Lenka Praznovcova
PhD
Department of Social and Clinical Pharmacy
Charles University Hradac Kralove
Czech Republic
Before the Czech healthcare system was reformed in 1989, all community and hospital pharmacies were state-owned, and community pharmacies were run without any commercial interest.
Pharmacy practice was implemented by the Institute of National Health, which was established in every region of the Czech Republic in the early 1960s. Hospitals and clinics functioned as one in this system, providing inpatient and outpatient care for the population. Hospital pharmacies were open to ambulant patients, including patients from outside the hospital.
Of the 983 pharmacies in the Czech Republic, 145 were hospital pharmacies. Only 32.4% of these were located directly inside hospital premises; 15.2% were located within 2km, and the rest (52.4%) were located in areas over 2km away. Location had a negative impact on the logistics of the system and limited professional contact between hospital pharmacy staff and the other health professions. At that time, 35% of health professionals were pharmacists.(1)
Impact of healthcare reforms
The transformation of the healthcare system following 1989 had a significant impact on the development of hospital pharmacy. Private and state health services were separated, with the private sector being given responsibility for outpatient care, including the running of community pharmacies. Hospitals and special institutions remained state-owned, and each was given responsibility for its own financial budget.
A health insurance system was established as the fundamental financial resource for healthcare, with health insurance companies paying as much as 81% of the total expenditure on healthcare. In 1999, the proportion of GDP allocated to healthcare was 7.51%. The costs of healthcare can be divided into expenditure for inpatient care (46.8%), outpatient care (17%), dental care (6.5%) and prescribed medications (22.5%).(2)
The number of community pharmacies increased from 600 in 1989 to 2,000 in 2001. All hospital pharmacies (about 90 in total) became part of hospitals. The network of establishments for inpatient care included 211 hospitals (67,457 beds, including 2,304 neonatal cots). Every hospital with more than 300 beds must have a hospital pharmacy. The director of the hospital pharmacy is accountable to the director of the hospital. Hospital pharmacies remain accessible to outpatients.
Drug policy in hospitals
With hospitals now responsible for their own budgets, hospital management was tasked with finding ways to regulate drug use, as this forms a substantial part of hospital spending. Drugs account for about 15% of overall spending in hospitals with specialised care.(3)
Most drugs are bought from wholesalers; purchasing directly from industry is possible, but drugs bought in this way form only a small proportion of the total used in hospitals. The most expensive drug groups include cytotoxics, antibiotics, plasma derivatives and immunomodulatory drugs.
In 1995, hospital policy in the Czech Republic started to function on similar principles to other European countries, with the emergence of formularies and therapeutic committees. Drug formularies were made mandatory for every hospital; drugs listed must always be stocked by the pharmacy and can be used without limitation. A drug committee is responsible for developing the formulary. Initially this method of drug regulation did not enjoy widespread acceptance, as doctors wanted to prescribe without limitation as before. Also, the fact that the price of drugs changed every three months necessitated a need for the drug formulary to change within a short period of time.(4) The introduction of drug policy in hospitals led to the acceptance of pharmacists as members of the healthcare team.
Drugs used in inpatient care form a significant part of the direct costs of big hospitals, and are covered exclusively by the hospital budget. Their use is usually regulated by hospital management.
Drugs for outpatient care do not form a direct cost for hospitals; they are reimbursed directly by the health insurance companies. A financial limit was introduced in 1998, and going over the agreed expenditure may result in financial sanctions for hospitals.
Education and training of hospital pharmacists
There is no special programme of undergraduate study for hospital pharmacists. The faculty of pharmacy at Charles University in Hradec Kralove focuses on the biomedical disciplines, including clinical pharmacy, which is very important for the training of hospital pharmacists. Specific courses for hospital pharmacists are available through a continuing education programme. Clinical pharmacy, pharmaceutical technology, pharmaceutical analytics and pharmacy practice are obligatory for the chiefs of departments of hospital pharmacy.
