Active ingredients: hospital pharmacy and medicines leadership
As well as being the most common intervention in health care, medicines are a particularly complex area of policy. Primarily prescribed by doctors, administered by nurses, manufactured by industry, regulated by government, and reviewed, dispensed, managed, counselled and compounded by pharmacists, medicines are a powerful example of the complexity of health care as numerous professionals interact to enable treatment for a single individual.
Australians have high expectations surrounding access to medicines, and rightly so. We should all be proud of the comprehensive policy framework that has evolved to support timely access to high-quality medicines in a wide range of healthcare settings. No longer are people willing to accept that a pharmacy, hospital or residential aged-care facility doesn’t stock a particular medicine. Even the highly regarded and independent Pharmaceutical Benefits Advisory Committee (PBAC) processes, which result in recommendations to the federal government regarding medicines that should be subsidised, have become the target of campaigns from consumers keen for the right to access expensive medicines at heavily discounted costs. Given the rate of medicines use in Australia, this is not surprising — nine million Australians take prescription medicines daily.
And yet medicines leadership remains piecemeal; rarely are medicine use, funding and clinical pharmacy care discussed in collaborative conversation. Given the multifaceted roles pharmacists play — from managing shortages to supporting prescribing in hospitals and treating patients — health policy has been slow to recognise the value in pharmacy care for people at risk of medicine-related complications.
Even the Medication Safety Standard, the accreditation requirements governing medicines management in our hospitals, makes little explicit mention of pharmacists and their in-depth medicine expertise. Similarly, the 1998 National Medicines Policy gives high priority to consumer medicine access and a sustainable industry, but little consideration to the fact that, without clinical pharmacy support, consumers are at heightened risk of undetected medicine interactions and debilitating side effects. More than 250,000 medicine-related hospitalisations occur every year in Australia.
In recent years, the maturing of medical research and technology has changed the nature of PBS medicine listings. Since 2013, more than 2100 new or amended listings have been added at an overall cost of around $10.6 billion; these listings are increasingly for the treatment of smaller groups of critically unwell patients in the acute setting. Approximately two-thirds of new PBS medicines listed in the last 12 months are dispensed predominantly in hospitals. Commonly subsidised under the ‘special arrangements’ classification, these medicines are prescribed under specific conditions, supplied only through hospitals, require specialist medical care and supervision, and are high in cost. Not surprisingly, they also require substantial clinical pharmacy care including polypharmacy management, therapeutic drug monitoring, daily dose adjustments, adherence support and outpatient follow-up.
In addition, the breadth of medicines now available has created a specific need for pharmacists to facilitate effective prescribing as part of the multidisciplinary team in the acute setting. In a high-pressure and extremely busy clinical environment, an electronic medical record will offer more than 3500 medicines to be prescribed at discharge, many with various brands of the same medicine, resulting in 18,200 options. This, alongside information about biosimilar substitution, altering therapy to accommodate shortages, reducing polypharmacy and navigating various medicine subsidy and access pathways, is an overwhelming amount of information to expect medical professionals to maintain while they undertake their core work to diagnose, treat and care for patients. Thankfully, hospital pharmacists already carry the expertise to effectively navigate this complexity: a major Australian hospital-based study found that for every dollar spent on a clinical pharmacist to initiate changes in medicines therapy or management, approximately $23 was saved on length of stay, readmission probability, medicines, medical procedures and laboratory monitoring.
SHPA has long advocated for greater recognition of the importance of clinical pharmacy services in both hospital and community settings. At our recent Medicines Leadership Forum in Canberra this was reaffirmed with calls to strengthen support for the pivotal transition of care — as people move from hospitals back into their community — through hospital referral for clinical review for patients who are on new medicines and at high risk of negative impacts. In addition, we would welcome a renewed commitment to the founding document of the successful ‘PBS medicines in hospital’ program. This statement, ‘Guiding principles to achieve continuity in medication management’, outlines a pathway to high-quality medicines management, including effective clinical handover and equitable medicines access on discharge.
To ensure Australians gain the greatest possible benefit from medicine use, medicine leadership must consider the workforce as well as industry and consumer concerns. The successful combination of effective medicine, provided in an accessible manner, with appropriate pharmacy care, is essential for the positive patient outcomes we all seek. Increased collaboration and understanding of the role of each part of this puzzle will help achieve greater synergy in medicines policy and high-quality patient care. Alongside 118,723 medical professionals and 378,325 nurses, 31,785 pharmacists are equipped with the knowledge and know-how to play their part.
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