Chapter 2 Models of pharmacy practice within healthcare systems
The development and role of pharmacy practice in the UK was detailed in Chapter 1. It can be seen that the role of, and demands on, the pharmacist has come a long way from being an apothecary or simply a dispenser of medicines. Chapter 6 describes the types of patient charges for prescriptions and their impact. What becomes clear from these two chapters is that there are many methods used by healthcare systems in different countries to charge patients for their medicines. Also, lists of medicines have to be drawn up in less well developed or economically poorer countries to assist them provide basic essential medicines for their populations (see Ch. 7). Thus it becomes apparent that different countries, depending on their economic circumstances and their values (political or otherwise), have developed numerous different methods to provide and distribute medicines to their communities.
Most countries of the world have some system of healthcare provision and involve a range of healthcare providers. The latter may range from very basically trained lay support or outreach workers to highly skilled, university-graduated, regulated and registered healthcare professionals. The skills and range of healthcare workers available in a country will depend mainly on the economic development of that country. Richer countries generally have more healthcare workers with more of them highly trained and skilled.
Healthcare provision throughout the world is not equitable. Although economically rich countries often help poorer countries with financial aid, medicines, medical equipment, advice and some healthcare professionals, etc., there is still inequality between countries. This can be demonstrated by comparing the average overall life expectancy between countries (Table 2.1).
Table 2.1 Life expectancy in years at birth for different countries
| Country | Life expectancy at birth (years) |
| World average | 67.2 |
| Japan | 82.6 |
| Australia | 81.2 |
| Singapore | 80.0 |
| UK | 79.4 |
| USA | 78.2 |
| Lithuania | 73.0 |
| Saudi Arabia | 72.8 |
| India | 64.7 |
| Gambia | 59.4 |
| Kenya | 54.1 |
| Nigeria | 46.9 |
| Swaziland | 39.6 |
Discussion of how equitable health care can be provided worldwide is outside the scope of this chapter. The chapter describes some of the actual healthcare systems to illustrate their diversity and, in particular, emphasizes the role of pharmacists, their education, regulation and registration, and the supply and distribution of medicines to a country’s inhabitants. Rather than describing the healthcare provision and the role of pharmacists in every country in the world, the aim has been to look at trends, similarities and differences between countries.
No one healthcare system is perfect for all situations and equally no system will be totally static. Countries do look at other healthcare systems and often copy, emulate and subsume the perceived ‘good ideas’ into their own systems. Healthcare systems will change depending on the economic stability, growth of the country and political or governmental changes. Other factors include changing demographics of the population, development of new medicines and medical technologies, the emergence of new diseases (e.g. HIV and AIDS) or the eradication of old diseases (e.g. smallpox). Most countries with the lowest life expectancies are those in which there are high incidence rates of HIV/AIDS, such as Swaziland, Botswana, Zimbabwe and Zambia. These countries also lack the finance to provide the population with antiretroviral drugs.
Pharmacists and/or pharmacy technicians (the names may vary in different countries) are present in most countries. Their roles may be widely different; for example in some countries the concept of pharmaceutical care or medicines management may not be accepted or well developed, so there will not be roles for pharmacists in those specialist areas. However, because of the increased availability of modern medicines of greater potency and cost, it becomes imperative that someone is responsible for their distribution and supply to the population, either via dispensed prescriptions or by sale over the counter. Due to their efficacy and side-effects, medicines are both potent and potentially dangerous. A rational distribution system safeguards the population by controlling the supply of medicines to the general public. In most countries pharmacists are normally given the authority to be the guardians of medicines. Thus they are the healthcare professionals with the responsibility for the safe, effective, rational and economic use of medicines. However, the extent of these responsibilities will be dependent on the healthcare system in the individual country and the legal controls placed on medicines, their supply and the healthcare professionals involved. Pharmacists will be employed in the pharmaceutical industry (if there is one in the country) as the developer and producer of manufactured medicines. Alternatively pharmacists will be engaged in controlling the importation of medicines, checking their authenticity and safety. Pharmacists or pharmacy technicians will be involved in the extemporaneous production or small-scale supply and distribution of medicines, whether in hospitals, in healthcare centres such as district clinics in remoter areas, or in pharmacies in the community.
