The Belgian Family Pharmacist: a review after 5 years and a preview on the future role of the community pharmacist

As in numerous other countries, Belgian community pharmacists are trying to promote health of their patients. A fundamental change came back in 2010, when the remuneration model for community pharmacies was transformed from a pure margin system to a mixed system. Today the majority of pharmacists’ income is composed of dispensing fees. Between 2010 and 2016, some prudent steps have been taken to develop new health promotion services in an economically sustainable way. For instance, a new medicines service for asthma patients was introduced in 2015. By early 2017, Belgian community pharmacists signed a multiannual framework with the Minister of Health. A first important milestone in the implementation of this agreement was the introduction of the concept “Family Pharmacist”. Five years after the start of this service, it is time to look back, but also to look forward on expanding to other services and thus shape the future role of community pharmacists.


Introduction
As in numerous other countries, Belgian community pharmacists are trying to promote health of their patients. A fundamental change came back in 2010, when the remuneration model for community pharmacies was transformed from a pure margin system to a mixed system. Today the majority of pharmacists' income is composed of dispensing fees. Between 2010 and 2016, some prudent steps have been taken to develop new health promotion services in an economically sustainable way. For instance, a new medicines service for asthma patients was introduced in 2015. By early 2017, Belgian community pharmacists signed a multiannual framework with the Minister of Health. A first important milestone in the implementation of this agreement was the introduction of the concept "Family Pharmacist". Five years after the start of this service, it is time to look back, but also to look forward on expanding to other services and thus shape the future role of community pharmacists.

Details of the service
The Family Pharmacist monitors chronic patients and accompanies them in the correct use of medicines. His main task is to keep the medication plan of his patients up-to-date and to make it available to the health care team (the family physician in the first place) and of course to the patients themselves. In order to do this, family pharmacists are required to systematically record all dispensed drugs in the patient's electronic local and shared pharmaceutical file. At each visit to the pharmacy, information is checked, consolidated, missing information (dosage, intake moment, OTC) completed, and registered in a complete, correct and up-to-date medication plan, validated and handed over to the patient.
The agreement between the patient and his family pharmacist is cemented when literally signing a contract between pharmacist and patient, hence the title of a large communication campaign "My pharmacist knows me, I sign up (chose today your family pharmacist)".
The service is covered by the compulsory universal health insurance, pharmacists receive a yearly fee per patient, without any out-of-pocket payment for the patient.

Advantages of the service
The complete, updated and patient-oriented medication plan is available to the patient himself and to other healthcare professionals who have a therapeutic relationship with him. This medication plan contains all medicines or health products dispensed to the patient, whether prescribed by the treating doctor or another prescriber (specialists, dentist), recommended by the pharmacist or taken on the patient's own initiative.
The medication plan, shared via secure platforms with the other healthcare providers, is of great importance to public health. It provides a full view of the patient's active medication. This is important when the patient consults a physician other than his usual physician, a specialist physician in a planned hospital admission or even when brought to an emergency department. On discharge from hospital, it is also helpful for the patient to take home the original medication plan that was changed within the hospital setting The Family Pharmacist is the contact person for the patient's medication, both for the treating doctor and for other healthcare professionals who have a therapeutic relationship with the patient. This will strengthen the collaboration between pharmacist and the general practitioner who, thanks to the medication plan, has a working tool where the prescribing doctor can make any Maced. pharm. bull., 68 (Suppl 1) 11 -12 (2022) necessary changes to it, verify the need for self-care medication and validate the plan.
For the patient, the medication schedule is a reminder to take all his medicines properly. It thus supports compliance, since it contains all the useful information on the posology, duration of treatment, timing of intake of each medicine and important advice on the proper use of medicines.

Results
The Family Pharmacist service officially started October 1 st 2017, and turned out to be an immediate success. By the end of 2017, more than 400 000 chronic patients had signed up for the service, and over the course of just 12 months, 650 000 patients benefited from their Family Pharmacist. At present day, more than 1 million patients (on a Belgian population of 11 million citizens) have signed up for the service, meaning that implementation was extremely effective.
About 1 year after the start of the service, community pharmacists offering the service were asked about the main problems encountered when drawing up a medication plan. Wrong intake timing, wrong dosage and drug omissions were more often cited, followed by not previously detected interactions and unintended double medication, clearly demonstrating the positive impact of the service on patient's health.

Future role
Clearly this particular service is only the starting point for other cognitive services that community pharmacists can offer to patients as a strategy to improve the quality of drug therapy and health care delivery system (Melton et al., 2017). Typically, these services relate to prevention, referral and pharmaceutical care:

Prevention
Being a trusted party for the patient, preventive actions are now more easily done than before. Examples are the awareness raising for vaccination (flu, pneumococcal disease, COVID-19) and the administration of certain vaccines . But on top of the health-promoting activities themselves , being the family pharmacist makes it also possible to do targeted follow-up of any specific measures to promote therapy adherence.

Referral
One of the biggest advantages of having a close relationship between the pharmacist and the patient is that it makes it possible for the pharmacist to detect minor changes in the physical and mental health of the patient.
Based on an established trust between the two parties, conversations on known and unknown conditions are straightforward, and if needed, a referral to a competent caregiver is easy. Screening programs for communicable and non-communicable diseases have been organised as pilot programs and could be expanded in the future.

Pharmaceutical Care
Building on patient trust in the family pharmacist, it certainly becomes easier to implement new services that are tailored to the specific needs of every individual (CoE Resolution CM/Res (2020)3). Pharmacists being highly educated professionals and experts in medicines dispensing and providing patient care, there are specific services that are being rolled late 2022: Examples are medication review for polymedicated patients (Wuyts et al.,2020), tapering programs for chronic long term benzodiazepine users, etc.

Conclusion
The visionary act five years ago to create the concept of 'family pharmacist' in Belgium not only consolidated the daily caregiving of Belgian pharmacists, but this also induced more patient centered pharmaceutical care. Next to that, the added value of the Belgian pharmacist within the care chain became more visible and recognized. This also made it more common to cooperate between pharmacists and other caregivers such as general practitioners. But it does not stop there. This collaboration means a big benefit for each patient who has no other choice than to rely on the quality of the provided pharmaceutical care. In Belgium, thanks to the concept of family pharmacist, this objective is already assured.