Hospital Pharmacist Vol 7 No 7
p202-204
July 2000 Interview
Bob Leach: Benefiting from a broad spectrum of experience
By I. Harrison, MBA, MPhil
The tables are being turned on our interviewer, Bob Leach. Here, Ian Harrison, health care consultant, speaks to him about his wide-ranging experience in pharmacy
Bob Leach's career spans a 40-year period, during which he has practised in several areas of pharmacy. During this time, he adapted well to each change in health care organisation. Younger pharmacists should find much from this interview to encourage them in their career development and survival strategies.
Ian Harrison: Bob, many hospital pharmacy managers probably know you as the editor of Pharmacy Management. How did you get involved in editorial work?
Bob Leach: I was invited to join the editorial board of Pharmacy Management from its inception in 1985 and, apart from the first one, I have edited every edition to date. I had previously done some writing, including several years of preparing (under the "Clinicus" nom de plume) the hospital "Broad Spectrum" column, as it was known then, for The Pharmaceutical Journal. Through this medium I endeavoured to advocate strongly for the development of hospital practice and also encourage individuals when hospital work hit the doldrums.
IH: You have an impressive list of some 40 publications, most of them in peer-reviewed journals. What were the topics you collaborated on for publication in the late 1960s?
BL: Owing to my move from the position of deputy chief pharmacist at the City hospital, Nottingham, to that of chief pharmacist at Birmingham Children's hospital, my interests largely related to paediatric formulations and their stability. Dosages for children based upon body surface area as opposed to weight, the effect of tetracyclines on growing teeth, and the avoidance of sugars in paediatric products were all important areas at the time, to which I contributed.
IH: I observed that many of your early publications had a strong laboratory-based, quality control element.
BL: Yes. This was because we had so many local formulations but were short of stability data. One particular study I undertook over a number of years had to do with the sterilisation and shelf life of chloramphenicol in topical formulations. The work originally started because, like many hospitals using substantial quantities of chloramphenicol eye drops, we prepared our own rather than individually reconstituting the commercially available freeze-dried product. We also prepared chloramphenicol as an intrathecal injection at that time. It was interesting to note that, although both products (the plain intrathecal solution and the buffered eye drops) were autoclaved, the plain injection solution underwent less hydrolysis of the amide moiety than the borate-buffered eye drops. However, at room temperature, the buffered product was more stable. My work, which at this time was being supervised by the late Ken James at the Welsh school of pharmacy, where I had graduated, showed that ion catalysis from the borate buffer speeded hydrolysis at high temperatures while, at room temperature, chloramphenicol formed a complex with borax which aided stability. (J Pharm Pharmacol 1970;22:607-11, 612-4). Subsequently, the monograph in the British Pharmaceutical Codex for chloramphenicol eye drops introduced a limit test for the amine formed by hydrolysis of the amide link.
Another interesting study, undertaken as a pre-registration project with Peter Hopley (who later became chief pharmacist at the Royal Victoria Infirmary, Newcastle upon Tyne and area pharmaceutical officer for Newcastle) and David Bott, examined pharmaceutical gums - complex galactosides which were potentially capable of undergoing hydrolysis in the gut to release galactose.
My interest in gums was aroused because mucilage of tragacanth or acacia might not have been suitable suspending agents in medicines for children with the rare disease of galactosaemia, where the enzyme which converts galactose to glucose is congenitally absent, leading to severe galactose-induced brain toxicity. Fortunately, we showed that these and a number of other gums were unlikely to release galactose when acted on by human amylase and disaccharidase. (Arch Dis Child 1970;45:436-7)
IH: After leaving Birmingham Children's hospital, you were involved in a computer prescribing project with clinical pharmacologists.
BL: That is true. In 1969 I joined a clinical pharmacologist and a number of computer experts to develop a computerised prescribing system at the Queen Elizabeth (QE) hospital. Linda Beeley was a clinical pharmacologist in the department of Owen Wade, who was professor of clinical pharmacology. Professor Wade became well known in the field of adverse drug reactions. John Bishop, one of the professors of medicine with a keen interest in using computers in medicine, had secured funds from the Department of Health as part of a large computer project at QE hospital. He and Paul Spencer, who was then professor of pharmacology at the University of Aston where I was a visiting lecturer, recruited me to the project designed to improve the safety and precision of prescribing.
The system was to be capable of checking for dose and drug-disease or drug-drug contraindications, and the concept was ahead of its time. It suffered from being slow and from the fact that, in those days, health care professionals were not used to working with computers. Furthermore, devising systems that would enable staff to record the administration of medicines was a particular problem. However, I learnt a lot, and so did the several pharmacists who followed me on the project. Although it went to trial on a ward, the system did not find its way into routine use. Subsequently, I became a honorary lecturer in Professor Wade's department. I wonder whether clinical pharmacology could enjoy a resurgence in today's evidence-based medicine culture.
IH: Going back to hospital pharmacy, the 1970 Noel Hall report was implemented very early in the West Midlands under the influence of Graham Calder, the first regional pharmacist. Were you involved?
