At the turn of the year, and as we move solidly into the second decade of the 21st century, it is interesting to reflect on what 2020 will look like and what we will have achieved by then. This applies to all aspects of our complex and increasingly globalised lives but of particular relevance to the readers of the International Journal of Pharmacy Practice we should focus our ideas around topics related to medicines and health.
Prediction is of course a poisoned chalice, unless one is blessed with supernatural powers. Generally it is easy to predict the future with the luxury of hindsight, if I can be allowed to use an oxymoronic phrase to make my point. So with that premise agreed let us consider the big achievements in our field in the previous decade. Looking at the papers submitted to, and published in, this journal there has been a large number on improving public health, with many reporting the use of medicine for primary and secondary prevention of longer-term diseases such as coronary heart disease or cancer, and/or the use of professional skills, often a pharmacist's, to improve people's lifestyles. This has included changing behaviours such as smoking, alcohol consumption, poor diet and lack of exercise. In fact, looking back it is quite surprising to observe the cultural paradigm shift that has occurred with respect to the general attitudes to these issues, and our enhanced understanding of the fact that it takes more than one event or belief ‘to collide’ to make a significant change happen. So with respect to smoking, the ‘events’ colliding included a better understanding of the exact harm caused by smoking, especially passive smoking and the harm to children, the changes in legislation in many developed countries prohibiting smoking in enclosed public places, the emergence of several effective treatments including psychosocial approaches and an appetite for new roles from professions such as pharmacy.
The other big change which might have been predicted but which so far has not delivered could be identified as the role of new technologies in the delivery of health care. Whether this be a shared approach to a common electronic record by members of the healthcare team, or online interactive decision support for professionals making recommendations for a particular pharmacotherapy, or remote access for these without local access to face-to-face health care via a videolink to a healthcare professional and/or remote robotic supply of medicines (either over the counter or prescribed), these developments are still only in their infancy. Some things have of course moved on, especially with internet pharmacies and electronic dispensing in both hospitals and community locations, but much remains for these to be fully exploited, and of course researched.
So my first prediction for the next decade is that we will see the benefits of IT for delivering safer, more convenient, more effective and more efficient health care. This should free up that elusive extra time all healthcare professionals need to undertake new duties resulting from changing demographic profiles in much of the developed world, better understanding of disease processes based on research by our more biomedical colleagues, availability of ever-more effective treatments and the blurring of professional boundaries. Thus in the field of medicines and the working environment of pharmacy we should see non-medical prescribing, including by pharmacists, more widely established, across and beyond the UK, new approaches to the management of long-term conditions, with people retained in their homes for longer, and the achievement of that much-aspired-to holy grail of the compression of morbidity: living longer at full quality of life due to prevention or good management of long-term disease, including the big two ones of cancer and coronary heart disease.
What else will this decade bring? I have two more issues to raise. I previously mentioned safety as an outcome of better IT support; this might come from appropriate medication choice targeted to the individual including individualised pharmacogenomic approaches, automated supply of medicines minimising human error at the point of drug ‘picking’ during the dispensing process and use of routinely acquired data to inform epidemiological study and enhanced pharmacovigilance. However, there remain many steps in the decision and supply chain required to assure ourselves that all preventable risks to safety are eliminated. Sadly there is not necessarily going to be a technological solution to all of these and already we are enlisting the intellectual help of our colleagues from other disciplines, such as psychology, who will help us find the key to helping understanding why safety issues still arise. The recent report on junior doctor prescribing commissioned by the UK General Medical Council serves to highlight the potential for mistakes just at the point of prescribing which are due to human frailty; beyond that there is the dispensing process and then of course there is the increasingly complex perspective of the patient to be studied. In the accompanying Editorial in this issue, Professor James McElnay holds out a tantalising vision of the ideal of ‘connected health’ which deserves far more than your cursory attention.
Finally the big one: global health. Increasingly global issues are on all our minds as we come to terms with, and seek to address issues of, health inequality not just within our own communities and nations but on a global level. Should we be spending money on expensive third-generation products, leading to ever-increasing marginal improvements in the life of perhaps only relatively small numbers of our own population, when the same expenditure on first-generation treatments could improve the lives of millions of people elsewhere? I am suggesting neither that we no longer develop new treatments or allow patients to experience their benefit, nor that there is an easy answer, but I do not think we can continually neglect this moral question. For too long we have looked at these population- versus individual-level judgements on a national level but we need to think more globally. Furthermore, should we throw away unused medicines here because of a technicality, when they could save lives elsewhere? How transferable are our standards of care to other contexts and needs and should these standards be flexible and proportionate to the context and scope of the problems we are addressing?
These issues I can almost certainly predict will not be answered in the next decade but hopefully our colleagues' research efforts can help shed light on some of these by more accurately quantifying benefit and risk and allowing informed judgements to be made. I hope the International Journal of Pharmacy Practice will contribute to the debate by publishing quality research in these as well as other areas.