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Ludwig Boltzmann-Institut for Sociology of Health and Medicine
Health promotion in General Practice and Community Pharmacy - Conclusions and Proposals from a European Project
Developed in co-operation with the project partners, edited by the Ludwig Boltzmann-Institute for the Sociology of Health and Medicine, Vienna, Special thanks to Drs. Loek Arts and Dr. Nico Haas as chairs of a task force

0. Introduction

This paper presents conclusions and proposals from the project “Health Promotion in General Practice and Community Pharmacy – a European project”, dedicated to support the further development of health promotion in general practice and community pharmacy in the EU Member States.

It is divided into two main parts – conclusions and proposals for general practice and community pharmacy respectively – and a short third part referring to conclusions/ proposals to be taken at the interface between the two professions.

Each main part begins with a brief summary of arguments that support the importance of the setting/profession for patient/user – oriented health promotion (see also the “Working definitions”, and the proceedings of the European Conference published in this report, e.g. the keynote lectures of Anderson, Kickbusch and van Weel. The second sub-section of each of the two main parts presents a summary of findings from the cross analysis which has been based primarily on 11 country reports from Community Pharmacy and 7 from General Practice. This database reflects that the overall reception of the project by the associations for general practitioners has been much more ambiguous than Community Pharmacy associations. The conclusions have also taken into consideration relevant literature and contributions made at the European Conference on Health Promotion in General Practice and Community Pharmacy in EU Member States (see conference proceedings), thus broadening the data-base for the conclusions and proposals considerably.

In a second step, proposals have been formulated as to how the Commission could support the further development of patient-/ user-oriented health promotion in these two settings/professions.

One remark on the character of these conclusions and proposals: Given the action-oriented, co-operative character of the project, and the fact that country reports have been provided primarily by professional organisations from the Member States, these conclusions strongly reflect the specific perspectives of the two professions and the countries that have accepted the invitation to get involved in the project.

Other perspectives, like health policy, patient organisations, health promotion, health services research and sociology, have been included in several forms, but the dominant perspective in all material has been that of the two professions and their participating associations.
Several drafts of these conclusions have been discussed with partners of the project within the framework of a task forces (special thanks to Dr. Nico Haas and drs Loek Arts) and in a broader forum at two meetings. Nevertheless, responsibility for this text rests with the co-ordinators of the project.

1. Conclusions and Proposals referring to General Practice

1.1. Why is general practice an interesting setting for health promotion? Arguments for strengthening health promotion in general practice

As seen from the professional perspective, general practice functions as an entry point of first contact care for a large part of the population of Europe (although there are considerable differences between the health care systems). General practice, based on the principle of co-ordination of care and inter-sectoral collaboration with regard to health promotion opportunities, seems in a rather good strategic position within the health care system.

Regularity and frequency of many of general practitioners contacts, as well as the relative continuity and comprehensiveness of care, are important assets - general practice/family medicine, with its frequently rather person- and context-orientation and its long-standing relationships, deals with a broad range of problems and faces a mixed typology of users/ patients: healthy people, well people at risk, people with health-damaging behaviour, common health problems and ailments, vulnerable persons such as unemployed people or ethnic minority groups and increasingly, persons with chronic and multiple conditions.

1.2. Conclusions on status quo, furthering and hindering factors

Conclusion 1: Health Promotion in Professional Role and Practice
In the country reports, in the literature and in the discussions in the project, health promotion has been understood by general practitioners and their associations primarily in the sense of a broad umbrella concept, primarily carried out in individually-oriented interventions within the consultation.

Health promotion in general practice is recognised in several policy statements as an integral part of the professional role. Professional organisations have been addressing this issue, both at a European and at a national level. There is some indication that at least some aspects are considered an important task in daily practice by many individual general practitioners. Nevertheless, the extent to which individual general practitioners are involved in health promotion seems to vary considerably.

In the material, this variation is primarily attributed to circumstances: As stated from the perspective of several of their associations, general practitioners demonstrate high interest in, and motivation for, health promotion and prevention, yet often encounter inadequate support.

All in all, so far it has been difficult to generate a reliable overall picture of current health promotion practice in everyday practice of general practitioners in Europe. As is the case with many other interventions in general practice, health promotion interventions are generally not well documented, evaluated and researched.

