Structure and organization of pharmacy
How pharmacy is structured on a global and national basis
How pharmacy within the NHS is currently structured
The difference between primary, secondary and tertiary care
Introduction
All countries of the world have medicines to treat ailments and maintain the health of their populations. The aims of each country will be to vaccinate even the youngest child against childhood diseases and provide medicines to treat them and the adult population. Generally, the pharmacist is the trusted healthcare professional that is given the responsibility for safe guarding and supplying medicines to the individual patient within the legal system of that country. Clearly, some countries will have more developed systems than others to control and supply their medicines and this will depend, to some extent, on the wealth of the country and its political stability. Concomitantly, the countries with more developed systems will have more pharmacists and more supply outlets for medicines. But with pharmacy and pharmacists worldwide, what structures and organizations are available to administer and support both countries and pharmacists in their endeavours to supply medicines to their populations? This chapter will consider global, state and local structures that organize and support aspects of pharmacy and pharmacists.
Global organizations
There are two major organizations that have an involvement in pharmacy worldwide. These are the World Health Organization (WHO) and International Pharmaceutical Federation (FIP).
The WHO is a directing and coordinating authority for health within the United Nations (UN). It provides leadership on global health matters, setting norms and standards, shaping health research agendas, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. It employs pharmacists in advisory and operational capacities. In the pharmaceutical sector of the WHO, the essential medicines concept was developed for low income countries and a Model List of Essential Medicines was produced. The essential medicines concept encourages countries to focus on access to those medicines that represent the best balance of safety, quality, efficacy and cost to meet the priority health needs in a country. The Model List of Essential Medicines was developed in the 1970s and has been revised regularly. The list consists of a ‘core’ of medicines that are the minimum required for a basic healthcare system, for example this would include analgesics and antibiotics, and a ‘complementary’ list, including essential medicines for priority diseases which may be cost effective but not, necessarily, affordable. Currently, the Essential Medicines List contains about 350 individual medicines and it is designed to guide the development of national and other essential medicines lists.
The WHO has a 6-point agenda to address health objectives, strategic needs and operational approaches. Currently, it is involved in patient safety campaigns and research, international health regulations, global vaccine safety initiatives and the role of pharmacists in tuberculosis care, among others.
FIP is a global federation of national pharmacy associations representing approximately 3 million pharmacists and pharmaceutical scientists worldwide. It has annual conferences and aims to set global pharmacy standards, through professional and scientific guidelines, policy statements and declarations, as well as collaborating with WHO and the UN. It publishes statements of policy on a wide range of subjects such as:
Quality assurance of pharmaceutical education
Pharmacists role in promoting a future free of tobacco
Role of pharmacists in the presentation and treatment of chronic disease
It also has projects on such topics as education initiatives on tuberculosis and patient safety, as well as producing a series of pictograms for labels to be used by patients without a working knowledge of a language.
Organization of pharmacy at a national level
Most countries will have a government, which will need specialist advice on all manner of subjects, including transport issues, financial issues and usually including health issues. And thus, the government will have specialist departments, for example, a department of health which will employ health professionals to advise the government ministers as and when the need arises. This section of the chapter will concentrate on the organizations in England, but similar arrangements exist in many other countries.
The Department of Health (DH), headed by the Minister of Health, is a department of the UK government which is responsible for health and social care matters and for the NHS in England. It develops policies and guidelines to improve the quality of care and to meet patient expectations. Among its employees, there is a Chief Pharmaceutical Officer to advise on pharmaceutical matters. It also employs other pharmacists in specialist capacities. A number of publications, such as the BNF and BNF for Children are published under the authority of the DH and the Joint Formularies Committee, which consists of representatives of doctors and pharmacists. The British Pharmacopeia Commission, which is responsible for the British Pharmacopeia (a collection of legally enforceable standards of quality for UK medicinal substances) recommends publication to the Minister of Health.
The Medicines and Healthcare Regulatory Authority (MHRA) is a UK government agency set up under the auspices of the DH (see Ch. 4). It regulates medicines and medical devices to check whether they work and are acceptably safe.
