Christine M. Bond

Introduction

Pharmacists are experts on the actions and uses of drugs, including their chemistry, their formulation into medicines and the ways in which they are used to manage diseases. The principal aim of the pharmacist is to use this expertise to improve patient care. Pharmacists are in close contact with patients and so have an important role both in assisting patients to make the best use of their prescribed medicines and in advising patients on the appropriate self-management of self-limiting and minor conditions. Increasingly this latter aspect includes OTC prescribing of effective and potent treatments. Pharmacists are also in close working relationships with other members of the healthcare team – doctors, nurses, dentists and others – where they are able to give advice on a wide range of issues surrounding the use of medicines.

Pharmacists are employed in many different areas of practice. These include the traditional ones of hospital and community practice as well as more recently introduced advisory roles at health authority/health board level and working directly with general practitioners as part of the core, practice-based primary healthcare team. Additionally, pharmacists are employed in the pharmaceutical industry and in academia.

Members of the general public are most likely to meet pharmacists in high street pharmacies or on a hospital ward. However, pharmacists also visit residential homes (see Ch. 49), make visits to patients’ own homes and are now involved in running chronic disease clinics in primary and secondary care. In addition, pharmacists will also be contributing to the care of patients through their dealings with other members of the healthcare team in the hospital and community setting.

The changing role of pharmacy

Historically, pharmacists and general practitioners have a common ancestry as apothecaries. Apothecaries both dispensed medicines prescribed by physicians and recommended medicines for those members of the public unable to afford physicians’ fees. As the two professions of pharmacy and general practice emerged this remit split so that pharmacists became primarily responsible for the technical, dispensing aspects of this role. With the advent of the NHS in the UK in 1948, and the philosophy of free medical care at the point of delivery, the advisory function of the pharmacist further decreased. As a result, pharmacists spent more of their time in the dispensing of medicines – and derived an increased proportion of their income from it. At the same time, radical changes in the nature of dispensing itself, as described in the following paragraphs, occurred.

In the early years, many prescriptions were for extemporaneously prepared medicines, either following standard ‘recipes’ from formularies such as the British Pharmacopoeia (BP) or British Pharmaceutical Codex (BPC), or following individual recipes written by the prescriber (see Ch. 30). The situation was similar in hospital pharmacy, where most prescriptions were prepared on an individual basis. There was some small-scale manufacture of a range of commonly used items. In both situations, pharmacists required manipulative and time-consuming skills to produce the medicines. Thus a wide range of preparations was made, including liquids for internal and external use, ointments, creams, poultices, plasters, eye drops and ointments, injections and solid dosage forms such as pills, capsules and moulded tablets (see Chs 32–39).

Scientific advances have greatly increased the effectiveness of drugs but have also rendered them more complex, potentially more toxic and requiring more sophisticated use than their predecessors. The pharmaceutical industry developed in tandem with these drug developments, contributing to further scientific advances and producing manufactured medical products. This had a number of advantages. For one thing, there was an increased reliability in the product, which could be subjected to suitable quality assessment and assurance. This led to improved formulations, modifications to drug availability and increased use of tablets which have a greater convenience for the patient. Some doctors did not agree with the loss of flexibility in prescribing which resulted from having to use predetermined doses and combinations of materials. From the pharmacist’s point of view there was a reduction in the time spent in the routine extemporaneous production of medicines, which many saw as an advantage. Others saw it as a reduction in the mystique associated with the professional role of the pharmacist. There was also an erosion of the technical skill base of the pharmacist. A look through copies of the BPC in the 1950s, 1960s and 1970s will show the reduction in the number and diversity of formulations included in the Formulary section. That section has been omitted from the most recent editions. However, some extemporaneous dispensing is still required and pharmacists remain the only professionals trained in these skills

The changing patterns of work of the pharmacist, in community pharmacy in particular, led to an uncertainty about the future role of the pharmacist and a general consensus that pharmacists were no longer being utilized to their full potential. If the pharmacist was not required to compound medicines or to give general advice on diseases, what was the pharmacist to do?

The extended role

The need to review the future for pharmacy was first formally recognized in 1979 in a report on the NHS which had the remit to consider the best use and management of its financial and manpower resources. This was followed by a succession of key reports and papers, which repeatedly identified the need to exploit the pharmacist’s expertise and knowledge to better effect. Key among these reports was the Nuffield Report of 1986. This report, which included nearly 100 recommendations, led the way to many new initiatives, both by the profession and by the government, and laid the foundation for the recent developments in the practice of pharmacy, which are reflected in this book.

