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Many pharmacists, especially those in hospital, will specialise in a clinical area. Each of these areas presents its own particular challenges and requires specific expertise and skills. Specialist clinical pharmacists within the NHS are usually within band 7 of the NHS agenda for change pay scale, for which the salary range is between £31,072 and £40,964. Below are descriptions of a few hospital pharmacy specialties.
Working with the elderly
The population of geriatric patients in the UK is rising — according to charity Age UK, the percentage of the total population who are over 60 is predicted to rise from around 23% in 2015 to almost 29% in 2034 and 31% in 2058. These patients present a range of challenges for clinicians — they are often taking many different medicines and can have problems with adhering to the medication regimen. As a specialist geriatric pharmacist, Seham Hussein identifies and addresses medicines management issues in the elderly and helps to reduce the number of elderly patients readmitted to hospital as a result of poor medicines management and adherence.
Hussein, who qualified over seven years ago, currently works at Imperial College NHS Trust, London. She developed an interest in geriatric pharmacy after working closely with consultant geriatricians to assess patients over 70 years old who had been admitted to the acute medical admissions unit. Hussein says: “I see the challenges of this role as an opportunity to grow professionally and to develop the geriatric services I help to deliver further.” For those aspiring to specialise in geriatrics, she adds that completing a postgraduate clinical diploma is a must.
Paediatric problems
Paediatric pharmacists can face similar challenges in helping their patients to manage and adhere to medicines. Judith Mante is a specialist pharmacist based at Great Ormond Street Hospital (GOSH), London, which treats sick children from across the world. Mante originally began working in paediatrics in 1991, when she took on a role as rotational pharmacist at GOSH because she had always been impressed with the innovative and specialist work done in paediatrics there. She moved to the USA in 1993, where she helped implement pharmacy computer systems in several hospitals. On her return to the UK in 2010, she took a post in paediatric pharmacy medicines information and has recently changed to a role implementing a new computer system while also developing a drug file for use in the paediatric intensive care units.
Mante says: “This role is particularly interesting to me because it straddles the boundaries of pharmacy and technology, using both my technological nous and clinical knowledge.” She adds: “It is imperative that I have a concise understanding of paediatric medicines, paediatric intensive care units and, of course, am able to train staff to use the computer systems that I help implement.”
Paediatric healthcare is made more complex because of the use of many unlicensed medicines and ‘off-label’ prescribing, Mante notes, adding that “other challenging issues include: altered pharmacokinetics at different stages of childhood development; lack of paediatric information sources; and lack of suitable formulations for the paediatric population”.
Mental health
Jeton Aliti is a specialist mental health pharmacist working at South Essex Partnership University NHS Foundation Trust. He began his career as a pharmacist at Moorfields Eye Hospital in London, where he obtained his postgraduate clinical diploma. He began working in mental health because he wanted to develop his clinical experience and knowledge further in another specialty.
Aliti explains that his current role is varied because mental illness is usually treated across a spectrum with each patient requiring treatment on an individual basis. Conditions covered by his role include schizophrenia, manic depression, bipolar disorder, Alzheimer’s disease, obsessive compulsive disorder and post-traumatic stress disorder.
He says: “This field of work appeals to me due to the broad patient demographic I encounter on a daily basis”. He explains that he requires a broad expanse of clinical knowledge, particularly because some patients present with co-morbidities. Additionally, “it is important to stay on top of the law and ethics around mental health”, Aliti emphasises. In the future, he hopes to complete further studies in psychiatric therapeutics and psychiatric pharmacy.
Of eyes and infections
Tackling antimicrobial resistance is an important issue for pharmacists in general — and in particular for specialist pharmacist Ed Hindle, who practises at Moorfields Eye Hospital. Having studied pharmacy at Liverpool John Moores University he took up a position at Moorfields for his pre-registration year and has worked his way up the ladder to become a pharmacist specialising in antimicrobials and formulary management. His job involves attending infection control committees, updating antimicrobial policies and tracking antimicrobial prescribing patterns to highlight inappropriate use.
Moorfields is a world-leading centre for ophthalmology and patients can present rare ocular infections and conditions. Hindle explains: “If these conditions are extremely rare there may be little or no data available to review before initiating treatment, which can cause difficulty.” He adds that medicines that are not normally used within the trust (non-formulary medicines) may be requested by a doctor. The doctor must submit an application for the use of the drug to Hindle, who then reviews the application and produces a review on the drug in terms of its efficacy, safety, convenience and cost.
Hindle says: “The postgraduate clinical diploma has been of great assistance to me in my current role, as has my understanding of evidence-based medicine and my ability to appraise trial data and evidence from journals critically.”
Kidney care
Margaret Kyegombe is a specialist renal pharmacist at St George’s University Hospitals NHS Foundation Trust in South London. Having worked in several areas of pharmacy, including intensive care and neonatal care, it was while working in renal pharmacy that Kyegombe found the area in which she wished to specialise. She says: “I fell in love with renal pharmacy when it became apparent to me the difference in quality of life we can make for those people suffering with chronic kidney conditions and [that we can] help them live as normal a life as possible.”
Although she has studied a renal pharmacy course, Kyegombe believes that most of her productive learning has been through close contact with other healthcare professionals specialising in renal disease. She explains: “This is because each patient requires treatment on an individual basis, factoring in many other issues and possible co-morbidities. As such, learning takes place on a daily basis and working within a specialist team enables us to tap into other health professionals’ opinions and experiences. ”
Difficulties in delivering a renal service include correct titration of doses in those who suffer with renal failure, according to Kyegombe. She adds that many side effects of medicines are poorly tolerated in patients with renal failure, which can cause difficulty for the healthcare team when assessing treatment suitability.
Cancer at Clatterbridge
As part of the specialist oncology team at Clatterbridge Cancer Centre NHS Foundation Trust in Wirral, pharmacist Marianne Pucsok focuses on developing and managing the dispensary process for the oncology service. With over eight years of experience as a pharmacist in Hungary, she moved to England in 2013 to begin a new career alongside her husband.
Pucsok helps patients spot ‘warning signs’ of problems with certain medicines, such as cytotoxics and immunosuppressants, which carry higher risks than other more commonly used medicines. She also tries to ensure the safe use of drugs with a narrow therapeutic window, which require therapeutic drug monitoring.
Again, Pucsok recommends that those interested in specialising in oncology undertake a clinical diploma, and explains that a variety of postgraduate oncology courses are also available.
Gastroenterology
Rachel Curley, senior clinical pharmacist in gastroenterology at Wirral University Teaching Hospital, completed her diploma during a residency post following pre-registration training there. The role appeals to her given the varied nature of gastroenterology, which splits further into two specialties; luminal, which includes motility disorders and disorders of the lumen, and hepatobiliary, which focuses on the liver, gall bladder and bile ducts. Curley says: “The ability to support colleagues, students and patients through presentations, study sessions and disease awareness events is a particular highlight of my role.”
Curley spends most of the working day on the ward supporting the wider clinical team, facilitating discharges and counselling patients. Other important aspects of the role involve supporting the inflammatory bowel disease specialist nurse team, the endoscopy unit and reviewing service guidelines and patient group directions.
Challenges particular to the role include the complexity of patients on the gastroenterology ward and the high turnover of patients on the ward, Curley explains. There is no specific training necessary for a pharmacy role within gastroenterology but in-house learning will help to improve specialist gastroenterology knowledge, says Curley. Non-medical prescribing courses, allowing pharmacists to write and amend prescriptions, can also be undertaken to support the clinical team.
