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SANDRA CAREYPresident McCann Pharmacy Initiative

MARK WORMANGlobal Marketing DirectorMcCann Health

WHITE PAPER SERIES

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PHARMACY’S GLOBAL TRANSFORMATION IS PHARMA’S OPPORTUNITY

March 2017

OUR HEALTHY FUTURE DEPENDS ON OUR ABILITYto interpret these new roles and relationships between Pharmacists, consumers, and health professionals and to facilitate the development of meaningful relationships that will drive health improvements and commercial outcomes for Pharmacy and the Pharmaceutical industry alike.

It is a paradox that healthcare’s most-trusted and -accessible healthcare professional has also been its most undervalued and underutilized.1 Pharmacy remains an untapped frontier in modern healthcare—we have not yet availed ourselves of its rich potential—but times, and indeed healthcare models, are changing. As health systems buckle under the pressure of rising demand and diminishing resources, governments are increasingly pursuing models of integrated care to maximize expertise across a multidisciplinary healthcare workforce. In the process, the Pharmacist—marginalized for so long—is being recognized as a key

player on the healthcare stage and a main protagonist in the delivery of effective, outcomes-based care.

It is vital that the Pharmaceutical industry take notice and, for the common good, recognize Pharmacy in its new role as a primary health interventionist.

The transformation of Pharmacy is, without question, a global movement, endorsed top-down by national governments and health-policy makers and inspired by initiatives from NGOs like the International Pharmaceutical Federation (FIP), which represents a skilled healthcare workforce of some 3 million Pharmacists and Pharmaceutical Scientists, their 139 national organizations, and academic and institutional memberships. These initiatives are designed to prepare Pharmacy for the future.

While the speed and mode of Pharmacy evolution differs around the world, the direction of travel is only one way.

As health systems buckle under the pressure of rising demand and diminishing resources, governments are increasingly pursuing models of integrated care to maximize expertise across a multidisciplinary healthcare workforce.

Pharmacy is at the center of a community healthcare redistribution, driven by an information-empowered, self-care-inclined consumer on the demand side and Pharmacy innovation, with escalating standards for quality of service (Good Pharmacy Practice) on the supply side. The Pharmacist, for many, is already the consumer’s most-trusted health expert, but Pharmacy is also moving fast to establish its role as health innovator, problem solver, health advocate, and primary health interventionist.

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These development stages are characterized by the maturity of healthcare markets, health infrastructure investment, population health, and socioeconomic challenges, but the trend is clear.

IT IS VITAL THAT THE PHARMACEUTICAL INDUSTRY RECOGNIZE PHARMACY IN ITS NEW ROLE AS A PRIMARY HEALTH INTERVENTIONIST

DEVELOPING MARKETS

EMERGING MARKETS

RAPIDLY EMERGING MARKETS

DEVELOPED MARKETS

HYPER- DEVELOPED

MARKETS

INDIA TURKEY JAPAN UK AUSTRALIA

CHINA BRAZIL ITALY GERMANY CANADA

EGYPT RUSSIA NETHERLANDS HONG KONG USA

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AROUND THE WORLD, Pharmacy’s role is expanding from supply chain to primary care, from intermediary and retailer to expert advisor in health and wellness. From the developing nations of India and China to more-developed markets like the UK, this evolution is accelerating, with Pharmacists poised to emerge as primary-care interventionists amidst a confluence of health providers. In developing markets such as Egypt, international collaboration has enabled new initiatives to enhance the contribution of Pharmacies to improve health metrics (see Figure 1). In hyper-developed markets like Australia and Canada, Pharmacy is also reflecting a shift from illness to wellness, fueled by health awareness, technology, and health empowerment, and is establishing itself as a one-stop health-and-wellness destination.

So what does all this mean? The implications for Pharmacy, of course, are considerable. We will witness the modernization of infrastructure while our experience in Pharmacy, as health consumers, will expand engagement with the Pharmacist, from dispenser to proactive health-and-wellness manager. Health protection, disease prevention, early disease management, and even gatekeeping for the treatment of escalating chronic disease will define Pharmacy practice in the near future.

