TY - JOUR
AU - Towse, Adrian, K.
AB - Abstract Purpose. The methods currently used by English National Health Service (NHS) hospitals to manage the use of medicines were studied. Methods. A questionnaire was mailed to directors of pharmacy at all English NHS hospitals in May 2001. Results. The response rate was 57% (157/ 275). Sixty-six percent of the responding hospitals provided general acute care services, and 34% provided mental health services. About 1 responder in 5 (19%) was a specialty hospital functioning either as a freestanding institution or alongside other hospitals. The average total expenditure by the hospital trusts was £94 million ($175 million), of which drugs accounted for £3.5 million ($6.5 million). Many hospitals either had formularies or were constructing them (86%), and most hospitals used a process to manage the introduction of new medicines. About three fourths of the hospitals had ≤20 pharmacist full-time equivalents. The implementation of national guidelines was variable, although some of this variation may have been due to differences in service provision. Few hospitals were actively monitoring compliance with guidelines (31%), but audits of current care were common (72%). Conclusion. A survey of English NHS hospitals provided information on pharmacy staffing, drug expenditures, and measures taken to ensure rational medication use. Audits, Compliance, Costs, Data collection, Drug use, Formularies, Hospitals, National Health Service (Great Britain), Pharmacists, hospital, Protocols, Rational therapy England’s roughly 50 million people are served by a centralized federal health maintenance organization (HMO), the National Health Service (NHS). The use of medicines in the NHS has, as in most health care systems worldwide, increased considerably over the past half century. The writing of a prescription is one of the most common therapeutic interventions, and the safe and effective use of medicines is a priority for many health care institutions. Spending on medicines has grown at a rate outstripping that of general NHS expenditures for a number of years and currently stands at around 15–17% of expenditures in primary care organizations, 4–5% of expenditures in NHS hospitals, and 15% of all NHS costs.1 Reasons for this include greater screening of the population, demographic changes (with a more elderly population receiving more medications), more effective medicines with indications against diseases that were previously difficult to treat, and national policies aimed at developing clinical services (known as National Service Frameworks [NSFs]) in such areas as mental health,2 coronary heart disease,3 care of older people,4 and diabetes.5 In addition, guidelines on more than 70 new technologies have been issued by the NHS’s special health authority, the National Institute for Clinical Excellence (NICE). The use of medicines has come under considerable scrutiny within the past decade. While more than 80% of NHS spending on medicines is incurred in primary care, the use of medicines in NHS hospitals is highly relevant for several reasons. First, a patient’s hospital stay is often dependent on the appropriate selection of, timely administration of, and effective response to medication. This will often determine the duration of stay and the setting within which a patient receives treatment (e.g., an in-patient or outpatient setting). Furthermore, general practitioners in primary care are often reluctant to change a drug that was started in the hospital. Medicines initiated in hospitals can therefore have a considerable impact on expenditures and clinical practice in primary care. Second, there is concern about the number of medication errors in NHS hospitals. Medication errors can lead to increased morbidity and mortality and often contribute to expensive litigation against NHS institutions. Such cases divert funding from the direct treatment of patients. The Department of Health recently established the National Patient Safety Agency and issued targets to NHS hospitals for reducing the number of serious medication errors by 40% by 2005.6 Finally, studies of the clinical efficacy and cost-effectiveness of medicines are frequently conducted or coordinated by NHS hospitals. The English NHS operates like a very large HMO with 50 million enrollees. There is, therefore, considerable emphasis on management procedures aimed at improving the use of resources. Medication management in hospitals encompasses the entire way that medicines are selected, procured, delivered, prescribed, administered, and reviewed to optimize drugs’ contribution to producing informed and desired outcomes of patient care.7 We report here a survey to document the methods currently used by English NHS hospitals to manage the use of medicines, with a view to informing future practice in the United Kingdom and beyond. Methods In England, hospitals are grouped into organizations known as hospital trusts, which may occupy more than one site. In this article, the word “hospital” refers to hospital trusts. We surveyed directors of pharmacy to ascertain the development of medication management and hospital pharmacy in England. The survey was pilot tested at six sites in various English NHS regions, modified according to the responses, and sent to chief pharmacists at all NHS hospitals in England in summer 2001. Hospitals in Scotland, Wales, and Northern Ireland were excluded from the survey because these countries have different organizational structures