Hospital Pharmacist
Vol 12 No 1 p25-26
January 2005

Association of Teaching Hospital Pharmacists

Ideas about increasing the amount of research carried out by pharmacists were among the visions set out at the 50th anniversary meeting of the Association of Teaching Hospital Pharmacists. Rachel Graham reports

What does the future hold for hospital pharmacy?

More hospital pharmacists should participate in research, according to Patrick Vallance, head of the division of medicine at University College Hospital, London.

Professor Vallance took delegates through the “medical model” of research, explaining that all hospital-based doctors undertake a period of full-time research in the middle of their careers. Following this, some of them remain in full-time research, others will never or rarely participate in this activity again, but many will go on to appointments where they are able to split their time between clinical practice and research. It might be useful for elements of this arrangement to be transferred across to the career structure of hospital pharmacists, he observed.

Getting the ball rolling, however, would not be easy, Professor Vallance acknowledged. Most research money comes from non-governmental institutions (such as the Wellcome Trust, Cancer Reserach UK and the British Heart Foundation) and tends to be given to those with experience of leading research programmes, which few pharmacists have. However, as far as government money is concerned, Professor Vallance pointed out that the Department of Health is keen to promote research carried out by clinical scientists other than doctors, but there are just not many such projects of appropriate quality put forward to it for consideration.

There are also far fewer hospital pharmacists than there are, say doctors or nurses, and so there may not be a “critical mass” to bring in this type of approach. In addition, becoming more involved in research activities reduces the amount of time that pharmacists can spend on clinical work. This has implications when there is a general shortage of pharmacists. The incentive for pharmacists themselves to adopt this type of career structure is also not necessarily there — the careers of hospital pharmacists can currently progress well without them needing to take time out from practice to undertake research projects.

Competencies and consultants

That research is an underdeveloped area in many hospital pharmacists’ careers was apparent from work carried out to develop and validate a competency framework, according to David Webb, director of clinical pharmacy at London, Eastern and South East specialist pharmacy services.

During the work, Mr Webb and colleagues mapped the responses of 28 leading edge practitioners in the hospital and prim-ary care workforce against a competency framework comprising six core clusters. Research and evaluation competencies were those that were most often rated by respondents as being “at foundation level” (25.5 per cent) or “not rated” (11 per cent). Only 29.5 per cent of respondents rated their competence at research and evaluation as being at the “mastery” level, compared with 73 per cent for the “expert professional practice” and 69 per cent for the “building working relationships” competency clusters.

Changes to the career structure of pharmacists will go some way to encourage pharmacists to carry out research, according to Kevin Taylor, head of clinical pharmaceutics at the school of pharmacy, University of London and at Camden and Islington Hospital Pharmaceutical Services. These changes are being brought about by the introduction of Agenda for Change and the creation of consultant pharmacist roles. Professor Taylor predicted that consultant pharmacists would split their time roughly equally between research and practice. A consultant pharmacist should be a “champion in practice, education and research who brings innovative solutions to patient care”, he said.

More familiarity with research should also mean that pharmacists will publish more work, both in specialist pharmacy journals and in medical journals, such as The Lancet and the BMJ and, where relevant, publications such as Gut. Medical journals generally have a higher “impact factor” in the overall hospital and research world, he said. This is mainly because (unlike many pharmacy journals) they tend to be abstracted onto on-line data bases, such as Medline.

Future emphasis is on localising services

Traffic gridlock is among the reasons why health services, including those provided by pharmacists, will need to be developed locally, according to Patricia Oakley, director of Practices Made Perfect Ltd. In all the major conurbations in the UK, travelling by road is becoming more difficult and it makes sense in the longer term to have a greater proportion of health care provision located nearer to where people live, hence the government’s strategy of “going local” she said.

As a result, there is now a much greater emphasis on investing in the “hospital at home” service, especially for patients who have long-term conditions, Dr Oakley said. Under this arrangement, to be put in place in England in the first instance, patients are to be cared for at home by a “community matron” and her team. Such a service would be supported by medical admission units, with access to GPs, clinical pharmacists, district nurses, social workers and care assistants. This local health care team would be supported by a network of local specialist centres, including the current teaching hospitals, while the specialised services, for example, genetic and transplant services would be provided at supra-regional or national levels.

Supporting patients who have been diagnosed with a chronic disease in their home is particularly important because the population is ageing, Dr Oakley said. The disease profile of patients as a whole is therefore changing, with conditions such as diabetes assuming a greater importance. “This is a big growth area for pharmacists,” she pointed out. Where care other than that which can be given at home is needed, it should be provided at a local level — there may well be some specialist cardiology, oncology and diabetes services available locally in the future, she added.

Other drivers towards localisation include advances in technology, such as changes to the IT infrastructure that will enable the transfer of prescriptions and data to be more efficient. Cables being laid at the moment will effectively transform what is currently a “country lane” in IT terms to a “12 lane highway” by the end of 2005, she said. Consumer choice is another factor, as are resources, with a “harsh spending review” on health expected in 2008, she added.

Dr Oakley warned that developments in pharmacy practice need to take account of this policy context. For example, competency frameworks developed for pharmacists (see p25) must be relevant to those operating from the “hospital at home” and admission units and not just specialist centres, she said. However, it may also be the case that pharmacists working at admission units and specialist centres will actually be the same person, with those who are experts in their field being expected to split their time between different types of organisations.

Think about using existing visions to shape services

Useful ideas about how pharmacy services should develop are already available, according to Tony West, chief pharmacist at Guy’s and St Thomas’ NHS Foundation Trust, London.

In particular, Mr West took delegates through the “2015 initiative” of the American Society of Health-System Pharmacists. The document sets out six main goals (see box), with associated objectives for each of these. Mr West said that he is not advocating the wholesale adoption of the initiative in England. However, objectives such as: “50 per cent of recently hospitalised patients or their carers will recall speaking with a pharmacist while in hospital” (under the first goal) are worth reflecting on when thinking about pharmacy developments, he said. Similarly, those concerned with the preparedness of pharmacy departments for an emergency are also highly relevant in the UK, he said.

There is also a case for the NHS to commission undergraduate pharmacy training and preregistration places, he said. “If community pharmacy is going to be part of the overall NHS, why leave student numbers to the universities?”, Mr West pointed out.

Forging links between hospitals and academia is important

Improving links between hospital and academic pharmacy is important, was the general message from both Kevin Taylor, head of clinical pharmaceutics at the school of pharmacy, University of London and at Camden and Islington Hospital Pharmaceutical Services and Peter Noyce, professor of pharmacy practice at the school of pharmacy, University of Manchester. According to Professor Taylor, there has been a real impetus of late to bridge gaps between hospital practice and academia, but there is still more to do. Two separate cultures still exist, he said.

Hospital pharmacy practice would benefit from better links with academia, because this helps nurture a research climate, [the importance of which is set out on p25]. In addition, the formulation expertise of academic pharmacists could be of practical use to hospital pharmacists, particularly when optimising formulations for clinical trial products, he said.

Academia would also benefit from closer contact with hospital pharmacists, Professor Noyce said. In particular, fewer staff in academic pharmacy departments come from a pharmacy background and so the involvement of pharmacists in degree courses is becoming more important if qualifications are to be informed by practice.