improving quality of health role of...

Quality in Health Care 1994;3:153-158

Improving quality of health care: the role ofpharmacists

Nick Barber, Felicity Smith, Stuart Anderson

This is the second article in the occasional series inwhich health professionals discuss the contributionof their specialty to quality of patient care.

Pharmacists are society's experts on drugs.They have been at the interface betweenprescribers and patients for centuries: in thecommunity particularly they have longprovided a direct service to the public. Formost of this time they have made medicinesand advised on their use, but the growth of thepharmaceutical companies - under increas-ingly stringent legislation - has removed muchof the need for local manufacturing andquality control. Pharmacists' traditional rolesof compounding medicines and dispensingprescriptions have been replaced withactivities requiring the full range of theirtraining and skills, ranging from avoiding druginteractions and detecting adverse reactions togiving advice and monitoring drug treatment.Pharmacists now have many varied new roles,sometimes called pharmaceutical care, torespond to the changing needs of the public,to changes in health care objectives, and tochanges in health service delivery.The role and potential role of pharmacists in

the community (retail pharmacy) and inhospitals have been set out in severaldocuments and reports.'6 The World HealthOrganisation has recently called on pharma-cists to support its drug strategy and has urgedgovernments to define the role of pharmacistsand to make full use of their skills in nationaldrug strategies.7 The independent Nuffieldenquiry into pharmacy in 1986 encouragedthe growth of the clinical advisory role incommunity and hospital, as did a healthcircular for hospital pharmacy in 1988.2 Fouryears later a joint report of the Department ofHealth and the Royal Pharmaceutical Society

Centre for PharmacyPractice,School of Pharmacy,University of London,London WC1N lAXNick Barber, professorFelicity Smith, lecturerStuart Anderson, lecturer

Correspondence to:Professor Barber

of Great Britain recommended ways in whichcommunity pharmacy should develop in theUnited Kingdom.3Although pharmacists working in hospitals

and in the community are committed toensuring the safe, effective, and economic use

of medicines, the activities of the two groups

differ in style and emphasis. Two of the keydifferences are access to the prescriber anddegree of professional isolation. Hospitalpharmacists work in close proximity tomedical staff, who are normally readilyaccessible. They have an important role inadvising junior doctors on prescribing and on

writing prescriptions. Most hospital pharma-cists also have the benefit of working alongsidecolleagues who can advise and support them.For community pharmacists contact with theprescriber is not always easy, and many workin relative professional isolation. A third rolefor pharmacists is developing in scope andimportance - that of adviser to commissioningagencies (district health authorities and familyhealth services authorities).The core functions of hospital pharmacy

services have been described by the NationalAssociation of Health Authorities and Trusts(NAHAT)8 and are summarised in box 1. Theextended role of community pharmacists hasbeen outlined by the Royal PharmaceuticalSociety (box 2).9 In addition, an increasingnumber of pharmacists now work for comm-issioning agencies, and the pharmaceutical

Box 1 Care functions of hospital pharmacy services8

Economical and efficient procurement andsupply of medicinesPreparation and assembly of medicines as

neededSafe and secure storage and efficientdistribution of medicinesFacilitating the safe, effective, and economicuse of medicines, including advice to doctors inrelation to the selection and dosage ofmedicines

Monitoring the quality of medicinesProviding comprehensive and continuouspharmaceutical care, including the interfacewith general practitioners and communitypharmacistsControlling the medicines' budget

1 Delivery services to household patients2 Services for groups with special needs3 Services for residential homes4 Out of hours services5 Domiciliary visits6 Hospital discharge and admission

procedures7 Health promotion activities8 Needle and syringe exchange schemes9 Distribution of welfare food10 Disposal of unwanted medicines11 Sale of prepayment certificates12 Health screening13 Patient referrals to general practitioners and

other health professionals14 Development of local formularies15 Provision of professional advice16 Advice on palliative care17 Supply of disability aids18 Reporting adverse drug reactions19 Provision of quiet area for confidential

conversations20 Supply of complementary medicines21 Advice on over the counter medicines22 Training of other health professionals

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Box 2 Extended role of community pharmacists'

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functions of these have also been described byNAHAT (box 3).' These three boxes give a

flavour of the diversity of roles and of activitiescurrently undertaken by pharmacists. In thispaper we will consider the roles of communityand hospital pharmacists separately.

