Commentary
Using health technology assessment to put pharmaceutical care on the political agenda • J a n i n e M o r g a l l Tr a u l s e n a n d B j ø r n O v e K l i n k e
Pharm World Sci 2004; 26: 61–63. © 2004 Kluwer Academic Publishers. Printed in the Netherlands. J.M. Traulsen (correspondence, e-mail:
[email protected]), B.O. Klinke: The Danish University of Pharmaceutical Sciences, Department of Social Pharmacy, Universitetsparken 2, 2100 Copenhagen Ø, Denmark Key words Health policy HTA Pharmaceutical care Technology assessment Abstract Pharmaceutical care is a widely accepted strategy in the world of pharmacy, as well as a topic of interest in pharmacy practice research. Most people in the field would agree that it is unfortunate that so little is known about pharmaceutical care outside the world of pharmacy. There is also wide agreement that the further development of pharmaceutical care requires that policymakers become aware of, accept and ultimately support it. Although attempts have been made, we have not yet managed to capture the attention and support of policymakers, including politicians. In this article we argue that the way to get the attention of policymakers/politicians is by changing the way we communicate with them, as a means of overcoming some of the barriers we normally meet when introducing pharmaceutical care. We suggest that one possible way of getting their attention and subsequent support is by gaining a better understanding of the way policymakers work in general and then adjusting our argumentation for pharmaceutical care to better fit into their rationality and work habits. In this article, we elaborate on this idea and discuss how proponents of pharmaceutical care can use ‘health technology assessment’ to argue their case. Accepted December 2003
Introduction Researchers and strategists in the world of pharmacy have been promoting pharmaceutical care (PC) for many years. There is basic agreement in the field that PC is an important and desirable strategy that can support rational drug therapy, benefit the public and contribute to more interesting jobs for professionals in this sector. At the Pharmaceutical Care Network for Europe (PCNE) Working Conference held in Denmark in January 2003, Professor Charles Helper 1 pointed out that the implementation of PC has reached a point where it is now necessary to capture the interest and support of policymakers if we want to further develop and increase it. In the lecture that followed dealing with health technology assessment (HTA) and pharmaceutical care (PC) 2, Dr Janine Morgall Traulsen picked up on this idea and suggested that the results of adopting the HTA model to assess PC can be used as a means of communicating with policymakers. Traulsen later discussed this idea with a colleague (Bjørn O. Klinke, a social scientist). The following is the result of these discussions and our proposal for a strategy. We began by formulating a goal or statement of purpose: The first goal must be to make PC a visible and accepted activity to decision- and policy makers; the next step is to get politicians and civil servants to in-
clude and support PC in their plans for the future of health care services.
The world of pharmacy – our reality and language We begin by taking a look at how we normally present information to each other within the field of social and administrative pharmacy. Communication and debates about PC occur in the form of peer review articles, seminars, conferences and reports. The majority of this communication appears in professional journals and newsletters, which by definition are mainly read by other pharmacists. The question is whether this is the kind of material we should use when we communicate with decisionmakers and politicians? Can we rely on this material to get their attention? In our opinion, the answer is no. It is probably safe to assume that politicians and decisionmakers are not avid readers of pharmacy research and practice journals.
Decisionmakers and politicians – their reality and language We will now take a closer look at the reality of decisionmakers and politicians when it comes to supporting and formulating health policy. The world of decisionmakers and politicians is dominated by a constant balancing of several agendas. Many people, organisations and interest groups vie for their attention and support. Time is of the essence. All too often, policymakers only have a few minutes to orientate themselves in an area new to them. Therefore, they prefer written information in a format that is easy and quick to read and understand. Material that is well-structured, relatively brief, comparable and reliable which they can use as a tool and basis for making decisions. We believe that technology assessment reports meet these criteria and we will illustrate that it is historically and practically integrated into the way policymakers already work. Technology Assessment (TA) is the comprehensive form of policy research that examines the technical, economic and social consequences of technological application. TA is especially concerned with unintended, indirect or delayed social impacts of technology. It can be traced back to the mid 1960s, where it emerged at the request of members of the US Congress 3. The need for new approaches to anticipate and control the consequences of technological change was identified through government hearings and studies. In order for members of Congress to make informed, unbiased choices, they requested that multidisciplinary teams be brought together under the (then) newly formed Office of Technology Assessment (OTA). OTA’s job was to assess all aspects of specific technologies and provide Congress with the appropri61
ate information in order to support a platform for decision-making. Since its inception, the major goal of the TA exercise has been to provide policymakers with information on policy alternatives, such as allocation of research and development funds, formulation of regulations, or development of legislation 4. TA continued to develop and expand to other countries, mainly in Europe. The technology assessed included weapons of war, energy producing technologies and, increasingly, health care technology. In the 1980s, health technology was singled out and gradually became administered separately from other technology assessments. On a national and international level, special agencies and committees were established to carry out and administer HTA. This trend can be explained by several factors. First and foremost, at the bottom of this interest in HTA was the desire to control public spending in health care, which was rapidly increasing in the western world. Next, it can be seen as a response to accidents and the undesired physical and social effects of health technology (exemplified by cases such as thalidomide, Diethylstilbestrol, etc.). Finally, and perhaps most important, were the rapid advances in the development of health technology accompanied by the medical profession’s increasing dependency on technology 3. Over the years, most European countries (as well as Canada, the USA and Australia) have established some form of organised HTA activities. Denmark has The Danish Centre for Evaluation and Health Technology Assessment (at the National Board of Health). The UK has The Health Technology Assessment Programme, which, by the way, had the largest single programme of research funding within the National Health Service Research and Development initiative in 1997. In Sweden, technology-assessment activities are considered a priority and have grown more visible and gained in importance in recent years. The goal of HTA has been to provide a comprehensive and systemic basis for health policy decisionmaking and budget planning, in that HTA is conceived of as multi-disciplinary, addressing as many interests as possible. In summary, it can be said that the reports (which contain the results of the assessment) produced by TA and HTA activities have become a familiar, helpful, accepted, and often preferred tool for guiding policymakers and politicians.
