Obviously I chose Pharmacy, and I have been very pleased with that choice. This profession has given me opportunity to carry out work that has greatly satisfied me and hopefully has provided some benefit to many patients and I have tried to help other members of staff along the way.
However the job is changing and I did reflect to someone recently that I am beginning to feel as much like an Accountant as I do a Pharmacist.
This of course is partly because the NHS, and the country, is in financially difficult times. We also have an aging population which brings with it increased health challenges. But it is also because we have seen some very major advances in medicines, some of which come with a huge price tag. In particular the introduction of highly effective biologic preparations, with very specific and targeted drug action. This is the result of some very sophisticated science, of which I am struggling to maintain my understanding. Indeed when I read of a future where big pharmaceutical companies are involved in licensing stem cell products to treat a range of conditions including cancers, cardiovascular diseases, CNS disorders and diabetes, I start to feel well out of my depth. And I dare not even consider the cost of these treatments.
Couple this with emerging work in the area of genomics and stratified medicines where vast amounts of clinical, lifestyle, environmental, genomic and biological data is collected for a patient, allowing us to move to individually tailored treatment and therapeutic strategies. We move away from standardised medication dosing towards made-to-measure medicines. It is believed this approach will improve the lives of millions, of chronic disease patients. If you are struggling to understand any of this, don’t worry my brain is starting to melt at the thought of it! But again it will not be cheap!
The new biologic medicines we currently have, have revolutionised care. In ophthalmology we can now stop some patients going blind with a regular injection, in rheumatology we have greatly improved the lives of arthritis patients, we have reduced the number of relapses multiple sclerosis patients experience and significantly reduced their rate of deterioration and we have improved the survival rates in a range of cancers to name but a few of the care benefits. But whilst as a healthcare provider we rightly celebrate these successes, the down side is they come at a huge cost at a time we have little money. This Board I have to say, has done extremely well to find funding for these medicines. This should be recognised and applauded. But if we have a financial challenge now, then a glance to the future is clinically exciting but financially frightening!
So how do we deal with a future that comes with seemingly endless opportunities to bring clinical benefit and yet no significant increase in the resource we have to deliver this?
To a large extent my answer is – I don’t know! But I do know we can’t expect our Finance colleagues to continually bail us out. We are all in this together.
There are some common sense steps we can take to increase the effective resource we have. Simple steps that we are doing, but must continue to do with increased vigour:
Reduce waste at all points of the health system.
There is not much waste nowadays I hear you say. Well research carried out by the University of York indicates around 10% of medicines prescribed are wasted. For us that means that with a budget of around £40m, perhaps as much as £4m is wasted. So there is work to do.
I also need to highlight that if there is 10% waste in a reasonably controlled process such as prescribing, what waste is there elsewhere?
Whatever you use, use it properly
Research has shown that around 10-20% of hospital admissions are associated with medication related incidents. By developing models of working across the whole care team including the patient we can improve on this greatly.
Use the most cost effective products
In prescribing we have made many great improvements in this area, with a high level of adherence to prescribing policies. We could however still improve, we need to challenge each other on this. We also need to look at all areas of healthcare and feel free to challenge each other.
All these above are very important and will help us to sustain our position for a little while. But the scale of the challenges we face in the future will not be dealt with by good housekeeping. We need to consider some more fundamental changes. This we cannot do alone. There are 2 other issues I think we need to deal with as a priority.
Understand and Work with Our Population
We need to work with our patients and with our population to determine what they want and need. It might be surprising!
Research carried out by respected organisations, such as the Health Foundation and the Picker Institute has shown that the patient and the population can take a very mature and sensible view about healthcare priorities. Indeed it has been demonstrated that affordability is a factor that citizens recognise as being important, as long as they can also have an opportunity to influence decision making.
Research by the Centre for Health Economics & Medicines Evaluation in Bangor also showed that the public had some very clear views on priorities and for example were not prepared to pay more for medicines that prolonged end of life, treated children, rare conditions or disadvantaged populations.
Whilst this is very interesting, all it says to me is that we need to understand our population. We need to ensure that when the real difficult times come, we are all working together with a clear agenda.
Finally we must:
Change the way we do things
One of the great things about NHS Dumfries & Galloway is that it is full of good people, who are great to work with and are reasonable. We make reasonable decisions. However I am reminded of a quote by George Bernard Shaw:
The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.
As we approach truly difficult times perhaps we need to encourage the unreasonable man (or woman). We cannot keep on doing what we are doing and expect a different outcome. We need radical change, and we need to do this in partnership with our population. So come on stop being so reasonable!! Lets challenge ourselves to deliver things in a different way to allow us to benefit from an exciting future.
Mike Pratt is Chief Pharmacist at NHS Dumfries and Galloway