from those in England. Survey questions addressed the type of hospital, the number of pharmacists employed, the total annual hospital expenditure and the proportion spent on medicines, the types of services provided by the hospital, the use of electronic facilities, the hospital’s medication management committee and other committees, prescribing policies, formularies, and the response to NSFs and to guidance from NICE. Questions were also asked about how medication management services had developed, including the use of patients’ own medicines, patient self-administration of medicines, and prescribing arrangements by pharmacists and nurses. We sent reminders to nonresponders over a three-month period. Respondents were promised an advance copy of the report and given the opportunity to participate in a prize drawing. Differences between the responders and all NHS hospitals in England were tested with the chi-square test (StatsDirect statistical software, version 2.2.5, Cheshire, United Kingdom). The a priori level of significance was 0.05. Results Two hundred seventy-five questionnaires were sent out and 157 were returned, yielding a response rate of 57%. Some returned questionnaires did not have a response for each question. The response sample was broadly representative of the population of hospitals in England in terms of regional distribution (p = 0.89, chi-square test). Description of responding hospitals Two thirds of responding hospitals (103/154) provided general acute care services. Over half of these acute care hospitals (59/103 [57%]) provided other services, including emergency care (39%), mental health care (21%), community care (19%), and tertiary care (17%). One third of the hospitals (53/154) provided mental health services, and most of these (87%) provided at least one other service, such as community care (55%), acute care (42%), and emergency care (25%). Services provided by the 30 specialty hospitals included care of the elderly, treatment of learning disabilities, neurology, obstetrics, oncology, ophthalmology, orthopedics, pediatrics, renal care, and care of spinal injuries. The remaining 21 hospitals included emergency, community, tertiary care, primary care, and teaching hospitals. Table 11 depicts pharmacist employment in the hospitals, and Figure 11 shows annual drug expenditures by the number of pharmacists employed in 2001. Table 1. Pharmacist Workforce in English Hospitals (n = 157) No. Pharmacists (Full-time Equivalents) No. (%) Hospitals with Indicated Workforce 1–5 31 (20) 6–10 28 (18) 11–20 60 (38) 21–30 20 (13) 31–50 14 (9) 51–75 2 (1) 76–100 0 101–150 2 (1) >150 0 No. Pharmacists (Full-time Equivalents) No. (%) Hospitals with Indicated Workforce 1–5 31 (20) 6–10 28 (18) 11–20 60 (38) 21–30 20 (13) 31–50 14 (9) 51–75 2 (1) 76–100 0 101–150 2 (1) >150 0 Open in new tab Table 1. Pharmacist Workforce in English Hospitals (n = 157) No. Pharmacists (Full-time Equivalents) No. (%) Hospitals with Indicated Workforce 1–5 31 (20) 6–10 28 (18) 11–20 60 (38) 21–30 20 (13) 31–50 14 (9) 51–75 2 (1) 76–100 0 101–150 2 (1) >150 0 No. Pharmacists (Full-time Equivalents) No. (%) Hospitals with Indicated Workforce 1–5 31 (20) 6–10 28 (18) 11–20 60 (38) 21–30 20 (13) 31–50 14 (9) 51–75 2 (1) 76–100 0 101–150 2 (1) >150 0 Open in new tab Figure 1. Open in new tabDownload slide Annual drug expenditure in English hospitals, grouped by number of pharmacists. Figure 1. Open in new tabDownload slide Annual drug expenditure in English hospitals, grouped by number of pharmacists. The median total annual hospital expenditure was £94.1 million ($157.3 million) (semiinterquartile range, £30.8 million [$51.5 million]). The median annual expenditure on medicines was £3.5 million ($5.9 million) (semiinterquartile range, £2.1 million [$3.5 million]), representing around 4% of all hospital expenditures. In 81% of the hospitals, drug budgets were controlled by the clinical divisions or directorates rather than by the pharmacy. Developments in information and communication technology (ICT) are important components of a modern health service. Table 22 shows the ICT facilities available in the 156 hospitals responding to this question. At the time of the survey, most departments had Web-enabled access from within the pharmacy, but only a small number had fully integrated information technology systems incorporating electronic prescribing and decision support. Table 2. Information and Communication Technology Resources in English Hospitals (n = 156)a No. (%) Hospitals Giving Indicated Response Resource Present Not Present Partially Present aOne hundred fifty-six responses to this question were received, but not every respondent answered each part of the question. Percentages may not therefore total 100. bEDI = electronic data interchange. Intranet access within the pharmacy 127 (81) 21 (13) 7 (4) Internet access within the pharmacy 135 (87) 7 (4) 11 (7) EDIb ordering of medicines from suppliers 63 (40) 64 (41) 18 (12) Pharmacy Web site on intranet or Internet 57 (37) 68 (44) 23 (15) Intranet or Web-enabled formulary 32 (21) 92 (59) 22 (14) EDI invoice processing 20 (13) 112 (72) 12 (8) Electronic prescribing 4 (3) 127 (81) 17 (11) No. (%) Hospitals Giving Indicated Response Resource Present Not Present Partially Present aOne hundred fifty-six responses to this question were received, but not every respondent answered each part of the question. Percentages may not therefore total 100. bEDI = electronic data interchange. Intranet access within