The implications for industry are equally consequential. Pharma’s engagement with Pharmacy historically has not optimized Pharmacy’s true potential, with most companies choosing to focus their commercial investments on other healthcare professionals within the primary-care establishment. Pharma has typically underutilized Pharmacy’s

knowledge and expertise, undervalued its emotional connection with patients, and underinvested in its potential to manage health outcomes. However, as this global movement gathers greater momentum, Pharma must move beyond the myopia of Pharmacist as shopkeeper to recognize Pharmacy’s greater potential. To reflect this, it must change the terms of engagement with Pharmacy while thinking more progressively about how it approaches Pharmacy and build greater salience into educational and promotional communications.

It must also be said that we overlook the significant commitments that Pharmacy has already made to improving global health by advancing Pharmacy practice and science to enable better discovery and development of, access to, and safe use of appropriate, cost-effective, and quality medicines worldwide and, at the community level, to building a stronger fabric of health management and illness prevention, improving the quality and delivery of health in community practice, and supporting consumer self-care.

As Pharmacy presses forward with this mission to play a leading role in the delivery of person-centered, outcomes-based care, Pharma is well advised to acknowledge these commitments and align with Pharmacy to work collaboratively in support of our health system’s goals. The benefits are both marked and mutual. Not only will better engagement make a positive contribution to health outcomes in developed and developing countries, but it can also act as a vector for change in industry by building new partnerships, greater trust, and a stronger system that will drive commercial gains, a win-win for Pharmacy, Pharma, policy makers, and, crucially, the consumer. But the time to act is now.

PHARMA’S ENGAGEMENT WITH PHARMACY HISTORICALLY HAS NOT OPTIMIZED PHARMACY’S TRUE POTENTIAL

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FIGURE 1

SAHETAK THARWETAK, OR YOUR HEALTH IS YOUR WEALTH

The metrics for improved health outcomes demonstrate some of the benefits. Malnutrition among infants under two years of age has dropped from 36% to 2%. The percentage of women receiving prenatal care increased from 54% to 67%. Medical-assisted deliveries have increased from 70% to 95%, and 79% of new mothers now use family-planning techniques, up from 50%. To use the title of the campaign’s family-planning pamphlets, “Mabrouk!,” or “Congratulations!”

More than 1.28 million people were reached through an integrated campaign of printed pamphlets, television programs, publicized mass-wedding events, and community-based components, supported by health providers and “Ask, Consult”-affiliated pharmacies. Ninety-eight percent of the nationwide pharmacy network was reached by

CHL’s integrated campaign, and community engagement projects were run in 120 villages throughout Egypt.

“Health metrics represent the true state of our nations,” observed John Cahill, CEO of McCann Health. Take the Communication for Healthy Living (CHL) “Ask, Consult” campaign to appreciate the contribution of pharmacies to improved health metrics in Egypt.

Founded by the Johns Hopkins University Center for Communication Programs and funded by the United States Agency for International

Development (USAID), CHL branded all its messages and activities with “Sahetak tharwetak,” or “Your health is your wealth.” Using marriage as the entry point for its communication strategy, CHL collaborated with 30,000 private companies to manage a network of physicians, pharma companies, and privately owned pharmacies to encourage behavior change related to family planning, prenatal and postnatal care, mother-and-child health, immunization, and breast feeding.

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DRIVERS OF CHANGEWhy Pharmacy and why now? A variety of factors are stimulating this global transformation. The rising incidence and cost of acute and chronic disease, along with an aging population, have forced governments to reimagine healthcare delivery. New approaches look to integrate different healthcare providers and leverage expertise far beyond the physician, with collaborative practice—connecting the full, multidisciplinary scope of our health professions—identified as the best hope for sustainable care. At the same time, national policy makers are sharpening their focus on health promotion, health protection, and disease prevention as viable and more cost-effective alternatives to disease management.

Society is changing. In a more wired, consumer-oriented world where patients are becoming active participants in their own health management, consumer expectations of health services are expanding with advances in technology. This is demanding greater flexibility in the design and delivery of healthcare services, as well as health education, and driving new models of self-care.

According to Carmen Pena, President of FIP, “Today’s patients have new demands. New needs. They are increasing in number and age. Many of our health systems were created in the 20th century for a society of patients with acute illness, but nowadays we live in a society of patients with chronic illness, many of whom require poly-medication.”

