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A synergistic interaction: Clinical Pharmacologists and Pharmacists

Even our BNF is a product of clinical pharmacologists working with pharmacists.

The British Pharmacological Society (BPS) have a new report out calling for a commitment from government to give greater support to clinical pharmacology.

The British Pharmacological Society launched today a new report calling for an increase in the number of clinical pharmacologists across the four UK nations. This medical specialty, the only one focusing on the safe, effective and economic use of medicines, is well placed to help the NHS surmount the biggest financial challenge since its creation.

This has led to some negative reactions from pharmacists on twitter.

I suspect the wording of the BPS “This medical speciality, the only one focusing on the safe, effective and economic use of medicines” is being misread as “Clinical pharmacology is the only profession focusing on the safe effective and economic use of medicines”. That isn’t the claim, the claim is that clinical pharmacology is the only medical speciality focusing on the safe and effective use of medicines. I would argue that clinical pharmacologists are friends of pharmacy and one of our best advocates.

Clinical pharmacology became important in the 1960s, in the wake of concerns about drug safety, yet even in the 1970s there was concern about lack of clinical pharmacology. Here is Professor Owen Wade, a member of the original Committee on the Safety of Drugs, on the importance of clinical pharmacology.[1]

“Medical schools in Britain, with a few exceptions on the Celtic fringe, have recently neglected clinical pharmacology. […] The establishment of full-time chairs in these subjects is an urgent need in any medical schools where they do not already exist. Undergraduate students need instruction on the proper use of drugs, knowledge of their common adverse reactions and appreciation of the dangers of their misuse.”.

These concerns have continued. Despite increasing governmental focus on drug safety in the past 10-15 years, clinical pharmacology has continued to diminish with 68 specialists in the UK in 2003. A 79% increase in medical specialists from 1993-2003, could be contrasted with a 24% fall in Clinical pharmacologists.[2] There have been recruitment difficulties, and careers were more likely to be found in the industry, rather than into academic medicine. Some of this loss was also due to the high value placed on clinical pharmacologists into organisations such as NICE and the MHRA, but clinical pharmacology has also been hit by a target driven NHS, the rise of cardiology and primary care in cardiovascular management, and changes in undergraduate medicine (around an integrated curriculum) that have damaged some disciplines (in particular the teaching of prescribing to undergraduates).[2] The BPS report highlights that there are now only 77 clinical pharmacologists in the UK.

The British Pharmacological Society, and their members, have for a number of years been concerned about this decline, and the effects on prescribing safety in particular. In recent years there has been a fight back, with the creation of the Prescribing Safety Assessment for undergraduates. Prior to this localised schemes were developed to assess competency in prescribing, and these have always drawn on pharmacists. Locally, I have been involved in OSCE assessments of prescribing competence, as have a number of other pharmacists. Clinical Pharmacologists and pharmacists working together to improve patient safety. A model that we ought to bear in mind.

I’ve worked with clinical pharmacologists for about 14 years, firstly on wards, where they were often the clinicians most likely to want a pharmacist on their ward round. [See note at end] Indeed, one was even a qualified pharmacist as well. Then as a pharmacist in a Yellow Card Centre, where the Director was a clinical pharmacologist. Wherever I have seen clinical pharmacologists work they have been a key ally of pharmacy in the medical arena, helping pharmacy push through Drug and Therapeutic committee decisions, and not anti-pharmacy at all. Senior academic clinical pharmacologists have been nurturing towards pharmacists, often encouraging pharmacists to develop their academic side, getting them involved in research, and in many cases setting pharmacists off on a course to obtain a PhD helping to develop the pharmacy workforce. Certainly, the Yellow Card Centres across the UK are one area where this can be seen, which are centres of excellence in terms of pharmacists working with clinical pharmacologists. I know I am not alone in seeing this synergism.

The BPS provides a quote from Roger Walker on the role clinical pharmacologists play with pharmacists, and gives an example of pharmacists working together with clinical pharmacologists:

The All Wales Therapeutic and Toxicology Centre (AWTTC), a partnership led by clinical pharmacologists working together with pharmacists in Wales was able to provide resources and training to support prescribers in Wales in reducing primary care prescribing costs in three main areas.