BL: Yes. I was fortunate to be appointed as Noel Hall area pharmacist for the Birmingham teaching hospitals in 1972. It was certainly a time for service development and we made great strides in drug information, quality control, sterile production, aseptic preparation or manufacturing and tablet pre-packing across the teaching hospitals. We were also well placed to develop ward pharmacy in all our hospitals.
We had major pharmacies at the General, Children's and QE hospitals which, for most of my time, were ably led by Ron Purkiss (and later by Anne Cope), Neeta Dain and Steve Potter respectively. They were each able to recruit excellent staff to carry forward the developments. Alan Broad commissioned and managed the important sterile fluids unit, which became a licensed supplier of specials to many hospitals within the region and beyond. We worked very much as a team. Ron Purkiss was an important innovator who provided real leadership and encouragement to his own staff and on a much wider scale.
I was particularly pleased to see emphasis rapidly shift from a supply orientation to a clinical pharmacy service. This was aided by the contributions made by many clinically aware pharmacists right across the district and by the effort they put into their work. It is probably invidious to quote examples, but Celia Feetam and Christine Hassall, who were initially at QE during their Aston MSc course, chose projects involving warfarin which I had suggested and supervised. They were able, early on, to show that pharmacists had expertise of their own beyond supply and patient monitoring and were able to make scientific contributions to the use of medicines in clinical practice. Celia's project demonstrated the absence of an important interaction between warfarin and ascorbic acid in large doses (Toxicol Appl Pharmacol 1975;31:544-7). Christine Hassall's work examined the potentiation of warfarin by co-trimoxazole (BMJ 1975;2:684 and Lancet 1975;2:1155).
IH: You also undertook some bioavailability studies, I believe?
BL: Wellcome, the original manufacturer of digoxin (as Lanoxin), changed their tablet formulation in 1972. This caused both bioavailability and clinical problems as there were two-fold differences between the old and new Lanoxin. Originally working together on a pre-registration project, Jeff Poston (now at the Canadian Pharmaceutical Association), Jeff Fraser and I showed that these differences could be predicted from work on dissolution profiles which showed a substantial variation between the many generic products available on the UK market. In the pharmacy at QE hospital, we examined the dissolution rate of 13 brands available in 1973 and carried out in vivo studies on four. The brand that was supplied on our regional contract had three times the bioavailability of the "old" Lanoxin. (Lancet 1972;2:541 and J Pharm Pharmac 1973;25:968-73). As a result of the problems with digoxin bioavailability, the British Pharmacopoeia monograph for digoxin tablets introduced a standard for dissolution rate, the first such in the pharmacopoeia. In subsequent work, I was able to relate the dissolution rate with the particle size of digoxin.
IH: In terms of your career, how did the various NHS changes affect you?
BL: In 1974, I became area pharmaceutical officer for Birmingham. I retained management responsibility for the services to the teaching district, but assumed a co-ordinating responsibility across both Birmingham's five districts and with community pharmacy. It was an important post, since Birmingham, with a million residents, accounted for 2 per cent of the English population. When, in 1981, area health authorities were abolished, I returned to the teaching district on a full-time basis.
IH: What happened next in organisational terms?
BL: In 1991, our district combined with South Birmingham district but subsequently divided into six separate NHS trusts and no longer required a pharmaceutical manager across the new trusts. I was therefore offered retirement. At the age of 55, I felt too young to stop working, so I decided to set up my own consultancy and writing business.
I was very fortunate to secure early work with the European Commission project to assist the Commonwealth of Independent States (CIS) - the former Russian republics - in purchasing medicines and medical equipment to maintain their health services. The work involved scrutiny of various tenders from the European Economic Community (EEC) or CIS countries, and it was interesting to work with a number of European pharmacists. Towards the end of this work I found myself working with Ian Simpson, whom I had known for many years, and this proved a bonus. Ian was then district pharmaceutical officer for Oxford. I was previously involved in the team under his direction which devised the Northern Ireland pharmacy audit document.
IH: You also became a pharmaceutical adviser.
BL: Initially, I worked on a part-time basis for Gloucester health authority, based in my home town. The brief was mainly the resolution of primary and secondary care interface problems and working with GPs. In 1994, I became a pharmaceutical adviser to Dudley health authority, where I stayed for five years. On a half-time basis, I assumed the full range of duties, working alongside the medical adviser. I became involved in prescribing analyses and cost (PACT), practice visiting, budget setting and monitoring, organisation of the prescribing incentive scheme, advising the health authority on community pharmacy and advice on funding of medicines and pharmacy services in secondary care. I also served as a member of hospital drug and therapeutic committees, secretary of the area prescribing committee and so on.
Andy Wakeman, the medical adviser, and I, undertook two studies during this time. First, we carried out a national survey of area prescribing committees in England to assess their characteristics, progress and effectiveness, as we were anxious to see how our local committee was performing compared with others. (Health Trends 1997;29:52-4). Second, we were keen to see how effectively community pharmacists, given extra training, could work with GPs to improve the cost-effectiveness of prescribing. This study proved encouraging, was well supported by GPs and showed good potential (Pharm J 1999;263:206-9).
