Posted on April 14, 2015 in: Innovative Practice
by Diana Behnam, Pharm.D., MSHP Organizational Affairs Committee
Over the last several years, the United States (U.S.) has experienced several major reforms to its health care system to increase quality of care to patients as well as minimize expenditures. As a result, I became interested in learning more about global health care and pharmacy practice in particular, and was fortunate to be given the opportunity to complete a five-week Advanced Pharmacy Practice Experience in England.
While the U.S. and England have many of the same medications on the market, there are some distinct and important differences. For example, melatonin can be purchased as an over-the-counter (OTC) medication in the U.S. but is only available by prescription in England. Moreover, the U.S. and England have different brand names for the same generic product; for instance, in the U.S. the branded forms of ibuprofen include Motrin® and Advil® whereas in England it is Nurofen®. In addition, England uses color-coded prescriptions to identify the prescriber type: public physicians write prescriptions on green paper, private physicians on white, dentists on yellow, nurse practitioners on purple, addiction specialists on blue, etc.
In England, there are far fewer insurance complications because there is less reliance on third-party payers. While private insurance plans still exist, the government uses tax-payer dollars to cover a portion or the entire cost of prescriptions. Medications are free for full-time students under 19, individuals under 16 years or over 60 years old as well as individuals with benefits. Individuals who do not fall into any of these categories pay a set fee depending on the medication type. Some medications, like birth control pills, are always free.
In the community pharmacy setting, a majority of the revenue comes from dispensing fees; however, there are additional revenue-generating opportunities for retail pharmacists. A medicines use review (MUR), which is equivalent to medication therapy management, can be completed for £27.50 ($40.29) in pharmacist reimbursement (per MUR). While there is no capitation on how many MURs can be completed annually, reimbursement is capitated at 400 MURs (equivalent to £11,000, or $16,113.13).
There are several strategies used in England to promote patient adherence and reduce medication errors. All maintenance medications are dispensed in a blister pack containing a four-week supply (i.e., 28 days). There is Braille on the packaging to assist the vision-impaired with taking their medications appropriately. However, technology used to promote medication safety is not as readily available. For example, they do not use barcode scanning to verify the correct medication was chosen. The pharmacist’s final check is the only safety net in place to prevent the dispensing of incorrect medications.
There are many legalities that differ between the U.S. and England. I learned that emergency contraceptives must be purchased by the female and require mandatory counseling to be performed prior to dispensing. Since no prescription is required to obtain the emergency contraceptive, mandatory counseling allows appropriateness to be assessed and to ensure that there are no contraindications. Interestingly, a significant amount of patient counseling is completed by the pharmacy technician. There is no federal law that mandates the pharmacist needs to complete medication counseling and education. However, patients can request to speak to the pharmacist directly and technicians are encouraged to confer with the pharmacist to answer unfamiliar questions.
I also had the opportunity to practice briefly in the hospital setting; specifically, the medicines information unit. Pharmacist responsibilities in this unit include answering drug information questions (from both internal and external sources, including patients), precepting student pharmacists on rotation, assisting with medication policy and procedure development, completing medication histories and assessing appropriateness of therapy (e.g., indication, dose, frequency, duration of therapy). Unfortunately, there is much less emphasis on the collaborative approach to medical care in England, and pharmacists practice primarily independently as opposed to being members of an interdisciplinary team. Furthermore, pharmacists do not participate in medical “rounds” with the physicians and mid-level providers.
I felt compelled to share my pharmacy practice experiences in England because I now have a better appreciation of how advanced pharmacy-driven clinical services and technology are in the U.S. I also believe that we can use the information learned from other health care systems (and pharmacy practice models) to improve our own.