Conclusion 2: Health Promotion in Education and Training
Structured programmes with relevance for health promotion and prevention in Continuing Medical Education have been mentioned in most of the available Country Reports. These educational and training activities are generally under the leadership of scientific general practice organisations. Many initiatives have only been developed in the recent past. Relevant activities involving a variety of formats, predominantly address life-style counselling and specific patient education techniques, in addition to specific disease-related topics, such as cancer screening (often within a framework of national programmes). Specific training in communication skills is usually not offered systematically, but recent European and national initiatives are increasingly establishing training possibilities.

In basic medical curricula and vocational general practice training schemes, courses that provide knowledge and skills relevant for health promotion and prevention, particularly communication skills, seem less well established, at least in the Member States contributing a country report.

Concerning utilisation of training options, competing high workloads and a general lack of funding have been identified as relevant barriers to participation in training activities.

Ultimately, there seems sufficient interest and motivation of general practitioners to increase knowledge and skills in the area of health promotion.

3. Conclusion: Health Promotion in General Practice Research
As is the case with many other Primary Health Care services, health promotion activities in general practice have not been well documented to date. Country Reports and literature have not only pointed to needs, but also to difficulties of (general) practice-based research. Some research activities, increasingly with involvement in national and multi-national research initiatives, are developing and small local research activities are being piloted. In many countries, research infrastructure and measures supporting general practitioners in getting involved in research in general are still in an early developmental stage. A coherent framework for research and evaluation seems to be needed.

4. Conclusion: Health Promotion and General Practice Infrastructure

Reimbursement and Incentive Policies
Generally, available Country Reports indicate that specific reimbursement schemes predominantly exist in national health insurance systems with general practitioner payment being made on a fee-for-service or mixed basis. Remunerated services in this context are established by law, entitlement and scope, specified in contracts and mostly concern prevention activities such as cancer screening, health checks and well child clinics, as well as specific counselling in disease-oriented clinics. Notably, no specific remuneration or incentive schemes explicitly reward communication or relationship aspects in the consultation. Thus, current arrangements seem to focus on procedural interventions instead.

Organisational Factors
Overall, health systems that are characterised by a primary care orientation seem to better enable general practitioners to work with a collaborative and co-operative, team- and community-oriented approach. In health systems with general practitioners predominantly in solo practice, it was felt that this form of general practice was not supportive in practitioners' health promotion and prevention work. Nevertheless, individual projects and initiatives to overcome this barrier have been launched and have been reported to be well accepted locally.

Generally, as information from Country Reports indicates, only a few guidance instruments (both guidelines and protocols) have been implemented. Areas covered are life-style counselling and specific patient education, however, no evaluation process in terms of the quality, applicability or utilisation of these instruments has been initiated yet.

1.3. Proposals: Health Promotion in General Practice

Proposal 1: General Statement
General practitioners are by no means the sole providers of health promotion, yet they can play an essential role in contributing to this movement within the health care sector. As has been verified in this project, general practitioners and community pharmacists (and others like e.g. community nurses) have considerable opportunities, as well as interest and motivation, yet their potential to engage in health promotion activities appears to be under-exploited.
Still, there are also concerns and difficulties general practitioners refer to when asked to play a more active role in health promotion. Considerable efforts will be required to enable these health professionals to better utilise their potential to provide health promotion in daily practice. Thus, the Commission should take a pro-active role in raising the profile of general practitioners in health promotion and in recognising this role as important within Community health promotion activities. This may also include the formulation of specific formal "Recommendations" put forward by the European Commission.

Proposal 2: Continue Dialogue and Partnership
Noting that in some of the Member States, relevant organisations such as patients' or consumer organisations, councils, or similar formal or informal bodies, as well as at the European level, actors such as the planned "European Health Forum" as envisioned by the Commission and many relevant players in the health field, European patients' organisations and relevant Non-governmental Organisations, relevant formal and informal consultation bodies and committees, are engaged and interested in establishing and fostering dialogue and discussion on health matters,

it is being proposed to the Commission
 that a platform be established with adequate resources for continuing dialogue of all actors involved in the health care sector, to ensure input of all concerned in the area of health promotion. Patients and citizens in particular should have a greater role and
that also, co-operation between the different providers (like general practitioners and community pharmacies) is furthered by specific measures, such as those mentioned in part 3 below.


