Chapter 1 The role of pharmacy in health care
Pharmacists are experts on the actions and uses of drugs, including their chemistry, their formulation into medicines and the ways in which they are used to manage diseases. The principal aim of the pharmacist is to use this expertise to improve patient care. Pharmacists are in close contact with patients and so have an important role both in assisting patients to make the best use of their prescribed medicines and in advising patients on the appropriate self-management of self-limiting and minor conditions. Increasingly this latter aspect includes over the counter (OTC) prescribing of effective and potent treatments. Pharmacists are also in close working relationships with other members of the healthcare team – doctors, nurses, dentists and others – where they are able to give advice on a wide range of issues surrounding the use of medicines.
Pharmacists are employed in many different areas of practice. These include the traditional ones of hospital and community practice as well as newer advisory roles at health authority/health board level and working directly with general practitioners as part of the core, practice-based primary healthcare team. Additionally, pharmacists are employed in the pharmaceutical industry and in academia.
Members of the general public are most likely to meet pharmacists in high street pharmacies or on a hospital ward. However, pharmacists also visit residential homes, make visits to patients’ own homes and are now involved in running chronic disease clinics in primary and secondary care. In addition, pharmacists will also be contributing to the care of patients through their dealings with other members of the healthcare team in the hospital and community setting.
Historically pharmacists and general practitioners have a common ancestry as apothecaries. Apothecaries both dispensed medicines prescribed by physicians and recommended medicines for those members of the public unable to afford physicians’ fees. As the two professions of pharmacy and general practice emerged this remit split so that pharmacists became primarily responsible for the technical, dispensing aspects of this role. With the advent of the National Health Service (NHS) in the UK in 1948, and the philosophy of free medical care at the point of delivery, the advisory function of the pharmacist further decreased. As a result pharmacists spent more of their time in the dispensing of medicines – and derived an increased proportion of their income from it. At the same time, radical changes in the nature of dispensing itself, as described in the following paragraphs, occurred.
In the early years, many prescriptions were for extemporaneously prepared medicines, either following standard ‘recipes’ from formularies such as the British Pharmacopoeia (BP) or British Pharmaceutical Codex (BPC), or following individual recipes written by the prescriber. The situation was similar in hospital pharmacy, where most prescriptions were prepared on an individual basis. There was some small-scale manufacture of a range of commonly used items. In both situations, pharmacists required manipulative and time-consuming skills to produce the medicines. Thus a wide range of preparations was made, including liquids for internal and external use, ointments, creams, poultices, plasters, eye drops and ointments, injections and solid dosage forms such as pills, capsules and moulded tablets.
Scientific advances have greatly increased the effectiveness of drugs but have also rendered them more complex, potentially more toxic and requiring more sophisticated use than their predecessors. The pharmaceutical industry developed in tandem with these drug developments, contributing to further scientific advances and producing manufactured medical products. This had a number of advantages. For one thing, there was an increased reliability in the product, which could be subjected to suitable quality assessment and assurance. This led to improved formulations, modifications to drug availability and increased use of tablets which have a greater convenience for the patient. Some doctors did not agree with the loss of flexibility in prescribing which resulted from having to use predetermined doses and combinations of materials. From the pharmacist’s point of view there was a reduction in the time spent in the routine extemporaneous production of medicines, which many saw as an advantage. Others saw it as a reduction in the mystique associated with the professional role of the pharmacist (see Ch. 2 for a more detailed discussion on the professional roles of pharmacists). There was also an erosion of the technical skill base of the pharmacist. A look through copies of the BPC in the 1950s, 1960s and 1970s will show the reduction in the number and diversity of formulations included in the Formulary section. That section has been omitted from the most recent editions.
Some extemporaneous dispensing is still required and pharmacists remain the only professionals trained in these skills. For this reason, Section 4 of this book deals with the types of medicine used, the ingredients employed in them and describes some of the practical skills required to make products suitable for use by patients.
The changing patterns of work of the pharmacist, in community pharmacy in particular, led to an uncertainty about the future role of the pharmacist and a general consensus that pharmacists were no longer being utilized to their full potential. If the pharmacist was not required to compound medicines or to give general advice on diseases, what was the pharmacist to do?
The need to review the future for pharmacy was first formally recognized in 1979 in a report on the NHS which had the remit to consider the best use and management of its financial and manpower resources. This was followed by a succession of key reports and papers which repeatedly identified the need to exploit the pharmacist’s expertise and knowledge to better effect. Key among these reports was the Nuffield Report of 1986. This report, which included nearly 100 recommendations, led the way to many new initiatives, both by the profession and by the government, and laid the foundation for the recent developments in the practice of pharmacy, which are reflected in this book.