the pharmacy 127 (81) 21 (13) 7 (4) Internet access within the pharmacy 135 (87) 7 (4) 11 (7) EDIb ordering of medicines from suppliers 63 (40) 64 (41) 18 (12) Pharmacy Web site on intranet or Internet 57 (37) 68 (44) 23 (15) Intranet or Web-enabled formulary 32 (21) 92 (59) 22 (14) EDI invoice processing 20 (13) 112 (72) 12 (8) Electronic prescribing 4 (3) 127 (81) 17 (11) Open in new tab Table 2. Information and Communication Technology Resources in English Hospitals (n = 156)a No. (%) Hospitals Giving Indicated Response Resource Present Not Present Partially Present aOne hundred fifty-six responses to this question were received, but not every respondent answered each part of the question. Percentages may not therefore total 100. bEDI = electronic data interchange. Intranet access within the pharmacy 127 (81) 21 (13) 7 (4) Internet access within the pharmacy 135 (87) 7 (4) 11 (7) EDIb ordering of medicines from suppliers 63 (40) 64 (41) 18 (12) Pharmacy Web site on intranet or Internet 57 (37) 68 (44) 23 (15) Intranet or Web-enabled formulary 32 (21) 92 (59) 22 (14) EDI invoice processing 20 (13) 112 (72) 12 (8) Electronic prescribing 4 (3) 127 (81) 17 (11) No. (%) Hospitals Giving Indicated Response Resource Present Not Present Partially Present aOne hundred fifty-six responses to this question were received, but not every respondent answered each part of the question. Percentages may not therefore total 100. bEDI = electronic data interchange. Intranet access within the pharmacy 127 (81) 21 (13) 7 (4) Internet access within the pharmacy 135 (87) 7 (4) 11 (7) EDIb ordering of medicines from suppliers 63 (40) 64 (41) 18 (12) Pharmacy Web site on intranet or Internet 57 (37) 68 (44) 23 (15) Intranet or Web-enabled formulary 32 (21) 92 (59) 22 (14) EDI invoice processing 20 (13) 112 (72) 12 (8) Electronic prescribing 4 (3) 127 (81) 17 (11) Open in new tab Hospital committees Ninety-seven percent of the respondents (149/153) had a pharmacy and therapeutics (P&T) committee (or a medication management committee) that covered the whole hospital. The committee met monthly in 35% of the hospitals (53/153), whereas in other hospitals it met every two months (42%) or every three months (20%). Membership on the P&T committee is shown in Table 33. On average, seven types of representatives sat on the committee (range, 2–11). Table 3. Membership in Pharmacy and Therapeutics Committee in English Hospitals Title No. (%) Hospitals Whose Committee Included Member with Indicated Title (n= 154) Median No. (Range) Members with Indicated Title on Committee (n= 72)a aOnly 72 of the 154 respondents specified the number of members on the committee. bPCO = primary care organization. Consultant (including medical director) 152 (99) 6 (1–21) Chief pharmacist 147 (95) 1 (1–2) Other pharmacist 141 (92) 2 (1–6) Nurse 122 (79) 1 (1–5) Primary care physician 105 (68) 1 (1–4) PCOb prescribing committee representative 104 (68) 2 (1–6) Area prescribing committee representative 101 (66) 1 (1–6) Finance manager 59 (38) 1 (1–2) Clinical governance committee representative 51 (33) 1 (1–2) General manager 50 (32) 1 (1–3) Junior physician 37 (24) 1 (1–6) Chief executive 5 (3) 1 (1–1) Regional prescribing committee representative 3 (2) 1 (1–1) Patient representative 3 (2) 2 (2–2) Title No. (%) Hospitals Whose Committee Included Member with Indicated Title (n= 154) Median No. (Range) Members with Indicated Title on Committee (n= 72)a aOnly 72 of the 154 respondents specified the number of members on the committee. bPCO = primary care organization. Consultant (including medical director) 152 (99) 6 (1–21) Chief pharmacist 147 (95) 1 (1–2) Other pharmacist 141 (92) 2 (1–6) Nurse 122 (79) 1 (1–5) Primary care physician 105 (68) 1 (1–4) PCOb prescribing committee representative 104 (68) 2 (1–6) Area prescribing committee representative 101 (66) 1 (1–6) Finance manager 59 (38) 1 (1–2) Clinical governance committee representative 51 (33) 1 (1–2) General manager 50 (32) 1 (1–3) Junior physician 37 (24) 1 (1–6) Chief executive 5 (3) 1 (1–1) Regional prescribing committee representative 3 (2) 1 (1–1) Patient representative 3 (2) 2 (2–2) Open in new tab Table 3. Membership in Pharmacy and Therapeutics Committee in English Hospitals Title No. (%) Hospitals Whose Committee Included Member with Indicated Title (n= 154) Median No. (Range) Members with Indicated Title on Committee (n= 72)a aOnly 72 of the 154 respondents specified the number of members on the committee. bPCO = primary care organization. Consultant (including medical director) 152 (99) 6 (1–21) Chief pharmacist 147 (95) 1 (1–2) Other pharmacist 141 (92) 2 (1–6) Nurse 122 (79) 1 (1–5) Primary care physician 105 (68) 1 (1–4) PCOb prescribing committee representative 104 (68) 2 (1–6) Area prescribing committee representative 101 (66) 1 (1–6) Finance manager 59 (38) 1 (1–2) Clinical governance committee representative 51 (33) 1 (1–2) General manager 50 (32) 1 (1–3) Junior physician 37 (24) 1 (1–6) Chief executive 5 (3) 1 (1–1) Regional prescribing committee representative 3 (2) 1 (1–1) Patient representative 3 (2) 2 (2–2) Title No. (%) Hospitals Whose Committee Included Member with Indicated Title (n= 154) Median No. (Range) Members with Indicated Title on Committee (n= 72)a aOnly 72 of the 154 respondents specified the number of members on the committee. bPCO = primary care organization. Consultant (including medical director) 152 (99) 6 (1–21) Chief pharmacist 147 (95) 1 (1–2) Other pharmacist 141 (92) 2 (1–6) Nurse 122 (79) 