Expert: Pharmacy Has Been a ‘Beacon in Communities Across the World’ During the Pandemic

Pharmacy Times interviewed Catherine​ Duggan, FRPharmS, honorary professor and chief executive officer of International Pharmaceutical Federation (FIP), on the role and the authorities of the pharmacist internationally compared with those currently present for pharmacists in the United States.

Alana Hippensteele: What is your experience with the role of the pharmacist in Europe, and what are some of the key differences between why patients seek care from pharmacists versus physicians in Europe, which I understand may vary country by country?

Catherine​ Duggan: Yeah, there's an awful lot of variation across Europe as well, but some examples that might be helpful to illustrate include ways in which patients and the public can access pharmacists for particular services, and these have been piloted and tested in various countries.

Then models of remuneration have been put in place so that they become part of the pharmacy service portfolio. These can include opportunities to have medicine use reviews. So, a patient will bring in their medicines and the pharmacist will go through them, and they'll have a discussion around some long-term therapies, or something that has been newly initiated.

There are often services that are offered to patients when they leave hospital a little while later, so that any changes in the hospital medicines can be followed up and checked on. Previously, anybody who was discharged from hospital, the information would go to their physician but wouldn't necessarily go to the pharmacist, and if there's a gap, if somebody goes to collect a new prescription, then that's where problems could occur.

We also see pharmacists being able to, in various countries, offer more targeted services to NCDs, respiratory clinics, or podiatry for diabetic patients, where they may either have someone coming into the pharmacy, so it becomes like a care hub, or they are able to do the checks themselves.

Of course, we have lots and lots of services like needle exchanges for drug misuses or for waste medicines. We have services where pharmacists go into care homes and check in on the patients there.

What you would find, Alana, is that you don't see one model routinely being rolled out across European countries. You see different approaches being taken. But what we're starting to see is the take up of many of them is increasing.

COVID-19 also had an impact on that because the visibility of pharmacies and pharmacists in every community has remained really high during the pandemic. We've got lots of examples of FIP, lots of case studies of different countries and different approaches where you may see certain types of clinics and of course access to testing and vaccinations has really come to the fore in times of COVID-19.

Alana Hippensteele:Yeah, that's fascinating. Some of the specific services that are under review for reimbursement under Medicare in the United States, in the case that has been brought to the US Supreme Court, are specifically around medication management, management of chronic conditions, point-of-care testing, and immunization screenings and administrations.

In certain states in the United States, those services are reimbursed by insurance companies, but under Medicare, which is a federal organization that would provide that reimbursement, that system does not currently reimburse pharmacists for these services, making it very difficult for patients who need it to be able to get these services.

So, in terms of Europe, are there countries at this time that do directly reimburse pharmacists or have systems in place that allow pharmacists to provide these services directly to patients?

Catherine​ Duggan: So, what you see across Europe, from the UK to Germany to Italy to the Scandinavian nations, Ireland and then you have the Mediterranean countries—you see either a fully state-supported health service, like we have across the UK nations, or you see some form of blended insurance and state funding. You'll see them all having a greater state involvement than you have in the United States.

As part of that, the state-funded models of care are offered to all patients; they can avail of them. That's where the pharmacists get their reimbursement from. So, it would have to be something like Medicaid in the United States to embrace this to make sure that you've got universal access to what might be regarded as essential services.

So, in the UK, we have 4 different health systems: You have Northern Ireland, you have Scotland, you have Wales, and you have England. In the England system, you have 4 different types of services that a pharmacist can provide and get different levels of remuneration for them, which becomes quite a bureaucracy.

You have in Scotland a very different approach. So, you have an opportunity for everyone to get all of this, and then the pharmacist is remunerated accordingly, rather than them having to kind of tier or categorize the services that they're giving.

So, we even see across the United Kingdom, a very different blended approach. Actually, I think that's where some of the variation comes from, when you have a state versus insurer model. Even within the state-funded model like the UK, we see variation.