Radical change, as recommended in the Nuffield Report, does not necessarily happen quickly, particularly when regulations and statute are involved. In the 23 years since Nuffield was published there have been several different agendas which have come together and between them facilitated the paradigm shift for pharmacy envisaged in the Nuffield Report. These agendas will be briefly described below. They have finally resulted in extensive professional change, most recently articulated in the definitive statements about the role of pharmacy in the NHS plans for pharmacy in England (2000), Scotland (2001) and Wales (2002) and the subsequent new contractual frameworks for community pharmacy. In addition other regulatory changes have occurred as part of government policy to increase convenient public access to a wider range of medicines on the NHS. These changes reflect general societal trends to deregulate the professions while having in place a framework to ensure safe practice and a recognition that the public are increasingly well informed through widespread access to the Internet.
For pharmacy, therefore, two routes for the supply of prescription only medicines (POM) have opened up. Until recently POM medicines were only available on the prescription of a doctor or dentist, but as a result of the Crown Review in 1999, two significant changes emerged. First, patient group directions (PGDs) were introduced in 2000. A PGD is a written direction for the supply, or supply and administration, of a POM to persons generally by named groups of professionals. So, for example, under a PGD, community pharmacists could supply a specific POM antibiotic to people with a confirmed diagnostic infection, e.g. azithromycin for Chlamydia.
Second, prescribing rights for pharmacists, alongside nurses and some other healthcare professionals, have been introduced, initially as supplementary prescribers and more recently as independent prescribers. To carry out these prescribing roles, pharmacists must have undertaken additional postgraduate training and be accredited by the Royal Pharmaceutical Society of Great Britain (RPSGB). It is anticipated that the training will soon be routinely incorporated into undergraduate curricula.
The council of the RPSGB decided that it was necessary to allow all members to contribute to a radical appraisal of the profession, what it should be doing and how to achieve it. The ‘Pharmacy in a New Age’ consultation (familiarly referred to as PIANA) was launched in October 1995, with an invitation to all members to contribute their views to the council. These were combined into a subsequent document produced by the council in September 1996 called Pharmacy in a New Age: The New Horizon. This indicated that there was overwhelming agreement from pharmacists that the profession could not stand still. Four main areas in which pharmacy should make a major contribution to health outcomes were identified:
During the consultation process, pharmacists expressed their views on the way the profession should change. These, too, may be summarized under four main headings:
The main output of this professional review was a commitment to take forward a more proactive, patient centred clinical role for pharmacy using pharmacists’ skills and knowledge to best effect.
Health services are expensive to run. Governments try to reduce expenditure as far as possible through a range of methods. In the UK some medicines have been identified as being ineligible for prescribing on the NHS. The so-called Black List was introduced in 1984 to reduce the size of the NHS bill. Furthermore the introduction of computer technology into prescription pricing has enabled far more data to be produced than was previously possible. Doctors now receive a regular breakdown of the drugs they have prescribed and their prescribing costs. Chapter 18 considers the use of prescribing data (PACT or SPA) by pharmacists when advising doctors about reducing their prescribing costs.
However, despite these moves, and in common with other developed countries, UK drug costs are inexorably rising due to the greater availability of new effective treatments, patient demand and changes in patient demography (more older people). This has made many governments look at other ways of controlling this item of expenditure, and there are two ways in which pharmacists can have a role.
First, it is recognized that not all prescribing follows the current best evidence for cost-effective practice. Pharmacists are seen as a profession with the necessary knowledge to support quality in prescribing at a strategic and practice level. At a strategic level they can appraise the evidence and make recommendations for the inclusion of a drug in a formulary. At a general practice level pharmacists can advise prescribers on the best drugs to prescribe for individual patients, and community pharmacists are well placed to monitor and review repeat prescriptions, which account for 80% of all prescriptions in primary care.
Second, in a move to promote self-care, pharmacists can encourage patients to be responsible for their own health care and, by implication, remove the cost of treating what is known as ‘minor illness’ from the NHS. Many drugs previously only available on prescription (POM) are now available over the counter from pharmacies (P) or from any retail outlet general sales list (GSL). All drugs are classified into legal categories which restrict their supply in the interests of patient safety. The main categories are: prescription only medicines (POM); pharmacy medicines (sale only under the supervision of a pharmacist; P); and general sales list (sale from any retail outlet including pharmacies; GSL; see Ch. 2). These changes have resulted in many potent drugs now being available for sale from community pharmacies and the advisory role of the pharmacist has therefore been greatly enhanced. In 1983, ibuprofen and loperamide were the first of the many drugs to be deregulated in the following decades, and there is no obvious end to the process. Initially, deregulated drugs were for the management of conditions already diagnosed and treated by pharmacists, such as dyspepsia, but where the choice of effective remedy was limited. Then deregulations became more focused on extending the licensed indications for P sale, such as the inclusion of eczema as an allowable indication for topical hydrocortisone. Most recently, deregulations have increasingly been for new drugs for ‘new’ conditions, such as emergency hormonal contraception and statins. Conversely, the two non-sedating antihistamines terfenadine and astemizole are rare examples of the reclassification to POM because of the emergence of major safety concerns when these drugs were taken by increasing numbers of people. Terfenadine was subsequently removed totally from the UK market. Overall these moves have implications for the pharmacist’s role as a first line provider of care for minor conditions, with a return to the traditional pre NHS advisory role including simple diagnosis and management.