Proposal 3: Enable Individual Professionals: Strengthening Competencies through Education, Training and Professional Development
Noting that in each of the Member States, relevant professional organisations such as national independent medical/general practice organisations, national general practice scientific organisations, as well as the relevant European professional organisations such as WONCA Europe/ESGP-FM (particularly through its network organisations EURACT, EGPRW and EQuiP, ), UEMO and its relevant Working Groups in their efforts to contribute to high quality training and education along with all academic institutions involved in medical education and training, are the main actors engaged in planning and managing activities of basic medical education and general practice development,

it is being proposed to the Commission
 that activities that encourage individual practitioners in their interest to further expand relevant knowledge and skills be facilitated by:
(co)-funding of relevant training initiatives or specific academic programmes,
promoting centres of excellence in general practice training,
fostering the establishment and development of training and professional development networks

It is also proposed to the Commission
 that activities be facilitated which call national governments to consider appropriate actions that specifically encourage general practitioners to more systematically provide health promotion services by stimulating quality efforts of individual practitioners in a positive manner and providing incentives that reward health promotion activities in daily practice, the actual form of which will be suited to the country concerned.

Proposal 4: Building Evidence: Strengthening Research and Development
Noting that in each of the Member States relevant scientific general practice organisations, as well as the relevant European general practice organisations such as WONCA Europe/ ESGP-FM (particularly through its network organisations EURACT, EGPRW and EQuiP, ) and EUROPREV, along with all academic institutions involved in clinical, general practice, and primary care research, as the main actors concerned, are engaged in planning and managing activities of basic medical and general practice research and development,

it is being proposed to the Commission
 that programmes and initiatives which aim at fostering a health promotion-driven research agenda and support relevant general practice-based research be supported by:
- contributing to the development of relevant research infrastructure in general practice
- providing (co)-funding to sustain successful initiatives and to further develop ongoing research activities
- providing (co)-funding to promising (practice) research initiatives which, to date, have not received necessary sponsorship (such as non-pharmacological, communicative interventions)
- facilitating implementation of practice-based initiatives,
- fostering networking

The Commission is also asked to promote further dissemination of relevant experiences and knowledge:
 - by supporting conferences, workshops, and scientific meetings in this area
- by supporting systematic reviews and the development of dissemination materials
- and by fostering inter-professional (e.g. General Practice, Community Pharmacy, Community Nursing) and multi-party exchange (especially including Patient representatives) across Europe.

2. Conclusions and Proposals referring to Community Pharmacy

2.1. Why is community pharmacy an interesting setting for health promotion? Arguments for strengthening health promotion in Community Pharmacy

Community pharmacies are very frequently the first contact with the health system, often before a GP is contacted (with considerable differences between European regions). There is a high frequency of contacts with low barriers to access: no appointments, no long waiting time, convenient opening hours, located within communities, information readily on display, often meeting “unmet need” after a doctor has been contacted. It is to be noted that the public has higher frequency of contact with their community pharmacist than with all other health care professions combined.

Contacts very often take place on a regular basis and include interactive, communicative and counselling aspects, using “teachable moment”. Community pharmacy contacts have a good potential to integrate the social environment into counselling (geographical distribution, positioning on the “high street”, i.e. in principal shopping areas).

Regular contacts offer access to a wide range of people: healthy persons, those showing symptoms and patients undergoing treatment; relatives and other care givers; people from all social strata.

So there is a large number of experts (pharmacists and other qualified staff) working in community pharmacies, offering a high level of competence and knowledge on medicines, who have an expert status and can figure as role models for health-promoting behaviour. Pharmacists also often actively provide a link to other health professionals, mostly to GPs. Depending on national conditions, these links are quite well-developed.

The relevant areas of work include core areas like the provision of prescribed drugs and provision of self-medication, but also the provision of health-related goods/products, (group) health education/advice/counselling (e.g. smoking cessation, medicine management), and finally also in some countries some types of screening and diagnostic testing (as will be discussed below, this is a contested area).

2.2. Conclusions on status quo, furthering and hindering factors

Conclusion 1: Current role of health promotion in community pharmacy
The core of the professional role of community pharmacists is centred on the provision of medication (including advice). The perception of this role has broadened in recent years, now positioning the community pharmacist as an important actor in public health and the community pharmacy as a “centre for health”. Also, a shift from a previously more product (i.e. medicines) -oriented approach to a more patient/- user-centred approach can be observed. Principles of health promotion overlap considerably with this approach, which is also supported by professional bodies on the national and international level and promoted via various media.

Community pharmacists are generally sympathetic to the notion of health promotion, especially when it can be related to the core task of provision of medication (prescriptions and self-medication).

Health promotion in community pharmacy is recognised in several policy statements as an integral part of the professional role. Professional organisations have been addressing this issue both at international and European level, as well as at a national level – references: Good Pharmacy Practice documents of WHO, FIP, PGEU and national documents.

Community pharmacists’ understanding of health promotion is clearly based upon core tasks of the provision of prescribed drugs and self-medication (being the most important ones), provision of health-related goods and services, and initiatives beyond the community pharmacy’s physical premises.

