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Setting new course

Pharmacists are taking on a larger role in steering the prescription and use of medicines, but is pharma on board with this new customer group?

A section of a ship's wheelMuch has been written about the UK pharmaceutical industry's expanding customer base and its impact on marketing strategy. Wholesale reform of the NHS has meant that prescribing decisions, traditionally the preserve of the doctor, are increasingly being influenced and, in some cases, made, by a growing number of additional healthcare stakeholders. Driven by the requirements of HTA, decisions are now based on a balance of clinical- and cost-effectiveness. The industry's customer base reflects this - comprising stakeholders from both clinical and non-clinical communities (payers). Yet, while pharma may claim a long-standing familiarity with clinicians, the growing clinical influence of the pharmacist is in danger of slipping under the radar.

Changing role
The world of pharmacy is changing. The government's ongoing programme of disease control and prevention has identified pharmacy as a key enabler in the delivery of healthcare and a central component in improving the quality of patient care. The ensuing development of a modern 'clinical pharmacy' approach is driving an environment where pharmacists are no longer confined to the dispensary, but are instead playing a critical and influential role in the prescription and use of medicines. But how much does pharma engage with this important customer group? As pharmacists in both hospital and community settings become vital stakeholders in the uptake of medicines, how much do you understand about their role and their information needs?

Clinical pharmacy
The term 'clinical pharmacy' has evolved. Historically considered synonymous with ward pharmacy and, therefore, relevant only to those who have direct contact with hospital inpatients, clinical pharmacy has now become part of the mainstream of the pharmacist's contribution to patient care. Protagonists argue that pharmacy's clinical role involves ensuring optimal care across every aspect of the patient pathway and that, in fact, all pharmacists are 'clinical pharmacists' – whether working in medicines procurement, production or, increasingly, in the community.

White paper
The 2008 white paper: Pharmacy in England: building on strengths – delivering the future, called on all pharmacy staff, in both primary and secondary care, to become more clinical. It outlined how pharmacies could help contribute to the shift towards more treatment in the community and self management of long-term conditions, encouraging pharmacists to extend their focus beyond simply dispensing to providing more clinical services.

In line with this, in November 2008, the DH's chief pharmaceutical officer, Dr Keith Ridge, appointed two national clinical directors for pharmacy - Jonathan Mason (community pharmacy) and Martin Stephens (hospitals). The creation of these positions, the first non-medical national clinical director posts, was a recognition of the key role pharmacy is playing in delivering patient care. "Having two senior pharmacists as clinical leaders alongside the other national clinical directors, and with seats on the NHS Medical Board is, I believe, of great significance," says Martin Stephens. "A central aim of the white paper is to unleash pharmacy's potential as a clinical profession, and that applies both in primary and secondary care. In fact, it might be said that the aim to become more clinical particularly applies in primary care. The contractual agreement has been very focused on the supply of medicine, which obviously needs to continue to be got right, but is actually now moving towards providing a whole range of broader services."

These 'enhanced services' include:
• Smoking cessation
• Minor ailment services
• Medicines Usage Reviews (MURs)
• Health checks
• Healthy living centres
• Supplementary prescribing
• Medicine compliance and supervision.

Critics claim that PCT commissioning of extended services to pharmacists has, so far, failed to match the expectations laid out in the white paper and that, in the community at least, the opportunity to develop the profession clinically is being missed. These are, however, early days and, as pharmacy evolves and the focus on improving quality gathers momentum, it seems certain that many current hospital-based services will move into the community, with pharmacists at the helm.

Hospital prescribing
At present, the majority of clinical pharmacy services occur in secondary care – and it is largely in this setting that the pharmaceutical industry perhaps needs to give greater consideration to the customer group. The secondary care market is an extremely valuable one for the industry. In 2007, hospital prescribing in England alone accounted for £3.05bn (27.2 per cent) of the total drugs bill. Of this, over £160m of drugs prescribed in hospital were dispensed in the community. The cost of medicines dispensed in hospitals grew by 12 per cent, and by 5.7 per cent overall. Figures for 2008 are due to be published by the NHS Information Centre this autumn and are expected to show a further increase in hospital prescribing.

The rise in hospital prescribing is being driven by two major factors. Primarily, many of the drugs positively appraised by NICE are only used in a hospital setting. In addition to this is the steady increase in the number of biopharmaceutical drugs coming to market as pharma turns to biologic therapies to soften the blow of imminent patent expiries on small molecule blockbusters. These biologics and biosimilars are generally only prescribed in hospitals, and also require specialist pharmacy knowledge to ensure safe and appropriate use. As the industry invests heavily in the development of specialist hospital products, the influence of the pharmacist as part of an extended, multi-disciplinary clinical team is becoming ever more important.