Radical change, as recommended in the Nuffield Report, does not necessarily happen quickly, particularly when regulations and statute are involved. In the 28 years since Nuffield was published, there have been several different agendas which have come together and between them facilitated the paradigm shift for pharmacy envisaged in the Nuffield Report. These agendas will be briefly described below. They have finally resulted in extensive professional change, articulated in the definitive statements about the role of pharmacy in the NHS plans for pharmacy in England (2000), Scotland (2001) and Wales (2002) and the subsequent new contractual frameworks for community pharmacy. In addition, other regulatory changes have occurred as part of government policy to increase convenient public access to a wider range of medicines on the NHS (see Ch. 4). These changes reflect general societal trends to deregulate the professions while having in place a framework to ensure safe practice and a recognition that the public are increasingly well informed through widespread access to the internet.

For pharmacy, therefore, two routes for the supply of prescription only medicines (POM) have opened up. Until recently, POM medicines were only available on the prescription of a doctor or dentist, but as a result of the Crown Review in 1999, two significant changes emerged. First, patient group directions (PGDs) were introduced in 2000. A PGD is a written direction for the supply, or supply and administration, of a POM to persons generally by named groups of professionals. So, for example, under a PGD, community pharmacists could supply a specific POM antibiotic to people with a confirmed diagnostic infection, e.g. azithromycin for Chlamydia.

Second, prescribing rights for pharmacists, alongside nurses and some other healthcare professionals, have been introduced, initially as supplementary prescribers and more recently, as independent prescribers (see Ch. 4).

The profession

The council of the Royal Pharmaceutical Society of Great Britain (RPSGB) decided that it was necessary to allow all members to contribute to a radical appraisal of the profession, what it should be doing and how to achieve it. The ‘Pharmacy in a New Age’ consultation was launched in October 1995, with an invitation to all members to contribute their views to the council. These were combined into a subsequent document produced by the council in September 1996 called Pharmacy in a New Age: The New Horizon. This indicated that there was overwhelming agreement from pharmacists that the profession could not stand still. Four main areas in which pharmacy should make a major contribution to health outcomes were identified:

During the consultation process, pharmacists expressed their views on the way the profession should change. These, too, may be summarized under four main headings:

The main output of this professional review was a commitment to take forward a more proactive, patient-centred clinical role for pharmacy using pharmacists’ skills and knowledge to best effect.

The NHS drugs budget

Health services are expensive to run and governments try to reduce expenditure as far as possible. In the UK, some medicines have been identified as being ineligible for prescribing on the NHS. The so-called Black List was introduced in 1984 to reduce the size of the NHS bill. Furthermore the introduction of computer technology into prescription pricing has enabled far more data to be produced than was previously possible. Doctors now receive a regular breakdown of the drugs they have prescribed and that have been dispensed and their prescribing costs, PACT (England) or PRISMS (Scotland)), and this information is also available on line (see Chs 22 and 23).

However, despite these moves, and in common with other developed countries, UK drug costs are inexorably rising due to the greater availability of new effective treatments, patient demand and changes in patient demography (more older people). This has made many governments look at other ways of controlling this item of expenditure, and there are two ways in which pharmacists can have a role.

First, it is recognized that not all prescribing follows the current best evidence for cost-effective practice. Pharmacists are seen as a profession with the necessary knowledge to support quality in prescribing at a strategic and practice level. At a strategic level they can appraise the evidence and make recommendations for the inclusion of a drug in a formulary. At a general practice level pharmacists can advise prescribers on the best drugs to prescribe for individual patients. Community pharmacists are well placed to monitor and review repeat prescriptions, which account for 80% of all prescriptions in primary care.

Second, in a move to promote self-care, pharmacists can encourage patients to be responsible for their own health care and, by implication, remove the cost of treating what is known as ‘minor illness’ from the NHS. Many drugs previously only available on prescription (POM) are now available over the counter from pharmacies (P) or from any retail outlet general sales list (GSL). These changes have resulted in many potent drugs now being available for sale from community pharmacies and the advisory role of the pharmacist has therefore been greatly enhanced (see Ch. 21).

The NHS workforce

As demand for health care grows, it is not only budgets that are stretched. Increasingly, there are insufficient trained professionals to deliver services, and innovative ways of working need to be introduced to maximize the skills of the different professionals in the healthcare team. This has resulted in recognition that many of the tasks previously undertaken by the medical profession, in both primary and secondary care, can be undertaken by other professions such as pharmacists and nurses. Thus, some of the professional roles originally identified by the profession, such as the management of chronic disease and a greater role in responding to symptoms are now supported by the wider healthcare community because they can contribute to more effective health care for the population. As a result, a team approach to managing health care has emerged.