The shift is precipitating a responsive redefinition of the role of Pharmacy and giving us a clearer line of sight on the Pharmacy of the future. It is stimulating the profession’s greater involvement in home care, healthcare, and self-care and driving the need for policies that enable cooperation and care coordination between healthcare practitioners.

With 75% of all healthcare costs spent on the treatment of chronic disease, Pharmacy’s role in enabling cost containment while assuring the quality use of medicines is more important than ever.2 Moreover, in the shift to wellness, Pharmacy’s role as expert advisor, coupled with its ability to help consumers make sense of an ever-expanding portfolio of over-the-counter (OTC) products, can advance cost-effective health outcomes.

This holds true around the world. In India, a shortage of physicians is pushing community Pharmacists to the center of patient care. In Brazil, Pharmacy is increasingly being included in multidisciplinary primary-care support teams. In Japan, a market where Pharmacy has very much resided at the lower rungs of the health profession, an attempt to move patient care from hospitals and into the community has seen Pharmacists included as medication experts within multidisciplinary teams, as well as key providers of home-care services and patient education, via pharmacist-managed clinics (see further details in Figure 2). Regulation separating drug prescribing and dispensing, or bungyo, is further expanding Pharmacy’s role in patient engagement.

NEW APPROACHES LOOK TO INTEGRATE DIFFERENT HEALTHCARE PROVIDERS

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FIGURE 2

THE LATEST PRACTICE FROM JAPAN: THE FUTURE IS ALMOST HERE

However, it is not just physical location that has brought PMCs closer to hospitals and their services. More services traditionally supplied by physicians are being managed by pharmacists, with new payment processes for those who counsel patients, obtain medical records, explore drug interactions, detect duplicate prescriptions, and deliver home-based pharmaceutical care services. Much of this is enabled through closer integration with other PMCs, physicians’ offices, and hospitals, thus allowing access to diagnostic data and patient medication history to ensure a personal approach in the full knowledge of a patient’s range of health challenges.

This has to represent a sense of direction for less-developed markets—a first-line, patient-oriented pharmacy space providing many services above and beyond dispensing and delivering system cost savings, increased adherence to medicines, and improved health outcomes.

The Global Dispensing Pharmacy in Ogimachi, Japan: designed to present a confidential, professional, and caring environment for patients

The first pharmacist-managed clinic (PMC) in Japan was established in 2000 at the Nagoya University Hospital for the management of anticoagulation therapy. Since then, PMCs have expanded into respiratory disease, Alzheimer’s disease, hypercholesterolemia, chronic hepatitis C, palliative care, chronic kidney disease, and ambulatory hemodialysis. Most recently,

since 2014, the number of PMCs for cancer chemotherapy has increased, as pharmacy services have become more integrated with other elements in the healthcare system, most notably through inclusion in universal health coverage and extending the services provided by pharmacists, in close association with physicians and hospital infrastructure.

All of this is based on the simple premise that education, counseling, and pharmacotherapy management are optimized in a familiar, accessible space that ensures privacy and the opportunity to engage in confidential communication. Indeed, much effort has been made to employ eco- and patient-friendly and high-tech design, with 70% of PMCs located in, or near, a hospital.

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This global trend toward Pharmacy involvement in multidisciplinary primary-care teams can be seen right across the map and is evident in health economies as diverse as Turkey, China, and Russia and Germany, Italy, and South Africa.

As health systems seek to leverage Pharmacy’s expertise, Pharmacists are incrementally assuming responsibility for a wider range of primary-care services. Vaccination services show prodigious growth. It is no surprise. According to FIP, at least 940 million people live in countries where over 193,000 community Pharmacies can potentially offer access to vaccination services. The European Pharmacists Forum has identified five key areas where Pharmacist expertise can be maximized to improve population health: medicine adherence; vaccination; screening; self-care; and disease prevention. In the United States and Australia, retail clinics are providing a similar range of patient-care services to manage chronic disease and overall health, leveraging digital innovation to promote wellness and enhance consumer/Pharmacist engagement. In Switzerland, for example, the netCare initiative enables more of the initial patient consultation responsibilities to move from primary-care physicians to Pharmacists (for further details, see Figure 3).