The National Patient Safety Authority (NPSA) monitored patient safety incidents including medical and prescribing errors. The key functions and expertise for patient safety developed by the NPSA has now transferred to the NHS Commissioning Board Special Health Authority. An off shoot of NPSA is the National Clinical Assessment Service (NCAS), which was set up to investigate concerns over the performance of individual doctors and dentists, but now pharmacists are included in their remit. The NCAS is currently hosted by the National Institute for Health and Care Excellence (NICE) and, in future, will be part of the NHS Litigation Authority.
NICE is currently a Special Health Authority and in the future will become a non-departmental public body. NICE currently publishes guidelines on:
Health technologies, such as the use of new and existing medicines and treatments
Clinical practice, such as the treatment and care of people with specialist diseases and conditions
Guidance for public sector workers on health promotion and ill health avoidance.
In the future, NICE will, also, produce quality standards for people and services involved in providing social care.
The NHS Confederation is a membership body for the full range of organizations that commission and provide NHS services. The membership includes hospital trusts, commissioning bodies and independent and voluntary organizations that deliver services to the NHS.
Health Education England is part of the NHS and is a national leadership body responsible for ensuring that education, training and workforce development drives the highest quality public health and patient outcomes. Pharmacy and pharmacists come under the remit of Health Education England. At a more local level, there will be Local Education and Training Boards (LETB) which are tasked with developing the NHS workforce at a local level.
The Pharmaceutical Services Negotiating Committee (PSNC) is recognized by the DH as the representative negotiating body representing community pharmacy contractors on NHS matters. This committee negotiates the remuneration that community pharmacy contractors receive for NHS dispensing services and other pharmaceutical services, such as MURs (see Ch. 51).
The Veterinary Medicines Directorate, is an agency of the Department of Environment, Food and Rural Affairs and aims to protect the public health, animal health, the environment and promote animal welfare by assuring the safety, quality and efficacy of veterinary medicines in the UK (see Ch. 28).
Structure of the NHS in the UK
In the UK, health care is primarily accessed via the NHS, which was launched in 1948 with the underlying ideal that ‘good health care should be available to all, regardless of wealth’.
The NHS is funded through public taxation and is managed by the DH. The Secretary of State for Health heads the department and is answerable to Parliament on all issues relating to health.
Some Members of Parliament have a special interest in pharmacy and belong to The All Party Pharmacy Group, whose stated purpose is ‘to raise awareness of the profession of pharmacy and to promote pharmacists’ current and potential contribution to the health of the nation’.
Within the DH guidance on professional pharmacy issues is provided by the Chief Pharmaceutical Officer.
The NHS is divided in to three main sectors, primary care, secondary care and tertiary care.
Primary care
Primary care is the largest sector of the NHS providing the main stay of patient care. It is, currently, structured into a number of local commissioning bodies throughout the UK which are responsible for organizing and commissioning services provided in both primary and secondary care. Most primary care is delivered via a local practice where a patient will be registered for treatment by a number of healthcare professionals including general practitioners (GPs) and community nurses. Patients can also access other healthcare services via other healthcare professionals such as dentists, optometrists and chiropodists at their respective practices. Community pharmacists are the main stay of medicine supply and advice on the use of medicines in this sector.
Secondary care
Secondary care is organized into different levels and types of services for patients known as ‘Trusts’ (mainly hospitals), which together deliver a comprehensive service for patients. There are a greater variety of healthcare professionals working in secondary care including doctors, nurses, pharmacists, radiographers, physiotherapists and dietitians, etc. Most patients will be seen in secondary care through a referral from primary care for diagnosis and treatment or they may also present to secondary care as an emergency through the accident and emergency department.
Tertiary care
Tertiary care includes more specialized medical centres and includes specialist centres in paediatric cardiac surgery or cancer care.
Pharmacists and pharmacy technicians work within all three of these areas providing advice, guidance and the supply of medicines and appliances.
The other way of obtaining medicines in the UK is through dispensing doctors. In rural areas where patients live over a mile from a pharmacy, patients can choose to have their medication dispensed by their GP as part of their NHS service. GPs will often employ a dispenser or pharmacy technician to support them in this role.
Private health care is structured in a similar way, as patients can access private care in the community through GPs and other healthcare professionals. These practitioners may provide, solely, private services or joint NHS and private services. Private secondary care is provided in private hospitals and treatment centres in a similar way to the NHS.