I would say there's not one size fits all, but to keep it as simple as possible, then it's easy bureaucratically and everybody kind of knows what they're entitled to.

Alana Hippensteele: Right, yeah. That's fascinating that there's some kind of similar difficulties around kind of a piecemeal structure in terms of, not quite state by state, but country by country.

So, in terms of more internationally, so beyond Europe and the United States, in your experience at FIP and in your work in the pharmacy field, how does pharmacists’ ability to provide direct care to patients defer throughout the world, and are there any international models that have been particularly successful in terms of acknowledgement of the critical role of the pharmacist in health care?

Catherine​ Duggan: So, at FIP, we've got a footprint in all of the WHO regions. So, we've got a very good idea of how services are delivered within each region—community pharmacy in particular, and, of course, hospital pharmacies are part of the whole picture as well, and the interface between hospital and community is super important. That's what I was meaning about patients coming out of hospital.

But we've got examples across Australia and New Zealand, where community pharmacists are really central to the health care models. In the US, but also in the Americas and the South American countries, you might see that countries that have a great demographic need avail of their pharmacists even more than countries that may be considered more developed in terms of health services.

What we've seen in the COVID-19 pandemic is that many health ministers would refer to doctors and nurses and health care workers, and there's been a shift to doctors, nurses, pharmacists, and health care workers. As the third largest profession, we're not seen as integral because, very often, pharmacies are viewed as separate from the health service model, and that's been a real benefit in the COVID-19 pandemic for governments.

They've started to realize that where they have this provider arm in all communities, that is a business on its own, it's self-sustaining—they just need to invest in the services that the pharmacists deliver rather than having to build the whole infrastructure again.

So, if community pharmacies didn't exist on the high streets in the pandemic, the governments would have had to put in place primary care centers where everybody could go and get their advice and get their medicines. As it happened, pharmacy took that risk on and then delivered.

Actually, Alana, we do see in many nations where we have low-income countries, they avail of their pharmacists in different ways. It's probably the middle-income countries in each region where you start to see pharmacy hasn't got the traction because it's hard for them to demonstrate to government that they are worth the investment in service provision, and perhaps patients in the public don't understand the benefit of pharmacists.

So, it becomes like a vicious circle, until you start delivering services patients may not ask for, those services they may not demand it, and therefore you don't get funded for it. So that's what we see, and we do see variations.

But we also see, particularly in vaccinations and in immunizations, but now looking at non-communicable diseases (NCDs), countries that have great examples of innovation and impact and remuneration can be used as case studies by other countries.

You know the phrase, “You're never a prophet in your own land”—it's very difficult to argue in your own state or in your own country for your profession. You almost have to show a model that has worked elsewhere for it to get traction, and that works superbly well.

So, I know that in the United States, each state is its own entity legally, regulatory, and the whole thing, but we've got lots of case studies that could probably be matched and married to the different states in terms of profile from different parts of the world that could be used as leverage.

The impact is that more of the public get access to services that meet an unmet or undiagnosed need. The other benefit is that more patients get their needs met, and you start to manage their medicines in a more seamless way, in a more effective way. So, you stop them bouncing in and out of hospital or in and out of care homes.

The benefit of that is that the general practitioner or the family doctor or the physicians—they aren't as inundated as they can be, so there is a win-win to everything. When you look at population demographics, frail, elderly patients take more medicines, and they get frailer, and to have a person managing the medicines as part of the jigsaw is really, really helpful.

Alana Hippensteele: Absolutely, yeah. That's a fascinating point that that more seamless cohesion and communication is of extreme importance in terms of patient care. Something that I think, at least in the United States, there's room for improvement in terms of that kind of communication.

So, you've talked a bit about the role of the pandemic in bringing about a shift in terms of understanding the role of the pharmacist globally. In terms of the shift that's occurring in the United States on this subject, there is right now greater momentum than there's ever been at pushing for greater expanded authorities for pharmacists.