This understanding also includes life-style advice, screening and diagnostic testing and co-operation with other providers. Screening/testing is an especially controversial area, as some authors have expressed doubts with respect to quality standards in screening and diagnostic testing and the potential of community pharmacy to fulfil these standards without, for instance, the prior training of pharmacists and a change in the physical layout of some premises.

Looking at the role expectations of others, it appears that health policy, neither on the European nor on the Member State level, has fully recognised the potential of community pharmacy in health promotion yet, at least in the eyes of the majority of professional bodies involved in the project. As far as patients/users are concerned, findings are not clear-cut: In some scientific studies available – primarily carried out in the UK – patients/users see community pharmacists as experts in medicines who may also provide health-related advice, but much fewer clients seem to explicitly ask for it. Nevertheless, patients’/users’ expectations seem to be changing, as they are increasingly asking for more involvement in decisions related to management of pharmacotherapy. It can be expected that this will also influence their advice-seeking behaviour. In the future, the role of community pharmacy in health promotion should receive greater recognition, among other professionals as well as health policymakers and patients, ultimately leading to an improved integration of community pharmacy in primary health care.

The implementation of health promotion and concepts related to health promotion into everyday professional practice varies greatly (depending on national context and conditions for health promotion), ranging from being an integral element of daily work to model projects and local initiatives.

Conclusion 2: Health Promotion in Education and Training
Up until now, topics related to health promotion have been integrated into education and training to a varying degree: while university training is predominantly science-based, issues related to health promotion seem to figure more prominently in postgraduate and continuing education, with national differences. It has been emphasised by relevant actors that in the future, in order to tackle health problems and the needs of patients and society, and to respond to current trends, lifelong learning, key issues will be development of counselling and communication skills, and collaborative training.

Conclusion 3: Health Promotion in Community Pharmacy Research
As compared to research activities in traditional areas, research relevant for health promotion in community pharmacy has only been realised to a limited extent so far. However, there are promising approaches towards research related to health promotion, be it in university departments for health promotion or Social Pharmacy, or via (international) co-operation of researchers and practitioners/representatives of professional bodies.

Conclusion 4: Health Promotion and Community Pharmacy Infrastructure
Factors related to the organisation of work in community pharmacy, resources, remuneration schemes and to co-operation with others have significant impact on community pharmacists’ involvement in health promotion.

Organisation of workflow and the development of the physical setting should follow the emphasis on patient/user-centred practice. Also, assignment of tasks to qualified staff and pharmacists should aim at allowing more time for counselling and advising patients (for the most part by community pharmacists).

An increased focus on cognitive services like counselling also challenges common remuneration systems, which are predominantly based on margins and/or a fixed amount of money per medication dispensed. Although cognitive services in community pharmacy clearly show a product link (medications or other health related products), new and innovative systems accounting for the increasing emphasis on cognitive services will have to be explored.

Increased co-operation with other providers, but also with patient organisations, is a priority of community pharmacists across EU Member States. The professional associations are aiming at better recognition of community pharmacists as health care providers and at better integration in the health care team, emphasising the role of community pharmacy as an important interface between the lay and the professional systems. Support from health policymakers is considered a key factor. Increased co-operation will be especially beneficial in relation to counselling in the area of pharmacotherapy (repeated consistent message, more compliance, better outcome). Currently, co-operation seems to work well at the professional-practical level, whereas co-operation seems to be far more difficult at the professional-political level.

2.3. Proposals to the EC to support health promotion in community pharmacy

Proposal 1: General Statement
Support for Community Pharmacy should build upon existing expertise and infrastructure, take into account a common core of tasks in community pharmacy across EU Member States, but also acknowledge diversity in cultural and organisational context and country-specific health policy, and involve existing international/trans-national networks of community pharmacy professionals and researchers aiming at further development of professional practice, e.g. EuroPharm Forum, PCNE – Pharmaceutical Care Network Europe, FIP – International Pharmaceutical Federation, community pharmacy section, PGEU – Pharmaceutical Group of the European Union, EAFP – European Association of Faculties of Pharmacy. Specific attention should be given to integrating pharmacists’ expertise with medications and health promoting interventions in the area of medication management (use of medicines, drug therapy management, self-medications, life-styles and pharmacotherapy).

Specific attention should be given to an integrated approach to health promotion, i.e. fostering co-operation with other providers and patient representatives, aiming at quality assurance and improvement of health promotion in community pharmacy.

