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University of Uppsala
Business Area Hospital Pharmacy
Healthcare in Sweden is predominantly publicly financed. There are 21 county councils, which are responsible for all hospital and primary healthcare, while the 289 municipalities are responsible for care of the elderly. The country is divided into six regions with nine regional/university hospitals. In addition to these highly specialised regional hospitals, there are 25 central county hospitals and about 40 county district hospitals. The total number of hospital beds decreased from 41,300 in 1995 to 31,500 in 2000. Whenever possible, patients are treated in their homes, and many hospitals operate outpatient clinics.
Until the mid-1990s, the county councils were responsible only for hospital (ie, inpatient) drug costs. All outpatient prescriptions were paid by the state (the National Social Insurance Board), except for the part paid by the patient (20–25% presently, up to a maximum annual fee of 1,800SEK, which equals about e200). However, a governmental decision required the county councils to assume budget responsibility for prescribed drugs by 1998. As a result, the county councils’ interest in drug evaluation and health economics increased markedly. The annual increase in drug expenditure in Sweden was more than 10% in the 1990s and has now decreased to about 7%.
The Pharmaceutical Benefits Board, a governing authority for assessing and deciding whether or not a prescribed drug should be included in the reimbursement system, was created in October 2002. It also decides on the selling price of reimbursed drugs.
The National Corporation of Swedish Pharmacies (Apoteksbolaget) was founded in 1971. Since 1998 the company has been fully owned by the state through the Ministry of Health and Social Affairs and its name changed to Apoteket AB. Apoteket has the exclusive right to sell pharmaceuticals to the public and is required to satisfy nationwide drug demands. The main objective for Apoteket is to achieve the greatest possible benefit from drug use at the lowest possible cost.
Hospital pharmacies (ie, drug deliveries to the wards) may be operated either by the county councils or by Apoteket. To date, all hospital pharmacies are run by Apoteket on a contract basis. Important advantages can be realised by integrating hospital pharmacy and outpatient services, such as, for example, the economic gains from efficient utilisation of resources such as storage, a more rational handling of extemporaneous preparations and better systems for continually educating pharmacists.
Apoteket operates about 850 pharmacies, 10% of which are hospital pharmacies. The company has 11,500 employees, of which 2,100 work in hospital pharmacies.
There is a continuing debate about Apoteket’s exclusive rights for drug distribution in Sweden, but there are several advantages of having a national pharmacy chain, such as:
There are two different pharmacy degrees in Sweden. The basic diploma (BSc) in pharmacy consists of a three-year curriculum and mainly focuses on prescription filling and patient information in pharmacies. The master’s degree curriculum can be completed in five years. Both these degrees lead to a licence as a Swedish pharmacist.
A 20-week course in hospital pharmacy, which focuses on pharmacotherapy/clinical pharmacy, was initiated at the University of Uppsala in 1993.
In 1999 a three-year specialist education in hospital/ healthcare pharmacy was started following collaboration between the Swedish Academy of Pharma-ceutical Sciences, the University of Uppsala and Apoteket. This curriculum comprises one year of theoretical studies and two years of hospital pharmacy practice. The first specialists graduated in June 2002, and a total of about 20 pharmacists have entered the programme.
There are no formal requirements for continuing professional development, but Apoteket AB and the Swedish Academy of Pharmaceutical Sciences offer many courses for hospital and other pharmacists, including the present development of e-learning systems.
Before 1971, the delivery of drugs to Swedish hospitals was normally organised through agreements made between the local community pharmacies and each hospital.
During the seventies the number of hospital pharmacies increased rapidly – from only 18 before 1971 to 75 in 1975. This expansion was a direct result of company policy that pharmacies should be located close to the healthcare providers in hospitals and primary care units. Thus the manner in which Apoteket has chosen to run its pharmacy operations is unique from a European perspective, and patients normally have easy access to their prescribed drugs from the pharmacy immediately after leaving the doctor. The system also enables effective communication and drug distribution when patients are transferred between different forms of care.
Hospital pharmacy in Sweden is divided into seven districts. The hospital pharmacy manager reports to a district manager in Apoteket and not to the hospital management. In practice, however, the hospital pharmacy collaborates closely with the hospital management as well as with the chairman and members of the Drugs and Therapeutics Committee.