Each country tends to develop its own system to accommodate its own particular needs and in line with its economic ability. Clearly the provision of pharmaceutical services and medicines will be different in a small economically rich country with good transportation and communication links when compared to that of a much poorer, geographically large country with remote areas and limited transportation and communication links.
The legal structure within a country will influence both the distribution of medicines and the place of the pharmacist in that distribution system. Laws may strictly regulate the production, distribution, marketing and supply of medicines, e.g. the UK Medicines Act 1968 and its subsequent amendments and subsuming of EU law. Other countries may have much less tight regulation of their medicines. The legislation in place will control, for example:
Further legislation may regulate the education of potential pharmacists and whether they need to register with a state or professional body before being able to practise. For example, the Pharmacist and Pharmacy Technicians Order 2007 in the UK details the education, registration and fitness to practise of pharmacists and pharmacy technicians, as well as the procedure for disciplining or even removing a pharmacist or pharmacy technician from the register. Thus the legislation in place at any time in a country will have a direct effect on the ability of a person to become and remain a pharmacist and their opportunities for employment and career prospects. These will be explored in more detail.
Pharmacists throughout the world have to operate within the particular healthcare system of their country. This will have a direct effect on their roles, responsibilities and employment opportunities. In most countries the aim is that all citizens have access to health care. This is called universality. However, how and whether this is achieved will differ between countries. Most countries have a private healthcare system running alongside a state or insurance-based system which will either fully or partially fund treatment. A system of claims and/or benefits may be in place for certain members of the country – for example the young, the old and the unemployed may receive free treatment.
In the UK, all the population (including visitors) are provided with a ‘free’ healthcare system provided by the National Health Service (NHS) which is funded through taxation. In the primary care sector, that is in the community, many healthcare professionals are independent but have contracts with the NHS to provide NHS services. For example doctors and dentists will have contracts with the NHS so that access to them is free, although in the case of dentists, while a dental check up is free, there is a co-payment scheme in operation for any treatment. In practice this means that patients can choose to be treated either as an NHS patient or as a private patient by their dentist, so the dentist operates in both the private sector and the NHS. Community pharmacists are similarly independent but most will have a contract with the NHS to provide dispensing and pharmaceutical services. This situation enables community pharmacists to dispense both private and NHS prescriptions and to provide private pharmaceutical services if they wish. The NHS also provides the secondary care structures such as hospitals, health centres/clinics, etc., and employs a wide range of healthcare professionals such as pharmacists, nurses, physiotherapists, nutritionists, social workers and doctors. Access to hospital treatment is free.
While most medicines are available on an NHS prescription, a few medicines, in particular some of the newer, more expensive drugs with limited long-term clinical evidence, may not be available. Thus if a person is financially able to afford these NHS-restricted medicines then a private prescription can be written alongside NHS prescriptions. Additionally community pharmacies, as independent retailers, can offer medicines as well as other goods for sale.
Alongside the NHS a private healthcare sector exists with a full range of hospitals and healthcare professionals and healthcare provision. Individuals choosing to be treated privately will have to cover all the associated costs. However, many individuals pay using insurance or private healthcare schemes which may be a benefit of their employment for themselves and their families.
For pharmacists the two systems mean that there are employment opportunities within both NHS and private hospitals. Likewise pharmacists employed in community pharmacy might find themselves dispensing both private and NHS prescriptions. Community pharmacists may find themselves providing medicines for minor ailments via a free NHS scheme to eligible patients, while other customers would have to buy the same medicine themselves because they are not eligible for the scheme. Thus pharmacists need to understand the healthcare systems in which they are working in order to be efficient and productive and provide a quality pharmaceutical service to their patients within the appropriate healthcare system.
In Australia the principle of universality aims to provide access to the same standard of care for all citizens based on a health insurance scheme called Medicare. All citizens contribute via the taxation system, depending on their ability to pay. However, unlike the UK NHS system, while access to public hospitals is free, cash benefits are paid from Medicare for the cost of access to general practitioners and other healthcare specialties, such as dentists and optometrists. Prescription medicines are provided from private pharmacies and a pharmaceutical benefits scheme exists which provides a co-payment scheme for prescriptions and lists of eligible medicines. The system is fairly complex with different levels of benefit depending on the status of the individual (welfare entitlement of the citizen) and the lists of eligible and non-authorized medicines. Patients may choose to pay extra for branded products rather than generically prescribed medicines. Australian pharmacists require a good understanding of the pharmaceutical benefits scheme and the medicines and brands of medicines available if they are to provide both a good pharmaceutical service for their patients and navigate the system.
