Why has it been so hard for me to get it? Probably because everything I've seen is high-level briefing papers that don't appeal to a pragmatist-activist learner like me. When I was pointed to a description, I saw a list of "drivers for change". I don't need to wade through drivers for change, I see these drivers at work every day. Every year I've practiced has been the year we've got to tighten our belts, improve adherence, comply with this or that - there's nothing new there, there's just a whole lot more of it.
When I was pointed to a definition of medicines optomisation, I saw the definition of medicines management with the words mixed up. I didn't see what medicines optimisation did on top of the mix of medicines management and pharmaceutical care that underlines my practice as a pharmacist. No-one was offering me an idea of what it meant to do medicines optimisation as opposed to anything else - when you're asking me to rethink the underlying philosophy of pharmacy practice, I need to understand what you want me to do differently.
Certainly I don't take kindly to the suggestion what I do is fatally flawed, that only gets me to defensively promote the virtues of the old things that you're claiming .
But now I think I understand it. And I think I can summarise what it is on the back of an envelope.
Here's the envelope:
And here's my definition:
Medicine Optimisation is the best of Pharmaceutical Care and the best of Medicines Management, in the environment of this newest NHS environment, so that the individual patient and everyone else gets the best from medicines.
Let me break that down:
Pharmaceutical Care is what I raised to do as a pharmacist. Systematic analysis of a patient's needs, determination of the appropriate course of action and monitoring whether the patient's outcomes meet what the evidence tells us should happen. However, pharmaceutical care was born in a very strange world - the idea of a single pharmacist practitioner working alone in a Michigan clinic doesn't easily translate to FP10s and inpatient prescription charts. It falls down because it expects a long-term relationship between pharmacist and patient, with little reference to the roles of other healthcare providers in our very diverse NHS.
Medicines Management came next, and was great in that it established the need for organisation-wide systems about responsible medicines use. Safe, Quality and Efficient Medicine Use was the responsibility of everyone that touched them. However, to what end was all this taken? For some, medicines management was about cost-control and risk-control. It wasn't the patient at the centre, it was the organisation's ability to deliver that was at the centre.
So two great philosophies of practice, that we've been using with variable success over the past two decades. Why not take the opportunity to mix them? Now everything's in flux through the controversial NHS changes (which you may or may not agree with, but we're stuck with them for now), could this be a time for us to bring the clinical pharmacy focus across the healthcare team, so that the patient gets the best value from their medicine, and so does everyone else? Could we use the challenges of today to evolve a better way?
How about a world where every time a medicine is prescribed by a GP, supplied by a community pharmacy, administered by a district nurse, transferred into hospital, changed by a hospital doctor, monitored by a hospital pharmacist - it's updates, modifies, replaces or is somehow in line with a Pharmaceutical Care Plan devised either directly or indirectly by a pharmacist, all with the understanding, involvement and agreement of the patient? Now that's something I'd like to see.
