Ellen Schafheutle

Affordability of Medicines and Patients' Cost-Reducing Behaviour: Empirical Evidence Based on SUR Estimates from Italy and the UK

IntroductionStudies have demonstrated that co-payments on medication reduce the consumption of both non-essential and essential drugs, and that the latter can lead to worse health outcomes. Far less is known about how patients cope with the cost of medication, particularly if affordability is an issue, and how this compares across two countries with different prescription charge policies. Therefore, the aim of this article is to explore empirically how, and to what extent, costs incurred by patients influence their decision-making behaviour in accessing medicines.MethodsBased on the findings from focus groups, a questionnaire was designed that addressed medication cost issues relevant to patients in both the UK and Italy. Using an econometric model, several hypotheses are tested regarding patients’ decision-making behaviour and how it is influenced by health status, sociodemographic characteristics and the novel concept of a self-rated affordability measure.ResultsQuite a large percentage of patients (70.3% in the UK and 66.5% in Italy) stated they have to think about the cost of medicines at least sometimes. Respondents adopted numerous cost-reducing strategies, subdivided into (i) those initiated by patients and (ii) those involving self-medication. Their use was strongly influenced by income and drug affordability problems, but the self-rated affordability measure was a stronger predictor. Commonly used strategies were not to get prescribed drugs dispensed at all, prioritising by not getting all prescribed items dispensed or delaying until the respondent got paid. Furthermore, respondents with affordability issues were also cost-conscious when self-medicating with over-the-counter (OTC) products for minor conditions such as dyspepsia. Despite patients in both countries using cost-reducing strategies, their use was more pronounced in the UK, where the prescription charge was significantly higher than in Italy.Discussion/conclusionThe results from this study provide detail on the kinds of strategies patients use to reduce the cost burden of prescription charges, and support previous research showing they may be foregoing essential medication. Because the same questionnaire was applied in two European countries, where the national health systems aim to provide healthcare services that are accessible to all citizens in need, it offers interesting insights for policy makers in other countries, where patients may have to pay a larger share of their drugs out-of-pocket, such as the US.

How do pharmacy students learn professionalism

Objective  To understand and clarify how professionalism is learnt, cultivated and facilitated in pharmacy education.

Support staff in community pharmacy: who are they and what do they want?

Objective To collect information on different categories of support staff, their deployment in community pharmacy, their levels of experience and qualifications, and their opinions on a number of topical issues, such as training and regulation.

Coping with prescription charges in the UK

Objective To explore cost‐related behaviour in patients subject to prescription charges.

Non-dispensing of NHS prescriptions in community pharmacies

Objective — To explore non‐dispensing of National Health Service (NHS) prescriptions in community pharmacies.

Ensuring continuing fitness to practice in the pharmacy workforce: Understanding the challenges of revalidation

BACKGROUND Revalidation is about assuring that health practitioners remain up to date and fit to practice, and demonstrating that they continue to meet the requirements of their professional regulator. OBJECTIVES To critically discuss issues that need to be considered when designing a system of revalidation for pharmacy professionals. Although providing international context, the article focuses in particular on Great Britain (GB), where both pharmacists (Phs) and pharmacy technicians (PTs) are regulated. METHODS Following a brief historical overview, the article draws on emerging evidence in context. RESULTS Revalidation may involve discrete periodic assessment or a continuous process of assessment against clearly identified standards. The evolving scope of pharmacy practice involves increasingly clinical roles and also practitioners in nonpatient-facing roles. The potential risk to patients and the public may require consideration. Although revalidation, or systems for recertification/relicensure, exist in numerous jurisdictions, most center on the collection of continuing education credits; continuous professional development and reflective practice are increasingly found. Revalidation may involve assessment of other sources, such as appraisals or monitoring visits. Existing revalidation systems are coordinated centrally, but particularly in larger jurisdictions, like GB, where approximately 67,000 pharmacy professionals are regulated, some responsibility may need to be devolved. This would require engagement with employers and contracting organizations to ensure suitability and consistency. Existing systems, such as company appraisals, are unfit for the assessment of fitness to practice owing to a focus on organizational/business targets. Certain groups of pharmacy professionals may pose particular challenges, such as self-employed locums, pharmacy owners, those working in different sectors, or returning after a break. CONCLUSIONS To ensure proportionality, it must be considered whether the same standards and/or sources of evidence should apply to all pharmacy professionals, either dependent on whether they are patient facing, their scope of practice, or whether Phs and PTs should be treated differently.

Strategies used by general practitioners to minimise the impact of the prescription charge

Objectives: To determine the strategies used by GPs to make medicines, both prescribed and over-the-counter (OTC), cheaper for patients when deciding whether, and what, to prescribe. Method: Five focus groups were conducted in three Health Authorities in the Northwest of England. Between 10 and 11 GPs participated in each group. Results: GPs used a wide range of strategies to try to make medicines either cheaper for patients or to increase their perceived value for money. These strategies included using the prescription charge system to the patients best advantage, by recommending the purchase of an OTC medicine or increasing the amount of medicine supplied. They could also prescribe more effectively by reducing the number of prescribed items or prescribing a medicine perceived to be more efficacious and more expensive to the healthcare system, to paying patients. Respondents also mentioned questionable practices such as re-using returned medication and prescribing more for a family member that was exempt from prescription charges. Conclusions: The UKs fixed charge prescription system, where patients pay a relatively high rate per prescribed item, may facilitate the development of a wide range of strategies to make medicines cheaper for patients. These strategies, and their diversity across EU member states, is an area that merits further investigation as an influence on patient management decisions at both the GP and patient level.