In Ireland the emphasis of health care is on the individual arranging their own private medical and surgical services for themselves and their family. However, there is a free healthcare scheme in cases of hardship, called the General Medical Services (GMS). This scheme also covers all under 16-year-olds and those over 70 years of age. Community pharmacies are privately owned and have to enter into an agreement with the local health board to provide GMS services. GMS provides a system of health care in which many individuals are covered to a greater or lesser extent by a drug payment scheme and a long-term illness scheme. Both are very convoluted and provide a level of benefits for almost every group of patients. These benefits can include a range of subsidized or free medicines and appliances. While the aim is a private GMS, the work of pharmacists working within the system will be increased by the system.
These three healthcare schemes are a mixture of private and public. The public scheme either covers the majority of the population or picks up the poorer or more dependent sections of the population. In Saudi Arabia all nationals are provided with free health care and medicines. In that country, all community pharmacies are privately owned and are recompensed by the state for dispensing and the other pharmaceutical services that they provide.
The different healthcare systems described above, while not comprehensive, do indicate the variety of healthcare systems available. Clearly pharmacists have to work in the healthcare system of a particular country. This may impose different systems of working because of characteristics of the provisions for health care. It is essential that, whatever the situation, pharmacists provide the best pharmaceutical services for their patients within any limitations imposed on them by the national healthcare system.
The legal classification used for medicines in a country will have a direct impact on the practice of pharmacists. Most countries have laws to restrict access to narcotic analgesics and other groups of potent medicines.
Some countries have a two-tier classification of drugs:
Some countries further divide non-prescription medicines into ‘pharmacy medicines’ and OTC medicines. ‘Pharmacy medicines’ are available for sale to the general public but only from a pharmacy and under the supervision of a pharmacist. Thus pharmacists have a direct input into the sale of these medicines. Germany, Ireland and the UK are examples of countries which have this three-tier classification. Australia also has a three-tier classification, but has further divided pharmacy medicines into those that can be sold:
The USA, Estonia and Saudi Arabia are examples of countries with a two-tier system in which only pharmacists control access by the general public to prescription only medicines.
In recent years some medicines have been reclassified, usually from prescription only to pharmacy or general sales classifications. This allows more medicines to become available to the general public for purchase. It also gives the pharmacist more control over the sale of medicines classed as pharmacy medicines. Such a process has given pharmacists a more professional image and increased the professional content of their work. The reclassification process can go from general sales to prescription only, but this would only be expected if a drug was found to have major side-effects not suitable for a general sales medicine. This would be unusual.
Many countries have strict controls on the advertising of prescription only medicines. For example, advertising to anyone other than a healthcare professional is banned in the UK. These controls are to help protect the public from the potential misuse of medicines. However, in other countries, banning advertising is considered to be a constraint on trade and so advertising of prescription only medicines is allowed, as for example in China. With the advent of the Internet it is very difficult for any country to completely control the advertising of prescription only medicines, and the general public can now access both advertising and information about prescription only medicines via the Internet. Some of the information on these sites may contain inaccurate information. However, having acquired this knowledge some patients consider themselves (often incorrectly) to be knowledgeable about medicines. They may become very demanding of pharmacists and doctors in their quest to obtain a particular medicine.
The advertising of pharmacy medicines and general sales medicines is usually permitted. However, most countries will have, as a minimum, some guidelines to ensure that advertisements are truthful and do not make excessive claims for their products. Again, this advertising of pharmacy medicines may result in difficult patients who are not prepared for the pharmacist to advise against, or refuse to sanction, their purchase of a particular pharmacy medicine. Thus the laws governing the advertising of medicines in their country will influence the everyday work of community pharmacists.