Proposal 2: Continue Dialogue and Partnership
Noting that in some of the Member States relevant organisations such as patients' or consumer organisations, councils, or similar formal or informal bodies, as well as European level actors such as the planned "European Health Forum" as envisioned by the Commission and many relevant players in the health field, European patients' organisations and relevant Non-governmental Organisations, relevant formal and informal consultation bodies and committees, are engaged and interested in establishing and fostering dialogue and discussion on health matters,

it is being proposed to the Commission
 that a platform be established with adequate resources for continuing dialogue of all actors involved in the health care sector, to ensure input of all concerned in the area of health promotion. In particular, patients and citizens should have a greater role so
that also, co-operation between the different providers (like general practitioners and community pharmacies) is furthered by specific measures as mentioned in part 3 below.

Proposal 3: Recognise the potential of Community Pharmacy

The Commission is asked
 to systematically consider community pharmacists’ expertise and potential in the area of health promotion by explicitly including community pharmacy as a relevant actor in health promotion programmes, documents etc. issued by the EC

Proposal 4: Promote education and training
The Commission is asked to facilitate education and training for health promotion
 by supporting the systematic review and assessment of existing programmes concerning the inclusion of topics relevant to health promotion (knowledge on health promotion topics, communication skills, etc.)
in university curricula (partner EAFP), in schools for technical staff e.g. pharmacy technicians in continuing education and training¸ with the partners PGEU (as representative of national professional organisations of community pharmacists) and EAFP (as representative from Faculties of Pharmacy)

by supporting European co-operation at the European level between pharmacy faculties and organisations providing vocational training, e.g. via EAFP to further develop curricula and the application of innovative teaching approaches, e.g. problem-based learning, knowledge and skills training, internship

Proposal 5: Building Evidence: Strengthening Research and Development

The Commission is asked
 to initiate/support a European research network, that should be based upon existing networks like EuroPharm Forum, PCNE, EAFP. This network should emphasise inter-sectorial and multidisciplinary co-operation and promote a patient-centred approach

to promote analysis, evaluation and exchange of existing experience relevant to health promotion in community pharmacy practice, including research in the areas of health education, prevention, counselling, Pharmaceutical Care and drug therapy management (and life-style counselling), especially for chronic diseases.

to foster priority-setting in research, emphasising theory-based research, development of adequate methods, highlighting relevance to daily professional practice and to foster dissemination of research findings

Proposal 6: Initiation of model projects

The Commission is asked
 to support the initiation of model projects aiming at creating an extended knowledge base on evidence-based health promotion interventions in community pharmacy, also involving patient organisations in model projects to ensure adequate representation of their interests, concerns and expertise.

Proposal 7: Support implementation projects

The Commission is asked
 to support projects that specifically focus on issues related to implementation (e.g. country-specific supportive factors and barriers), including the development of instruments (e.g. protocols, guidelines), that take into account and build upon existing protocols, (e.g. developed by EuroPharm Forum) with the aim of demonstrating that health promotion in community pharmacy works in daily practice.
These projects should also support favourable attitudes of professionals towards health promotion by creating a knowledge base (country specific) on contextual factors/conditions furthering/hindering health promotion in daily practice

Proposal 8: Dissemination and exchange of experiences

The Commission is asked
 to support the dissemination of common knowledge on concepts, projects, models of good practice, protocols, practice guidelines, new and innovative approaches in education and training. Dissemination and exchange can build upon existing networks and communication structures:
to support databases, specifically the continuation of the database set up in this project, by a professional organisation with the necessary credibility among professionals,
to support European conferences, meetings, workshops and websites, not only for pharmacists, but in order to foster multidisciplinary exchange (e.g. with general practitioners) and the inclusion of the perspective of patients/users.


3. Health Promotion and the Interface of General Practice and Community Pharmacy


Conclusion: Health Promotion and development at the interface of general practice, community pharmacy and patients/ users

In the project, there has been significant interest in an integrated collaborative approach to health promotion in primary health care not only focused on patients and their needs and demands, (patient centred approach) but also optimising the interface between general practice and community pharmacy.

Proposal: Enhancing an inter-professional approach
It is proposed to the Commission
 that actions on all levels that promote this approach be supported by fostering co-operation between the two professions for the benefit of the patients/users/clients.
In the area of education and training, this should start at the university level, but also be supported in continuing education.
In research, new, innovative co-operative approaches to health promotion in PHC should be furthered by supporting model projects focusing on co-operation, and by supporting exchange and dissemination of experience, e.g. via conferences, databases etc.

     
   
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