I am part of a team that obtained a grant to develop Safe Prescriber a website about prescribing safety for F1 doctors, that is now being rolled out nation wide for other prescribers. That team consists of clinical pharmacologists and pharmacists from the start. The main editor is a pharmacist. From the start modules have been largely co-developed with a medical and pharmacist contributor. In my main job as a Programme Director on an undergraduate pharmacy course, the clinical pharmacologists are an essential resource.

Clinical pharmacologists are not a threat to clinical pharmacy, nor do they devalue pharmacy. Why would they put a quote from a pharmacist in their own report to back-up their own importance if they felt pharmacists were not valued? Practically, there are not enough pharmacologists to deal at ground level with the tsunami of drug-related harm that patients experience, they need pharmacists as a partner.

I am a member both of the BPS and the Royal Pharmaceutical Society. These organisers work together, for one example see here. I hope we continue to do so, and I would hope that we can support the clinical pharmacologists in their call to re-envigorate their speciality.

The swamp of medicine-related problems is vast. Neither pharmacy and or clinical pharmacology is going to drain it alone, but we can at least work together to fix the parts we can.

  1. Wade OL. Adverse Reactions to Drugs. 1st ed. London: William Heinemann Medical Books Ltd, 1970
  2. Maxwell RJ, Webb DJ. Clinical pharmacology – too young to die? The Lancet 2006; 367(9513):799-800

Additional note: Rather than focusing on a non-existent threat from clinical pharmacology pharmacy ought to concentrate on its own profession. There are a number of threats to clinical pharmacy services in the UK, such as re-banding and redundancy pressures on senior experienced clinical pharmacists in the NHS. Additionally, ward rounds, anecdotally, appear to be contracting as hospital pharmacy starts to focus on process driven targets, rather than clinical care in its widest sense. We ought to start a discussion about how we can insure that pharmacists become part of clinical teams, to ensure that the clinical aspects of their expertise that cannot be measured with targets continues to be valued. Why not speak to your clinical pharmacology colleagues to see how you can work together?

Fringe session at the Royal Pharmaceutical Conference 2014

Birmingham Library

If you are attending the Royal Pharmaceutical Society’s Conference this Sunday and Monday, Birmingham and Solihull RPS would be pleased to see you at our breakfast Fringe session at 8am until 9:30am on Monday the 8th of September 2014. There will be coffee and danish pastries… Further details should be in your Conference Pack and at the registration desk. There is a form to register at the end of this post.

Here’s what you can see, and there will be time for Questions and Answers.

Innovation in pharmacy practice: Three case studies.

1. West Midlands Emergency Department Project (8:10am until 8:30am)

Health Education West Midlands identified a role for the Pharmacist in areas such as pre-discharge medicines optimisation in the ED and Acute Medicine Units, as well as within Clinical Decision Teams in the undertaking of medicines-related and minor¹s-focused clinical duties. This project aims to develop enhanced roles for Pharmacists, to improve patient safety, the patient experience and to increase capacity in the acute care pathway.

2.RPS BNFc QRG and SCRIPT Paediatric E-learning Modules (8:30am-8:50am)

SCRIPT eLearning is an established innovative and interactive eLearning programme to improve prescribing competency. Initially commissioned by Health Education West Midlands for Foundation trainees, the project has recently been extended to Paediatric Specialist Trainees, with 12 modules commissioned for development in collaboration with the University of Birmingham and Birmingham Children¹s Hospital. This exciting project sees Paediatricians, Specialist Paediatric Pharmacists and Nurses collaborating to develop module content that will improve knowledge relating to prescribing and therapeutics, with the overall aim of reducing medication errors in the paediatric setting. The learning will be made available online at www.paediaticprescriber.org.

3. PINCER: The use of a pharmacist led technology intervention method to show a reduction in patient harm (8:50am-9:10am)

The PINCER trial published in the Lancet February 2012 demonstrated that a pharmacist-led technology intervention method was effective in reducing a range of medication errors in general practice. Walsall CCG medicines management team has implemented a systematic process across all member practices to implement these safety interventions utilising the expertise of the informatics team and a software tool from PRIMIS. The improvement is safety and quality of prescribing has been demonstrated by the reduction in numbers of at risk patients across all categories and reduction of new patients identified.