In addition, Pharmacy is shaping this global movement with a display of leadership on crucial issues such as medicine usage reviews, counterfeit

medicines, and the environmentally sustainable use of medicines—areas where Pharmacy and industry share common goals—presenting a growing opportunity for Pharma to align with Pharmacy’s mission and to provide salient interventions that will drive a mutually beneficial value exchange.

EMERGING OPPORTUNITIES FOR PHARMASo where can industry support Pharmacy for mutual gain? One starting point will be the development of education and training programs to prepare Pharmacy, across all its various constituents, for its advanced role. A McCann Health study of Pharmacists in 14 countries, across five continents, revealed that 88% of Pharmacists anticipate a high rate of change in their roles over the next five years, with 76% believing that transformation will require the development of new skills.3 The study, supported by FIP, revealed widespread motivation to support Pharmacy’s role in self-care, but also identified skills gaps that need addressing.

Guided by Good Pharmacy Practice and FIP’s framework for workforce transformation, the profession is advancing workforce planning, training, and education to equip Pharmacy with the requisite skills, but there is also a huge opportunity for Pharma to support this endeavor.

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FIGURE 3

NETCARE: DRIVING OUTCOMES THROUGH PHARMACIST-PHYSICIAN COLLABORATION

It is common for the shortage of physicians in many countries to lead to problems in the delivery of primary healthcare services. The Swiss Pharmacists’ Association launched a collaborative care project called netCare, where community pharmacists triage patients, treat patients, or through collaboration with physicians via video consultation, treat or refer for further care.

The program was set up to lower the threshold entry into the healthcare system. In Switzerland, a study by Bednall et al4 demonstrated that 19% of all cases coming into an already-overcrowded emergency room could have been treated by a general practitioner (GP), but 42% of those could have been treated by a pharmacist.

Pharmacists with extra training triaged patients using a decision tree for 24 common conditions and, if necessary, requested a real-time video consult with a physician. In the trial, pharmacists

triaged 4118 cases over 21 months, cases in which it was estimated the patient would have gone to a physician. Of these, the majority of cases were resolved in the pharmacy: 76% by the pharmacists alone and 17% with the backup of the online physician consult. These results are in line with the UK minor ailment schemes, where complete resolution of symptoms range from 68% to 94%, and with a Canadian study, where clinical improvement or complete resolution was achieved in 90% of cases.

Fewer visits to GPs—the first line of physician care in many countries— and a significant reduction in prescriptions for these types of conditions mean a potential saving of millions of pounds each year for governments. Of course, there are also practical and financial benefits to sufferers through direct and indirect cost savings through reduced travel and wait times.

“This example illustrates the changing role of the pharmacy in a healthcare system—more proactive, more accessible and more value-focused for patients. This gives consumer health, life science, medical device, and pharma companies many opportunities to engage with pharmacists in a very different way,” commented Sandra Carey, president of McCann Pharmacy Initiative.

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“SYSTEMS THINKING” IS BASED ON THE PRINCIPLE THAT HUMANS DO NOT MAKE DECISIONS IN ISOLATION

If it is to develop an effective role in proactive wellness management, Pharmacy must upskill consumer engagement and interaction. This leads to training requirements on aspects such as health literacy, consultative selling, OTC/disease-state management, triage, and preventive care. The industry is well placed to provide a wide range of interactive training and online learning programs to support the consumer-facing components of Pharmacy’s transition to expert advisor, such as the myPharmAssistTM program from GSK Consumer Healthcare (see further details in Figure 4).

Similarly, Pharma can help with “service bundling,” assisting the Pharmacy-led delivery of patient-centered care through tools and training to support chronic disease management, minor ailment triage, and transition of care. Enhanced and personalized resources in this crucial area can help establish Pharmacy as a primary entry point into the healthcare system and an expert concierge that prevents consumers from unnecessarily progressing to more-expensive hospital care.

Moreover, Pharma’s experience as communicator can play a positive role in promoting Pharmacy expertise as its role expands. As medicines move from prescription to OTC, Pharmacy’s role as expert advisor, along with its transition to a community wellness destination that provides enhanced services, needs championing. Industry can support the development of PR programs, clinic kits, and healthcare seminars that put

Pharmacy on the primary-care map, reducing the pressure on other healthcare settings and driving better outcomes through person-centered care.