The availability of medicines in a country is usually dependent on the general wealth of the country, with the richer countries usually having a full range of all the marketed medicines and the ability to import from other countries as required. Thus pharmacists in these countries will deal with many hundreds of different medicines, especially if there is a range of proprietary and generic medicines available for the same drug. Pharmacists will need to use their full range of knowledge and skill. This situation contrasts very sharply with poorer countries, in which even essential medicines (see Ch. 7) may not be available. In such countries the role of the pharmacist will be limited and some aspects of clinical pharmacy will not be possible.
The education of pharmacists follows a similar pattern worldwide. This is not surprising since a few countries have exerted a wide influence through a history of domination. Europeans settled in many countries in their quest for discovery and wealth and thereby influenced the development of those countries. One example was the British, whose empire dominated many countries; the British Empire eventually evolved into the less dominant but still influential British Commonwealth.
More recently the creation of the European Community, later the European Union (EU), has resulted in the need to harmonize the education and recognition of professionals throughout member countries. This has resulted in a minimum of 4 years’ undergraduate university education for the awarding of an accreditable pharmacy degree in the EU. An agreement to standardize the curricula between member countries within the EU has emerged. The 4-year degree is followed by a 1-year practical training (called pre-registration in the UK, internship in Germany) in a pharmaceutical setting and under the supervision of a pharmacist. In some countries the 1-year practical training may be incorporated into the degree structure, thereby lengthening the degree.
Countries as geographically widespread as New Zealand, Australia, Singapore, Brazil and Saudi Arabia have also developed this 4 plus 1 model of pharmaceutical education.
The legislation in most countries requires registration as a pharmacist with a professional and/or regulatory body or the state. For example, Singapore has a Pharmacists Registration Act requiring pharmacists to register with Singapore’s Pharmacy Board, while in the UK, the Pharmacy and Pharmacy Technicians Order is the legal basis setting out the registration requirements. Requirements usually include the prospective registrant to have achieved success in a professional examination, usually termed the registration examination, prior to applying for registration. Unless actually registered, a person cannot work as a pharmacist, even if they have completed all the educational and registration requirements. Pharmacists wishing to work in a country other than the one in which they were educated will usually have to complete further training. This is likely to include practical training and passing at least one examination. The latter may be equivalent to the registration examination, but may require more extensive knowledge before applying for registration in that country.
In the UK, prospective pharmacists have to successfully complete the pre-registration year and the registration examination before registering with the Royal Pharmaceutical Society of Great Britain (RPSGB). The RPSGB is an example of a combined professional and regulatory body. Plans are in place to separate these two roles and establish a separate regulatory body which will register and monitor ‘fitness to practice’ of pharmacists (see Ch. 10). It will have disciplinary powers to deregister, if necessary. The other body will have a professional role. Similarly other countries, such as New Zealand, have recently and successfully separated these functions.
In South Africa, pharmacists must register with the South African Pharmacy Council, which is the statutory body. Its objectives include the control, promotion and maintenance of standards of pharmaceutical education and pharmacy practice. It also plays a role in the control and maintenance of the professional conduct of registered pharmacists. This system is an example of a separate registration body. Professional organizations exist in South Africa, including the Pharmaceutical Society of South Africa, to professionally represent pharmacists.
In Saudi Arabia, the Pharmacy Board of the Saudi Food and Drug Authority acts as the regulatory and registration body for pharmacy.
In very small countries such as Bermuda, which does not offer its own pharmacy degrees, overseas trained pharmacists are employed, usually with US, Canadian or UK degrees. They are required to undertake a 1-month pre-registration training to acquaint themselves with the Bermudan system before taking a pre-registration examination. Success in the examination will allow the individual to register as a pharmacist with the Pharmaceutical Council of Bermuda.
Most of the regulatory bodies place requirements on registered pharmacists including compliance with codes of practice or standards. For example, the South African Pharmacy Council publishes Rules for Good Pharmacy Practice and a list of products that should not be sold in a community pharmacy. Continuing professional development (CPD) is rapidly becoming a mandatory requirement for continuing registration as a pharmacist. Some countries require obligatory credits, for example Saudi Arabia requires 60 credits over 3 years. Other countries simply require the pharmacist to undertake CPD, while yet others, including the UK, require written records.