As demand for health care grows, it is not only budgets that are stretched. Increasingly there are insufficient trained professionals to deliver services, and innovative ways of working need to be introduced to maximize the skills of the different professionals in the healthcare team. This has resulted in a recognition that many of the tasks previously undertaken by the medical profession, in both primary and secondary care, can be undertaken by other professions such as pharmacists and nurses. Thus, some of the professional roles originally identified by the profession, such as the management of chronic disease and a greater role in responding to symptoms, are now supported by the wider healthcare community because they can contribute to more effective health care for the population. As a result a team approach to managing health care has emerged.
There are currently around 46 000 registered UK member pharmacists, including those who are working in different sectors of the profession as well as those who are in non-pharmacy-related posts or retired, both in Britain and overseas. The register is divided into practising and non-practising sections. There are 40 000 pharmacists on the ‘practising’ register, of whom approximately 70% work in community pharmacy, 20% in hospitals, 8% in primary care and 4% in the pharmaceutical industry. The next section will summarize the community, hospital and the other NHS roles as they are practised today, with indications of likely changes and challenges in the near future.
As a result of the final recognition of the pharmacist’s role beyond solely dispensing, new community pharmacy contractual frameworks were agreed for England and Wales, and for Scotland, in the early part of this century. In England and Wales, the contract is based on a list of essential services to be delivered from all NHS contracted pharmacies, and then an advanced service specification for specially accredited pharmacists operating from enhanced premises with private consultation areas. At the time of writing the only advanced service is the medicines use review (MUR) and prescription intervention service. Enhanced services, which are negotiated locally with individual NHS primary care organizations, are also delivered. These are summarized in Box 1.1. In Scotland, the new contract is similar, but there is an emphasis on all pharmacists delivering all of the four core service areas: these are the acute medicines service (AMS), the chronic medicines service (CMS), the minor ailment service (MAS) and the public health service (PHS). More detail on these is provided in Box 1.2. In Northern Ireland, a new contract is proposed but is not yet delivered. However, whichever contractual framework pharmacists are operating under, the following generic services will be delivered.
Box 1.1 Community pharmacy contractual framework (England & Wales), introduced 2005
| Essential services | Dispensing of prescribed medicine |
| Repeat dispensing | |
| Disposal of unwanted medicines/waste management | |
| Public health | Healthy lifestyle campaigns, prescription-linked healthy lifestyle interventions |
| Signposting | |
| Support for self-care | E.g. advise on treatment of minor illness including OTC medicine sale, maintain records of clinically significant products purchased |
| Clinical governance | E.g. in relation to public and patient involvement, monitoring by NHS, participation in clinical audit, undertaking risk management and supporting self and staff with education and professional development |
| Appropriate use of information and compliance with statute such as the Data Protection Act 1998, the Human Right Act 1998, the NHS Code of Practice on Confidentiality, the Disability Discrimination Act 1995 and Health and Safety legislation | |
| Maintenance of patient medication records | |
| Advanced services | Medicines use review |
| A service initiated by either the pharmacist, the GP or the patient in which accredited pharmacists undertake structured concordance centred reviews with patients on multiple prescribed medicines. The aim is to help patients understand and comply with their treatment, identify problems if any, and provide a report to the patient and the GP | |
| Enhanced services (locally negotiated) | A wide range of services such as alcohol screening, anticoagulation monitoring, asthma, care homes, care staff, controlled drugs, record cards, chronic obstructive pulmonary disease, databases, emergency hormonal contraception, gluten-free foods, Helicobacter pylori testing, minor ailments, needle and syringe exchange, needle collection, ‘not dispensed scheme’, out of hours, palliative care, Parkinson’s disease, phlebotomy, point of care testing, prescription intervention, quality and outcomes framework, seasonal influenza, sexual health, smoking cessation, supervised administration (e.g. of methadone), vascular risk assessment, weight management and obesity |
Box 1.2 New Scottish community pharmacy contract, introduced incrementally from 2006
| Minor ailment service (MAS) (from mid-2006) | The provision of a range of pharmacy and general sale list medicines (e.g. to treat skin problems, pain, coughs and colds) from the community pharmacy on the NHS to patients registered with that pharmacy and not normally paying an NHS prescription charge |
| Public health service (PHS) (from end 2006) | All interactions with patients should include provision of opportunistic healthy living advice, take part in four national campaigns a year, e.g. flu, vaccinations, meningitis by poster display and provision of health promotion messages, and offer smoking cessation service, emergency hormonal contraception supply and Chlamydia testing and treatment |
| Acute medication service (from July 2008) | Dispensing prescribed medicines, plus advice. Electronic transmission of prescriptions between GP and community pharmacy |
