Pharmacy in Practice

The traditional role of the community pharmacist is the sale and supply of medicines, including the dispensing of those prescribed by general medical practitioners as well as over the counter (OTC) sales of medicines for self-medication. Dispensing includes authenticating the prescription, reviewing and confirming it, filling it, and advising patients on the safe and effective use of the medicine.

The development of additional professional roles has enhanced pharmacists’ roles within the health care team. ‘Medicines Management’ encompasses a range of activities intended to improve the way that medicines are used, both by patients and by the NHS. Medicines management services are processes based on patient need that are used to design, implement, deliver and monitor patient-focused care. The Priorities for Action has endorsed the development of a Medicines Management service so that the full utilisation of community pharmacists’ skills can begin to take place. Areas that community pharmacy can contribute to the Medicines Management agenda include ongoing medication review, improving patient concordance with prescribed medication, developing care programmes and services for ‘at risk’ patient groups, protocols for patient counseling and self-medication, health promotion and multidisciplinary research, audit and drug utilisation review.

The role of the community pharmacist has long been established. However it is also important to note the substantial role pharmacists play in providing prescribing support. In this context there are a number of pharmacists working at individual practice, Local Health and Social Care Group and HSC Board level. These pharmacists also contribute to the Medicines Management agenda. Examples of the key areas of involvement include prescribing analysis and feedback; formulary development and maintenance; review and management of repeat prescribing processes; and medication review.

Another area where work is underway is the development of prescribing policies across the primary/secondary care interface and across the whole of the pharmaceutical sector developing opportunities for pharmacist prescribing allied to the Crown Report.

Health Service dispensing is carried out under contract between the owners of each pharmacy and the Area Health and Social Care Board. Of the 508 registered pharmacies in Northern Ireland, 504 hold health service contracts; the other 4, therefore, although able to sell medicines, do not dispense health service prescriptions. Formerly the owner of any registered pharmacy premises was entitled to apply for and automatically receive a health services contract. However, on 1 July 1987 a newly negotiated contract for community pharmacists came into being and this, for the first time, limited entry to the pharmaceutical list. A contract will now be granted only if the applicant can demonstrate that the provision of the intended pharmaceutical services is ‘necessary and desirable’.

Each Health and Social Services Board determines what is ‘necessary and desirable’ by means of a Pharmacy Practice Committee. An independent National Appeals Panel will consider any appeals from a Board’s decision either to grant or refuse a contract. The Health and Personal Social Services Pharmaceutical Services Regulations (Northern Ireland) 1997 provides for the Terms and Conditions applying to pharmaceutical contractors as well as matters relating to the control of entry.

As indicated earlier pharmacy practice has been evolving to meet the needs of a contemporary health care system. The modern role of the community pharmacist is well articulated in the Report of the Joint Working Party on the Future Role of the Community Pharmaceutical Service published in 1992. Added to this has been a major and ongoing initiative by the Royal Pharmaceutical Society of Great Britain, ‘Pharmacy in a New Age’ which seeks to set out what pharmacy does and can offer, supported by, for example, IT, education and training, audit and research. Similarly, the Pharmaceutical Society of Northern Ireland has also published ‘Vision 20/20’ its own strategic document for the future of community pharmacy. Emerging from this are some key themes, namely the role of the pharmacist in:-

In 2002/2003, the DHSSPS has been working with stakeholders and produced the consultation document Making it Better  (PDF 234 KB) - A strategy for pharmacy in the community. The consultation period will last until mid September 2003, after which the finalised Strategy and Action Plan will be issued.

The evidence from a local survey commissioned by the Department into the public utility of community pharmacy demonstrated the opportunities for, and impact of, these services on the health and well-being of the public.

Over 120,000 people visit community pharmacies on a daily basis reporting high levels of satisfaction with the services provided. Over 80% of people visit the same pharmacy consistently rising to over 90% in the elderly population. Therefore, community pharmacy can be regarded as the ‘open door’ of the Health Service.

On the strategic front, the Central Pharmaceutical Advisory Committee to the DHSSPS has produced a strategic agenda outlining the pharmaceutical dimensions of implementing the current strategy for Health and Social Well-being in Northern Ireland. This takes as its theme ‘Pharmaceutical Care and Medicines Management’ and demonstrates the ways in which pharmaceutical skills can be fully utilised to benefit patients.

The Department has since allocated funding to HSS Boards for the implementation of a community pharmacy based medicines management service, which centres upon a review of medication for those patients deemed to be at risk because of multiple therapy, poor compliance or lack of career support. Further developments of medicines management services have been called for under the first report of the Review of Community Care  (PDF 303 KB).

The Central Pharmaceutical Advisory Committee has also undertaken some novel work setting out the opportunities for building partnerships between community pharmacy practices and the communities they serve. This supports the community development concept aimed at enabling communities to contribute to the development of health and social services specific to their local needs. The subsequent project report is available here

This initiative has attracted considerable interest across the statutory and voluntary sector and work is in progress with the Community Development Health Network to develop these concepts in practice.

Paralleling these initiatives is the wider development primary care policy and within this progressing the extended role of community pharmacists. The recommendations arising out of the UK wide Review of the Prescribing, Supply and Administration of Medicines, published in 1999, will have an impact on future practice and the first resultant legislative changes on Patient Group Directions were introduced in August 2000.

