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