The history of clinical pharmacy in the UK

The history of clinical pharmacy in the UK

Clinical pharmacy is now practised in all healthcare settings, but its main origins lie in the hospital sector. Until the mid-1960s, hospital pharmacists were mostly engaged in traditional pharmaceutical activities such as dispensing and manufacturing. Then, the increasing range and sophistication of medicines available, awareness of medication errors and the widespread use of ward-based prescription charts brought pharmacists out of the dispensary and on to the wards in increasing numbers.

This was initially described as ‘ward pharmacy’ and was mostly a post hoc process with the emphasis on the safe and timely supply of medicines in response to medical and nursing demands. However, the service quickly evolved into something significantly more proactive, seeing pharmacists inter-acting with patients and other healthcare professionals and directly interven-ing in the patient care process. The growth in these services over the 1970s and 1980s was said to represent a change in hospital pharmacy from product orientation to patient orientation and was formally acknowledged as ‘clinical pharmacy’ in the 1986 Nuffield report. The report welcomed these changes and recommended an increased role for hospital pharmacists through the development of clinical pharmacy services.

The recommendations made in the Nuffield report were officially recog-nised in a 1988 Health Services circular that outlined the main aims of the Department of Health with respect to hospital pharmacy:

the achievement of better patient care and financial savings through the more cost-effective use of medicines and improved use of pharmaceutical services obtained by implementing a clinical pharmacy service.

A number of key areas where pharmacist input could assist other clinicians and benefit patients were highlighted, including contributing to prescribing decisions, monitoring and modifying drug therapy, counselling patients and involvement in clinical trials. The document acknowledged that, by helping to ensure patient safety and appropriate use of medicines, clinical pharmacy services could prove to be cost-effective.

As clinical pharmacy services expanded, there was increasing specialisa-tion, with the expertise of individual pharmacists in certain therapeutic areas contributing to more significant developments in service provision. The speed of progress was demonstrated in a review undertaken in the early 1990s, which showed that the majority of NHS hospitals in the UK provided clinical pharmacy services and most hospital pharmacists participated in ward-based clinical pharmacy activities. However, the range of clinical pharmacy ser-vices varied enormously, from almost 100% of hospitals having pharmacists who monitored drug therapy to less than 10% for services such as infection control, clinical audit or medical staff education. Since then, the widespread development of clinical pharmacy services has continued, with significant expansion in the number and range of services provided at most hospitals.

Wide variations in the extent and nature of hospital clinical pharmacy services were also noted in the Nuffield report and large differences still exist across much of the UK. This lack of uniformity applies not just to clinical pharmacy, but also covers almost every aspect of hospital pharmacy services. The absence of specific directions from government and from the pharmacy profession, coupled with the varying degrees of success with which individual pharmacy managers in each hospital have been able to develop services, has allowed diversity to flourish with wide variations in the proportion of time spent on clinical pharmacy activities, ranging from less than 30% of pharma-cist time at some hospitals to over 70% of pharmacist time at others. The Audit Commission recommended that hospitals undertake reviews of their staffing levels and consider whether there were adequate resources to provide all aspects of clinical pharmacy services, so it is likely that the national figures on implementation of clinical pharmacy services will be changing for some time.

One of the differences between hospital and community pharmacy is the location of the patient and how this affects the dynamics of providing clinical pharmacy services. Most hospitals provide their pharmaceutical services to patients on (but not exclusively) wards of various kinds. Thus, in order to deliver care the pharmacist needs to visit the ward and interact with the patient, doctor, nurse and others, as well as have access to consult and contribute to the patient’s medical records.

Clinical pharmacist presence on wards allows dialogue with patients and professionals in addition to ensuring supplies of medicines are adequate for patients’ needs, and that medicines are stored appropriately and safely. Pharmacy technicians, assistants and others work with ward staff to provide effective supply of commonly used items and, with the pharmacists, are increasingly leading the introduction of the reuse of patients’ own drugs (PODs) schemes to reduce waste and, where appropriate, patient self-medication to support concordance.

The importance of communicating requests for medicines and the need to record administration of medicines have led to the universal usage of the ward prescription chart. Various reports on the value of recording the prescription and administration of medicines emanated from situations where there was no record of them having been given. Requiring nurses and doctors to record the administration of medicines offered the rudiments of an audit trail for medicines.

The design and use of these charts have consumed much time and energy from a variety of clinicians in order to produce a hybrid document that serves the multiple purposes of conveying: (1) patient details such as iden-tification, age, weight, gender and allergies; (2) prescribing details such as medicine, form, dose, route and frequency of administration and previous medicines; and (3) medicine administration details including who adminis-tered (nurse, doctor, patient), when and by which route. It also serves to indicate when a medicine has not been given. An alert from the National Patient Safety Agency on reducing harm from omitted and delayed medi-cines in hospital requires all healthcare organisations to identify a list of critical medicines where timeliness of administration is crucial.¹⁶ It also requires them to ensure that medicine management procedures include guidance on the importance of prescribing, supplying and administering critical medicines, timeliness issues and what to do when a medicine has been omitted or delayed. Incident reports should be regularly reviewed and an annual audit of omitted and delayed critical medicines should be under-taken to ensure that system improvements to reduce harms from omitted and delayed medicines are made. Figure 9.1 is an extract from a typical hospital inpatient medicines chart.

The Welsh NHS took this one step further in 2004 with the introduction of a new all-Wales prescription chart, accompanied by prescription-writing standards and an e-learning tool installed on the intranet systems of hospital trusts and included in medical degree teaching.

The important sets of prescription form data are essential for the efficient and effective delivery of pharmaceutical care to the patient and also form the basis for the development of electronic prescribing systems within the NHS. This is discussed further in Chapter 15.