The Pharmaceutical Journal
Vol 269 No 7207 p94
20 July 2002

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Inspiring work — respiratory patients benefit from pharmacist’s expertise

We have seen consultant hospital pharmacists in specialties such as cardiology, intensive care and renal medicine. One of the latest areas to benefit from the expertise of a specialist pharmacist is respiratory medicine, and the gains seen in secondary care may soon be coming to the community. Naomi Kempner talks to one of the first pharmacists to work in this area

Job promotion can have drawbacks. In the National Health Service, promotion is often accompanied by increasing management and administrative tasks rather than clinical duties. This may suit some employees, but not pharmacist Anna Murphy, who wanted to pursue her skills in respiratory medicine.

Fortunately for Ms Murphy, a new consultant post has recognised her expertise in care of the respiratory patient.

Ms Murphy, who works for University Hospitals of Leicester NHS Trust and is based at Leicester's Glenfield hospital, has now been working as a consultant respiratory pharmacist for one year and believes she is one of the first pharmacists of her kind for respiratory medicine.

After working at a respiratory hospital in Sussex, she moved to Leicester where she became directorate pharmacist for general and respiratory medicine. Her role involved providing services to wards and developing new services but it moved her away from patient care — a change she did not really want.

Funding then became available for both a respiratory pharmacist and pharmacy input into the hospital's specialist centre for adult cystic fibrosis. Ms Murphy recognised how the funding could be combined to create a consultant pharmacy post and developed the idea with Professor David Upton, pharmacy manager at the trust, and the consultant respiratory physicians.

She is now part of the respiratory care multidisciplinary team with her own caseload of patients referred from physicians, general practitioners, nurses in both secondary and primary care, and from other pharmacists. She is based on the hospital's respiratory ward, supporting inpatients as well as running outpatient clinics.

In her outpatient work, Ms Murphy deals mainly with asthma, chronic obstructive pulmonary disease (COPD — which includes chronic bronchitis and emphysema) and bronchiectasis, in addition to cystic fibrosis.

All the patients she sees have medication problems. Some have difficulties with compliance, others have suspected adverse reactions and many are receiving multiple therapies. Ms Murphy reviews all medication, not just respiratory medication. She ensures it is optimal, using therapeutic guidelines where appropriate. She also checks that medication is rationalised to fit with the patient's lifestyle as far as possible. Side effects are explored and possible interactions are investigated, whether with other medication, over-the-counter products or herbal medicines. Appropriate prescription of oxygen is also confirmed.

This, like checking theophylline levels, may resemble everyday clinical work with respiratory patients. But Ms Murphy also undertakes specialist roles, such as taking sputum samples to investigate antibiotic sensitivity, and performs spirometry to investigate lung function and to help diagnosis — especially of obstructive airways disease. She also carries out oximetry testing to check levels of oxygen in the blood.

Ms Murphy helps patients with smoking cessation and ensures they are suitably vaccinated, for example against influenza. Taking a holistic approach, she also aims to deal with non-pulmonary symptoms. These can include anxiety and depression, seen particularly in COPD, or the threat of osteoporosis from long-term steroid therapy. She can recruit help from other members of the respiratory team, such as the occupational therapist, as part of rehabilitation schemes that have been found to be effective in some types of lung disease. There are many cross-referrals to and from the hospital's respiratory nurse consultant.

As well as running an outpatient clinic, Ms Murphy visits around five patients at home each week. Some of these patients have compliance problems but most are housebound with severe respiratory disease. One aim of this service is to prevent patients from being admitted to hospital with a deteriorating condition. Ms Murphy says that although the home visit scheme is costly, it is regarded as a good quality service. She hopes that promising outcome data on its efficacy will be available by the end of the year.

In addition, pharmacy input is sometimes required in the hospital's early discharge scheme for respiratory patients, in which nurses visit and support patients at home for two weeks after they leave the ward.

Ms Murphy liaises closely with a specialist nebuliser nurse who works in the community and she is involved with a "hospital at home" scheme providing intravenous therapy for patients with cystic fibrosis and bronchiectasis. She also runs a telephone support service which, she says, provides reassurance and support that in a few cases has prevented hospital admission.

At present, Ms Murphy is funded by secondary care, but she hopes to pilot respiratory pharmacy clinics in the primary sector, operating from either GP practices or community pharmacies, with funding from primary care trusts.

At the very least, she sees a place for pharmacist medication review in the existing respiratory clinics often run by nurses in primary care. (These may have been established as asthma clinics and expanded to take on COPD and other respiratory patients.)

As part of the primary care project, Ms Murphy also hopes to provide training and education for community pharmacists and practice nurses. "Community pharmacists are in an ideal position to screen for common respiratory diseases," she says.

She is looking to work with pharmacy advisers who are setting up clinics in primary care, for example, reviewing asthma management. Either specialist pharmacists can go into established clinics or advisers can be trained to expand their services, Ms Murphy says.

Ms Murphy is a true advocate for consultant pharmacists. "I hope there will be expansion of this type of service," she says. "The role of the consultant pharmacist is not fully acknowledged, with no uniform job description yet available." She backs higher grades awarded to pharmacists for their patient care skills rather than those given solely for management.

"I do perceive a need for consultant respiratory pharmacists, particularly those who could offer a domiciliary service," she adds.

Ms Murphy may inspire a future generation of consultant pharmacists with her lectures on respiratory medicine to pharmacy, as well as medical and nursing students, and a plan to initiate her own student ward rounds.