The Department has galvanised these various developments by commissioning the production of a Strategy for Community Pharmacy. This is due to be published in 2003.

Up to the mid 1960’s, the majority of hospital pharmacists engaged in the traditional pharmaceutical activities of dispensing medicines and manufacturing pharmaceuticals. The most significant development in the intervening period has been the pharmacist’s increasing clinical involvement, supported through the Department’s circular in 1989 and, in effect, applying the pharmaceutical care concept articulated above. The result has been that modern hospital pharmacy has been moving to a very substantial direct ‘patient orientation’ as opposed to a merely ‘product orientation’ in the provision of its services and clinical pharmacists are a well-established cadre of practitioners.

Clinical Pharmacists have become involved in specialist clinical roles that reflect the increased complexity of modern drug treatments. These include:

Through participation in these activities hospital pharmacists are a vital part of the clinical team with their own unique contribution to make to patient care. It is estimated that a hospital may spend as much as 40% of its clinical supplies budget on medicines. The pharmacist’s knowledge and present clinical roles can help to ensure that, in co-operation with medical colleagues, medicines’ budgets are used to best effect. This does not necessarily mean seeking out the cheapest available product but it does mean selecting medicines that are best suited to a particular patient’s need.

The comprehensive training of pharmacists on all aspects of medicines' use - from formulation to applied therapeutics - makes these professionals pivotal to the medicines management process, ensuring the safety, efficacy and economy of drug use.

A review of clinical pharmacy services  (PDF 349 KB) has recently been undertaken in Northern Ireland.

There have, of course, been other significant and important developments in hospital pharmacy, which may be seen as developments of the pharmacist’s traditional role. These include:

These services recognise the pharmacist’s expertise in the aseptic preparation of prepared sterile solutions for administration to patients. Such preparations, due to the very high standards of quality and safety required, must be under the control of a pharmacist. TPN Services provided by hospital pharmacies are an essential ingredient in maintaining patients at home who otherwise would be hospitalised.

This is a growing service and will be crucial to the performance of the designated cancer centre and five cancer units in Northern Ireland. The functions are twofold: firstly a technical function, similar to the above, in the aseptic preparation of medication for oncology patients. Secondly it draws on the pharmacist’s clinical skills and in particular the counselling and education of patients relative to ensuring maximum safety and efficacy in their use of medicines.

Pharmacists are also involved in the provision of radiopharmaceuticals for diagnostic and therapeutic use and in this area collaborate closely with the Northern Ireland Medical Physics Agency.

Manufacture and assembly of pharmaceutical products has been a common feature of the work of hospital pharmacy departments for some considerable time. However, since Crown Exemption was removed from hospitals in 1992, this work is now concentrated in a number of specialised production units. The Trusts now hold Medicines Act Manufacturer’s (Specials) Licences, which are issued by the Medicines Control Agency of the Department of Health (London) following inspection by the Medicines Act Inspector for Northern Ireland.

The Regional Pharmaceutical Laboratory Services (RPLS) offers the full range of quality control (QC) support to pharmaceutical production and assembly in Trust Pharmacies or other facilities, including the Regional Medical Physics Agency, where medicinal products are being prepared and dispensed. There is also, however, local QC input at each manufacturing facility as required under the terms of a Manufacturer’s licence. Local QC services also function to support, for example, aseptic dispensing services and medical gas testing. The RPLS is managed through the BCH Trust.

Clinical pharmacy services are closely allied to, or supported by, pharmacy based drug information services. This has always been a traditional role of the pharmacist, but the increasing complexity of the work has led to its development as a separate specialty. Each major hospital has its own drug information resources, which support the provision of evaluated information about particular drugs to health care staff both in primary and secondary sectors. The Regional Medicines and Poisons Information Centre, based at, and managed from, the Royal Hospitals Trust, provides in-depth information on a Province wide basis, publishing quarterly information bulletins (‘Drug Data’) on topical issues of importance. It also operates as a source for poisons information and in both dimensions of its work collaborates closely with medical colleagues.

In April 2000 Chief Executives of HSS Trusts reconstituted the Pharmaceutical Contracting Executive Group charged with securing optimal arrangements for the regional procurement of pharmaceuticals held in the hospital sector. New systems of contracting have been developed to move from a product-based system to a therapeutic based system where safety, quality efficacy and economy are the key elements in comparing products in the same therapeutic class. A pharmacist specialist, based in United Hospitals Trust, acts as a regional co-ordinator for the procurement of medicines for Trust Hospitals.

The establishment of Self-Governing Trusts throughout the hospital services in Northern Ireland has dramatically changed the structure of the hospital pharmaceutical service, which had been managed by the Area Health Boards through their respective Directors of Pharmaceutical Services.

With the emergence of Trusts, however, the role of these Directors has undergone significant change. Whereas, formerly, they had overall responsibility for the professional management of the service, they are now concerned with the commissioning or securing of pharmaceutical services consistent with the needs of each Board’s population.

The management of the hospital pharmaceutical services has now devolved to the individual managers of pharmaceutical services at each Trust who are, together with their clinical counterparts, accountable to their respective Trust Chief Executives.

To ensure a consistent approach to risk management within the HPSS, the DHSSPS has recently issued controls assurance standards. The Medicines Management Controls Assurance Standard issued in April 2003 will contribute to this consistent approach.