"In hospitals, more and more pharmacists are now working as core members of specialist teams, alongside specialist nurses and consultants," says Alison Currie, senior clinical adviser at WG Consulting. "This has long been the case in oncology, but it's becoming more prevalent in other areas too. In the process, clinicians have become much more open to specialists joining their team, so that they have a share of voice."

A good example is MRSA, which in the past few years has seen the creation of a number of dedicated microbiology pharmacist roles. These are working as part of specialist teams with microbiologists and infection control nurses to monitor antibiotic prescribing in hospitals. But this is not unique. In addition to oncology, there are now specialist pharmacists working across a whole range of therapy areas, such as renal, cardiology, diabetes, respiratory, paediatrics, critical care and pain management.
The increased number of specialist pharmacists in hospitals underlines the growing influence of pharmacy in secondary care. But hospital pharmacists have long played a crucial role. "In the past, pharma companies believed that if they could persuade the doctor in the hospital to prescribe the drug, the prescription would be written and the drug would be supplied. But this has not happened in hospitals for a long time," says Currie. "If a clinician sees a drug representative and is sold on a particular drug and wants to prescribe it, they must at some stage go through pharmacy – whether that's the chief pharmacist, formulary pharmacist or a specialist."

Pharmacist presence on formulary and prescribing committees is, of course, standard – but even this model is evolving. Some SHAs have moved away from having separate hospital and PCT formularies, and instead operate a joint formulary across the health economy. Yet again, the pharmacist plays a key role. Omar Ali, a formulary development pharmacist, says the 'shared care' approach deployed in Surrey & Sussex NHS Trust follows a model recommended by the National Prescribing Centre and the DH. The full breadth of Ali's role demonstrates its significance for industry. "I have four main objectives. Firstly, the managed entry of NCEs onto the formulary. When a new product comes to market, my role is to evaluate it and provide a summary for the Area Prescribing Committee. I also write the shared care guidance for new drugs once they are approved onto the formulary. This directs which physicians are responsible for pre-agreed elements of prescribing and monitoring and referral criteria. Thirdly, I look at budgetary impact and horizon scanning. This incorporates new commissioning decisions, horizon scanning for new molecules and how best to plan for them, and requirements for new business cases. Finally, I have to ensure the implementation of NICE guidelines within three months of publication."

Influencers and implementers
The industry's customers generally fall into three categories; influencers, implementers and decision makers and it is important to understand which role fits into which category. Pharmacists are rapidly beginning to fall into all three. They have long been regarded as implementers – they can ensure that, once it has gone through formulary, a product is used appropriately within the setting in which it has been agreed. As valued members of specialist teams, pharmacists are playing a more central role in clinical ward rounds and are, as such, becoming important influencers. The advent of independent prescribing and the recent introduction of consultant pharmacists, means that pharmacists are also becoming decision makers. Consultant pharmacists have independent prescribing rights and can actually see patients and determine which drugs they need.

The vast majority of pharmacists will, of course, remain as influencers and implementers. However, their role in reviewing prescriptions and identifying whether a particular medicine is suitable for a patient, and – if not – making alternative recommendations to get a prescription change, makes the pharmacist a key customer for industry.

The future for pharmacy
Pharmacists are also playing a major role in helping to implement many of the initiatives laid out in the Darzi Review and being built on through Quality Innovation, Productivity and Prevention (QIPP). "Darzi focused on quality, safety, outcomes and the patient experience, which are all absolutely pertinent for hospital pharmacists," says Martin Stephens. "Making sure that the patient experience is as good as it can be is key. Likewise, ensuring patients take their medicines in a timely way and that they have the right information is critical. This will play a role in helping achieve good outcomes with medicines. Central to all of this is ensuring the safety of medicines."

The white paper identified chief pharmacists, whether in secondary care or in PCTs, as the leaders in safety of medicines. It talked about making sure that safe practice is embedded in patient care. "Pharmacy has always been about making sure that medicines are safe, but this is really about taking it to the next level," says Stephens. "We know that there have been lots of issues with harms occurring in secondary care, whether that is in administration, in prescribing that's not quite right, or problems with supply/dispensing. We need to refocus on these things and look at where we can improve. There are still around 4-5 per cent of hospital admissions that are associated with things going wrong with medicines – that's a big burden of ill health where we aren't getting medicines right. It's time for pharmacy in hospitals to move up a gear and become even more engaged."

And so, as the clinical pharmacy movement gathers pace, the question for marketers is simple: pharmacists are preparing to become more engaged – how engaged are you?

The Author
Chris Ross is a freelance writer

4th November 2009

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