Developing clinical practice through 50 years of a drug information network

Now is the time for the profession to celebrate the contributions to the development of clinical pharmacy, which followed the first meeting of regional drug information (DI) pharmacists 50 years ago on 28 November 1975 in Bristol. It quickly established the structure for a developing UK-wide DI network that helped transform pharmacists into the experts on medicine usage. Its work laid the foundations for the UK Medicines Information (UKMI) service and several original members helped drive that forward throughout their working career.

In 1975, the pharmacy world was very different, and the future of the profession was increasingly in doubt as pharmacists’ centuries-old compounding role was industrialised, and we were seen by many as just tablet counters in a role not needing a degree qualification. Many pharmacists rarely left the pharmacy, and many did not have the confidence or knowledge to change. 

Pharmacy courses at that time were chemistry focused and had limited clinical content, so those wanting to advise on modern medicines usage had to self-educate in many areas. Access to the literature and current knowledge was essential in pharmacy libraries. Hospital ward visits got some pharmacists out of dispensaries, but clinical pharmacy was in its infancy. DI was the driver of clinical pharmacy practice in the United States, and the hope was it could be here.

Stimulus for impartial information

The pharmaceutical industry was making more effective and reliable medicines, which led to more side effects, overdoses and interactions being reported. 

The pharmaceutical industry and product promotion had few legal controls. Brand names were promoted, and often free overseas product launch conferences and free gifts influenced prescribers, with no counterbalance.

Discharged patients were confused by hospitals using approved names and GPs using branded versions. Side effects and overdoses occurred when some patients took both branded and generic products unknowingly. 

The need for controls and independent advice was soon obvious after several incidents, including thalidomide being promoted as “safe in pregnancy” with disastrous results^​1​.

The 1968 Medicines Act established a Medicines Commission, requiring licensing of all medicine-related activities and marketing restricted to indications approved on data sheets for doctors^​2​.

The Noel Hall report, published in 1970,  proposed regional and area pharmacists and quality control and DI specialist posts^​3​. A Royal Pharmaceutical Society Great Britain (RPSGB) working party on DI provided guidance and an NHS reorganisation in 1973 enabled their establishment with attractive salaries^​4,5​. 

Appointment of regional DI pharmacists

Progress was patchy and after suggesting, in my political naivety, a UK-wide network, Joyce Tinegate, the south-west regional pharmacist, worked hard to support and deliver that objective under the radar without asking for formal approval. Tinegate invited nominations from regions and countries UK-wide. Amazingly, all sent nominations, so at the first meeting some attendees were established regional appointees and DI experts; some were new appointees, like me, who came from academia and industry; other nominees were from area centres. Wales, Northern Ireland and three Scottish boards were represented. 

Tinegate opened the meeting and said we were pioneers and would have to find ways of proving our worth as we would be challenged.

The first meeting agreed to the acronym ‘RDIPG’ and to reduce duplication of effort, which included:

• Chair and secretary and ways of working;
• A code of practice and guidance;
• A collaborating and knowledge sharing DI network from regional and area centres to ward level;
• The need for data collection on service usage;
• The principle of sharing the abstracting and indexing of journals between regions;
• The need for specialist national DI centres on drugs in pregnancy, breastfeeding, renal or liver disease;
• The need for training — initially in handling questions;
• Annual network conferences to rotate between regions. 

External threats

Within weeks, Tinegates’ words proved prophetic. In a Lancet article, published in December 1975 by Michael Rawlins, district consultant clinical pharmacologists were proposed to as the way doctors should learn about new medicines^​6​. A letter about pharmacists’ medicines expertise was dismissed on the basis that we had no clinical training^​7,8​ .  
 
They weren’t alone as the pharmaceutical industry believed they were best placed to advise on their products, and medical librarians saw a clinical role from the newly established MEDLINE database.
 
We learned from Yorkshire how pharmacists set up the first poison information service in Leeds but were later excluded from a National Poisons Information Service set up by the Department of Health after they had copied all their information — could DI go the same way? 
 
The RDIPG had to quickly demonstrate pharmacists’ capabilities and that the DI network was a better option.

Official recognition

In 1977, a drug information subcommittee (DISC) was established by the Department of Health, comprising RDIPG members, a regional pharmacist and department staff. Graeme Calder, the then deputy chief pharmacist for England, chaired it and was hugely influential in advising us, especially about the politics involved. He soon invited a few of us to explain the network and what we did to department doctors considering implementing clinical pharmacologist developments. The data we had collected demonstrated the scope and nature of our work.

The outcome

Clinical pharmacologist numbers increased only slowly as DI developed, and clinical practice developed more quickly. The spat continued for some years^​9​. 

In my eight years in DI, the DISC and RDIPG established many more things, including:

• Standards of practice, established well ahead of the profession itself;
• Thesaurus of abstract indexing terms; 
• Many journal articles raising awareness about the service^​10,11​;
• Well-attended annual conferences, rotating around the regions;
• Courses in MEDLINE searching and computerisation;
• A conference on medicines information for the public;
• Computerisation of abstracts into PharmLine; 
• External networking with others;
• DI pharmacists supported the establishment of the United Kingdom Clinical Pharmacy Association in 1981;
• Collaboration with friendly local clinical pharmacologists — one of whom taught a clinical pharmacy MSc from 1975, which is now attracting overseas students.