1 (1–5) Primary care physician 105 (68) 1 (1–4) PCOb prescribing committee representative 104 (68) 2 (1–6) Area prescribing committee representative 101 (66) 1 (1–6) Finance manager 59 (38) 1 (1–2) Clinical governance committee representative 51 (33) 1 (1–2) General manager 50 (32) 1 (1–3) Junior physician 37 (24) 1 (1–6) Chief executive 5 (3) 1 (1–1) Regional prescribing committee representative 3 (2) 1 (1–1) Patient representative 3 (2) 2 (2–2) Open in new tab Drug-use policies Seventy-eight percent of the hospitals (123/157) had a hospital formulary in use, and a further 8% (12/157) had one under construction. Seven percent of the hospitals (8/120) said that their revision process was ongoing (continuous). Where formulary revision was not an ongoing process, the average (median) date of the last revision was September 2000, about 15 months before the survey was sent. One hospital had not updated its formulary in nine years. Ninety percent of the hospitals (142/ 157) had a formal scheme for managing the introduction of new medicines, and another 6% (10/157) reported that their scheme was currently under construction or review. Ninety-four percent of the schemes (143/152) took the impact on primary care into account, and 77% (115/149) were involved in decisions in conjunction with primary care representatives. Of the hospitals with a scheme for managing the introduction of new medicines (including a scheme under review), 23% (35/152) did not name the products currently being managed by the scheme. Most of the nonresponders (30/35) did not provide general acute care services. Only 3% of the hospitals (5/157) had no scheme for managing new medicines. All of these hospitals employed 10 or fewer full-time-equivalent pharmacists. Only one provided general acute care services, three provided mental health and community services, and one was an eye hospital. Specific policies that were in place in the fiscal year 2000–2001 are listed in Table 44. These were identified as areas that were being highlighted as good practice in national guidelines recently issued in the United Kingdom.7,8 Respondents were given the list and asked whether these policies were current practice in their hospital. Under patient group directions, nurses or pharmacists may facilitate the supply and administration of medicines to defined patient groups without a prescription; the survey revealed that nurses are more likely to undertake these activities than pharmacists. Response to national guidelines NICE was set up as a Special Health Authority for England and Wales on April 1, 1999, to provide guidelines on clinical and cost-effective practice for the NHS.9 We asked pharmacy directors about their hospital’s response to a sample of recent NICE guidelines on proton-pump inhibitors,10 rosiglitazone,11 and taxanes.12 A summary of these guidelines appears in Appendix A, and the hospitals’ responses are presented in Table 55. Table 5. Responses of Hospitals to National Institute for Clinical Excellence Guidelines for Selected Drug Groups (n = 140) No. (%) Hospitals with Response Response Proton-Pump Inhibitors Rosiglitazone Taxanes aP&T = pharmacy and therapeutics. Audited current practice against guidelines 60 (43) 17 (12) 33 (24) Established subcommittee to move recommendations forward 15 (11) 5 (4) 10 (7) Made submission to P&Ta committee; P&T committee recommendations modified 33 (24) 71 (51) 21 (15) Reviewed disease management guidelines 40 (29) 29 (21) 21 (15) Identified indicators for monitoring compliance 14 (10) 7 (5) 11 (8) Requested funding for drug use 3 (2) 15 (11) 55 (39) Circulated guidelines 92 (66) 91 (65) 75 (54) Issued specific directive 16 (11) 15 (11) 10 (7) Modified formulary 43 (31) 61 (44) 18 (13) No action taken 37 (16) 30 (22) 43 (36) No. (%) Hospitals with Response Response Proton-Pump Inhibitors Rosiglitazone Taxanes aP&T = pharmacy and therapeutics. Audited current practice against guidelines 60 (43) 17 (12) 33 (24) Established subcommittee to move recommendations forward 15 (11) 5 (4) 10 (7) Made submission to P&Ta committee; P&T committee recommendations modified 33 (24) 71 (51) 21 (15) Reviewed disease management guidelines 40 (29) 29 (21) 21 (15) Identified indicators for monitoring compliance 14 (10) 7 (5) 11 (8) Requested funding for drug use 3 (2) 15 (11) 55 (39) Circulated guidelines 92 (66) 91 (65) 75 (54) Issued specific directive 16 (11) 15 (11) 10 (7) Modified formulary 43 (31) 61 (44) 18 (13) No action taken 37 (16) 30 (22) 43 (36) Open in new tab Table 5. Responses of Hospitals to National Institute for Clinical Excellence Guidelines for Selected Drug Groups (n = 140) No. (%) Hospitals with Response Response Proton-Pump Inhibitors Rosiglitazone Taxanes aP&T = pharmacy and therapeutics. Audited current practice against guidelines 60 (43) 17 (12) 33 (24) Established subcommittee to move recommendations forward 15 (11) 5 (4) 10 (7) Made submission to P&Ta committee; P&T committee recommendations modified 33 (24) 71 (51) 21 (15) Reviewed disease management guidelines 40 (29) 29 (21) 21 (15) Identified indicators for monitoring compliance 14 (10) 7 (5) 11 (8) Requested funding for drug use 3 (2) 15 (11) 55 (39) Circulated guidelines 92 (66) 91 (65) 75 (54) Issued specific directive 16 (11) 15 (11) 10 (7) Modified formulary 43 (31) 61 (44) 18 (13) No action taken 37 (16) 30 (22) 43 (36) No. (%) Hospitals with Response Response Proton-Pump Inhibitors Rosiglitazone Taxanes aP&T = pharmacy and therapeutics. Audited current practice against