Pharmacy in the UK
Regulation and training
Pharmacy in the UK is regulated by a regulatory body called the General Pharmaceutical Council (GPhC) whose main functions are to maintain the safely of patients and the public by regulating pharmacy and pharmacists (see Ch. 5).
There are a number of general organizations that support and represent pharmacy and pharmacists, such as the Royal Pharmaceutical Society (RPS) a professional body whose aim is to promote pharmacy and support its members (Table 14.1).
Table 14.1
Some general pharmacy organizations
| Organization | Role |
| Royal Pharmaceutical Society | Professional leadership body in the UK. Hosts many specialist groups |
| Local Practice Forums | Bring together providers of pharmacy learning, employers and pharmacists |
| Centre for Pharmacy Postgraduate Education (CPPE), Wales Centre for Pharmacy Professional Education (WCPPE), NHS Education Scotland (NES) | Providers of post-graduate pharmacy education |
| Pharmacist Support | Independent charity providing support to pharmacists and their families |
| Pharmacists’ Defence Association (PDA) | Defends their members when faced with conflict and lobbying organization. Provides indemnity insurance to pharmacists |
| International Pharmaceutical Federation (FIP) | Federation of national associations |
| UK Clinical Pharmacy Association (UKCPA) | Promotes excellence in clinical practice and medicines management, hosts specialist clinical groups |
The four main fields of pharmacy are: community pharmacy, hospital pharmacy, industrial pharmacy and primary care pharmacy; however, there are many other roles for pharmacist in other sectors.
Community pharmacy
The community pharmacist is one of the main providers of medicines and medicines advice in primary care. They are based in pharmacies either on the high street, in supermarkets or attached to GP practices. This sector has the largest proportion of registered pharmacists working within it. The business may be anything from an independently run single pharmacy, small chains of pharmacies, or a large multiple chain of pharmacies. The community pharmacy is a privately run business which is contracted to deliver NHS services including the dispensing of NHS prescriptions and other NHS services.
The NHS community pharmacy contract for England and Wales outlines all the NHS services to be provided by a community pharmacy. There are three levels of service to be delivered by pharmacies; essential service, advanced services and enhanced services (see Chs 9, 48, 49 and 50). The Drug Tariff (DT) outlines the remuneration structure that community pharmacies receive for providing these services.
Community pharmacies also deliver some healthcare services privately. This may take the form of dispensing prescriptions written by a private practitioner, the sale of over the counter medicines or the provision of private services for which the customer and not the NHS pays, e.g. Flu vaccination.
Various organizations provide support for pharmacists working in community pharmacy and some of these are covered in Table 14.2.
Table 14.2
Some community pharmacy organizations
| Organization | Role |
| National Pharmacy Association (NPA) | Trade body for community pharmacists |
| Company Chemists’ Association (CCA) | Represents the views of the nine largest multiple pharmacy chains |
| Association of Independent Multiples (AIMp) | Represents the views of smaller more regional pharmacy chains |
| Pharmacy Voice | An umbrella organization of the NPA, CCA and AIMp working to share best practice and represent most community pharmacies |
| Local Pharmaceutical Committee (LPC) | A statutory body representing community pharmacy in a locality to negotiate with local commissioners |
| Pharmaceutical Services Negotiating Committee (PSNC) | Negotiates nationally with government in England on contract and payment issues (comparable bodies in Wales and Scotland) |
Hospital pharmacy
The hospital pharmacy is usually based within the hospital in question; this may be an NHS or private hospital and is the second largest employer of pharmacists. The pharmacist’s role within the hospital is more specialized than that of the community pharmacist and, usually, there is more than one pharmacist working in the same hospital. They work closely with other healthcare professionals in the hospital to ensure the safe use and delivery of medicines to the patient regardless of the type of hospital.
Hospital pharmacists are responsible for the purchase, manufacture, dispensing and supply of all the medicines used in the hospital. One of their main roles is to advise other staff on the most safe and effective use of medicines for individual patients including the selection of the drug, dose, formulation, administration and monitoring of that drug.
