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It's always interesting when something that is intuitively likely to work turns out not to. This week, two research papers examine the role of community pharmacists in primary care. Community pharmacists are well placed to provide advice on medications. They have the knowledge and skills and are accessible when doctors may not be, so in theory they could help to tackle social inequalities as well as improving health. Sadly, as summarised by Peri Ballantyne in an accompanying editorial (doi: 10.1136/bmj.39213.660394.80), the studies found that pharmacists' advice didn't have much impact on behaviour or health outcomes and may even have made things worse. Richard Holland and colleagues' randomised controlled trial (doi: 10.1136/bmj.39164.568183.AE) found that sending a pharmacist to visit patients with heart failure in their homes to review their medication and give general advice didn't significantly reduce hospital admissions or mortality. Charlotte Salter and colleagues' qualitative analysis of home visits to elderly patients found that the pharmacist's advice was often resisted or rejected. It also tended to undermine patients' views of themselves as being competent to look after their own health (doi: 10.1136/bmj.39171.577106.55). The authors conclude that “caution is needed in assuming that common sense interventions necessarily lead to health gain.”
Which is why it is so crucial that we test our assumptions—especially in primary care, where 80% of NHS consultations occur. Primary care research was once the Cinderella of the research establishment, with few training posts, low expectations, and lack of a prevailing research culture. Over the past decade, a research infrastructure has emerged supporting some excellent and practice changing research, much of it published in the BMJ. The recently established UK Clinical Research Network could help to advance matters further, say Frank Sullivan and colleagues (doi: 10.1136/bmj.39190.648785.80). There are still substantial barriers to be surmounted before our research priorities reflect the realities of healthcare provision, but primary care research networks are an important innovation that deserve support.
It seems to be the BMJ's mission at the moment to fuel controversy. We like nothing better than a good, hard hitting debate, provided it's firmly based on evidence. Two recent head to head debates have been followed by polls on bmj.com. A few weeks ago we asked whether patient groups should take money from drug companies (BMJ 2007; 334:934-5, doi: 10.1136/bmj.39185.461968.AD); 84% of responders to our poll said they shouldn't (http://resources.bmj.com/bmj/interactive/polls/accept-money-poll). Two weeks ago we asked whether women should be offered statins routinely despite the lack of direct evidence of benefit from trials in women (BMJ 2007;334:982-3, doi: 10.1136/bmj.39202.399942.AD); 81% of poll responders said no (http://resources.bmj.com/bmj/interactive/polls/lower-cholesterol) and you can read some of their comments in this week's journal (doi: 10.1136/bmj.39224.456632.59). This week we ask whether presumed consent is the answer to organ shortages. Veronica English (doi: 10.1136/bmj.39199.475301.AD) argues that it is, since it will increase availability where alternative policies have failed. Linda Wright (doi: 10.1136/bmj.39199.492894.AD) thinks the problem is more complex, especially in cultures where trust in the healthcare system is not universal. In some cultures, financial incentives might be more effective, she says. Give us your views on bmj.com, and if you have a suggestion for a head to head debate, please let us know.