guidelines 60 (43) 17 (12) 33 (24) Established subcommittee to move recommendations forward 15 (11) 5 (4) 10 (7) Made submission to P&Ta committee; P&T committee recommendations modified 33 (24) 71 (51) 21 (15) Reviewed disease management guidelines 40 (29) 29 (21) 21 (15) Identified indicators for monitoring compliance 14 (10) 7 (5) 11 (8) Requested funding for drug use 3 (2) 15 (11) 55 (39) Circulated guidelines 92 (66) 91 (65) 75 (54) Issued specific directive 16 (11) 15 (11) 10 (7) Modified formulary 43 (31) 61 (44) 18 (13) No action taken 37 (16) 30 (22) 43 (36) Open in new tab When hospitals took no action in response to guidelines, this some-times reflected the types of services provided. For example, a hospital providing only mental health services would not need to respond to guidelines on taxanes for the treatment of advanced breast cancer. When hospitals did respond to NICE guidelines, the response was marginally greater for rosiglitazone (median number of responses, three; range, one to nine) than for proton-pump inhibitors (median, two; range, one to eight) or taxanes (median, two; range, one to nine), although the difference was not significant (p = 0.7374, d.f. = 2, analysis of variance [ANOVA]). Passive types of responses, such as circulating the guidelines (73% of hospitals did this for at least one topic), were more common than active responses, such as monitoring compliance (14%) or auditing current practice (49%). NSFs are one of a range of measures designed to promote quality nationwide and to decrease geographic variations in service.9 NSFs set national standards and identify key interventions for a defined service or care group. We asked hospital pharmacists about the action taken by their hospital in response to the first two NSFs published, namely those for coronary heart disease3 and mental health2 (Appendix B). Overall, 74% of the hospitals (111/150) responded actively to the NSF for coronary heart disease, compared with 45% (68/150) for the mental health NSF (Table 66). This is unsurprising, given that two thirds of our respondents provided no mental health care. However, 24 hospitals with no formal mental health care provision did respond to the NSF for mental health, typically by circulating the guidelines (16/24), establishing a subcommittee (12/24), or auditing current practice (11/24). Although the number of positive responses by individual hospitals for both types of NSFs ranged from one to nine, the median number of responses was slightly higher for the NSF for coronary heart disease (four) than for the mental health NSF (three). However, the difference was not significant (p = 0.1484, d.f. = 1, ANOVA). Active responses, such as monitoring compliance (done for at least one NSF by 23% of the hospitals) or auditing current practice (54%), were less common than passive responses, such as circulating the guidelines (67%) or reviewing disease management guidelines (59%), although the difference was not as marked as that for the responses to NICE guidelines. Table 6. Responses of Hospitals to National Service Frameworks (NSFs) (n = 150) No. (%) Hospitals with Response Response Coronary Heart Disease Guidelines Mental Health Guidelines aP&T = pharmacy and therapeutics committee. Audited current practice against NSF 63 (42) 37 (25) Established subcommittee to move recommendations forward 61 (41) 47 (31) Made submission to P&Ta committee; P&T committee recommendations modified 41 (27) 18 (12) Reviewed disease management guidelines 67 (45) 34 (23) Identified indicators for monitoring compliance 27 (18) 12 (8) Requested funding for drug use 53 (35) 27 (15) Circulated guidelines 84 (56) 49 (33) Issued specific directive 12 (8) 7 (5) Modified formulary 30 (20) 10 (7) No action taken 28 (26) 82 (55) No. (%) Hospitals with Response Response Coronary Heart Disease Guidelines Mental Health Guidelines aP&T = pharmacy and therapeutics committee. Audited current practice against NSF 63 (42) 37 (25) Established subcommittee to move recommendations forward 61 (41) 47 (31) Made submission to P&Ta committee; P&T committee recommendations modified 41 (27) 18 (12) Reviewed disease management guidelines 67 (45) 34 (23) Identified indicators for monitoring compliance 27 (18) 12 (8) Requested funding for drug use 53 (35) 27 (15) Circulated guidelines 84 (56) 49 (33) Issued specific directive 12 (8) 7 (5) Modified formulary 30 (20) 10 (7) No action taken 28 (26) 82 (55) Open in new tab Table 6. Responses of Hospitals to National Service Frameworks (NSFs) (n = 150) No. (%) Hospitals with Response Response Coronary Heart Disease Guidelines Mental Health Guidelines aP&T = pharmacy and therapeutics committee. Audited current practice against NSF 63 (42) 37 (25) Established subcommittee to move recommendations forward 61 (41) 47 (31) Made submission to P&Ta committee; P&T committee recommendations modified 41 (27) 18 (12) Reviewed disease management guidelines 67 (45) 34 (23) Identified indicators for monitoring compliance 27 (18) 12 (8) Requested funding for drug use 53 (35) 27 (15) Circulated guidelines 84 (56) 49 (33) Issued specific directive 12 (8) 7 (5) Modified formulary 30 (20) 10 (7) No action taken 28 (26) 82 (55) No. (%) Hospitals with Response Response Coronary Heart Disease Guidelines Mental Health Guidelines aP&T = pharmacy and therapeutics committee. Audited current practice against NSF 63 (42) 37 (25) Established subcommittee to move recommendations forward 61 (41) 47 (31) Made submission to P&Ta committee; P&T