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Hospital pharmacy in Portugal

MA Soares
Faculty of Pharmacy
University of Lisbon and Mozambique Pharmacy School (ISCTEM)
Drug Information Centre (Cedime from Associaçáo Nacional das Farmácias)

MM Pereira
Pharmacy School of Lusofona University
Council for Hospital Pharmacists
Pharmacists’ Society

The Portuguese National Health Service is funded from the government budget for healthcare. It incorporates public hospitals (approximately 100), GPs and specialists, is available to everyone and is almost free (there is a small amount to pay as a tax). Prescribed medicines can be bought in pharmacies, the price depending on the type of drug. The elderly and those on a low income receive a 10% discount. Certain groups of patients can get medicines for free in hospital, such as those taking HIV medicines or anticancer drugs. It is often easier and faster to be treated in one of the small number of private hospitals. Private hospitals are small, with about 20–30 beds, and tend to be too expensive for the general population.

All public hospitals have their own pharmacy services staffed by fulltime pharmacists. There are about 400 Portuguese hospital pharmacists in total. The number of pharmacists in each hospital depends on the size of the hospital (number of beds) and the kind and number of services that the hospital provides. About 45% of the country hospitals (which tend to be smaller) employ just one hospital pharmacist.

Fifty per cent of all Portuguese pharmacists are hospital pharmacists. In Portugal it takes six years of university training to obtain the basic pharmacy qualification, with the last year spent training in the community or hospital or both. To become a hospital pharmacist, further postgraduate training is required. However, there are very few places (about 10) for this training, and the course doesn’t run every year. Pharmacy graduates are allowed to work in a hospital pharmacy without this training (mainly because there are so few hospital pharmacists), and after three or more years these pharmacists are allowed to apply to become a hospital pharmacist (an examination also needs to be passed at this stage). Hospital pharmacists’ salaries are considered to be very low compared with those working in the pharmaceutical industry.

The Pharmacists’ Society (see facing page) has a specialist hospital pharmacist section with about 270 members. In 1999 it published Good Pharmacy Practice for Hospital Pharmacists, which includes drug information as well as information on management, drug manufacturing and control, drug distribution and ambulatory care. Each year the society approves new members (who must have at least five years of hospital pharmacy experience and must also pass an examination).

The hospital pharmacy service
The hospital pharmacy service operates independently from other clinical services. It is responsible for the management of medicines throughout the hospital, and it reports to the hospital administration board.

In addition to medicines management, the hospital pharmacist is responsible for medicine distribution and providing drug information to other health professionals. The hospital pharmacist’s role also includes:

  • Clinical pharmacokinetics (therapeutic drug ­monitoring). Some hospital pharmacies are involved in therapeutic drug monitoring, making recommendations on drug dose adjustment according to blood drug level for some substances.
  • Preparation of parenteral nutrition and cytotoxic medicines.
  • Raw materials analysis.
  • Pharmacosurveillance.
  • Conducting clinical trials.
  • Teaching and training.

Clinical pharmacy in Portugal is developed in different ways. In some hospitals, pharmacists assist doctors and nurses on the ward. They make recommendations regarding drug selection and doses, provide information on drug incompatibilities, interactions, and so on.

As high-technology medicines (ie, those that are prepared through genetic engineering), ambulatory cytostatics, antiretrovirals and other medicines are often very expensive, outpatients can get them free of charge from the hospital pharmacy service, and at the same time receive drug information from the hospital pharmacist.

Each hospital pharmacy service has its yearly budget, which must be adhered to. Most medicine acquisitions are conducted through a national centralised process, whereby the least expensive brand is chosen. This centralised acquisition is detailed in the National Hospital Formulary. Some hospitals have created their own hospital formulary or addenda to the National Hospital Formulary according to their own needs and services.

Each hospital has several multidisciplinary commissions that have representatives from the hospital pharmacy services.

The Pharmacy and Therapeutics Commission
The main goal of the Pharmacy and Therapeutics Commission is the establishment of the medicines regulations in the hospital. It evaluates new medicines and decides whether they should be added to the hospital formulary, or whether they should be bought for a specific patient.

The Commission is coordinated by the clinical director of the hospital. The other members comprise equal numbers of pharmacists and physicians. Most hospitals have other consultative commissions with pharmacist representatives, such as:

  • Antibiotics.
  • Cytotoxics.
  • Blood derivatives.
  • Disinfection.
  • Nutrition.
  • Ethics.

Considering the importance of the hospital pharmacy, health authorities have recognised that there are several problems with the current service: high workload; not enough hospital pharmacists (50% of qualified hospital pharmacists work outside hospital pharmacy; 45% of hospitals have just one pharmacist), not enough room to run the hospital pharmacy, no provision for continuous education, and few technicians, which forces the pharmacists to do their job as well. The last two years have been spent evaluating and designing a new strategy for hospital pharmacy services. The main proposed changes can be divided into three areas:

  • An integrated system for drug information and management using computerised prescriptions to optimise the rational use of drugs in the hospital.
  • Improvement of pharmacists’ physical conditions – better equipment, better ratio of hospital beds to pharmacists, and so on.
  • Creation of a national system for hospital ­pharmacy services accreditation.

These changes are about to be piloted in certain hospitals.

And finally …
In Portugal, hospital pharmacy services are doing their best, but it is recognised that there is a need for change, for updated and more efficient services in terms of quality of care and economy, as high-technology medicines are used more frequently and are becoming increasingly expensive. The new government has some budget restrictions, so we don’t know yet what is going to happen in the near future for hospital pharmacies.

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