Contract with healthcare providers
A national agreement existed between Apoteket and the Federation of Swedish County Councils from the beginning of the 1970s until the late 1990s. However, the different county councils have developed different pharmaceutical service requirements. Therefore from 1996/97 onwards negotiations have instead been conducted in each of the 21 county council areas. In general, Apoteket offers a basic service contract including drug delivery and information services. Various additional services are also offered and priced separately and can vary between different hospitals. Such services include participation in Drugs and Therapeutics Committees and expert groups, hygiene and isotope committees, audit of drug handling on the wards, extemporaneous preparations, radiopharmaceuticals, drug information and educational services, drug consumption analyses, aid in the preparation of drug budgets, clinical pharmacy services, and so on.
Development of logistics
Extensive work has been carried out during the last decade to implement the concept of unit-dose packaging, which enables the nurse to spend more time with patients. Apoteket also prepares trolleys containing various fluids for the hospital wards.
Apoteket has various ongoing activities to increase the efficiency of the drug supply chain. This includes assuming responsibility for drug storage, ordering systems and supplies for the wards, as well as setting up distance pharmacies in four places in Sweden. Automating drug handling and having full IT-based information on patients’ needs will help lay the foundations for Apoteket’s new supply strategies, which include the concept of dose-dispensed drugs.
Apoteket has four production units, located in Malmö, Gothenburg, Huddinge/Stockholm and Umeå. These units serve all community pharmacies with extemporaneous preparations and also prepare nonregistered drugs that have acceptable stability for the hospital pharmacies.
Of the 83 hospital pharmacies, 44 have extemporaneous/sterile facilities, nine of which prepare only cytotoxic drugs. About 1,400 different compositions are prepared by hospital pharmacies and about 500 by the production units. There is still a potential for further rationalisation of this production. Whenever possible, according to customer requirements for delivery times and production costs, orders are handled by the production units.
Drugs and Therapeutics Committees
One of the most important tasks of the hospital pharmacist is to participate in the Drugs and Therapeutics Committees or the various expert groups making recommendations about drug usage in both hospitals and primary care. The pharmacist contributes his/her knowledge about drug development and new products, various aspects of formulation, production and stability, parmacology/ pharmacokinetics as well as distribution systems, procedures for drug purchasing and statistics on drug consumption.
Drug information centres
In the university hospitals, hospital pharmacists are allocated to drug information centres to answer qualified questions from the hospital or from other healthcare staff. The drug information centres are often operated in collaboration with the departments of clinical pharmacology, but the organisation varies according to tradition and location in the hospital.
Apoteket offers the pharmaceutical industry and the healthcare sector a number of services in connection with clinical trials, such as reliable storage and dispatch procedures, labelling of trial drugs, randomisation, manufacture and reformulation, destruction and archiving of documentation. Apoteket also contributes to training activities and planning and executing clinical trials, as well as research cooperation and expert assistance when trials are undertaken by the health services.
Clinical pharmacy and research projects
The need for clinical pharmacy services and agreements to perform these services in Swedish hospitals has increased substantially in recent years. Since Apoteket is a company based on expert knowledge about drugs, we have also found it important to contribute to gaining new knowledge, especially about optimal dosages and the clinical use of drugs in patients. Therefore there are some positions for research pharmacists (PhD) and for PhD pharmacy students at the university hospital pharmacies.
The research policy of Apoteket states that our research should contribute to better therapy and aim at minimising drug-related problems. The work should be combined with other qualified tasks such as drug information or clinical pharmacy services and should be performed objectively and in close collaboration with hospital clinics or institutions.
The research and development projects in hospital pharmacies have not only contributed to improvements in drug therapy and drug distribution, but have also enabled the recruitment of talented young pharmacists to the company. Some of these will hopefully fill specialist and/or management positions in the future and go on to further develop the collaboration and integration of hospital pharmacies and clinics in Swedish hospitals.
The future of Swedish pharmacy
There is presently a general shortage of pharmacists in Sweden; however, the situation is worse in community pharmacies than in the hospital pharmacy area. Young pharmacists are attracted by the possibilities arising from the development of clinical pharmacy services.
Other issues facing hospital pharmacy include the creation of new, effective logistic systems, including good IT support, the development of clinical pharmaceutical services, and getting them financed despite the troublesome economic situation in the county councils. The solution will involve documenting and communicating the value of pharmaceutical services, including the potential savings to the healthcare system, focusing not only on the drug bill, but also on minimising patients’ drug-related problems.