committee recommendations modified 41 (27) 18 (12) Reviewed disease management guidelines 67 (45) 34 (23) Identified indicators for monitoring compliance 27 (18) 12 (8) Requested funding for drug use 53 (35) 27 (15) Circulated guidelines 84 (56) 49 (33) Issued specific directive 12 (8) 7 (5) Modified formulary 30 (20) 10 (7) No action taken 28 (26) 82 (55) Open in new tab Discussion The vast majority of all health care provision in the United Kingdom is undertaken through the NHS, which is a state-run, free-at-the-point-of-need care provider funded by federal taxation. It is not surprising, therefore, that pharmacy services in the hospital sector have evolved from national directives in a uniform fashion. The most significant of these directives appeared in 1988 after the Nuffield Foundation report on U.K. pharmacy13 and provides a prescriptive blueprint for clinical pharmacy services.14 A significant further modernization of hospital pharmaceutical services was described in “Pharmacy in the Future—Implementing the NHS Plan”15 and “A Vision for Pharmacy in the New NHS.”8 These documents highlighted the changing role of pharmacy in general and hospital pharmacy in particular and addressed such issues as medication management services, nonmedical prescribing, automation, information technology, and reduction of medication errors. Our survey examined some of these areas. The response rate for this survey is not dissimilar to that achieved in surveys of hospital pharmaceutical services in Australia in 1998 (58.5%)16 and surveys by the American Society of Health-System Pharmacists in 2001 (49%)17 and 2002 (46.7%)18 and might have been higher but for “survey fatigue” among chief pharmacists (the profession was subject to three major national surveys in 2001).7,8,19 Our survey sought to ask questions in the same way as these national surveys. A number of the hospitals surveyed had recently merged, so in some cases the postal database did not match the new structure or chief pharmacists were not in place at the new institutions. However, we believe that the results provide a good indicator of the nature of the developing services in English hospitals. The survey did not attempt to examine basic hospital pharmacy services, such as drug purchasing, preparation, distribution, and dispensing; aseptic services; and drug information, but rather those services subject to the government’s modernization agenda. A key aspect of the modernization agenda is the use of ICT systems. The requirements for the NHS have been laid down in a national strategy for local implementation.20 In the second phase of implementation, substantial progress was expected to be seen in delivering an electronic patient record and an electronic health record. A specific target was that 35% of all acute care hospitals were to have implemented an electronic patient record system that included electronic prescribing between 2000 and 2002. Our study found that fewer than 5% of NHS hospitals had such systems; for the subgroup of acute care hospitals, the figure was 3%. However, most hospitals had departmental or hospital access to the Internet, so they are achieving one of the other targets for ICT. The National Electronic Library for Health is accessible through intranets in all NHS organizations. New government guidance includes the goal that, by December 2006, prescribing catalogues must be created and linked to local guidelines, national formularies, and accredited pharmaceutical reference databases. Good progress must have been made toward real-time electronic prescribing across the health care community.21 Our survey showed that over 80% of all hospitals’ drug costs had devolved to the budgets of the specialized clinical services. This means that physicians, nurses, pharmacists, and managers within these specialized areas have to account for drug use in much the same way as any other treatment. Furthermore, prescribers are engaged in the future planning of health services, particularly for new treatments coming onto the market. As in U.S. hospitals, most NHS hospitals have a multidisciplinary P&T committee that meets at least six times a year.17 Membership consists of several clinical professionals, as well as hospital managers. Patient representatives are infrequently involved. Of particular note is the move toward consideration of the use of medicines in the whole health economy (i.e., hospital and family physician practice). Prescribing privileges for pharmacists and nurses are beginning to be established in England, similar to the trend in U.S. hospitals.22 Patient group directions are an intermediate step toward full prescribing by these health care professionals. Pharmacists and nurses are currently training for and achieving competency under a scheme called supplementary prescribing.23 Some nurses are also achieving competency for independent prescribing by using an extended formulary specifically for nurse prescribing. The way that medicines are issued to patients is changing. Rather than being issued medicines in unit dose packs, as is common in the United States, patients are encouraged to bring in and, if appropriate, self-administer their medicines. This is seen as good practice, since it allows patients to continue to take medicines with which they are familiar and reduces medication errors. There is also a move toward using original patient packs for solid oral medicines. In England and Wales, NICE issues guidelines to the NHS on the cost-effectiveness of pharmaceutical