| Chronic medication service (anticipated mid-2009) | The management of long-term conditions by monitoring, medications review, adjustment of doses (by those with prescriber qualification), repeat dispensing |
| National funded optional services | E.g. palliative care, prescribing clinics |
| Locally negotiated services | These will also continue, e.g. services for drug misusers (needle exchange and supervised consumption), flu immunization and drugs as per the English contract (see Box 1.1) |
Despite the recent contractual recognition of new clinical roles, which are described later, dispensing remains a core role of community pharmacy and would still account for the majority of a pharmacist’s time. The preponderance of original pack dispensing means that, compared to even a decade ago, while the name may remain the same, the similarity ends there. The focus of dispensing now rests not only on accurate supply of medication but also on checking that the medication is appropriate for the patient and counselling the patient on its appropriate use. All community pharmacists maintain computerized patient medication records which are a record of previous prescriptions dispensed (see Chs 24 and 47). While not necessarily complete, since patients are not registered with an individual pharmacy, in practice the vast majority of patients, particularly those on regular prescribed medication, do use one pharmacy for the majority of their supplies. Thus pharmacists have a database of information which will allow them to check on issues such as accuracy of the new prescription, compliance and potential drug interactions.
In the future the dispensing role will be further enhanced as connection of community pharmacy into the NHS net becomes a reality. Electronic transmission of prescriptions is currently being universally implemented in England and Scotland. Under this scheme, GPs will send prescriptions to a central ‘cyberstore’ from which pharmacists can download the information using a unique identifier, and dispense the prescribed supplies or medications to the patient. Ultimately this electronic link should allow access by the pharmacist to at least a selected portion of the patient’s medical record, further enhancing the pharmacist’s ability to assess the appropriateness of the prescription. It is hoped that there will also be a facility for pharmacists to write to the patient record, so that GPs will know whether or not prescriptions have been dispensed and what OTC drugs have been purchased.
A further enhanced dispensing role is in the management of repeat prescriptions, which until recently have been issued from GP surgeries with little clinical review. Following research projects which demonstrated that when given this responsibility, community pharmacists could identify previously unrecognized side-effects, adverse drug reactions and drug interactions, as well as saving almost a fifth of the costs of the drugs prescribed, this repeat dispensing service is now part of the new community pharmacy contract (see Boxes 1.1 and 1.2).
This opportunistic clinical input at the point of dispensing is also being developed in a more systematic way, such that patients with targeted chronic conditions, such as coronary heart disease, have formal regular reviews with the community pharmacist about their medication and other disease-related behaviours. Again schemes like this, with research evidence of benefit in small studies, are currently undergoing national implementation through the new contractual frameworks. Such services, called medicines management (see Ch. 17), medicines use review (MUR) or chronic medicines services (CMS), are part of a more holistic approach often referred to as pharmaceutical care. Supplementary and independent prescribing will greatly enhance this role for pharmacy.
Provision of advice to customers presenting in the pharmacy for advice on self-care is now an accepted part of the work of a pharmacist which, as described earlier, has been enhanced by the increased armamentarium of pharmacy medicines. Advertising campaigns, particularly those by the National Pharmaceutical Association (NPA), have brought to public attention the advice which is available from the pharmacist, as have the commercial adverts from the pharmaceutical industry for their deregulated products. The increased emphasis on the provision of advice from community pharmacies has also extended to the counter staff, who require special training and must adhere to protocols. Some of the principles of responding to symptoms are dealt with in Chapter 22.
The full contribution of this advisory role to health care has been limited, to some extent, to the more advantaged sections of the population, particularly since the deregulation of many potent medicines referred to earlier. Many of these newer P medicines are relatively expensive, and those on lower incomes, and particularly those who are exempt from prescription charges, may in the past have attended their doctor only for the purpose of obtaining a free prescription for the drug. This has now been circumvented. Under the new contract in Scotland, all patients who would not normally pay for their prescription can access any medicine normally available without a prescription on the NHS from their local community pharmacist. Patients have to register with a community pharmacy to receive the service and all records are maintained centrally and electronically. Ultimately they will be able to be linked to other patient information through a unique patient identifier, known as the CHI (Community Health Index). In England, similar schemes also exist under the new contract but they are an enhanced, locally negotiated service rather than an essential service. At the time of writing, only about 25% of English community pharmacies provide this service.