Pharma can also play its part in helping Pharmacy adapt and respond to new technology and transform the consumer experience through its application. Technology opens up new possibilities for online, real-time patient counseling and same-day medication delivery, which will disrupt Pharmacists’ traditional role as dispenser in brick-and-mortar locations. Moreover, as consumers become custodians of their own health, trends such as “the quantified self,” self-diagnosis, and home monitoring will further evolve the role of the Pharmacist and change the dynamics of consumer engagement.

Technology is also helping inform commercial strategy within the Pharmacy business; from sophisticated logistics tools to shopper science, disruptive innovation is helping reimagine the retail environment and revitalizing the customer experience. Over time, technology will transform Pharmacy into that one-stop health-and-wellness destination, creating healthcare hubs led by Pharmacists and powered by digital tools to support the prevention, diagnosis, and management of disease. Technology is a means by which Pharmacy can deliver not just better service, but also better clinical outcomes. Pharma’s ability to help curate salient content that sits within these digital environments as part of a consistent, omnichannel brand experience may prove crucial to healthcare models of the future.

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FIGURE 4

ASSISTING THE PHARMACY IN BECOMING THE NEW ONE-STOP HEALTH-AND-WELLNESS DESTINATION

If the role of pharmacies and pharmacy employees is changing, it stands to reason that efforts are required to enhance the organizational capability of the pharmacy, linked to the knowledge and skills of pharmacy staff. Take, for example, myPharmAssistTM, the worldwide pharmacy education program delivering engaging customized content to community/retail pharmacists, pharmacy assistants, and independent pharmacy businesses from GSK Consumer Healthcare.

The blended-learning program extends understanding of certain chronic conditions and enhances knowledge about the science behind decisions to recommend medications and the commercial implications of that. The chronic conditions included in the learning modules reflect GSK’s portfolio of products across pain relief, digestive health, respiratory health, smokers’ health, skin health, oral health, and nutrition. A range of learning channels are included, such as web-based, print, and “meeting in a box” support packages that provide options for learning styles and preferences.

As the role of the pharmacist graduates from dispenser to trusted advisor, the key purpose of the initiative is to improve health outcomes for shoppers and/or patients by enhancing the ability of the pharmacy to provide accessible, discrete, and consumer-focused care.

myPharmAssistTM is part of a broader strategy to enable shopper-patients to take better care of

themselves, prevent chronic conditions, stay adherent to medicines, and reduce healthcare

costs by using pharmacies as their health hub. “At the heart of myPharmAssistTM are human

interactions, enhanced by data and technology

to deliver a more personal experience to each

and every customer,” explained Kimberley Hunt, Global Pharmacy Channel Marketing Lead for GSK Consumer Healthcare. “As the pharmacy becomes

the first-line health management venue, we believe

this benefits all the interested parties: patients;

pharmacies; government health budgets; and

businesses like GSK that invest in enabling

this transition.”

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ENGAGEMENT STRATEGIES BY PHARMATo maximize this opportunity, Pharma must rethink the terms of its engagement with Pharmacy. Traditionally, companies have developed commercially focused, transactional relationships with Pharmacy, presenting products while failing to engage in the important clinical- and patient-focused conversations. Very often, companies use derivative materials, developed for consumers and then adapted with the token addition of “science.” Such an approach falls well short of meeting the information needs of the various constituents in Pharmacy—from Pharmacists to assistants, technicians, business owners, or clinical experts, for example, in nutrition or diabetes. One size does not fit all and derivative materials will not serve anyone. For one, it fails to respect the Pharmacist’s role as a highly educated, expert healthcare professional.

A shift from presentation to conversation will enable Pharma to engage Pharmacists in the top one-third of their degree, not with token science. There can be little doubt that as Pharmacy embraces its enhanced responsibilities, Pharma must rethink its approach. This will drive more-progressive, -informed, and -evidence-based communications that will support Pharmacy in its transformation.

SUPPORTING THE GLOBAL MOVEMENTAs this global movement continues, Pharmacists’ influence as primary-care interventionists will only increase. The challenge for Pharma is to understand its trajectory, recognize its momentum, align with its mission, and develop salient, value-added services that fit into Pharmacists’ lives.