treatments. Our survey showed that hospitals’ responses to these guidelines are variable. Although some of this variation may be due to the specialized nature of certain hospitals, other variation remains unexplained. One possible conclusion is that hospitals are not always fully implementing NICE guidelines on cost-effective prescribing, but the reasons for this are unclear. In Europe, health technology assessment (HTA) agencies vary considerably in the methods they adopt to disseminate evidence into clinical practice.24 Although there is no centralized HTA agency in the United States, the Academy of Managed Care Pharmacy (AMCP) publishes a format for formulary submissions.25,26 These guidelines aim to ensure that increased use of medicines is appropriate and that newer products offer clinical and economic benefits. Although adoption of the format has increased, AMCP stresses that this will not necessarily lead to a decline in the expenditure on medicines.27 The strength of this work is that it provides a reasonably comprehensive review of the state of medication management services in English NHS hospitals. The limitation is that the situation is constantly changing. Nevertheless, the survey results offer a useful snapshot of the British government’s initiatives to promote the safe, effective, and cost-effective use of medicines. Conclusion A survey of English NHS hospitals provided information on pharmacy staffing, drug expenditures, and measures taken to ensure rational medication use. Appendix A—Summary of National Institute for Clinical Excellence guidelines on proton-pump inhibitors (PPIs),10 rosiglitazone,11 and taxanes12 PPIs for dyspepsia Patients with mild dyspepsia should not normally be treated with PPIs on a long-term basis. PPIs should not be used for patients with confirmed ulcers. Patients diagnosed with nonulcer dyspepsia should not be routinely treated with PPIs. PPIs may be used for patients with severe gastroesophageal reflux disease or an ulcer caused by a nonsteroidal antiinflammatory drug. If a PPI is recommended, the least expensive appropriate PPI should be used at the lowest dosage that provides effective relief of symptoms. Rosiglitazone for type 2 diabetes mellitus Patients should be offered rosiglitazone combination therapy (as an alternative to injected insulin) if they are unable to take met-formin and a sulfonylurea as a combination therapy or if their blood glucose concentration remains high despite an adequate trial of this combination treatment. The combination of rosiglitazone and met-formin is preferred to the combination of rosiglitazone and a sulfonylurea, particularly for obese patients. Rosiglitazone plus a sulfonylurea may be offered to patients who are unable to take metformin. Taxanes for breast cancer As patients reach the appropriate stage in their treatment for advanced breast cancer, they should be offered either docetaxel or paclitaxel. The use of taxanes for adjuvant treatment of early breast cancer or for the first-line treatment of advanced breast cancer should be limited to clinical trials. Appendix B—Summary of National Service Frameworks for coronary heart disease3 and mental health2 Coronary heart disease Standards 1 and 2 address the reduction of heart disease in the population. Standards 3 and 4 cover the prevention of coronary heart disease in high-risk patients in primary care. Standards 5, 6, and 7 address the treatment of heart attack and other acute coronary syndromes. Standard 8 covers the investigation and treatment of stable angina. Standards 9 and 10 address revascularization. Standard 11 covers the management of heart failure. Standard 12 covers cardiac rehabilitation. Mental health Standard 1 addresses mental health promotion and the discrimination and social exclusion associated with mental health problems. Standards 2 and 3 cover primary care and access to services for anyone who may have a mental health problem. Standards 4 and 5 cover effective services for people with severe mental illness. Standard 6 relates to individuals who care for people with mental health problems. Standard 7 draws together the actions necessary to achieve the goal of reducing suicides. Table 4. Drug-Use Policies in English Hospitals in Fiscal Year 2000–2001 Policy No. (%) Hospitals with Policy in Operation or Being Implemented (n= 157)a aAll respondents answered this question, but not every respondent answered each part of the question. bPGDs = patient group directions. Nurse authorization of supply of medicines through PGDsb 130 (83) Reuse of patients’ own medicines 114 (73) 28-day, original-pack, outpatient dispensing 105 (67) Self-administration of medicines 97 (62) 28-day, original-pack, one-stop discharge dispensing 107 (68) Pharmacist authorization of supply of medicines through PGDs 43 (27) Policy No. (%) Hospitals with Policy in Operation or Being Implemented (n= 157)a aAll respondents answered this question, but not every respondent answered each part of the question. bPGDs = patient group directions. Nurse authorization of supply of medicines through PGDsb 130 (83) Reuse of patients’ own medicines 114 (73) 28-day, original-pack, outpatient dispensing 105 (67) Self-administration of medicines 97 (62) 28-day, original-pack, one-stop discharge dispensing 107 (68) Pharmacist authorization of supply of medicines through PGDs 43 (27) Table 4. Drug-Use Policies in English Hospitals in Fiscal Year 2000–2001 Policy No. (%) Hospitals with Policy in Operation or Being Implemented (n= 