpreventingdisease,
prolonginglife,promoting,protectingand
improvinghealthforallthroughorganised
effortsofsociety
Thisdefinitionembracesarangeofactivities,implicitly
acknowledgestheneedtoworkwithpatients,thepublic
andotheragencies,cutsacrossprofessionalandnon
professionalboundariesandclearlyindicatesthereisno
singleapproachtopharmaceuticalpublichealth.Asa
consequence,pharmaceuticalpublichealthrequiresacore
frameworkofactivityanalogoustothatofpublichealth.It
must:
Improvepharmaceuticalsurveillanceofthehealthof
thepopulationcentrallyandlocally
Encouragepoliciesandpracticethatpromoteand
maintainhealth
Ensuremeansareavailabletoevaluateexisting
healthservicesthathaveapharmaceutical
component

Panel2:Examplesofhealth
promotionactivitiesprovidedin
communitypharmacies
Healthylifestyle(healthyeating,
nutrition,exercise,alcohol,
familyplanning,passive
smoking,smokingcessation)
Asthma/respiratorydiseases
(chronicbronchitis,allergies,
inhalerdevices,medicinesand
asthma,childrenadults)
Healthyheart(healthyeating,
exercise,highbloodpressure,
angina,useofaspirin)
Sexualhealth(HIV/AIDS,safe
sex,infertility,emergency
contraception,emotional
support,sexuallytransmitted
disease,contraception)
Safety/prevention(Safeuseof
medicines,dumpcampaigns,
travelabroad,firstaid,accident
prevention,sportsinjuries)
Substanceabuse(solvents,
alcohol,drugs[illicitor
prescriptiondrugs],needle
exchange)
Elderly(adviceforcarers,
compliancedevices,mobility
aids,incontinence,stomacare,
influenza,footcare)
Parentsandbabies(breast
feeding,milksubstitutes,folic
acid,immunisation,nappyrash,
teething)
Children(headlice,parasites,
meningitis,immunisation,
vitamins,sugarandsaltinfood)
Women'shealth(breastcancer,
cervicalcancer,migraine,stress

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Barrierstothedevelopmentofpharmaceuticalpublic
healthincludethelowlevelofcooperationbetween
sectionsoftheprofession,theuniprofessionalculturethat
understatesthevalueofpartnerships,apoorknowledgeof
pharmaceuticalneedsandtheabsenceofcommondatasets
tomonitorhealthandhealthrelatedissues.
Toprogresstheconceptofpharmaceuticalpublichealth,
pharmaceuticalhealthneedswillhavetobeidentifiedand
monitoredinastandardisedandsustainableformatthatis
integratedwiththeservicesprovidedbypharmacyand
otheragencies.Thesecommondatasetscouldbeutilisedto
monitorhealthneeds,healthpatternsandhealthseeking
behavior.
Anypharmaceuticalhealthsurveillancethathastobe
undertakenmustbeincidentaltoclinicalandservice
activityandnotanadditionalburdenontheindividual
practitioner.Forexample,allcommunitypharmaciescould
berequiredtocollectspecifieddata.Alternatively,a
representativesampleofcontractorscouldbeused.
Independentreportsonthestatusofpharmaceuticalpublic
healthforagivenpopulationsuchasalocalityorhealth
authorityshouldbecompiled.Thesereportscouldthenbe
collatedtopresentthenationalpicture.Atthesimplest
level,pooleddataofproductsalescouldbeusedtoindicate
outbreaksofheadliceinfection,allergicrhinitis,diarrhoea
ortheuseandabuseofoverthecountermedicines.
Prescriptionrecordscouldbebetterusedtomonitorthe
therapeuticmanagementofpatientsinnursinghomesand
residentialhomesatlocality,healthauthorityornational
level.Likewise,prescriptionrecordscouldbeusedto
providemoretimelyfeedbackonprescribingpatterns,the
incidenceofcommondruginteractions,theuptakeofnew
drugsinspecificpatientgroups,variationsofdosage
regimensprescribedortheissueofprivateprescriptionsfor
givenproducts.

incontinence,thrush,cystitis,
menopause,osteoporosis)
Men'shealth(prostateproblems,
heartattacks,lungcancer,stress,
indigestion/heartburn)
Oralhealth(cancerofthe
mouth,mouthulcers,babies'
teeth,dentures,dentalcare,cold
sores,sugarfreemedicines)
Skincare(cancer,eczema,
psoriasis,acne,sunscreens,
scabies)