In 1986, a Nuffield Foundation review reported that “one of the most important developments in a specialist activity have taken place in the provision of drug information … today about 200 hospitals have a drug information centre”^​12​.

Many members from 1975 remained to develop the UKMI service. Others left to make significant contributions to pharmacy and the NHS — a chief pharmacist, a deputy chief pharmacist, two heads of pharmacy schools, professors and general managers are just a few from my eight years. After I left, many initiatives continued but even greater achievements followed DI involvement in establishing Drug and Therapeutics Committees producing local formularies and the 2014 UKMI/RPSGB Faculty Medicines Information Curriculum^​13​.

Clinical pharmacology collaborations gradually developed into the National Institute for Health and Social Care under the same professor Michael Rawlins, where now medicines information pharmacists do much of the work in assessing new products suitability for NHS use.

Summary

The RDIPG and DI pharmacists were pioneers and played a significant role in safeguarding pharmacy as a profession, leading it out of the dispensary to become clinical team medicine experts. Group members produced more than the sum of their parts through motivation, support, camaraderie, direction and purpose, shared values, networking, collaboration and sharing of knowledge through consensus. Many of us learned how to deal and work with doctors.

Amazingly, all of this happened voluntarily with no approval sought other than paid expenses. Decisions had no managerial authority, but the fact that they were implemented is testimony to members’ commitment and vision. 

The RDIPG was the most enjoyable years of mine and many other members’ careers. Sadly, a number of them are no longer here and are missed. 

Long live UKMI services in the Royal College era.

Howard McNulty, FRPharmS member

Update from Howard McNulty

My letter has sparked a number of pioneers to get in contact to add to the story. This is an update and 50th anniversary celebration of UK Medicines Information (UKMI), for those who contributed to its longevity and success.

I forgot to mention probably the most important early development. 

We agreed a pro forma and shared the task of reviewing new medicines from the early days, a role that has become a national one with first the National Institute for Health and Care Excellence and the Scottish Medicines Consortium taking over. 

Attempts to involve community pharmacists were made by several regions. Many hospital preregistration pharmacists trained in drug information (DI) and learned the role and skills needed to deal with other professions. Some went into general practice. 

DI specialist files included paediatrics, a role extended by the paediatric pharmacists group.

A drug information subcommittee (DISC) was not needed after the 19th meeting in 1983, as Graham Calder left to become Scotland’s chief pharmacist. A regional pharmacist attended subsequent RDIPG meetings to give advice and guidance. 

Earlier history came from Jim saying there was an article in the PJ by Mike Rogers in 1972 about the DI Service at the Royal London. This led to a meeting before I joined the NHS at which the Chief Pharmacist Douglas Whittet and he spoke. At that time Mike Rogers NE Thames, Frank Leach North West RHA, Liz Morrison Yorkshire RHA and Elena Grant West Midlands RHA had been appointed regional specialists.

These set the standards and led the way for the rest of us to follow  

By the first ‘RDIPG’ meeting additional regional appointments been made with me in South West, John Smith in Mersey, Jim Smith in the Northern, Mike Brandon in East Anglia, Peter Noyce in north-west Thames, David Hands in Wessex, Felicity Lee in Wales and Marie Maguire in Northern Ireland.

Other regions appointed over the next few years and the initial attendees were replaced. 

The following lists the appointed regional principal pharmacists and shows those who spent their career helping it evolve into UKMI.

Where group members left, their successors up to the 1980s are shown. Those known to be deceased are indicated by ^:

• East Anglia: Mike Brandon until 2007;
• Mersey: John Smith^ to November 1983, followed by Katrina Simister;
• Northern: Jim Smith until December 1990, followed by Anne Lee;
• North: Western Frank Leach until 1999;
• North-east Thames: Michael Rogers to October 1992;
• NW Thames: Peter Noyce^ until Feb 1979, followed by Neil McConachie to October 1981. He was followed by Sue Noyce and Jean Blake from March 1987;
• Oxford: Tony Trice from September 1977;
• South-east Thames: Bronwyn Davies from September 1977–November 1982, followed by Jane Caisley to February 1986;
• South-west Thames: Ros Grant from September 1976—May 1979, followed by Tina McKee in September 1982;
• South-west to 1983 then Glynis Drew^ to September 1987 and Trevor Beswick from March 1988;
• Trent: Peter Golightly from September 1976 to beyond 2007;
• Wessex: David Hands to June 2000;
• West Midlands: Elena Grant to beyond 2007;
• Yorkshire: Liz Morrison to February 1979, followed by Alan Judd;
• Glasgow: Janet McCabe^ from March 1976–1989;
• Lothian: Dorothy Anderson^ from February 1980–December 1992;
• Tayside: Gus MacConnachie^ to 1979;
• Northern Ireland: Marie Maguire to June 1980, followed by Eilish Smith;
• Wales: Felicity Lee to May 1983, followed by Mike Spencer to December 1987. He was followed by Fiona Woods.

As chair and the secretary were re-elected after two years, many of these were able to lead the way forward over the years since.

Those I know who left to become regional pharmacists:

• Jim Smith
• Trevor Beswick

Those who became civil servants, both of whom then became professors and heads of schools of pharmacy:

• Peter Noyce, deputy chief pharmacist
• Jim Smith, chief pharmacist 

Regions were merged in 1994 so beyond then my research may be faulty. You will see many eminent members who contributed significantly to our professions development.

Thanks and best wishes to all and spare a moment to think of those who left too soon.

Howard McNulty