Hospital Pharmacist
Vol 9 No 9 p250
October 2002

Why hospital pharmacists should keep looking over their shoulders

By Stuart Anderson, PhD, MRPharmS

Hospital pharmacy has had more than its fair share of scrutiny by committees of enquiry, with recent reports continuing that trend. Until now, that trend has extended from the earliest one, undertaken by the Royal Pharmaceutical Society on the eve of the Second World War in 1938, through to the Nuffield report on pharmacy in 1986, which contained some 39 recommendations concerning the hospital pharmaceutical service. In between were no fewer than three other reports of enquiries into the service: the first and second Linstead reports in 1955 and 1958, and the Noel Hall report, published in 1970.

The recent reports on the hospital pharmaceutical service have appeared under the aegis of the Audit Commission. The first of these, "A spoonful of sugar — medicines management in NHS hospitals," was published in December 2001. The second, "Medicines management," appeared in the "Acute hospitals portfolio: review of national findings" series and was published in June 2002. These should be read in conjunction with another document, "Pharmacy in the future — implementing the NHS plan" which was published in September 2001.

When so many reports emerge from so many different sources, there is a danger that the significance of some may be missed. But no one should underestimate the importance of the recent reports from the Audit Commission. In many ways, they can be interpreted as a glowing endorsement of hospital pharmacy, both in how it is currently practised and what it plans for the future. However, they are hugely significant documents in several important ways.

First, the reports give a clear indication of how individual health care professions are perceived in Government and elsewhere. The focus of "A spoonful of sugar" is not on a particular group of staff (in this case pharmacists) but on a process which is patient orientated (in this case medicines management). This represents a substantial shift in previous forms of enquiry, which have generally been initiated by professional concerns rather than patient ones.

Secondly, the approach taken is a multi-professional one. "A spoonful of sugar," calls for the removal of barriers between the various health care professionals, emphasising the generic nature of many health care skills. Optimum medicines management will only be achieved by effective action from doctors, nurses and pharmacists working together.

Thirdly, these approaches together represent official endorsement of the value of the concept of "medicines management," a key element of which is its emphasis on multi-professional teamwork. By inference, there is no official support for the concept of "pharmaceutical care," which suggests a single disciplinary approach to a complex and multi-faceted issue. Pharmaceutical care, a term which achieved recognition in the 1990s, clearly has no future and it is inevitable that the term will be quietly dropped.

Fourthly, and perhaps most significantly, the recent reports represent the latest in a long series of enquiries into the state of the hospital pharmaceutical service in Great Britain. Together, the reports tell the story of the progress and development of the hospital pharmaceutical service from the middle of the 20th century to the beginning of the 21st. "A spoonful of sugar" represents the final stage in this process.

In many ways, "A spoonful of sugar," along with the other documents, represents the "re-medicalisation" of hospital pharmacy. Three major shifts in this direction can be identified. First, "Pharmacy in the future" proposes a new model in which pharmacists have an important role in the diagnosis of disease state. Hospital pharmacists already have some limited confirmatory diagnostic rights, at least in relation to medication review on admission.

The second shift towards the "re-medicalisation" of pharmacy is the move to give pharmacists prescribing rights of their own. These are likely to be limited initially, but also seem likely to increase as time moves on.

Thirdly, one of the specific recommendations of "A spoonful of sugar" is that the role of chief pharmacists should be elevated to the equivalent of a clinical director and that they should be members of the trust's management executive.

With "A spoonful of sugar," the battle which hospital pharmacists fought for much of the 20th century — for role, status and recognition — has effectively been won. Is all this good news, or are there cautionary lessons to be learnt from pharmacy's past? Is the "re-medicalisation" of hospital pharmacy really what hospital pharmacists have aspired to, and is the move towards it now unstoppable?

Hospital pharmacy has been here once before. In the early 19th century, hospital pharmacy began to achieve a degree of recognition which had previously been lacking, particularly in the voluntary hospitals which generally employed apothecaries rather than less qualified individuals. However, the Apothecaries Act of 1815 recognised the right of apothecaries to diagnose and treat patients as well as supplying medicines. As a result, most hospital apothecaries chose to practise as physicians rather than as hospital pharmacists. The consequences for hospital pharmacy were dire. In reviewing progress in 1955, the first Linstead report concluded that the original development of the pharmaceutical service in hospitals was halted when the apothecary obtained recognition as a general practitioner of medicine. The report explains why hospital pharmacy had to make a fresh start in the middle of the 19th century.

The new model for principal responsibilities in medicines management, described in "Pharmacy in the future," has one feature that pharmacists ignore at their peril: it is that, unlike doctors and nurses, there is no one job that pharmacists will do exclusively. They will diagnose disease state, deciding therapy in conjunction with doctors and nurses, but they will have no role at all in the supply of therapy.

The serious recruitment difficulties in hospital pharmacy are likely to continue. Those pharmacists recruited will almost all be clinical pharmacists. As clinical pharmacists increasingly take on medical roles, the supply functions will be taken on by technicians and nurses.

Hospital pharmacists themselves will doubtless ensure that the recommendations contained in the various reports are fully acted upon. The vision for hospital pharmacy contained in the reports will surely be fulfilled. Hospital pharmacists will, nevertheless, be wise to keep one of their eyes looking firmly over their shoulders.