Background
The increasing need for palliative care in the community ^1,2,3 and patient preference for death at home ^4,5 is well documented. Recognition of these changes in care and patient choice have been demonstrated through Government policy ^6,7 and a general trend towards the primary care team as a focus for provision of care⁸. In recognition of these changes, organisations representing the pharmacy profession have made recommendations regarding pharmaceutical palliative care and how to ensure that pharmacists' skills are used to best effect ^9,10.

Objective
To survey the reported experience and views of GPs and pharmacists in relation to current and future community pharmacy based palliative care services.

Method
Quantitative cross sectional surveys of the 533 Nottinghamshire GPs and 185 pharmacies, registered with Nottingham and North Nottinghamshire Health Authorities (NHA and NNHA), were undertaken using self-completion questionnaires specifically designed for this study.

Results
Responses were received from 289 (55%) GPs and 123 (66%) pharmacies in Nottinghamshire. The main palliative care roles carried out by Nottinghamshire pharmacists in the year prior to study were: supply and delivery of medication (73%, n=92), disposal of unwanted medication (90%, n=113), assessment and provision of medication compliance aids (48%, n=60), educating patients and carers (52%, n=65) and providing drug information to other health professionals (50%, n= 63). GPs in both areas were generally aware of these roles.

The majority of GPs and pharmacists acknowledged that the recommendations of the Hospice Pharmacists Association (HPA) 10 and Royal Pharmaceutical Society of Great Britain (RPSGB) 9 concerning pharmaceutical care in the palliative care setting, were important. However, pharmacists, in both Health Authority areas, were significantly more likely than GPs to rate discharge procedures (NHA, Fishers test p=0.00, NNHA, chi-squared = 11.638, p=0.00) and community pharmacy registration of chronically ill patients (NHA, chi-squared = 5.392, p=0.02, NNHA, chi-squared = 8.722, p=0.01) as very important. The majority of GPs and pharmacists acknowledged that poor communication, lack of discharge procedures and poor availability of medication were barriers to the delivery of an effective community pharmacy palliative care service. Pharmacists also indicated that financial constraints and lack of pharmacist palliative care training were additional barriers to effective service provision. The study also identified support for an audit of palliative medication in order to examine local prescribing and supply and joint GP and pharmacist training on the pharmaceutical aspects of palliative care.

Conclusions
The current role of community pharmacists in Nottinghamshire is largely based around the historical supply model of care. The proposals of the RPSGB 9 and HPA 10, whilst largely held to be important by Nottinghamshire GPs and pharmacists for the effective delivery of a community pharmacy palliative care service, have not been implemented. The barriers to care identified by these surveys and the support of local practitioners for joint training initiatives and medication supply audit may be used to inform and support future service development.

References

1. Field D. Sociological perspectives on health, illness and health care: Palliative care for all. Pp 192-209. 1998 Oxford Blackwell Science Ltd
2. National Council for Hospice and Specialist Palliative care services. Needs assessment for Hospice and specialist palliative care services : From philosophy to contracts. Occasional paper No 4 Dec 1993
3. Higginson IJ. Ch 2 Quality, costs and contracts of care. The future for Palliative care: Issues of Policy and Practice. Ed Clark David 1993. Buckingham. Open University Press.
4. Hinton J. Can home care maintain an acceptable quality of life for patients with terminal cancer and their relatives. Palliative Medicine 1994;8:183-196.
5. Townsend J, Frank AO, Fermont D, Dyer , Karran O, Walgrove A, Piper M. Terminal cancer care and patients preference for place of death: a prospective study. BMJ 1990;301:415-417.
6. Calman K, Hine D, (chairs). Expert Advisory Group on Cancer: A policy framework for commissioning cancer services, Department of Health 1995. London HMSO.
7. NHSE EL(96)85. A Policy framework for commissioning cancer services - palliative care services. 1996 NHSE
8. Department of Health (1997) The new NHS: Modern, Dependable. London. HMSO.
9. RPSGB. Pharmaceutical care of cancer patients in the community. Pharmaceutical Journal 1997;258:54-57.
10. Hospice Pharmacist Association. Pharmaceutical care in the palliative care setting: Improving access to medicines used in palliative care in the community.1997. St Albans.