An exploration of the utility of appraisals for the revalidation of pharmacy professionals in community pharmacy in Great Britain

BACKGROUND With revalidation in pharmacy in the United Kingdom fast approaching, appropriate systems of revalidation in community pharmacy are required. With little known about the potential use of appraisals for evaluating fitness to practice in pharmacy professionals (pharmacists and pharmacy technicians) in this sector, research was undertaken to explore their potential utility in a revalidation process. OBJECTIVES To examine existing structures and processes in community pharmacy appraisals in Great Britain (ie, England, Scotland, and Wales) and consider the views of pharmacy stakeholders on if, and how, appraisals could contribute to revalidation of pharmacy professionals. METHODS Semi-structured telephone interviews were conducted with senior staff (eg, superintendents and professional development managers) from chain community pharmacies as well as pharmacy managers/owners from independent pharmacies. Senior staff from locum agencies and pharmacy technician stakeholders were also interviewed. RESULTS Appraisals were in place for pharmacists in most chain pharmacies but not in independent pharmacies. Locum pharmacists were not appraised, either by the companies they worked for or by the locum agencies. Pharmacy managers/owners working in independent pharmacies were also not appraised. Pharmacy technicians were appraised in most chain pharmacies but only in some independent pharmacies. Where appraisals were in operation, they were carried out by line managers who may or may not be a pharmacist. Appraisals did not seem to cover areas relevant to fitness to practice but instead focused more on performance related to business targets. This was particularly true for those in more senior positions within the organization such as area managers and superintendent pharmacists. CONCLUSIONS Existing systems of appraisal, on their own, do not seem to be suitable for revalidating a pharmacy professional. Considerable changes to the existing appraisal systems in community pharmacy and employer engagement may be necessary if they are to play a role in revalidation.

Internationally trained pharmacists in Great Britain: what do registration data tell us about their recruitment?

BackgroundInternationally trained health professionals are an important part of the domestic workforce, but little is known about pharmacists who come to work in Great Britain. Recent changes in the registration routes onto the Register of Pharmacists of the Royal Pharmaceutical Society of Great Britain may have affected entries from overseas: reciprocal arrangements for pharmacists from Australia and New Zealand ended in June 2006; 10 new states joined the European Union in 2004 and a further two in 2007, allowing straightforward registration.AimsThe aims of the paper are to extend our knowledge about the extent to which Great Britain is relying on the contribution of internationally trained pharmacists and to explore their routes of entry and demographic characteristics and compare them to those of pharmacists trained in Great Britain.MethodsThe August 2007 Register of Pharmacists provided the main data for analysis. Register extracts between 2002 and 2005 were also explored, allowing longitudinal comparison, and work pattern data from the 2005 Pharmacist Workforce Census were included.ResultsIn 2007, internationally trained pharmacists represented 8.8% of the 43 262 registered pharmacists domiciled in Great Britain. The majority (40.6%) had joined the Register from Europe; 33.6% and 25.8% joined via adjudication and reciprocal arrangements. Until this entry route ended for pharmacists from Australia and New Zealand in 2006, annual numbers of reciprocal pharmacists increased. European pharmacists are younger (mean age 31.7) than reciprocal (40.0) or adjudication pharmacists (43.0), and the percentage of women among European-trained pharmacists is much higher (68%) when compared with British-trained pharmacists (56%). While only 7.1% of pharmacists registered in Great Britain have a London address, this proportion is much higher for European (13.9%), adjudication (19.5%) and reciprocal pharmacists (28.9%). The latter are more likely to work in hospitals than in community pharmacies, and all groups of internationally trained pharmacist are more likely to work full-time than British-trained ones. Adjudication pharmacists appear to stay on the Register longer than their reciprocal and European colleagues.ConclusionAnalysis of the Register of Pharmacists provides novel insights into the origins, composition and destinations of internationally trained pharmacists. They represent a notable proportion of the Register, indicating that British employers are relying on their contribution for the delivery of pharmacy services. With the increasing mobility of health care professionals across geographical borders, it will be important to undertake primary research to gain a better understanding of the expectations, plans and experiences of pharmacists entering from outside Great Britain.

Identifying and managing performance concerns in community pharmacists in the UK.

Objectives To explore current arrangements for identifying and managing performance concerns in community pharmacists in the UK. Methods Semi-structured qualitative telephone interviews were conducted with 20 senior managers from community pharmacies and locum agencies. Results A strong emphasis was placed on business performance alongside other aspects of professional performance in the identification of performance concerns in pharmacists. The majority of concerns were identified reactively, through customer complaints, peer- or self-referral, or following a dispensing error. Community pharmacies sought to manage performance concerns internally where possible, but only the larger organizations had the infrastructure to provide their own training or other remedial support. Several challenges to identifying and managing performance concerns were identified. There were few mechanisms for identifying and supporting locum pharmacists with performance issues. Conclusions Being ‘for-profit’ organizations, community pharmacies may prioritize business performance over ensuring the professional performance of pharmacists, the responsibility for which would be left to the individual pharmacist. This may be detrimental to the quality of care provided. With the growth of independent sector providers more widely, these findings may have implications for the regulation of other health care professionals’ performance.