157)a aAll respondents answered this question, but not every respondent answered each part of the question. bPGDs = patient group directions. Nurse authorization of supply of medicines through PGDsb 130 (83) Reuse of patients’ own medicines 114 (73) 28-day, original-pack, outpatient dispensing 105 (67) Self-administration of medicines 97 (62) 28-day, original-pack, one-stop discharge dispensing 107 (68) Pharmacist authorization of supply of medicines through PGDs 43 (27) Policy No. (%) Hospitals with Policy in Operation or Being Implemented (n= 157)a aAll respondents answered this question, but not every respondent answered each part of the question. bPGDs = patient group directions. Nurse authorization of supply of medicines through PGDsb 130 (83) Reuse of patients’ own medicines 114 (73) 28-day, original-pack, outpatient dispensing 105 (67) Self-administration of medicines 97 (62) 28-day, original-pack, one-stop discharge dispensing 107 (68) Pharmacist authorization of supply of medicines through PGDs 43 (27) References 1 Calvert RT. Medicines management—fit to bust. Health Serv J . 2002 ; 112 : 24 –5. 2 National Service Framework for mental health: modern standards and service models. London: Department of Health; 1999 . 3 National Service Framework for coronary heart disease: modern standards and service models. London: Department of Health; 2000 . 4 National Service Framework for older people. London; Department of Health; 2001 . 5 The National Service Framework for diabetes. London: Department of Health; 2002 . 6 Building a safer NHS for patients: implementing ‘an organisation with a memory.’ London: Department of Health; 2001 . 7 A spoonful of sugar: medicines management in NHS hospitals. London: The Audit Commission; 2001 . 8 A vision for pharmacy in the new NHS. London: Department of Health; 2003 . 9 Department of Health. The new NHS: modern, dependable. London: Her Majesty’s Stationery Office; 1997 . 10 NICE technology appraisal guidance no. 7: guidance on the use of proton pump inhibitors for the treatment of dyspepsia. London: National Institute for Clinical Excellence; 2000 . 11 NICE technology appraisal guidance no. 9: guidance on rosiglitazone for type 2 diabetes mellitus. London: National Institute for Clinical Excellence; 2000 . 12 NICE technology appraisal guidance no. 6: guidance on the use of taxanes for breast cancer. London: National Institute for Clinical Excellence; 2000 . 13 Committee of Inquiry. Pharmacy: the report of a committee of inquiry appointed by the Nuffield Foundation. London: Nuffield Foundation; 1986 . 14 Health services management: the way forward for hospital pharmaceutical services. Heywood, England: Department of Health and Social Security; 1988 . 15 Department of Health. Pharmacy in the future—implementing the NHS plan. London: Her Majesty’s Stationery Office; 2000 . 16 Wilson SG, Tsui M, Tong N et al. Hospital pharmacy service provision in Australia—1998. Am J Health-Syst Pharm . 2000 ; 57 : 677 –80. Crossref Search ADS PubMed 17 Pedersen CA, Schneider PJ, Santell JP. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2001. Am J Health-Syst Pharm . 2001 ; 58 : 2251 –66. Crossref Search ADS PubMed 18 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2002. Am J Health-Syst Pharm . 2003 ; 60 : 52 –68. Crossref Search ADS PubMed 19 Department of Health. Controls assurance standards for the NHS. Medicines management. www.hcsu.org.uk/standards/standard/medicines.htm (accessed 2004 ). 20 Information for health: an information strategy for the modern NHS. London: Department of Health; 1998 . 21 The national strategy for IT in the NHS. London: The NHS Confederation; 2003 . 22 Clause S, Fudin J, Mergner A et al. Prescribing privileges among pharmacists in Veterans Affairs medical centers. Am J Health-Syst Pharm . 2001 ; 58 : 1143 –5. Crossref Search ADS PubMed 23 National Prescribing Centre. Supplementary prescribing. A resource to help healthcare professionals to understand the framework and opportunities. www.npc.co.uk/publications/healthcare_resource.pdf (accessed 2003 Apr). 24 Granados A, Jonsson E, Banta HD et al. EUR-ASSESS project subgroup report on dissemination and impact. Int J Technol Assess Health Care . 1997 ; 13 : 220 –86. Crossref Search ADS PubMed 25 AMCP unveils its format for formulary submissions, begins dissemination efforts. Hosp Formul. 2000 ; Dec 1: 35 . 26 Fry RN, Avey SG, Sullivan SD. The Academy of Managed Care Pharmacy format for formulary submissions: an evolving standard—a Foundation for Managed Care Pharmacy task force report. Value Health . 2003 ; 6 : 505 –21. Crossref Search ADS PubMed 27 Foundation for Managed Care Pharmacy. Format for formulary submissions. Alexandria, VA: Academy of Managed Care Pharmacy; 2002 . Author notes The National Health Service personnel who helped with the pilot survey and who participated in the survey are acknowledged. Supported by GlaxoSmithKline UK through an unrestricted grant to the Office of Health Economics. Presented in part at the Annual Meeting of the United Kingdom Drug Utilisation Research Group, Manchester, January 30, 2003. Copyright © 2005, American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Medication management in English National Health Service hospitals
JF - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/62.2.189
DA - 2005-01-15
UR - https://www.deepdyve.com/lp/oxford-university-press/medication-management-in-english-national-health-service-hospitals-JiGb6Cq9ZQ
SP - 189
VL - 62
IS - 2
DP - DeepDyve
ER -