Community pharmacyPharmacists have a long and distinguishedhistory of presence in the community for thesupply of drugs, both in accordance with pres-

criptions from medical practitioners and as

part of their advice to people with minor ail-ments (so called counter prescribing).Upheavals in community and primary care in

recent years have probably had less directimpact on pharmacists than on other healthprofessionals. However, pharmacists are aware

that they must respond to these changes andare keen to do so; they are now identifyingareas in which they can enhance the quality ofpatient care in line with current health care

objectives and the government's priorities forthe delivery of health care. These changes havepresented new challenges for pharmacists. Notonly do they need to adapt their roles torespond to these changes but they also need tomonitor and evaluate the services they offer.The potential of community pharmacists as

primary health professionals has so far notbeen fully exploited. These changes are beingencouraged by financial incentives. Comm-unity pharmacists are independent prac-

titioners contracted to the family healthservices authorities in England and Wales andto the health boards in Scotland and NorthernIreland. They are remunerated for their NHSservices principally on the basis of the numberof prescriptions dispensed, although in recent

years the basis for the remuneration hasdiversified; they now receive separate pay-

ments for services to residential homes and formaintaining computer based records of drugtreatment for their regular clients. In thefuture the basis of remuneration may berestructured to encourage diversification oftheir role in serving current health care

objectives, such as giving advice and promo-

ting health. The money will be provided byreducing dispensing fees. Currently, Scotlandis taking a lead on this.

All community pharmacies are staffed by a

registered pharmacist, who is present on thepremises during all opening hours. Thispharmacist will have undertaken a similareducation and training (three year degreecourse and one year of preregistrationtraining) to that of pharmacists in otherbranches of the profession.

RISlPONtIN(, 1 () S \IP' OAI S

An average pharmacist advises around 10people daily on the management of minor

ailments.1 This amounts to over 100 000people daily across the country, or 30 milliona year - a number which is thought to beincreasing and unlikely to fall. Increased clientinterest and concern about drug use will leadto more demand from pharmacists for advice.Their role in advising people with minorailments is as old as the profession, andpharmacists are a readily available source ofadvice, as they are usually immediatelyavailable to clients who need advice.'Pharmacists are well aware of the need to

show quality in these services, and they havebeen forced to acknowledge this need by thescrutiny of their role in responding to minor

ailments by outside organizations."'3Several of these investigations have attracted

much media attention, and pharmacists haverecently embraced professional audit. Manystudies have been performed on the quality ofadvice offered by pharmacists. Methods andfindings have been mixed, and some causes forconcern have been uncovered. 1h' Smith et cilconcluded, however, that, although a third ofcommunity pharmacists gave very poor advice,half of them gave very good advice.' Theseissues are being addressed by pharmacists to

ensure higher standards of care in the future.Despite the long tradition of pharmacistsadvising on minor ailments it is only recentlythat education and training for this role hasbecome a substantial part of the under-graduate curriculum and an important featureof postgraduate education. The increasing

number of drugs that have changed fromprescription only medicines and have becomereadily available in pharmacies means thatmore clients will go to their local pharmacyfirst. This may also increase the proportion ofvisits to medical practitioners that are referralsfrom a pharmacist.