IH: Tell me about the survey. What were the findings?
BL: The survey found that 39 per cent of pharmaceutical advisers judged their local committees to be effective or very effective while a further 52 per cent rated them as moderately effective. It was very interesting to note that these figures corresponded almost exactly with the results of a survey of hospital drug and therapeutics committees I had conducted in 1994 (Pharm J 1994;253:61-3). There was very considerable overlap of work between committees and this suggested there was a need for either national or regional committees to undertake some of this work. Perhaps this study contributed to the many other reasons which led to the establishment of the National Institute for Clinical Excellence.
IH: You have now left the health authority to work for a primary care group (PCG)?
BL: I have. It became impossible to carry out my duties on a part-time basis. This would have become more of a problem when our health authority split into five PCGs. I therefore worked to convince the authority that they needed a full-time appointee to co-ordinate prescribing across Dudley, including with the local trusts. I was fortunate to secure a part-time PCG prescribing adviser post for one of our Dudley PCGs.
IH: As primary care groups aspire to trust status, what challenges do you see for pharmacy?
BL: The pressure from the chief executives to save on prescribing continues, possibly because the NHS Executive has oversold the potential savings to the Treasury and the health authorities. Generic prescribing rates have doubled from 35 per cent to 70 per cent over almost 10 years and, of course, this has been the easiest method of making savings but is now exhausted for most PCGs. GPs are feeling demotivated and perceive that there will be insufficient resources to implement the National Service Frameworks. It will be difficult for young pharmacists to support adequately the quality aspects of prescribing which remain of equal importance to cost-effectiveness. If GPs were to perceive that prescribing advisers were no longer unbiased and tended to recommend cheap, rather than cost effective prescribing, advisers would rightly lose all credibility.
A key issue for the profession is to determine who will co-ordinate PCG prescribing advisers and their messages across the interface between primary care groups and trusts (PCG/Ts) and acute hospital trusts. PCG advisers will not generally be hospital employees since the trend is for PCG/Ts to appoint their own staff. The answer, of course, is for the health authority prescribing adviser to work with the area prescribing committee which has PCG advisers, hospital DTC (drug and therapeutic committee) chairmen, trust chief pharmacists and GP leads as members.
IH: What advice would you give to the new breed of primary care pharmacists/prescribing facilitators?
BL: Those at practice level who have a community pharmacy base will need a high degree of clarity regarding their role, professional and managerial co-ordination, and adequate training to cover behavioural and clinical competencies
IH: What would you most like to see changed for the benefit of the profession?
BL: Probably the implementation of pharmacist prescribing in long term chronic therapy and in appropriate hospital settings. Allied to that, I am aware that many patients still receive prescriptions for items or dosages they no longer need. We therefore require fuller access by pharmacists to repeat prescribing systems with authority not only to review medication but to take action to discontinue or change medication where appropriate.
I also want to see pharmacists actively contributing to formularies and treatment guidelines common to primary and secondary care.
IH: You have received impressive professional awards and have been active in a number of professional groups. Tell me about these.
BL: It was an honour to be made a Fellow of the Royal Pharmaceutical Society and to receive the Guild of Healthcare Pharmacists (GHP) gold medal. I had been an active member of the guild over the years, including serving as secretary to two of its branches.
I was made a member of the College of Pharmacy Practice on the basis of the publications mentioned earlier. I have particularly valued my involvement with the Association of Teaching Hospital Pharmacists. It was characterised by an excellent corporate spirit among some of the most able and experienced hospital pharmacists in the UK. From 1980 to 1986, I was also the vice-chairman, then chairman, of the Association of Pharmaceutical Officers. In Birmingham, I had served on the local branch committee for some years and was chairman of the local British Pharmaceutical Conference committee in 1992.
IH: If there were one or two of your actions that you feel have had far-reaching implications for the profession, what would you cite?
BL: I believe my contribution to the development of ward pharmacy in the early days was important. In order to gain national momentum there had to be several early centres across the UK. The Birmingham teaching hospitals certainly became one of these. I was also involved in original negotiations which led to the setting up of the Aston MSc course for hospital pharmacists and this was very important at the time.
I also feel that I have made worthwhile contributions by stimulating others to achieve - perhaps through encouragement when undertaking developments, projects or investigational work. It is important to the profession that able junior colleagues are supported, gain expertise and promotion, and that these colleagues integrate their scientific knowledge and organisational skills to the benefit of patients in both hospital and community practice.
IH: It must be a unique "selling" point for you that, unlike many interviewed in this series, you have taken on roles in different areas of the profession. Your need to change with the professional environment reminds me of the Acker Bilk song "Travelling On". You have been involved in community pharmacy, hospital pharmacy (including teaching hospital experience), academia, publishing, consultancy, health authority and now primary care group work.
BL: I think on the whole I am fortunate to have gained such a broad experience. Perhaps I should now experience more holidays and travel!
IH: On behalf of the readers, thanks for sharing your thoughts and, of course, for providing us with the excellent interview series in Hospital Pharmacist.