McCann Health commenced its own Pharmacy practice seven years ago for this purpose and today it comprises some 50 Pharmacists across 20 countries developing programs by experts, for experts. We recognize Pharmacy’s flourishing role, growing influence, and positive impact and, through our global Pharmacy expert group, are committed to supporting this transformation and translating this to commercial value for our clients.

The requirements we see as essential to achieving this include a comprehensive knowledge of Pharmacy’s regulatory environment so that we are able to capitalize on regulatory changes to maximize Pharmacy’s growth potential. It requires an understanding of how Pharmacists practice in different global markets so that we can create appropriate interventions for training and professional development. And it requires an understanding of just how diverse Pharmacy business models are—from traditional trade, to independent, to Pharmacy-only chain, to integrative chain, to e-commerce—so that our interventions are customized for these Pharmacy types.

McCann’s role then is to support industry to improve its engagement with Pharmacy across the regulatory, practical, and business aspects of its transformation.

ONE SIZE DOES NOT FIT ALL AND DERIVATIVE MATERIALS WILL NOT SERVE ANYONE

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As Pharmacy embraces its enhanced responsibilities, Pharma must rethink its approach

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THE CHANGE IS FOR GOOD, AND FOR GOOD REASON We conclude with these summary observations:

● Demand for healthcare services, at less cost, continues to increase.

● Countries are changing the scope of what their healthcare professionals are able to do while trying to manage spiraling healthcare costs and substandard patient outcomes.

● Pharmacists are considered an underutilized healthcare professional in this context in most countries.

● International organizations such as FIP are working with other international organizations such as the World Health Organization and FIP’s national bodies to promote responsible use of medicines and redefine the role that Pharmacy can play.

● Pharmacists are accepting greater responsibility for the outcomes of medicine use and are evolving their practices to provide patients with enhanced medicine-use services.

● Evolution of Pharmacy practice is dependent on different factors, the most notable being changing regulations, education, and how the profession delivers services through practice in individual countries.

● Trends are emerging that are good predictors of how the profession will evolve.

● Many governments now focus on health promotion, health protection, and disease prevention as viable alternatives to disease management.

● Countries where Pharmacy practice is advancing are seeing the evolution of community Pharmacy as a community health management/wellness destination.

● Trends are emerging across most markets where patients and consumers are becoming more sophisticated in choices of self-medication, wellness, and illness prevention.

● Consumers use technology and social platforms to research health, disease, and medicine with precision, so they are presenting to Pharmacy differently.

● Patients and consumers are demanding that healthcare professionals focus on wellness as well as sickness, with the expectation of a more proactive approach to healthcare decisions.

● The new business of Pharmacy is positioning the Pharmacist as a gatekeeper between wellness and sickness as new Pharmacy store models (e.g., Walgreens and Watsons) emerge with expanded offerings.

● In a study of five countries (England, United States, Nigeria, Indonesia, and India),* it was clear that each is at a very different point in the evolution of Pharmacy practice and each has very different challenges and opportunities.3

● In all cases, the biggest determinant of how the Pharmacy channel is changing is how governments are managing healthcare challenges within their respective countries.

Undeniably, the global evolution of Pharmacy is an essential ingredient in the development of affordable and sustainable models of outcomes-based care. Getting there is Pharmacy’s mission. However, as an industry, it is incumbent upon Pharma to recognize this global movement for the good it can bring and to align its efforts in support of a mission in common and for mutual gain.

At McCann Health, we’re helping our clients navigate this journey. It is Pharmacy’s time. Let’s start the conversation.

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References1. Habeeb Ibrahim AR, Deepak J, Jegan RS. Pharmacists in the

wider public health workforce – a review. Arch Pharm Pract. 2012; 3 (2): 166–169. Retrieved from: http://apps.who.int/medicinedocs/documents/s19291en/s19291en.pdf.

2. National Center for Chronic Disease Prevention and Health Promotion. The Power of Prevention. 2009. Retrieved from: https://www.cdc.gov/chronicdisease/pdf/2009-power-of-prevention.pdf.

3. McCann Health Study, 2016. Data on file.

4. Bednall R, McRobbie D, Duncan J, Williams D. Identification of patients attending Accident and Emergency who may be suitable for treatment by a pharmacist. Fam Pract. 2003; 20 (1): 54–57.