PRISCRIBE) I)RUGS

The quality of prescribing needs to beassessed, and good treatment still needs to bemonitored - roles for which pharmacists are

ideally placed. They can detect inadvertentchanges in prescriptions for medicines, checkfor possible adverse drug reactions, anddiscuss any other problems with the treatmentthat the client may have. Dispensingprescriptions is probably the most well known

function of community pharmacists; it is themost important activity financially and

accounts for a large proportion of their time.Pharmacists are, therefore, centrally placed to

monitor drug treatment. Research has high-lighted inadequate monitoring of drug

1 Strategic planning including pharmaceuticalinput into needs assessment of localpopulation

2 Pharmaceutical aspects of public health3 Pharmaceutical input into contracting for

secondary and tertiary care4 Primary care commissioning issues, ensuring

community pharmacists make a fullcontribution to health gain

5 Effectiveness and clinical audit6 Developing a purchasing strategy for special

pharmaceutical support services7 Pharmaceutical input into statutory

inspection functions for nursing andresidential homes

8 Advising on the pharmaceutical aspects ofpolicies for care in the community

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treatment in the community - for example,high incidences of adverse drug reactions andpotential drug interactions. Elderly people - arapidly rising proportion of the population -are particularly at risk. Adverse drug reactionsare estimated to account for at least 10% ofhospital admissions in elderly people.17 Manypharmacists now keep records on computerfor their regular clients taking drugs long termto enable them to monitor closely their clients'drug treatment. As more prescription onlydrugs become available without a prescription,this monitoring role will become moreimportant. It will also become increasinglylikely that symptoms which are drug relatedwill arise, though they may not always beidentified as such by the client. Communitypharmacists are well placed to identify sucheffects and to advise the patient accordingly.The poor level of prescribing and drug treat-

ment in many residential and nursing homes iswell known. In many states in the United Statesevery nursing home must by law be visited bya consultant pharmacist once a month to reviewthe clinical appropriateness of all prescribing.We may need to act similarly in the UnitedKingdom, and domicilary visits by pharmacistshave unearthed more drug related problems.

Pharmacists believe that they have animportant part to play in promoting adherenceto (or compliance with) drug treatment byreenforcing the prescribing instructions orhelping sort out problems by recommendingdifferent formulations or drugs. Pooradherence to treatment frustrates many pres-cribers: it is estimated that only about 50%/ ofclients take their drugs as and whenintended.'8 Reasons for lack of adherence aremany, ranging from a lack of understanding ordislike of the taste to doubts about the approp-riateness of prescriptions and fears (orexperience) of adverse effects. Home visits bypharmacists allow the drugs to be discussedwith the patient, side effects to be identified,and problems to be sorted out.

DISEASE PREVENTION AND HEALTH

PROMOTION

Community pharmacists are ideally placed toprovide disease prevention and health pro-motion services in line with the government'spriorities.'9 Many people, representing a broadcross section of the population, visit phar-macies every day. The potential of these visitsfor health promotion activities has beendeveloped since the inquiry into pharmacyconducted by the Nuffield Foundation' andalso the government's white paper PromotingBetter Health.6

Pharmacists have opportunities to discussdisease prevention and health promotion whenclients request advice on managing minorailments. Some pharmacies also display healthpromotion literature and take part in localinitiatives such as advising on immunisation,first and second line treatments for hair infes-tation, giving up smoking, and needle exchangeschemes for intravenous drug misusers.

Privacy is an important aspect of quality ofcare. If pharmacists are to develop their

advisory role, then discussions with clientsabout their problems with over the countermedicines must clearly take place in a privatearea set aside for this purpose. The professionis aware of the need for privacy if clients arenot to be inhibited from raising their concernsand pharmacists are not to be inhibited fromdiscussing sensitive issues in consultations.Private areas are also useful for discussingprescription drugs with clients. The develop-ment of suitable consultation areas is beingencouraged and paid for in some family healthservices authorities.

TEAMWORK

Pharmacists have an important role within theprimary health care team. Although theyusually work separately from other membersof the team, what they do with their clients isa clear extension of the work that starts in thegeneral practitioner's surgery. The relativeisolation in which many pharmacists work,and the fact that they work on premisesdistinct from the rest of the other healthprofessionals, mean that they are sometimesconsidered to be only on the fringes of theprimary health care team. Although pharma-cists are required to be on the pharmacypremises during opening hours, there are,nevertheless, many opportunities for meaning-ful collaboration between them and otherprimary health care professionals and forregular contact between them, both by tele-phone and in person.Community pharmacists share their clients