A large number of people pass through the nation’s pharmacies in any one day; on the basis of prescription numbers this is frequently said to be 6 million people per day in the UK. Another way of looking at this is that over 90% of the population visit a community pharmacy in any single year. Thus the pharmacist is one of the best placed healthcare professionals to provide health promotion information and health education material to the general public. This has now become part of the pharmacist’s NHS contract and formalized as a core service to be delivered by all pharmacies in England and Wales, and Scotland. The service specification is generally limited to participation in healthy lifestyle campaigns and opportunistic intervention. More aspirational roles can also be delivered and there are extensive opportunities for proactive, targeted and specialist advice to be provided from community pharmacies. The development of cancer and cardiovascular disease, major causes of morbidity and mortality, are both closely linked to lifestyle factors such as diet, exercise and smoking. Pharmacists can give out patient information leaflets on healthy nutrition, which may reduce the development of disease which would otherwise occur and lead to the need for expensive treatment. Smoking is considered to be the single biggest cause of preventable ill health. Pharmacists have a successful record in supporting smoking cessation though tailored face-to-face advice and the supply of smoking cessation products such as nicotine replacement therapies (see Ch. 5), and the vast majority of pharmacies are engaged in local smoking cessation schemes.
Certain groups of patients have particular needs which can be met by community pharmacists more cost effectively than by any other healthcare professional. Such specific patient services often cause the remit of a profession to change almost overnight in response to an unexpected national issue. One such example is drug misuse and the spread of blood borne diseases such as hepatitis and AIDS. Drug misuse is an increasing problem in society today. It is now generally accepted that drug misusers have a right to treatment both to help them come off their addiction and to reduce the harm they may do, either to themselves or to society, until such time as they are ready to undergo detoxification. The vast majority of pharmacists will be involved to a greater or lesser extent in a number of ways, as discussed in Chapter 49. In particular, pharmacists have become involved in needle exchange schemes and in instalment dispensing and supervised consumption of methadone. Because of the urgent need for these important services, and to some extent because of the unwillingness of some community pharmacists to become involved on the grounds of professional responsibility alone, these services have unusually been recognized by specific locally negotiated remuneration packages. These local arrangements continue within the new contracts.
Pharmacists have traditionally delivered oxygen to a patient’s home, and many pharmacists will visit a small number of patients in their own home to deliver medicines and provide advice on their use. This will now be extended to include other situations where patients could benefit, such as on discharge from hospital, including highly specialized services (often called the ‘hospital at home’) where patients may be on palliative care, cytotoxic agents, intravenous antibiotics or artificial nutrition. These topics are discussed in more detail in Chapters 40 and 41. As medicines management services for people on chronic medication continue to evolve, and with more early hospital discharge, this could mean more domiciliary visits to housebound patients. There is also a separate but related need for services to be provided in care home settings, to include both advice on the storage and administration of medicines as well as clinical advice for individual patients (Ch. 48).
One of the requirements of the current regulations is that a pharmacist has to be in personal control/supervision of registered community pharmacy premises at all times. The principle is that the pharmacist should be aware of any transaction in which a medicine is provided to a member of the public and be able to intervene if deemed necessary. This requirement was intended to protect the public but it has been a barrier to innovative practice, and it has been interpreted as the pharmacist needing to be physically present in the pharmacy and aware of all transactions involving P and POM medicines. For single-handed pharmacists this has been difficult to combine with new roles undertaken outwith the pharmacy premises, such as domiciliary visits, or multi-professional meetings. A recent consultation reviewed this stringent requirement and recommended that the pharmacist can, under exceptional circumstances, leave their premises for professional reasons only, for short periods of time during the working day. The current Code of Ethics and Standards, released at the time of writing, promotes greater use of professional judgement, stating principles and removing detailed technical requirements. It remains to be seen exactly how it will be implemented.
A further challenge to established practice will also come from the increasing use of the Internet for personal shopping; and the acquisition of medicines, whether prescribed or purchased, will not be immune to such developments. Already mail order pharmacy and e-pharmacy are making small inroads into medicines distribution and supply, and challenge some of the principles of the Code of Ethics and professional practice points which encourage personal counselling wherever possible. Again, the new Code of Ethics and Standards has responded appropriately, with guidance to professionals on how they can still deliver the same standards of care as from face-to-face premises. Although online services are probably more developed in North America, such changes to practice are inevitable and need to be managed professionally, remembering that best care of the patient, rather than professional self-interest, must be the rationale of any decision making.
