Hospital pharmacy: thinking the unthinkable

Hospital pharmacy has often been seen as the “engine of innovation” for pharmacy services and, since the introduction of ward pharmacy in the late 1960s, hospital pharmacy has become increasingly patient orientated. However, supply remains a major part of the pharmacy service and together with specialist compounding and information support is a mainstay of any hospital pharmacy. How will this change in the pharmacy of the future? Although any future vision is likely to be as reliable as my predictions for the National Lottery, if we examine the services currently offered and the main drivers for change, this might give a reasonable idea of what changes may occur. I will propose a vision for the future and illustrate how that vision was informed. It is then for the reader to take the issues and the drivers for change to inform their own vision of the future.

In this article I was asked to “think the unthinkable” and I have thought quite a long way into the land of the “unthinkable”, so many may find the vision far-fetched. However, much of what I will refer to is already in place in other countries or other industries and so I would urge readers not to dismiss this as science fiction: it is all too real science fact!

Most hospitals still provide the full supply chain for pharmaceuticals involving purchase, storage and distribution of medicines, including dispensing. In recent times, specialist compounding or assembly, particularly of aseptically prepared items, has increased within the hospital service, although in the community, growth of “specials” manufacturers has reduced the amount of extemporaneous dispensing done in pharmacies. The drug information service is one of the success stories of hospital pharmacy and, together with active participation in research, drug history taking and involvement in the cardiopulmonary resuscitation team, DI services have been shown to reduce patient mortality in hospitals in the United States.¹

Drug history taking is clearly a major feature of the provision of pharmaceutical care and I would add to this active education programmes and a focus on clinical economy and pharmacovigilance, particularly with regard to medication errors, to complete the range of services offered within hospital. The greater focus on pharmaceutical care, concentrating on the medication needs of the patient, is clearly growing in the United Kingdom,^2,3
and will doubtless increase benefits to patients. But how are these services to be maintained, much less developed, in the light of the current recruitment crisis? And what of the future?

Drivers for change

The main drivers for change stem from the Government’s agenda for change within the National Health Service. Greater focus on the quality of clinical care and the introduction of a unified, cash-limited budget across primary and secondary care has put the use of medicines into sharp focus. Renegotiation of the Pharmaceutical Price Regulation Scheme, the patient pack initiative and the increased cost of schedule D drugs have all raised the issue of drug expenditure, and in the light of a unified budget, is the discount available to hospitals likely to continue?

The changes in the NHS have done much to increase demand for pharmacists. The introduction of primary care groups (PCGs) has led to an increase in prescribing advisers in primary care. Changes in shopping patterns in supermarkets have led many of the bigger chains to open extended hours pharmacies, employing four or five pharmacists rather than the single proprietor pharmacist they may have replaced. The move to a four-year pharmacy course will clearly have an effect, markedly reducing the number of preregistration trainees in 2000 and the number of pharmacists in 2001. These pressures look set to continue with reduced intake into schools of pharmacy, unless a solution is found to the funding shortfall created by extending the course. Nor is this pressure on recruitment and retention restricted to pharmacists. There are difficulties in recruiting other pharmacy personnel and problems in many other disciplines, including nursing and medicine, and these will increase as demand continues to increase.

The conflict between the drive for greater throughput of patients, reduced surgical waiting lists, improved quality of care and lack of staff and constrained budgets will inevitably result in some change and I would predict that this will be a change in the type of patients managed in hospital. This change started some time ago and I believe it will accelerate as the need to manage still more patients at home increases.

One of the drivers to facilitate change is the Government’s drive to modernise the NHS and the introduction of an information and technology strategy, outlined in “Information for health”.⁴
This could facilitate the improved management of patients, reducing communication difficulties and confusion and allowing the care of patients to be radically redesigned. Another is the introduction of pharmacogenomics, allowing medication to be truly “tailored” to meet the needs of the individual.

The future

We now come to my vision for the future. It is a vision that will cause some disquiet in the breasts of many hospital pharmacists but it is a prediction of the potential future and, as such, it is a vision that may prove illusory. I believe that in the early part of the next decade, the introduction of electronic transfer of information within the NHS will open up a number of opportunities. The current problems associated with poor communication between primary and secondary care will be alleviated and drug history taking will be an automated process. Diagnostic support systems will allow the automated introduction of clinical pathways of care that can be tailored to the needs of the individual by health care professionals (and to some extent by computers, fed with information about vital signs and pharmacological and physiological responses to therapy).

Information about the medication needs of the patient will be fed directly to the pharmacy to facilitate supply, and this supply will be delivered by automated picking linked to pneumatic air-tube delivery. Alternatively, the organisation may choose to operate a floor-stock system, with a point of sale technology reorder facility, which allows the pharmacy resupply to individual patients to be delayed by over 12 hours and facilitates the delivery of the supply service from a local pharmaceutical wholesaler. Drug administration will be streamlined by allowing patients who are capable of self-medication to do so and all drug administration will be audited using a bar-code scanning system linked to each drug administration. This will reduce medication errors, ensuring appropriate resupply and checking of the medicine and the patient against the prescription record, further minimising risks to patients.

Prescribers wishing to deviate from the predetermined care pathway can access all the information necessary to ensure their choices are evidence-based from their hand-held mini-computer, linked into the hospital’s main web-based virtual library. This will already have been customised to the needs of individual care units, such as cardiology or intensive care. Rules-based clinical decision support, integrated into the clinical care pathway, will ensure that treatment is optimised on an individual basis.

As many chronic diseases will be managed remotely, with the patient cared for in their own home or in a minimal care facility, the type of patients who are hospitalised will differ from those seen currently. Patients will be more acutely ill, and surgical and trauma cases will dominate the case mix. Even here the use of technology will allow many patients to be monitored from a central nursing care station, allowing physiological measurements such as blood pressure, electrocardiograph and oxygenation to be continuously checked. The nurse could also remotely manage certain interventions, such as turning the patient to prevent pressure sores, by means of a motorised bed (increasingly common in high dependency units), reducing or increasing infusion rates, or interacting with the patient via digital television link.

Meaning for pharmacy

With integrated health records, the drug history will be a thing of the past. Virtual libraries, tailored to an individual’s needs, would allow ready access to up-to-date evidence on a full range of treatment options. If we are to practise in an evidence-based fashion, this leaves us with research and CPR! Never fear: although the transfer of information may be seamless, that does not guarantee that the information that is transferred is the right information. Assessing the patient’s medication needs will continue to be a prime role for pharmacy. Our own experience suggests that many patients are prescribed unnecessary treatments or even wrong treatments or are receiving doses that are either excessive or subtherapeutic. Just as the remote monitoring system cannot replace the ill-defined and unmeasured effect of a nurse who is literally “hands-on”, so the electronic prescription checking system and the robot dispenser will not replace the pharmacist. These things are simply tools – complex and expensive tools to be sure – but in the end the real challenge is not how do we survive the introduction of new technology but how we use these tools to achieve better care for our patients.