Services provided by the hospital pharmacy
A recent study has revealed that the standard of hospital pharmacy in the Czech Republic is of an acceptable level.(4) The most important factor limiting the service provided by hospital pharmacies is the lack of sufficient numbers of pharmacists: the movement of hospital pharmacists to community pharmacies soared after privatisation in 1989, for several reasons, including better salaries. Only 34% of hospital pharmacies have acceptable staffing levels. In a two-year period, 47% of pharmacists and 31% of technicians left hospital pharmacy.(4)
A range of different services are provided by the hospital pharmacy, and these are shown in Table 1. Traditionally, pharmaceutical services provided in the hospital pharmacy include preparation of extemporary drugs and reagents. To date most hospital pharmacies continue to provide only these two functions. Other services are now provided in some hospital pharmacies, including total parenteral nutrition (TPN), all in one and reconstitution of cytotoxic drugs.
[[HPE05_table1_53]]
In practice, only two hospital pharmacies prepare cytotoxic drugs. Traditionally they are prepared directly in hospital wards by nurses, a practice that is believed by physicians to be highly effective; hence they do not support the idea of shifting the provision of this service to the hospital pharmacy. However, reconstitution of cytotoxic drugs directly in the hospital pharmacy has been a success in other European countries, and the Czech Republic could benefit from this experience.(5)
Hospital pharmacists have been able to participate in other important services since the 1990s (see Table 2). Hospital pharmacists have made a huge contribution to drugs policy in hospitals. Recognising this, hospital management have made each director of hospital pharmacy a member of the drug committee. They are also involved in developing hospital drug formularies.
[[HPE05_table2_53]]
Most hospital pharmacies provide information and consultation services exclusively for hospital staff. Only one information centre has been established directly within a hospital pharmacy. Information provision is extended to outpatient care outside hospitals.
The participation of hospital pharmacists in drug monitoring and clinical trials is minimal. Clinical pharmacologists play an important role in this area. Hospital pharmacists began to participate two years ago and have been successful, but it is too early to evaluate their participation.
Pharmacists have traditionally not performed ward visits, despite the need for health professionals to work together for the benefit of patients. A few hospital pharmacists have started to work with physicians on the wards, but this practice largely depends on both the pharmacist’s and (especially) the physician’s personal preference. There is a need for an official standpoint on this issue in order to boost the involvement of hospital pharmacists in the management of patients directly in the hospital ward rather than in the hospital pharmacy alone. There is no doubt that this will prove to be a great challenge, but it should lead to more efficient utilisation of the knowledge and experience of hospital pharmacists by physicians and other hospital staff.
The Section of Hospital Pharmacists, established in 1991, is officially responsible for the development of hospital pharmacy in the Czech Republic. An official document produced in 2001 defined the concept of hospital pharmacy, and, on the basis of that, it is possible to anticipate further development of hospital pharmacy in the Czech Republic.
Conclusion
In line with European hospital pharmacy practice, standardisation of pharmaceutical services is necessary. Besides the basic service of distributing drugs to inpatients and outpatients, distributing health materials, and preparing extemporary drugs and sterile drugs, the focus should be on the development of clinical services.
The hospital pharmacist should be an integral member of the multidisciplinary hospital team, and should take responsibility for the process of optimisation of pharmacotherapy. They should participate in the evaluation of pharmacotherapy in hospitals, including performing pharmacoeconomic and clinical evaluations. There is a need to develop information services for patients and other health professionals, and the role of the hospital pharmacist in this area should not be neglected. These activities should be finalised and established through accreditation.(6)
References
- Dofkova L, et al. Problems of hospital pharmacy in Czechoslovakia. Historical acceptance and actual situation. Farm Obzor 1968;37:198-202.
- Institute of Health Information and Statistics of the Czech Republic. Czech health statistics yearbook 1999. Prague: Institute of Health Information and Statistics of the Czech Republic; 2000. p. 13-5.
- Urbanek K. Importance of drug policy for management of the big hospitals. Olomouc: Pharmacology Department, Medical School, Palacky University. Available from URL:http://www.zdrav.cz.
- Pilkova A. Hospital pharmacy in transformation of the health care system in the Czech Republic [thesis]. Hradec Kralove: Charles University; 1996.p. 53,90,92.
- Praznovcova L. Will cytotoxic drug reconstitution also be in the Czech Republic? J Czech Pharmacists 1995;67(3):23.
- Section of Hospital Pharmacy of the Czech Pharmaceutical Association. CLS JEP: Hospital pharmacy –conception. Czech Republic: Ministry of Health; 2001.