The NHS call centres NHS Direct (England and Wales) and NHS 24 (Scotland) handle health-related telephone enquiries from the general public and triage them on to appropriate services. Referral to community pharmacy is one of the formal dispositions included in the algorithms used by the call handlers. It is intended, therefore, that the community pharmacist will not be bypassed by the new telephone help lines. It should also serve to educate the public about the role of the community pharmacist and to increase general awareness that the community pharmacy is just as much a part of the NHS as is the general practice. Audits of calls have revealed that a high proportion are linked to medicines and could have been handled directly by pharmacists. As a result pharmacists are now employed directly to provide online advice from NHS 24/NHS Direct phone lines, and there is also a recognized need to divert the public back to the community pharmacist as the port of call during normal working hours. Finally there are moves to extend accessibility to face-to-face out of hours pharmaceutical advice through links between community pharmacies and out of hours centres.
Clinical pharmacy services have been established in the hospital setting for some time; indeed many of the innovations identified for community pharmacy come from earlier experience in hospitals. In general there is already a greater working together of the professions in the hospital setting compared to primary care, including pharmacists’ involvement in medication history taking, active engagement in research, and for the provision of 24-hour services. In 1988, the NHS circular Health Services Management: the Way Forward for Hospital Pharmaceutical Services laid down the government policy aim as ‘the achievement of better patient care and financial savings, through the more cost effective use of medicines, and improved use of pharmaceutical expertise obtained through the implementation of a clinical pharmacy service’. Two main components were identified. One is the overall management of medicines on the hospital ward. This is achieved through the provision of advice to medical and nursing staff, formulary management and ensuring the safe handling of medicines. The other component is the development of individual patient care plans. This is achieved through the provision of drug information and assisting patients with problems which may arise. In practice there are many stages and activities involved in these processes. A working group in Scotland published Clinical Pharmacy in the Hospital Pharmaceutical Service: a Framework for Practice in July 1996 (Clinical Resources Audit Group 1996). The framework advocates a systematic approach to enable the pharmacist to focus on the key areas and optimize the pharmaceutical input to patient care. Some of the thinking behind this document is discussed subsequently in Chapter 5.
There is a growing awareness of the problems which arise at the interface between community (primary) and hospital (secondary) care. Patients move in both directions. Their medical and pharmaceutical problems also move with them. Over the next few years it is hoped that a large proportion of these problems will have been resolved through the greater involvement of pharmacists at admission and discharge with effective (ultimately electronic) transfer of information, from hospital pharmacist to community pharmacist. As more patients are discharged early, and with more serious and specialized clinical conditions, there will need to be greater communication at this interface and possibly hospital pharmacists operating outwith their traditional secondary care base.
As in community pharmacy, technical skills for local manufacturing of individual products is also now greatly reduced and the skills of hospital pharmacists are more utilized in decisions about the cost-effective and clinically effective selection of drugs, and contributing to drug and therapeutic committees, formulary groups and quality assurance procedures. Issues of supply and efficient distribution of medicines are increasingly becoming automated.
During the 1990s there was increasing evidence of close working between pharmacists and the rest of the general practice based primary healthcare team. Doctors realized that pharmacists had many possible additional clinical roles in primary care, beyond their traditional community pharmacy premises. Many pharmacists now provide doctors with advice on GP formulary development (Ch. 18) and undertake patient medication reviews, either seeing patients face to face or through review of patient records, either globally or on an individual basis. They may also take responsibility for specific clinics following agreed protocols, such as anticoagulant and Helicobacter pylori assessment clinics. These pharmacists are known as primary care pharmacists. However, as community pharmacy develops along the lines described above, and IT links become the norm, it is envisaged that many of the tasks now done by primary care pharmacists will ultimately be carried out from the community pharmacy base.
As new NHS structures emerge in primary care, services are being delivered in an integrated way, involving the wider healthcare team as well as local authority managed services such as social work, and other community workers. In England these organizations are called primary care organizations, in Scotland community health partnerships, in Wales local health boards, and in Northern Ireland health and social services. Management teams for these organizations generally include a senior pharmacist who will coordinate pharmaceutical care for the organization, integrating community pharmacy into the delivery of core health care, and coordinating the primary care pharmacist workforce to achieve area wide goals in prescribing.
Strategic health authorities in England and NHS boards in Scotland administer larger geographical areas. Most of these also have a senior pharmacist, operating at consultant level, as part of the public health team. They have a specific responsibility for local pharmacy strategy development, compliance with statutes and the managed entry of new drugs, as well as providing local professional leadership and advice on professional governance alongside their senior pharmacy colleagues in the trusts. Increasingly as professional boundaries begin to merge, they are also seen as public healthcare professionals and take their share of the generic public health workload. Many are now gaining formal recognition as public health practitioners through membership of the Faculty of Public Health or the UK Voluntary Register for Public Health Specialists.