with other practitioners and need to developthese links, not only with prescribers but alsowith others such as district nurses, healthvisitors, specialist nurses in the community,physiotherapists, chiropodists, dentists, andoccupational therapists. Some pharmacistswork with general practitioners on practiceformularies, prescribing practices, theinterpretation of prescribing analysis and cost(PACT) data, and the review of drugs as partof a home visit. However, there are matters ofconcern to all health professions - forexample, the appropriate use of benzo-diazepines, on which communication iscurrently minimal.20 Both pharmacists anddoctors recognise the need to address thisproblem, to advise clients about appropriateuse, to monitor for misuse, and to be preparedto discuss reducing doses when asked. Thereis growing concern about the participation inissues such as this by members of the twoprofessions, and there is increasing discussionand awareness of the other's activities andcontribution to the health of the community.

Hospital pharmacyTHE PAST 30 YEARSThe role of hospital pharmacists has shownremarkable development over the past 30years and is a major influence on prescribingand drug use. Many factors have contributedto this. For example, during this time drugtreatment has become both more effective andmore complex. In the late 1960s high numbersof drug administration errors were discovered

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in hospitals. Systems that entailed drugcharts and pharmacists visiting wards were

shown to be effective and were subsequentlyrecommended for implementation in allhospitals in the Gillie report. 6These changes led to pharmacists seeing

patients and being more clinically involved. Inthe 1970s many hospital pharmacies intro-duced drug information centres, and theapplication of pharmacists' knowledge to thewellbeing of the patient became known as

clinical pharmacy. In 1988 a health circular on

the way forward for hospital pharmacy services

set out the roles of pharmacy in hospitals andthe ways pharmacy should be promoted in

several clinical areas.' The changes were

recommended for implementation withoutadditional funding as they were expected to beself financing from economies resulting frombetter drug use.

IMPROVING PRRES( RIBING

In hospitals pharmacists are well recognised as

a useful source of advice on prescribing. Thisis now an extensive service; over one week in

North West Thames Region there was aboutone intervention for every three acute bedsand over 3000 prescriptions were changed on

the advice of pharmacists.' This has extendednaturally into a wider role in medical andclinical audit. " The core of pharmacists'contribution to appropriate prescribing anddrug use is the ward pharmacy service, in

which pharmacists visit wards - usually daily -

to check the drug charts of all patients in orderto clarify any ambiguities, to initiate supply ofthese drugs not stocked on the wards, and tointervene in the prescribing, supply, or

administration processes wherever necessary.

Pharmacists will also check that any intra-venous lines are running correctly. In effect,this activity represents a constant audit ofprescribing. A great deal of information is usedin monitoring prescribing besides the drugchart, including talking to patients, observingpatients, reading the information available atthe end of the bed, and looking in the notes ifnecessary. Several studies in the UnitedKingdom and United States show that doctorsreadily accept the suggestions of pharma-cists. Pharmacists' interventions relate tothe whole range of prescribing, many beingconcerned with the choice of drug, dose, androute of administration. When judging theappropriateness of prescribing other factorsalso come into play, including the effectivenessof the drug, its cost, and the effect on thequality of life of the patient. Unfortunately,this activity is largely undocumented and un-

recognised, and it tends to take place mainlybetween pharmacists and junior doctors.

In many hospitals at least one pharmacistwill attend a consultant's round. There is littleresearch on the contribution the pharmacist

makes, but recent work suggests that the inputis variable. Some simply act as an informationsource when asked a question, whereas on

some specialist rounds, such as those ofnutrition or pain teams, the pharmacist may

offer around half the suggestions made to

initiate, alter, or end treatment. i The dis-advantage of pharmacists being on rounds is

that much of the round may be of little rele-vance to drug treatment, and it may be difficultto justify releasing a member of staff for threehours to make an active contribution for only

10 to 15 minutes. Attending rounds does haveother advantages, however, particularly in

helping pharmacists to understand the cormplexities of therapeutic decision making and in

helping clinicians consider wider aspects ofdrug treatment (and in some cases to makemedical staff consider drug treatment at all).