What is your perspective on the emergence of this awareness of the role of the pharmacist in the United States, and where is this awareness level, in your view and in your work, in relation to other nations around the world?

Catherine​ Duggan: So, I think, in all countries, pharmacy often feels undersold or underheard. We feel quite an exploited profession—exploited for our skills and our expertise. We often feel that we're sidelined and that's due to lots and lots of things. That's due to perhaps traditional roles, and perhaps that's being seen as shopkeepers, perhaps us being seen as part of a retail arm of the profession.

It's also, I'd say consolidated, when you see some of the big chains, and how they put pharmacy in the corner of the pharmacy store, so to speak, rather than having the whole place as a health environment. So, there is something about the perception there.

As far as why have we suddenly found ourselves in a much higher awareness state right now—it's because in COVID-19, went lights went off in all other parts of the high street or all of the parts of our communities except for pharmacy, and pharmacy de facto was the beacon in the high street, the beacon in all the communities. We see that actually not just in the United States, but it's across all of Europe, it's across all our African nations, all of our Asian nations, across India, across all of the nations in the world, really.

Because of that, the patients and the public have become so much more aware because they've gone in and received consistent supplies of medicines. They've also been seeking some of the myth busting, and what we know now compared to what we knew this time last year is just phenomenally different.

So, they've sought pharmacy as a port of call. This was always there, but I think patients in the public now are so much more aware of it. We've always seen research that shows that when you use a pharmacy, you tend to understand what a pharmacy can give you, and what the pharmacist in that pharmacy can give you, and many people in the public don't use a pharmacy or they use it for someone else, like they go and collect their parents’ medicines or something else like that.

So, I think this has really raised everyone's awareness. My goodness me, they keep all those medicines, they store all those medicines, they advise me on my medicines, they're the ones who can advise me on this changing evidence base around the whole of the pandemic, and they're trusted, and they'll get me my stuff, and they'll keep me and my children and my elderly parents safe—and that's what we're hearing.

That's the bit of magic that I think has been missing. The moment patients and the public get it, then they start to lobby for it, and then you start to hear the ministers’ perceptions changing. Now, we are a very highly qualified profession. Scientifically and with all the medicines, and we're also very adaptive, trying to do things absolutely precisely and absolutely right.

So, what you've got in that workforce is quite a perfectionist, very highly skilled workforce, and we're not always deployed in that way. So, I think the future's looking very bright because there's a lot of health need out there.

More than ever, there's a lot of need to immunize. It looks we're going to go through different seasons with coverage, and we're going to need influenza injections, we're going to need pneumococcal injections, we're going to need to keep those children and babies safe, we're going to need to keep the elderly safe. You're going to need to mobilize that pharmacy workforce to manage that, all of the unmet health needs, and all of the things that have been exposed in the pandemic.

Alana, diabetes is a major risk factor for COVID-19. Most of our societies suffer with diabetes. We make a joke about it in FIP, we get countries saying I think we're the most prevalent with it—like winning.

We've also seen the emergence of such a critical moment in mental health. Then we've got all of the cancers that haven't been treated for this time. What about respiratory diseases, and we see air pollution impacting that more and more.

Then, of course, you've got your cardiovasculars—they're your 5 top NCDs. And then we have pharmacists who work with patients with Parkinson, motor neurone disease, and other debilitating or degenerative diseases.

So, the place for pharmacy, alongside everywhere else, is as never before. It's really a good opportunity for pharmacists to make the case that they're part of the solution for health care provision.

Alana Hippensteele: Absolutely, I completely agree. It's a really exciting time, and I look forward to seeing how things progress.

Could you discuss a little bit what the International Pharmaceutical Federation is, and what its role in the global pharmacy industry is today?

Catherine​ Duggan: Sure, so we are an international federation of about 150 member organizations. So, we have member organizations in all the regions of WHO, and our member organizations have individual pharmacists as members, or they themselves may be members of member organizations.