Increasingly patient satisfaction with new services is monitored in formal health services research projects, as part of innovative pilot schemes and for ongoing routine quality control. Indeed one of the requirements of the new contracts is that community pharmacists should ‘have in place a system to enable patients to give feedback or evaluate services’. Large surveys of the public’s opinion of community pharmacy services have also been conducted. In general such surveys find that the public are satisfied with the service they receive, and that pharmacy is a trusted profession. Research also tells us the public regard community pharmacy services as an important resource for them to access when managing symptoms of minor illness, and that they prefer to seek such advice from a pharmacist rather than a GP or one of the NHS online services. However, it is also shown that they are more wary of hypothetical situations in which pharmacists become involved in the delivery of new roles which have previously been delivered by GPs or nurses working with GPs. In particular older people are less open to new models of service, whereas younger people are much more positive. Once new services have been trialled, such as repeat dispensing, medicines management and prescribing, patient feedback is highly positive. Nonetheless, when asked whether or not they would prefer a doctor or pharmacist to provide the service, there is a status quo bias in favour of the GP. This is not really surprising, but the profession needs to be aware of this. New services have to earn their place in the public’s esteem, building confidence in the quality of what they offer and the advantages of pharmacy delivered services. There is also a need for other healthcare professionals to value the pharmacist’s new roles and to recognize their increasingly central place in the NHS team.
Some high profile examples of substandard health care, most particularly the investigation into the standards of children’s heart surgery at Bristol Royal Infirmary, have focused attention on the need to identify and learn from mistakes and to systematically assess and manage risk. There is now an increasing understanding of the components of a quality assured NHS, and the systems that need to be in place to support this.
Clinical effectiveness is a term often used to describe the extent to which clinical practice meets the highest known standards of care. Clinical governance is a term used to describe the accountability of an organizational grouping for ensuring that clinical effectiveness is practised by all functions for which it is responsible. Central to this is the use of evidence-based guidelines and protocols, which have increased dramatically in the past decade. (An overview is provided in Chapter 8.) These guidelines are a way of increasing the quality of service because they are developed after systematic searches of the research evidence and make recommendations for ‘best practice’ which are easily understood and widely accepted.
The extent to which guidelines are actually applied in particular situations should be measured by clinical audit. Chapter 11 aims to give the background to the need for audit and the different ways in which it may be carried out. Audit is also an important tool in the raising of standards of service delivery.
Training, research and development are also all important strands of clinical effectiveness, as are professional reflection and development. Structures established to deliver this agenda for pharmacy are described in more detail in the next section.
In such a rapidly changing profession, there is a need for continual updating of knowledge. The RPSGB, through The Pharmaceutical Journal, has established a regular pattern of continuing education (CE) articles on a wide range of topics and has introduced a formal portfolio-based continuous professional development (CPD) initiative. The council of the RPSGB, through the Code of Ethics, requires that all pharmacists undertake at least 30 hours of continuing education each year. This is now monitored more closely through an online record which requires both details of activities undertaken and reflection on the values of the activities to practise. This approach is thus more about tailored personal and professional development.
Continuing education is further supported by the centres for postgraduate or post-qualification pharmaceutical education (CPPE). They are located in Manchester (England), Cardiff (Wales) and Belfast (Northern Ireland). The Scottish centre is amalgamated with sister organizations in medicine, dentistry, psychology and nursing as a special health board, the NHS Education for Scotland Board. This is an exciting development, once again reflecting new approaches to healthcare delivery and facilitating teamwork across professional boundaries. Courses from all four centres are provided free to pharmacists who are employed in the provision of pharmaceutical services to the NHS.
There is, therefore, good provision for continuing education, which pharmacists use to good effect. At the moment there is no requirement for a further assessment of competence once the pre-registration year is successfully completed but it is unlikely that this will remain the case for much longer.
The RPSGB has historically undertaken an unusual dual role as a professional body and a regulatory body. For the latter function it is responsible for the registration of pharmacists and premises, for the maintenance of standards though a network of inspectors, and for disciplining those who do not meet the required standard through the Statutory Committee. With increasing public concerns about standards of health care in general, the regulatory function is increasingly open to public scrutiny and the Council for the Regulation of Healthcare Professionals was established. As part of a recent review of the regulation of all healthcare professionals, arising from some high profile cases of suboptimal care, a recommendation has been made that the regulatory functions of the RPSGB will be delivered by an independent body, the General Pharmaceutical Council, and a new body for pharmacy should be created to deliver the complementary professional role. Again at the time of writing, the exact shape of this new body is unknown but it has been suggested it will be akin to that of a royal college, such as is established for the medical specialities. See Chapter 10 for further information on CPD and fitness to practice.