Let’s have some over-the-counter evidence

I have an editorial in The Pharmaceutical Journal on over the counter medicines and pharmacists relationship with them. Here’s part of it:

While the secret shopper work carried out by the consumer watchdog Which? in 2013 investigated[1] the quality of advice on OTC medicines given in pharmacies at the point of sale, an earlier report[2] in Which? published in 2012 focused on OTC products themselves. Among the products that were judged to be below par were sub-therapeutic doses of drugs, dubious herbal slimming tablets, oils that allegedly reduce scarring and some highly implausible alternative remedies. A pharmacist drawing up a local formulary of prescription drugs for a GP would take into account evidence of effectiveness, advice from evidence-based guidelines and a positive risk-benefit ratio. How many OTC products would reach the required standard?

Read more…

E-Cigarettes

Here’s a link to my brief piece on e-cigs in The Pharmaceutical Journal:

No drug is safer without regulation and that includes nicotine. Licensed e-cigarettes used as part of pharmacists’ smoking cessation role would be a step forward. Concern at the meeting that e-cigarettes were becoming an “easy fix” was supported by suggestions that smoking cessation services were not being renewed on the basis that e-cigarettes had solved the problem. Pharmacists need to defend the added value of those services and ensure e-cigarettes are an option when we have a licensed product.

In the meantime, we cannot support the sale of unlicensed e-cigarettes in pharmacies. This places pharmacists in a difficult position of selling an essentially recreational product with no licensed medicinal claim. There is potential for variation in dosing with unlicensed e-cigarettes, without the regulatory oversight of quality and safety the MHRA provides.

 

The pragmatic regulation of herbal products

Echinacea - another herb of dubious value

I have a letter in the BMJ about pragmatism in relation to the regulation of herbs:

The risks to patients from unregulated herbal preparations means a scheme that reduces the risk of adulteration carries a public health benefit, even in the absence of known efficacy. Differing licensing requirements for prescribed drugs and herbal products do not reflect dual standards of evidence; a herbal product licence is an admission that the product has no proved efficacy.

Yellow Card Scheme 50 today

Tuesday will see the 60th year since the breaking of the four minute mile by Roger Bannister, but today has an equally important milestone. The UK’s Yellow Card scheme for the collection of spontaneous reports of suspected harm from medicines was started 50 years ago today.

Derrick Dunlop's letter
The 1964 letter establising the Yellow Card scheme

The scheme was started after the failure to detect serious birth defects associated with the drug thalidomide (my post on the 50th anniversary since thalidomide was launched is here). Since then the scheme has been an extremely useful tool to help detect signals (a brief discussion of what a signal is here) of drug harm. During the past 50 years, there have been ups and downs, including notable problems such as practolol and benoxaprofen, but the scheme has undoubtedly led to safer drugs in the UK. It, and the pharmacovigilance expertise of the UK, has been influential worldwide, particulary in the European Union. Even in the first year of its operation, the scheme was able to issue a warning of drug safety.

Derrick Dunlop’s name is on the letter, but the man whose name is most associated with the formation of the scheme is Dr BIll Inman. Inman contracted polio at the age of 21, undertaking his medical training in a wheelchair (more on him here). In the early years of the Yellow Card scheme, Bill Inman manually examined hundreds of Yellow Cards, sorting and piling differing reports by hand, to prove that the risk of thrombosis associated with early oral contraceptives could be reduced by lowering the dose.

That’s fifty years of doctors (and now all professionals and patients) reporting to the Yellow Card scheme as a simple act of altrusim – there is no payment. Every card is of help to future users of medicines, by helping regulatory agencies keep their eye on emergent drug safety issues.

If you want to celebrate the Yellow Card scheme’s fiftieth birthday, honour it, and the memory of Dr Bill Inman, not by sending a card, but by sending a Yellow Card next time you suspect a medicine has harmed either yourself or a patient.