SPECIAL IS SERVICES

Several specialist hospital pharmacy services

have been developed, although a recent census

of hospital pharmacies in the United Kingdomshowed appreciable differences in their avail-

ability.3 There is some evidence that pharma-cists are better than doctors in taking drughistories, as they tend to detect more drugsbeing taken and obtain additional informationabout the use of over the counter and herbalmedicines. This pharmacy service has not

been widely available in the past, but it may

develop when analysis of interventions showsthat a poor drug history causes problems. Forexample, it is not uncommon for about a thirdof interventions in orthopaedic wards to be dueto incorrect clerking and prescription writingon admission. Pharmacists are also commonly

active in pain control in terms of producingdrugs, filling devices, and giving advice on thechoice of treatment and dose."

Therapeutic drug level monitoringreporting the concentration of a drug in theblood and using pharmacokinetic calculationsto recommend a new dose and frequency is

commonly practised as part of the hospitalpharmacy service.3"' Audits have shown thatover half the samples taken are inappro-

priate.4" Some hospital pharmacies now

offer a complete service: they are given thename of the patient and they take the blood,measure the drug concentration, and advise on

any alterations to the dosing regimen. At some

sites pharmacists also run warfarin clinics."Special adverse drug reaction monitoringschemes have been successful, and pharma-cists might be able to report such reactionsdirectly to the Committee on Safety ofMedicines in due course.45

Hospital pharmacists also contribute to theeconomic aspects of drug use - controllingpurchasing costs and working with clinicianson formularies, treatment protocols, review

and evaluation of drug use, and medical andclinical audit.4 " At the core of these activitiesis information from computerized purchasingand dispensing systems and informationbrought back from the wards by pharmacists.These roles are coming together in theprovision of advice to directorates, and clinical

directors are increasingly tending to pay theirown pharmacists to provide these services.

The futureThe future of pharmacy is inextricably linkedwith the future of medicines. The continuing

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high cost of drugs will ensure the growingimportance of pharmacoeconomics. Down-ward pressures on drug costs will shave themargins of industry and wholesalers, and newtechnology will change the purchasing andsupply stucture. For pharmacy the emphasiswill be on a "value added" supply service, withmuch of the value being in providing infor-mation and monitoring quality. Although someof this can be undertaken by computers, thereare limitations to this, and there is nosubstitute for contact with patients. Thedevelopment of new drugs through biotech-nology will lead to difficulties in formulationand administration that will keep pharmacistschallenged and involved. The increase indomiciliary care will also make home visits and"closed door" pharmacies common, perhapsleading to competition between hospital andcommunity pharmacists. The effect of marketforces on newly established NHS trusts isalready forcing reductions in the number ofhospital pharmacists, a quarter of senior postshaving already gone.5' The danger is that thismay lead to a reduced quality of service atsome sites. Both purchasers and trusts need toset firm quality standards to ensure thatpharmacy services to not become stagnated oratrophied. In community practice the lawrequiring pharmacists to remain on thepremises at all times creates constraints infurther developing the role of pharmacists. Onepossible development is to have more than onepharmacist in each pharmacy so that a widerrange of services both inside and outside thepharmacy can be more effectively pursued.

ConclusionPharmacists have responded positively tohealth service changes and to developments indrug treatment. They make a substantialcontribution to the overall quality of healthcare by ensuring that the prescriber'sintentions are translated into the safe, effec-tive, and economic use of medicines; that theprescribers themselves have the informationnecessary to make such decisions; and thatpatients have the information they need toobtain maximum benefit from theirtreatment.Although there are clearly ways in which

improvements can be made, the profession ofpharmacy can move forward in the knowledgethat the benefits of a pharmaceutical serviceprovided by highly educated, motivated, andaccessible professional people is well recog-nised, not only by its clients but also bydoctors and by those making policy decisions.It can grasp the many opportunities availableto it in the future, including the new roles ofthe commissioning agencies, with confidenceand enthusiasm.

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