Teaching of pharmacy was traditionally under four subject headings: pharmaceutical chemistry, pharmaceutics, pharmacology and pharmacognosy. This was seen as a restraint on the development of new ideas of teaching to make the course more relevant to the profession. The course has to have a firm science base, building on knowledge acquired in secondary school, but be relevant to practice. Pharmacognosy is no longer a core part of the undergraduate curriculum. Pathology and therapeutics, law and ethics, and the teaching of dispensing practice all have their place alongside clinical pharmacy, which is now accepted as a subject in its own right and one of the most important parts of the course. The course also includes social and behavioural science – a broad subject area which covers many sociological and psychological aspects of disease and patients – and communication skills. Although communication cannot be learned solely by studying a book, it is still useful to have an understanding of the underpinning theoretical framework when learning to put good professional communication into practice. In this book, chapters have been included dealing with social and behavioural science (Chs 3 and 4), communication skills (Ch. 13) and counselling skills (Ch. 44).
Most schools of pharmacy involve both primary and secondary care pharmacy practitioners in undergraduate teaching. The aim of utilizing these teacher–practitioners is to ensure that the university course is relevant to current professional practice. This reflects the situation in other healthcare professions such as medicine. Other ways of learning from current practice as part of course provision are also used, such as visiting lecturers, making GP practice and hospital visits, using part-time teaching staff, staff secondment to practice and joint academic/practice research studies.
As a result of the need to harmonize the undergraduate courses across the EU as far as possible, all UK courses are now of 4 years, and at master level, with a further year of structured pre-registration training in a practice situation (see below).
The purpose of the pre-registration year is for the recent graduate to make the transition from student to a person who can practise effectively and independently as a member of the pharmacy profession. At the end of the year the pre-registration trainee has to pass a formal registration exam prior to entry to the register. Pre-registration training is carried out, in either hospital or community pharmacy practice, in a structured way with a competency-based assessment after 12 months. The recommendation to include both hospital and community practice in the pre-registration year has not yet been acted upon. Some of the differences between community and hospital practice are becoming less distinct as pharmacists in the community take on roles which in the past have been common in hospital practice, such as prescribing advice to doctors. In the future, it may be that a combined pre-registration year may be introduced and interchange between the two areas of practice will become easier to achieve than it is at present.
As recently as the 1980s only a few taught MSc degrees were available. A wide range of such courses is now offered. Some are relatively short; others offer a postgraduate diploma or a master of science. Subject matter may be very specialized or more general. Study may be full time or part time. There are also distance learning courses for those who have limited opportunity to be away from their place of work. Additionally, taught PharmD courses are gaining in popularity and are provided from a small number of institutions across the UK. The programmes are intended to allow pharmacists to develop specialist skills in their chosen area, through formal learning, together with the conduct of either a substantive piece of research or work-based project.
Research has also developed, and research articles appear regularly in the Pharmaceutical Journal and the International Journal of Pharmacy Practice as well as other academic journals from medicine and primary care. There are practice research sessions at the British Pharmaceutical Conference each year, and there is an annual dedicated Health Service and Pharmacy Practice Research Conference. Many students are now graduating with a doctorate for studies undertaken in aspects of pharmacy practice, and, reflecting the integrated multidisciplinary delivery of care, many pharmacists are carrying out research in multidisciplinary research teams. The development of the discipline of pharmacy practice research has a lot to be proud of. The generation of research evidence of the clinical and cost-effective contribution which pharmacists can make to health care has had a key part to play in the innovations in professional practice we have seen in the past decade, and which have been summarized in this introductory chapter.
During the 20th century, pharmacy has undergone major changes. This process has accelerated since the introduction of the NHS in 1948, the Nuffield Report in 1986 and, most recently, the new plans for the NHS published at the turn of the century. As will be evident from reading this chapter, many changes are still ongoing, demonstrating the vibrant and dynamic nature of both the health service and of our profession. Pharmacists now deal with more potent and sophisticated medicines, requiring a different type of knowledge and a different skill set than was previously the case. At the same time, the public has become more aware of the services which are available from pharmacists. People are making increasing use of the pharmacist as a source of information and advice about minor conditions and non-prescription medicines. This is now extending to the general public regarding pharmacists as a source of information and advice about their prescribed medicines and seeking help from pharmacists with any medication problems which they may encounter. This process is likely to develop further as society moves into the 21st century. We are also likely to see further changes reflecting the merging of professional boundaries and competency based delivery of health care. Thus generic healthcare professionals may emerge, and many may undertake tasks traditionally undertaken by one profession. In addition, in order to free up professional time, we can expect to see pharmacy technicians taking on greater responsibility for the technical aspects of the pharmacist’s role while qualified pharmacists concentrate on cognitive functions and interact directly with the patient.
Pharmacists need to have the knowledge and adaptability to take a lead in these processes, so that they can have a key role in ensuring that the health care of the public can be delivered as efficiently as possible. The undergraduate pharmacy courses must reflect these changes to ensure that their graduates meet the demands of the future NHS workforce.