Joan Peppard, the immediate past president of the European Association of Hospital Pharmacists, discusses the evolution of the hospital pharmacy specialist.
The prescribing of medication is the most common healthcare intervention for a patient. Hospital pharmacists are experts in the field of medicines and provide a wide range of services which can be grouped into three distinct functions. The first function encompasses much of the traditional role of the pharmacist and includes purchasing, storage, manufacture, dispensing, quality testing and supply of all the medicines used in the hospital.
In the clinical services function, the pharmacist is an integral part of the healthcare team where the focus is firmly on patients. The pharmacist works on a daily basis with doctors, nurses and other members of multidisciplinary teams to advise on the selection of medicine, the dose and route of administration for individual patients. They provide information about potential side effects and ensure that new treatments are compatible with existing medication and monitor the effects of treatment to guarantee that it is safe and effective.
In the medication management function, pharmacists lead on the development and management of hospital-wide medication management policies and the implementation of these agreed policies. This includes the managed introduction of new and expensive medicines as well as ongoing review of the use of all approved medicines and medicines used as part of a clinical trial.
Taking on medication shortages
A continuing challenge in one of the traditional pharmacist roles of medication procurement and supply is the requirement to meet patient needs when faced with a medication shortage. Increasingly resources are directed towards this issue in each hospital across Europe. Problems caused by medicines shortages are serious, threaten patient care in hospitals, and require urgent action to ensure continued care of patients with the best treatment available. The forced substitution of an alternative product may increase the risk of error, stress and overall cost to the healthcare system.
The European Association of Hospital Pharmacists (EAHP) has called for action on medication shortages since 2012 and it published the first Europe-wide survey on the topic in 2014. Many of the actions called for at that time are currently underway, with increased research on the topic in an EU-funded initiative, the COST Action on medication shortages1 and actions at national level supported by the European Medicines Agency (EMA) and the Heads of Medicines Agencies. As an example of this activity the Health Products Regulatory Agency (HPRA) in Ireland published its framework for the management of medication shortages in July 2018. EAHP has undertaken a second survey on shortages and will publish the findings on 7 November 2018.
EAHP believes that there is an increased risk of medication shortages in 2019 and 2020 because of the manufacturing changes required by the Falsified Medicines Directive and because of Brexit. Many marketing authorisations need amendments because of medications authorised for use in Europe through the UK medicines agency (MHRA). As it is believed that this agency will not be part of the European network post-Brexit, pharmaceutical companies need to examine their marketing authorisations to ensure these are valid for Europe post-Brexit. The EMA has already issued a statement on this topic.
EAHP believes that the research from the COST Action will indicate where further steps need to be taken to alleviate shortages and that the national frameworks will enhance transparency and communication about the topic. All these changes will improve the availability of medicines at the point of care for the patient and reduce the diversion of significant amounts of the time and attention of a hospital pharmacist from other tasks important in the provision of high-quality, safe and efficacious care.
The falsified medicines challenge
Also related to role of the pharmacist in the supply chain is the issue of falsified medicines. Thankfully, falsified medicines have not been a significant issue in European hospitals to date with only three occasions described in the literature. With increasing safeguards in other jurisdictions, it is possible that additional attempts will be made to introduce falsified medicines into the European supply chain. Hospital pharmacists are engaging with the new safeguards being implemented under the Falsified Medicines Directive. There are IT and staffing requirements for this function that have to be provided by hospital owners to enable full compliance.
The greatest risk to patients and the public is shown to be in online purchasing of medication from unauthorised sites, i.e. sites without the agreed kitemark. Hospital pharmacists have a role to play with all healthcare professionals in advising the public not to obtain medications from these and other unreliable sources.
The hospital pharmacist and the patient
The clinical patient-facing role for hospital pharmacists continues to develop and increase in many countries. One of the most recognised roles is that of the antimicrobial pharmacist. The hospital pharmacist is the secret weapon in healthcare systems to manage the use of antimicrobials. Working as part of the multidisciplinary team with the microbiologist, surveillance scientist, medical scientists and infection control nurse, the hospital pharmacist is ideally placed to positively contribute to the effective use of antimicrobials. With many years of study focused on the use of medications and with the management of the supply chain and supply to each speciality under the control of the pharmacy department, the hospital pharmacist can contribute to the development of prescribing guidelines and manage their implementation by an agreed access programme supported by subsequent clinical use audits. The hospital antimicrobial pharmacist identifies areas for improvement for the antimicrobial/infection control team to ensure the availability of effective antimicrobial therapy into the future and to support hospital and health system governance by providing data for key hospital performance indicators on antimicrobial consumption.
Other pharmacist roles include the areas of oncology, haematology and rheumatology, all areas that have seen a rapid expansion of medication treatment options in recent years. The use of the specialist knowledge of hospital pharmacists ensures the safe, effective and cost-efficient use of these medicines for the individual patients but also for the whole of the hospital patient population to manage the increasing demands for the expensive medications now required for many conditions. These new medicines add to the financial pressures in health spending, for which there is no simple solution.
Prevention and promotion
EAHP welcomes the increasing emphasis on prevention and promotion strategies which help the individual to remain healthy and which, over time, will reduce the incidence of diseases, including those arising from lifestyle issues such as obesity. Within the population for whom medications are required to manage or treat an illness, there is evidence of poor compliance with complex medication regimes and increased medication wastage.
Hospital pharmacists, as part of the multidisciplinary care team, can counsel on side effects and the incidence of these so that the individual patient will continue to take the medication or to again discuss their options with their physician. The hospital pharmacist improves medication management at the hospital-to-home interface, supporting the patient routinely taking medications, possibly for the very first time. At the hospital level, the hospital pharmacist manages the medication supply chain within hospitals to minimise wastage and maximise the medication benefit, including the management of clinical trial medication and compassionate access medication programmes.
For expensive medicines, currently the subject of health technology assessments (HTA), EAHP welcomes the creation of a stakeholder network at the European level. The role of this network and the involvement of healthcare professionals, such as hospital pharmacists, should be strengthened. Only the direct involvement of healthcare professionals, including hospital pharmacists, will ensure that their extensive experience and knowledge in medicine use is utilised in HTA processes to maximise the benefit to the health system. Ultimately, the level of health spending is a matter for citizens and national governments due to competing national priorities for funding.
Skills and expertise
The skills and expertise of the hospital pharmacist contribute to the care of the individual patient, effective use of allocated resources at the hospital level and in policy formation in national and regional committees. There is no standard approach to the utilisation of the hospital pharmacist as medication expert, and hospital pharmacists are recognised differently depending on the health system and country. EAHP is working with its member organisations to increase the recognition of the hospital pharmacy speciality and to improve cross-border harmonisation of the requirements for the speciality with our common training framework project, developed under the Professional Qualification Directive. As complexities around medicines and medicine-related processes continue to increase, there is a growing recognition of the need for professional education in the hospital environment.
The specialised skills and knowledge of the hospital pharmacist are required for the wellbeing of the patient and to support other healthcare professionals such as doctors and nurses in the prescribing and administration of medications. Inclusion of the specialist hospital pharmacist in the hospital multidisciplinary team and on national committees with increased utilisation of their knowledge and skills improves the translation of national medication goals into reality at the hospital level in the healthcare systems and promotes sustainable and equitable access for patients to safe and appropriate medication use by the application of the knowledge and skills of the hospital pharmacist.