The requirement for registration and the concomitant application of ‘rules of professional behaviour’ and CPD places responsibilities and obligations on pharmacists in their practice of pharmacy. Ignorance of these ‘rules’ and CPD requirements may place a pharmacist in the position of being disciplined by the regulatory body and ultimately de-registered. Thus a knowledge of the continuing requirements for registration must influence how a pharmacist behaves professionally both at work and during leisure.
From the earlier description of healthcare systems, it is apparent that most community pharmacies are privately owned. State owned pharmacies were the norm in the former Soviet Bloc countries, but these have now been privatized. In some countries, for example Estonia and Switzerland, only pharmacists can own a pharmacy. Some countries limit the number of pharmacies which a pharmacist can own. In Germany, for example, pharmacists are limited to owning no more than four pharmacies, while in some Australian states the limit is no more than three pharmacies. In Finland, no pharmacist can own more than one pharmacy, but with permission, can own up to three ‘subsidiaries’ in the neighbourhood. In Finland, a 5–6-year masters degree in pharmacy is offered in addition to a 3-year bachelors degree, but a pharmacy can only be owned by a pharmacist with a masters degree.
In some countries the ownership of pharmacies is not restricted to pharmacists and the number of pharmacies owned is similarly not restricted. This arrangement gives rise to chains of pharmacies and pharmacies within supermarkets. The UK, Australia, USA, Lithuania and Saudi Arabia are examples of countries with this latter model. Some countries have regulations limiting the number of pharmacies within a geographical area or even the location of pharmacies.
In a similar way to the registration of a pharmacist, most countries will require a pharmacy to be registered and/or licensed with an appropriate body. This body may impose conditions on the pharmacy, such as required equipment, grades and numbers of staff, dispensary size, having counselling areas, places for health promotion leaflets, etc.
Some of these requirements mean that pharmacists in such pharmacies will be expected to use the counselling room for medication reviews. This is the case in the UK and Australia, for example. In some countries there may be an emphasis on the provision of health promotion advice, possibly accompanied by a leaflet. Other pharmacies will have testing equipment to provide, for example, cholesterol or Chlamydia testing. Yet other pharmacies may develop expertise in extemporaneous dispensing.
Thus, depending on the country in which they work, community pharmacists will find themselves able to own a pharmacy or be employed in an independent pharmacy or a chain or supermarket pharmacy. The registering or licensing body decides the conditions in which they work and the type of work that they are required to undertake. These different models will clearly affect the working conditions of a pharmacist.
Pharmacists may work in either private or public hospitals depending on the healthcare organization in the country. The role of hospital pharmacists in different countries will be dependent on the range of medicines available, the distribution systems in place and the extent of development of clinical pharmacy and other specialist areas.
Hospital pharmacy was originally concerned with the distribution and manufacturing of medicines. In many wealthier countries and those with an abundant supply of medicines this function has changed to one with more emphasis on clinical pharmacy and the rational and appropriate use of medicines. Thus pharmacists are not confined to the dispensary, but will conduct patient medication reviews, take part in ward rounds, provide therapeutic drug monitoring, deliver drug information services and advise on medicines management. Additionally, specialist pharmacists have evolved with the spread of clinical pharmacy in areas such as intensive care, HIV/AIDS and psychiatric pharmacy, for example. With a diminution of the manufacturing function, the distributive and manufacturing functions in hospital pharmacy are often delegated to others, for example pharmacy technicians, who develop their own areas of specialization.
In many countries, hospital pharmacists have developed their own organizations. An example is the Society of Hospital Pharmacists of Australia. These organizations unite hospital pharmacists, promote their role and provide routes for exchange of information and education and training.
Thus the practice of hospital pharmacy will depend on the country, the availability of medicines and the extent of development of clinical pharmacy.
While there are many similarities in the roles of pharmacists working in different countries, the dissimilarities are also evident. The role of pharmacists depends to a great extent on the healthcare systems in place. In most countries, there is a mix of private and public health care and most community pharmacists will be working in a private community pharmacy which will contract to provide pharmaceutical services to both private and state systems. Thus the pharmacist must have a wide understanding of the system of charging patients and the system for reimbursement from the public healthcare system. The role of hospital pharmacists is changing from distributive and manufacturing pharmacy to patient centred pharmacy. However, the role of all pharmacists will be dependent on the medicines available and their legal classifications.