The power relationship – them and us
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We will now examine the relationship between the pharmaceutical world and the world of decisionmakers. The decision-makers including politicians have the formal power, i.e., their decisions make policy and legislation. They are busy and have to prioritise a variety of issues during a very brief period of time. Several organisations, groups and individuals vie for their attention. The questions and agendas from the pharmaceutical world are not automatically on the top of the politicians’ agenda. Since our world does not have the formal power to make decisions, it is necessary to capture the attention of policymakers in order to gain influence. One could assume that they probably never heard of or are very interested in PC. This is a barrier that we need to overcome. Unless we can first get their attention and explain to them why PC is so important,
there is little chance they will actively support PC activities in the health care sector. In brief – why should they spend time and resources on PC? One method could be to try to adjust the means and message of our communication in a way that is relatively easy for them to understand and to accept.
HTA and the principles of learning According to the principles of learning originally presented by Piaget in 1969 5, people learn either by assimilation or by accommodation. You assimilate new knowledge, when it is similar in form to something you already know and can adapt it into the way you already think. On the other hand you accommodate new knowledge when the existing conceptual schemes are not equipped to understand the new information. Therefore, if we want to understand new information we either have to change the existing conceptual scheme or produce a new one. In summary, it is much more difficult and time consuming to accommodate than to assimilate. Supported by this argument we suggest presenting information to policymakers and politicians in a way that is already familiar to them. Since HTA reports are not only known by politicians but are often a preferred source of information, we suggest that presenting PC in the form of a HTA report is logical and could lead to assimilation. Of course, this assumes that the pharmacy world is willing and able to put PC through the HTA process. The idea of putting PC through a HTA experience that will result in an HTA report is no guarantee that PC will come out in an entirely positive light. The HTA process requires that the health technology in question (in this case PC) be compared to alternatives. Some pharmacists may be reluctant to take this chance. One other disadvantage could be that HTA takes resources away from other things. There are also questions about who should perform the HTA. We would also be competing with all the others who are trying to get the attention of the policymakers. We could go on and on but why concentrate on potential problems?
Advantages of HTA There are several advantages for promoting PC by adapting a HTA approach: • First and foremost, policy makers are familiar with HTA reports. • Conducting a HTA of PC will provide pharmacists with an evaluation tool that they can use to further develop PC. • Carrying out a HTA on PC will provide a broad focus by emphasizing the social, political and economic aspects of PC services. • HTA is multi-disciplinary. Initiating a HTA of PC will provide an opportunity for pharmacists to work with other professions. • HTA could provide the pharmacy profession with a platform on which to market PC to a wider audience. In addition, we strongly suggest that prior to embarking on a HTA of PC, it is essential for each of us to identify people and institutions that carry out HTA in
the country where we live and work, where both ad- care visible to a wider audience, including politicians and policymakers. vice about HTA and funding are often available.
Conclusion This article suggests a strategy for bringing pharmaceutical care to the attention of policymakers. We have argued that since it is the policymakers who have the formal power and we who want their attention, it is we, not they who must change. We must therefore adjust our arguments and the way we communicate to better fit the system and the people we are trying to influence. We conclude that health technology assessment can contribute to the implementation of pharmaceutical care by creating the evidence and documentation necessary to make the advantages of pharmaceutical
References 1 Hepler C. Pharmaceutical care – the way forward. Opening lecture, PCNE working conference – Pharmaceutical Care Research – the next generation. Hillerød, Denmark, 12–16 February 2003 (http://www.pcne.org/conferences.htm). 2 Traulsen JM. Health technology assessment. Lecture, PCNE working conference – Pharmaceutical Care Research – the next generation. Hillerød, Denmark, 12–16 February 2003 (http:// www.pcne.org/conferences.htm). 3 Morgall, JM. Technology assessment. Philadelphia: Temple University Press, 1993. 4 Banta DH, Luce BR. Health care technology and its assessment. Oxford: Oxford Medical Publications, 1993. 5 Piaget J, Inhelder B. The psychology of the child. Translated by Helen Weaver. New York: Basic Books 1969.
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