During ward rounds hospital pharmacists will speak to patients to improve patient understanding and concordance with their medicines during their stay and before they leave the hospital and some pharmacists will develop specific clinical specialisms to support this work. Other pharmacists will work in other areas of hospital pharmacy (see Chs 16, 40, 41, 45 and 46).
Depending on the area the pharmacist works in they may belong to various organizations that relate to their specialism (Table 14.3).
Table 14.3
Some hospital pharmacy organizations
| Organization | Role |
| Guild of Healthcare Pharmacists | Provides a voice for employed pharmacists working in hospitals and primary care |
| Supported by either RPS or UKCPA for various specialisms | Specialisms include oncology, mental health, nutrition, technicians, HIV, palliative care, radiopharmacy, critical care, neonatal and paediatrics |
Pharmacy industry
Privately run industrial companies are the main source of research and development for medicines worldwide. The pharmaceutical industry is largely responsible for the identification and development of new medicines and ensuring the safety of the medicine. Pharmacists have a number of roles within industry including identifying a compound which could become a medicine, testing its safety, formulating it into a usable medicine and marketing the final product for sale and distribution.
Primary care pharmacy
One of the newer roles in pharmacy is the primary care pharmacist. They are employed by the local commissioning body. This role entails medicines management, prescribing advice, working with GPs and being clinical governance leads. The aim of medicines management is to maximize the benefit and reduce the risks of medicines but also take in to consideration cost-effectiveness. Pharmacists use evidence-based medicine to develop formularies and prescribing guidance for use in primary care (see Ch. 20). They may also be involved in budgeting and the development of new services in the community.
Other pharmacy roles
Pharmacists as the experts in medicines are useful to a number of different organizations and have developed many different roles outside the main four already discussed.
Veterinary pharmacists are experts in the supply of medicines for the use in household animals or livestock (see Ch. 28).
Pharmacists may also work in a prison pharmacy supplying medicines and pharmaceutical care to inmates. This role combines aspects of both hospital and community pharmacy and pharmacists will often have trained to prescribe and run clinics within the prison. Within the prison setting, a higher percentage of the population will have mental health and addiction problems than in the wider community which often steers the specialism of the pharmacist. Both legal and illegal drugs can have ‘value’ within the prison, so the pharmacist will have to be able to advise on the production of the formulary within the prison to reduce the risk of increasing drug misuse (see Ch. 23).
Some pharmacists will work in teaching and training capacities. They could be based in a University, teaching pharmacy students or on other related courses, e.g. non-medical prescribing. Others will design and deliver training within sectors of the profession.
Regulatory pharmacy provides career opportunities for a small number of pharmacists. They may work for a pharmacy regulator, such as the GPhC, in industry, for either a drug company or the MRHA and in a more general healthcare regulator, e.g. the Care Quality Commission in the UK.
Another area that pharmacists work in is with the armed services. Armed services provide medical services for personnel and their families on bases both within the UK and abroad. Personnel also need medical services when they are on tours of duty. Pharmacy will need to be part of these teams. Services pharmacists will be commissioned as officers within the service they have joined and in the UK, the Army sponsors some pharmacy students who are then required to serve for 6 years within the Army on qualification.
Within in all sectors, pharmacists have the opportunity to move into management roles. Groups that support these areas of work are listed in Table 14.4.
Table 14.4
Areas/groups covered by other pharmacy organizations
Area covered
Locum pharmacists
Overseas pharmacists
Rural pharmacy
Secure environment pharmacists
Pharmacy students
History of pharmacy
Pharmacist prescribing
Veterinary pharmacy
Science and research
Qualified persons
Management
Pharmacy law and ethics
Conclusion
There is wide variability in the delivery of health services around the world; how it is delivered within any particular country will depend on many factors. The supply of medicines in any country invariably involves a pharmacist or pharmacy technician to ensure the safety of the public and compliance with local regulations. Health care in the UK is mostly delivered through the NHS using a wide range of healthcare professionals, though private care is also available. Pharmacists work in the NHS and private care in a number of different capacities with the main role of ensuring the safe supply of medicines to patients.
Key Points
Pharmacy works in different ways in different countries
Different countries have different legislation and training requirements relating to pharmacy and pharmacists
The majority of pharmacists work as community or hospital pharmacists
A wide variety of groups provide links, networking opportunities and support to pharmacists working in different areas of the profession