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Pharmacyinsecondarycarealsohasakeyroletoplayinpharmaceuticalhealthsurveillance
althoughit,too,needstoensureithasembracedacultureofcollaborativeworking.Areasfor
potentialsurveillanceincludedischargemedication,utilisationoftelephonehelplineservices,
dischargeofpatientstocarehomes,provisionofpackagesofcomplexcare,hospitalathomeand
palliativecareservices.
TheNationalHealthServicedeservesanintegratedservicefromapharmaceuticalprofessionthat
operatestoitsfullcapability,workswithothers,contributestoanddefineshealthpolicyandplaysits
partinmonitoring,promoting,protectingandimprovingthehealthofthepopulation.Societywill
notbenefitfromapharmaceuticalservicethatisfragmentedandpitchesmultipleagainst
independent,multipleagainstmultipleorprimarycareagainstsecondarycare.Similarly,everyeffort
mustbemadetoensureeveryonehasreadyaccesstopharmaceuticalservices.Deprivedareaswith
themosttogainfromacomprehensivepharmaceuticalservicearestillamongthosemostlikelytobe
deniedthisservice.
Theneedtocollaborateandundertakepharmaceuticalpublichealthsurveillanceandutilise
anonymiseddataisdesirableandachievable.Theemergenceofpharmaceuticalpublichealthwill
notmarktheendofpharmaceuticalcareandmedicinesmanagement.Ratheritwillservetorefocus
ontheindividualinthecontextofhisorherphysical,socialandmentalwellbeingwithinsociety.An
activepharmaceuticalpublichealthpolicy,haditbeeninplace,mayhavehelpedavoidproblems
associatedwiththeinappropriateuseofantibioticsorthehighuseofantipsychoticsinnursing
homes.Ifputinplaceitcouldhighlightinequalitiesinprescribingwithdrugssuchasthestatinsor
hormonereplacementtherapy.Thecollectionofadditionaldatafromprescriptions,prescriptions
dispensedoutofhoursandOTCsalesdatacouldbeusedtoprovideindicatorstomonitortheimpact
ofdeprivation,poorhousingorredevelopmentschemesonhealthandthehealthofchildrenin
particular.Likewiseproxymarkers,suchastheprescriptionofinhalers,couldbeusedtoindicate
environmentalpollution.
Bothpharmaceuticalcareandpharmaceuticalpublichealthcanhelptheprofessionhighlightthatit
candomorethanprovideasupplyandcostcontrolservice.Pharmaceuticalpublichealthisareal
valueaddedrolethattheprofessionhas,todate,chosennottoexploit.Aspartofthebigpictureof
healthdeterminants,itmaybeabletomakeamoresignificantcontributiontothehealthofthe
populationthanmoretraditionalaspectsofpharmacy.Canweaffordnottosupportitsdevelopment?
RogerWalkerisdirectorofpharmaceuticalpublichealthatGwenthealthauthorityandprofessorofpharmacy
practiceattheWelshschoolofpharmacy,Cardiffuniversity.Addressforcorrespondence:WelshSchoolofPharmacy,
CardiffUniversity,KingEdwardVIIAvenue,CardiffCF13FX(emailwalkerr@cf.ac.uk)

References
1.SecretaryofStateforWales.Betterhealth,betterWales.London:WelshOffice,1998.
2.SecretaryofStateforWales.Strategicframework.Betterhealth,betterWales.London:Stationery
Office,1999.
3.SecretaryofStateforHealth.Ourhealthiernation:acontractforhealth.London:Stationery
Office,1998.
4.SecretaryofStateforHealth.Savinglives:Ourhealthiernation.London:StationeryOffice,1999.
5.TheScottishOfficeDepartmentofHealth.WorkingtogetherforahealthierScotland.London:
StationeryOffice,1998.
6.RoyalPharmaceuticalSocietyofGreatBritain.Pharmacyinanewage:Buildingthefuture.
London:TheSociety,1997.

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7.McKeownT.Theroleofmedicine.Oxford:BasilBlackwell,1979.
8.Reportofthecommitteeofinquiryintothefuturedevelopmentofthepublichealthfunctionand
communitymedicine.London:HMStationeryOffice,1988.
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