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About this book
provides reference to the various systems of weights
and measures that may be encountered by pharmacists. Appendix 4 provides guidance on presentation
skills; pharmacists throughout their professional
careers require such skills. Key references and guidance to further reading for all the chapters are collated
in Appendix 5.
For us as editors, it has been a daunting task to
produce a textbook of a reasonable size that covers
all the possible topics in pharmacy practice. We realize that it is possible only to provide an overview and
supply key information. Any reader requiring more
information on the topic should initially consult Ap-
pendix 5 for suggested additional reading, then use
the information in Chapter 23 to practise their skills
at information retrieval.
Finally, we acknowledge that changes will take
place between writing and publishing that will mean
that by the time this book appears in print some of it
will almost certainly be out of date. This process of
obsolescence will continue with time. Therefore it is
suggested that readers keep up to date by reading
current medical and pharmaceutical journals and
literature.
xix
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Section One Section One Section One Section One Secti
o
Section One
Pharmacy Practice and Society
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Chapter One
The role of pharmacy in health care
Christine M. Bond
1
STUDY POINTS
*
The historical development of pharmacy
*
The position of pharmacy within the National
Health Service in the UK
*
Recent developments in the services being
provided by pharmacists
*
The need for lifelong learning
*
The public’s attitudes to pharmacy
Introduction
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.
The changing role of pharmacy
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
SECTION ONE Pharmacy practice and society
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
whichhave agreater conveniencefor 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 productionof medicines, which manysaw 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 baseof the pharmacist. A look throughcopies
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 extended role
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 wayto manynew 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 Nuffie ld
Report, does not necessarily happen quickly, particularly when regulations and statute are involved. In
the23yearssinceNuffieldwaspublishedtherehave
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
framewo rk 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,
4
The role of pharmacy in health care CHAPTER 1
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 profession
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 N ew 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:
*
Management of prescribed medicines. This covers
drug development, provision of medicines,
information and support, and ensuring patient
needs are met safely, efficiently and conveniently
so that they can get maximum benefit from their
medicines.
*
Management of chronic conditions. Here the need is
to improve the quality of life and outcomes of
treatment for the patient. Pharmacists may help by
supplying medicines and advice, helping to develop
local shared care protocols, ensuring that patients
are taking or using their medicines properly and
working as part of the healthcare team.
*
Management of common ailments. Patients require
reassurance and advice, with or without the use of
non-prescription medicines, and referral to other
professionals if necessary.
*
Promotion and support of healthy lifestyles.
Pharmacists can help people protect their own
health through health screening, giving advice on
healthy living and providing educational materials.
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 strengths of pharmacy. There was a high level of
consensus that the knowledge base of pharmacy
was very important. This is based on both the study
of and experience with medicines and also in
managing the medicines and handling relevant
information. A second strength which was seen as
important was pharmacists’ availability and
accessibility in a wide range of different locations in
the heart of the community, such as conventional
high street premises, health centres, supermarkets,
hospitals and in people’s homes. This accessibility
is strengthened by easy communication with both
patients and other professionals, giving pharmacists
a pivotal position. The growth of information
technology could be a potential threat to this,
although pharmacists are noted for their
adaptability.
*
Demonstrating the value of pharmacy. Pharmacy
must claim its rights as a profession and accept the
responsibilities which come with this. Thus high
standards must be set and achieved. Additionally,
evidence must be produced which demonstrates
clearly the value of pharmacy in health care. This
will require research and professional audit (see
Ch. 11). Further support for this development will
come from increased continuing education and
recognition achieved by effective promotion of the
profession.
*
Changes in practice. Three main areas where
there could be an increase in services were
identified. These are: the enhancement of
services to patients (advice, counselling,
domiciliary visits, health promotion and nonprescription medici ne sales); improved
relationships with other healthcare professionals
(closersupportforprescribers,medicine
management, l iaison between hospital and
community pharmacy and different communi ty
pharmacists, training for other professionals and
carers); and practice research and audit,
continuing education and better use of
information technology (all required to support
the other developments). There was also a high
5
SECTION ONE Pharmacy practice and society
level of support for a reduction in the mechanical
aspects of dispensing, sale of non-health-related
products and routine paperwork associated with
the NHS and business activities.
*
A sustainable future. These elements could make
up a sustainable future for the profession. In
particular, pharmacy would be concerned with
advice and counselling, dispensing, health
promotion, the sale of non-prescription medicines,
medicines management and as a first port of call for
health care. Some of these may require changes in
the setting of pharmaceutical provision and others
may require different types of employment for
pharmacists. Other changes which would be
required included changes to the system of
payment under the NHS, a rationalization of
pharmacy distribution and at least two pharmacists
being employed per community pharmacy.
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.
The NHS drugs budget
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 (PACTor 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 rec ognized that not all presc ribing
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 c ommunity 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 r esponsible 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 av ailable 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 r ole of the pharmacist
has therefore been greatly enhanc ed. 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’sroleasafirstline
provider of care for minor conditions, with a return
to the traditional pre NHS advisory role including
simple diagnosis and management.
6
The role of pharmacy in health care CHAPTER 1
The NHS workforce
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.
The current and future roles of pharmacists
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.
Community pharmacy
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.
Dispensing, repeat dispensing and
medication review
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. Electronictransmission
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 shouldallow access by the pharmacist to
7
SECTION ONE Pharmacy practice and society
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
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
8
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