Let’s start with the similarities. England is divided into counties, across which services differ. The same happens in Canada, where local commissioning by provinces results in a postcode lottery as to whether patients will benefit from a particular service or not.
Medication reviews are carried out in some provinces in the local GP practice by the community pharmacists. Our new model sees clinical pharmacists carrying out reviews in the surgery with the community pharmacist soon to be frozen out, while the model in British Columbia (BC) allows the benefit of the patient relationship in the community to be carried through to a clinical review. If community pharmacists in England had access to full medical records and were properly recognised as the clinical professionals they are, they would be the ones to carry out the review, just as in Canada.
In Canada, pharmacists have to know the indication for which a drug has been prescribed. We may have access to summary care records here in England, but it does not include this information. Pharmacists in BC are obliged to contact the prescriber if the patient does not know the condition for which they have received a prescription. Wouldn’t it be so much easier for patient care if we knew the diagnosis? That’s surely another reason for full integration of clinical systems including read/write access for pharmacists.
Independents focus on enhanced services and personal care and are the centre of their community, just like us in the UK.
Canadian pharmacists and patients have much more control over their prescription – no onerous paper repeat slips or online portal messages there. Prescriptions are repeatable and kept by the patient. A ‘too soon’ policy prevents patients from asking for prescriptions too early, although a ‘travel supply’ regulation applies for holidays or travel out of province (Canada is so big, our equivalent would be going to Europe). After an initial 30-day supply of a repeatable medicine, supplies of 100 days can be given for the long term. A dispensing fee of up to $10 Canadian (around £6) means the reduced volume of prescriptions still provides remuneration, while freeing up time for service provision.
Although pharmacies in Canada cannot access GP records, they do benefit from a common platform for recording dispensing and interventions, so all prescription issues can be viewed, no matter where they have been made. This is essential to support their multiple dispensing model and has the added benefit of enabling claims for payment to be made every day. In the UK the only systems coming close to such coverage would be those like PharmOutcomes or Sonar, which can flag up patients presenting for multiple flu jabs across different pharmacies, for example. Wouldn’t it be marvellous if we had a common system that supported greater note keeping and recording of interventions in one record per patient, accessed each time they present at any healthcare setting? This is the holy grail.
The Canadian exemption categories for prescription payment are based on their Pharmacare system, so are primarily determined by wealth rather than condition or age. Patients over 65 years of financial means continue to pay for prescriptions throughout their lives. Reimbursement is based on a specific manufacturer in the case of generics, although patients may opt to pay extra if they want a different make.
As for Canadian pharmacy generally, in BC few independent pharmacies remain, and those in chains are usually part of large drugstores selling groceries, household and health and beauty products, or in supermarkets. The independents focus on enhanced services and personal care and are the centre of their community, just like us in the UK.
So, can we learn anything from Canada? A push to integrate systems or at least give community pharmacy sight of clinical records would help immeasurably to improve patient care and facilitate the new roles community pharmacy is embracing. A reduction in the administrative burden of dispensing would free up time and focus resources appropriately on more skilled work.
Nothing is perfect in any healthcare system, and the complexities of the Pharmacare insurance system, whose rules and funding models alter from province to province, far outweigh our fixed exemption category foibles in the NHS. However I, for one, would advocate a broad look at systems throughout the world to see if we can learn anything that would support the changes in UK community pharmacy and make them a real success.