We also have 180 academic institutions as members as well, and we represent pharmacists, pharmaceutical scientists, and pharmacy educators. Our footprint is around 4 million of those professionals under our umbrella, and we work to advocate for the profession, we work to support the profession, we work to seek to get pharmacy recognized and utilized to best advantage the vision of FIP.

Newly ratified in 2019 is a vision for a world where everyone has access to safe affordable medicines and technologies and the role of pharmacy within that. Our mission is to advance the profession across practice, science, and education. You can imagine that's all been really heightened during COVID-19 because access to vaccines is a huge issue of ethics, economics, and health.

Then, also here in the year of centenary of insulin being invented—insulin is available in about 40 of countries, so even something as essential as insulin is not available everywhere. So, we've got work to do.

We've signed pharmacy up to the Astana Declaration in 2018, which was held in Kazakhstan, and from that we've made a commitment that we will demonstrate impact on the prevention agendas from self-care to immunization, the NCDs, I mentioned, and the safety agendas by 2023. So, we'll have evidence of impact to show House Ministers at a summit that we’ll hold in 2023.

So, we've got big pieces of work going across all our regions to support our members to help pharmacists deliver those agendas. We are not the pharmaceutical industry, but we have pharmacists who work in the industry as part of our membership.

We also have a section in our practice board for pharmacists working in industry, and we have a lot of scientists who work in the industry as well. We do work with the industry, and we have a partnership with WHO since 1948, and recently renewed a memorandum of understanding around all of the issues of prevention and safety in the workforce and NCDs, and we comply with the rules that WHO laid out about working with the industry. But we often work with unrestricted educational grants to provide education, training, and all sorts to our members.

Alana Hippensteele: That's really interesting. There's a lot going on that's really exciting in terms of what FIP is working towards.

What are your hopes for the future of pharmacy and pharmacists’ role in health care globally beyond the pandemic, which may be with us for some time?

Catherine​ Duggan: Yes, so I think what I saw from my profession during the pandemic is what I want to see more of. So, unquestionably, without asking, without considering themselves at all, we saw a profession step up and step into the space of providing public health advice and patient care. We saw the industry stepping up, pharmacists in the industry stepping up, we saw our pharmaceutical scientists stepping up, and just really repurposing existing drugs and identifying new molecules and new methods of delivery and formulation.

We saw our educators just really adapting, bending over backwards to provide not just education to students, but also to the profession to adapt to everything that was coming down the line. So, of course we can't keep that pitch and pace of change up. You just simply can't. It's too much to ask for everybody.

We know that all health workers are on their knees, but I really want to see all of the profession recognized for adapting and for delivering great public health and patient care. I also want our systems to identify that if you keep your public healthy, then you can focus better on the patients that need your care rather than ignoring the public health messages, whether that be pandemic or whether it be self-care or keeping yourself healthy, and then waiting for people to become patients before you start to intervene.

So, we have that great role in the prevention agenda, as well as making sure all medicines are safe, and everything I've mentioned about pharmacy stepping up and pharmacists stepping into this space is what we do already. It's just to get that shift and that technology is seen as an enabler and an advancer of all of the care that we can deliver, rather than an add-on and something that just burdens us even more.

We know, Alana, everybody is loving the fact that we can do this by Zoom, but you also know that technology can now get in the way when you get your 3 am zoom call scheduled, and nobody thinks about your time zone.

So, it's got to be practical and pragmatic as well, but wouldn't it be great if our development goals set us in a line in 2030. We're part of the United Nations health agenda, pharmacy is part of all of the solution.

This will make it a very attractive career for people to go into, and let me tell you, it's such an adaptable career. You can sidestep into different areas—that's really what I'd love to see.

Alana Hippensteele: Absolutely, thank you so much. This has been a fascinating insight into really just a global perspective on how things are advancing for pharmacists and for the field of pharmacy. Thank you so much for taking the time to speak with me today on this subject, Dr. Duggan.

Catherine​ Duggan: You're very welcome, Alana. It's been a pleasure. Thanks a million.