‘Heading for the perfect storm?’ was a strange piece by Philip Brown (BJ Clin Pharm 2010;2:255). In one part he is hoping that Lindsey Gilpin, chair of the English Pharmacy Board of the Royal Pharmaceutical Society (RPS), will become the ‘Margaret Thatcher of Pharmacy’ (Lindsey is far too nice to even think of it). He proposes that hospital pharmacy will be the one sector to be really hit following the publication of the Coalition Government’s White Paper. Then he concludes that the answer is for greater representation of the managed sector at the RPS.

An autocratic approach is all very well, but the last thing we want right now is our equivalent of the Grand Old Duke of York. One could argue that the responsible pharmacist regulations are pharmacy’s equivalent to the poll tax debacle, and we hope we do not repeat such mistakes with the debate about supervision.

The hospital sector has been no stranger to the financial storm of late. The QIPP (quality, innovation, productivity and prevention) agenda was associated with significant cuts in funding, and maintaining funding for posts is a perpetual problem. Despite such problems, the recruitment of pharmacists has become easier with a larger pool of potential recruits of truly able clinical pharmacists.

However, a key point missed from Dr Brown’s article is the failure of the profession as a whole to deal with what happens with specialist care outside of the hospital. As the length of stay in hospital becomes shorter, treatments in hospital become more high-tech, and more patients require and receive specialist treatments outside of hospitals (with the prescribing and dispensing of medicines occurring in the community), the ability of the GP and the community pharmacist to have any sensible role here becomes diminished. Hospital pharmacists, along with nurses and medics, have become more aligned to specialities, but pharmacy has not developed any effective outreach role. Unless hospitals pharmacists do so, their role and scope will shrink to that of reducing harm during a very brief stay. There is no point in having the best clinical pharmacists in the world if the moment the patient leaves secondary care it all goes wrong.

One could reflect that it was the development of primary care trusts that curtailed this — instead of providing the link between secondary care and general practice follow up, PCTs evolved primarily into a separate entity whose main purpose was to control GP prescribing. The abolition of PCTs provides an opportunity for a realignment of our support for these specialist activities. Most PCT provider arms are now becoming the business of acute hospital or mental health trusts, and this may create an opportunity for change.

Dr Brown’s next question is whether we have the right team at Lambeth to support the hospital sector. Both the current hospital pharmacists (Sue Kilby and myself) elected to the English National Board of the RPS are specialists, so may not be seen as ‘mainstream’ hospital pharmacists. However, I see the role of the RPS as working with and supporting the many organisations we have in pharmacy, and close working with the Guild of Healthcare Pharmacists is the way forward here. The loss of the technician post within the Board is a great blow and needs to be compensated in some way.

Finally, to demonstrate the problems occurring at the interface of primary and secondary care, I thought I would share a case I was involved with recently. A 45-year-old man with complex epilepsy, behavioural problems and learning disabilities was on about 10 different medicines, and we had very little understanding of why these had accumulated. The reason for the referral was a gradual deterioration in the patient’s health over the past nine months. The residential home maintained that his deterioration corresponded with a change from risperidone to olanzapine. However this was being disputed by the consultant, who said the drugs had been changed more than two years previously. When the GP records were examined it turned out the consultant had written to the GP two years ago asking for olanzapine to be prescribed, but had failed to ask for the risperidone to stop. This error was only identified and corrected nine months ago. Worse still, the patient had been prescribed fluoxetine (increased risk of seizure induction) by a locum doctor, with a review date of one month. It had never been reviewed. Sadly, this is not an isolated case. The error rate is incredibly high and I always ask for a full printed copy of the medication history from the GP whenever I am involved in such a case.

So, if we want some targets for future issues we should start at the interface between primary and secondary care. We should start to challenge some of the activities of commercial enterprises that provide specialist services that bypass pharmacy, such as those that exploit the current loophole on VAT so they can be 20% cheaper. We should revisit nursing homes and consider how the changes will increase clinical pharmacy input. We should start to challenge the whole idea of ‘the big brick wall’ between hospital and community provision giving private companies an advantage. We should start to challenge the idea that involvement of hospital pharmacy with all these specialist teams is someone else’s business.

I think we would find that, given a level playing field, the managed sector’s ability to be entrepreneurial and provide what GPs want might just surprise us.

Dave Branford, Chief pharmacist, Kingsway Hospital
Derbyshire Mental Health Services NHS Trust, Member of the English Pharmacy Board of the Royal Pharmaceutical Society