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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR61

Exploring hospital clinicians' views of medicines management

By Selwa El-Beik and Rachel Elliott*

Introduction Medicines management can be defined as the promotion of safe, effective and cost-effective medicines usage, usually through the implementation of a range of policies, such as formularies and guidelines. In hospitals, this is directed historically by drug and therapeutics committees (DTCs), implementation of formularies and pharmacists' ward-based activities.1,2 Medicines management generally works by encouraging changes in clinicians' prescribing behaviour.3 The success of these activities is dependent upon clinicians' awareness and views of them and can be perceived as cost cutting that reduces clinicians' freedom.4 The investigation of clinicians' views of medicines management has not previously been explored.
This study was carried out at Central Manchester healthcare trust (CMHT), because a formulary is being implemented. The aim of this project was to explore clinicians' views on medicines management, particularly formularies, DTCs and pharmacists' role in medicines management.

Method Clinicians' views were obtained by carrying out 11 semi-structured interviews between December, 1999, and February, 2000. Semi-structured interviews were used to allow deeper exploration of views and experiences. A topic guide was developed from discussions with the medicines management pharmacist. An interview schedule was piloted on one senior and one junior clinician, then slightly modified prior to the full study.
To obtain views from a range of grades and specialties, a consultant, senior registrar, registrar, senior house officer and house officer were selected from each of the medical and surgical directorates, and a consultant anaesthetist. Twelve clinicians were selected from the hospital telephone directory and invited to participate in an interview; ie, a convenience sample was used. Eleven agreed to be interviewed. The interviews were tape-recorded and then transcribed. One interviewee did not agree to be tape-recorded but field notes of the interview were made.
Qualitative analysis of the 11 transcribed interviews was then carried out, using the thematic approach. The main themes identified were views around DTCs, formularies and pharmacists. Areas of particular consensus or dissent were examined, and relationships between themes were also investigated.

Focal points

  • Formularies are perceived as restrictive lists of drugs aimed at cost-cutting
  • Clinicians are generally unaware of the role of the drug and therapeutics committee in medicines management
  • Clinicians are supportive of formularies that contain guidelines, are user-friendly and contain information on doses and side-effects
  • Clinicians feel that there is a lack of communication and interaction between themselves and pharmacists
  • Clinicians are supportive of the role of pharmacists in medicines management

Results The key themes expressed can be summarised in the following categories.
DTCs - There was poor awareness among junior doctors of DTCs. Negative experiences of DTCs were reported, but generally there was no strong opposition.
Formularies - A formulary was perceived as just a restrictive list of medicines, to decrease costs. Junior clinicians felt a formulary allowed standard prescribing. Senior clinicians and pharmacists should decide the content of a formulary. It had to be broad, with choice and guidelines, and it should be available, publicised and user friendly and should include information on doses and side effects.
Pharmacists' role in medicines management - All clinicians supported the role of pharmacists, but there was a lack of communication and interaction between pharmacists and clinicians, and pharmacists should attend ward rounds. Pharmacists should audit formularies and provide feedback. Pharmacists could have more power to correct mistakes on charts or to write in the patients' notes.

Discussion This study discovered a relatively high level of consensus around the issues of DTCs, formularies and the pharmacist's role. DTCs need to work to improve clinicians' awareness of their contribution to medicines management. Formularies are more likely to succeed if they are acceptable to the customer. As a result of this study, recommendations have been made to aid formulary implementation within CMHT.
Although the results of this study are only directly applicable to CMHT, more general recommendations can be made. Further work of this kind must be carried out in co-operation with primary care prescribers as joint formularies are developed.
This study suggests that clinicians value the role of the pharmacist but it is clear that, as pharmacists become more strategic members of medicines management, they must examine their relationship with clinicians.

Pharmacy department, Manchester Royal infirmary; *School of pharmacy and pharmaceutical sciences, University of Manchester

References

1. Leach RH. Drugs and therapeutics committees in the UK in 1992. Pharm J 253;61-3.
2. Joshi MP, Williams A, Petrie C. Hospital formularies in 1993: where, why and how? Pharm J 253: 63-5.
3. Fuller S, Petty D. Develop evidence-based guidelines. Pharmacy in Practice 1998; (Feb):50-8.
4. Onion CWR, Walley T. Clinical guidelines: development, implementation, and effectiveness. Postgraduate Med J 1995;71:3-9.