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Over the last 20 years much of the development in hospital pharmacy has been in clinical pharmacy. In many countries in Europe this development continues to take place. In my personal background as a clinical pharmacist, I have seen clinical pharmacy in the UK evolve from a ward top-up and visiting service to a care-based activity integrated into a whole range of healthcare activities. However, we must remember that clinical pharmacy is only one part of a hospital pharmacy service. It is important that the right medicines are chosen for patients, given in the safest way and monitored for both effectiveness and safety. But it is equally important to ensure that the patient gets a medicine of the highest quality that will meet their individual needs as a patient.
When I started as a hospital pharmacist, I remember vividly making great vats of creams and ointments. At one hospital we used to prepare on a monthly basis 100kg of “The Back Ointment”. I recall enormous amounts of oral liquids such as magnesium trisilicate mixture and literally thousands of bottles of disinfectants such as sterile chlorhexidine and the ubiquitous EUSOL. For most of us these days, the pharmaceutical industry has taken this burden off us, producing these and many other preparations in better forms and at better value for money. So is there any need for the pharmacist’s traditional formulation and compounding skills? Is this the death knell of our secundum artem?
I think not. Yes, there is no longer the need for us to make vast quantities of simple medicines, which the pharmaceutical industry can do better. Nor is there a need for us to be preparing traditional nostrums from scratch. However, the great strength of the pharmaceutical industry – to prepare large amounts of high-quality products at reasonable cost – becomes one of its great weaknesses when we need small amounts of specialist medicines or require great flexibility. The new secundum artem is for specialist formulations of products not available from the industry for reasons of stability, small patient groups or basic lack of commercial viability. Hence we need to keep our formulation and compounding skills to make products like clozapine suspension, fentanyl lollipops, diuretic liquids for preterm neonates and developmental drugs. We also need these skills for the preparation of parenteral nutrition, cytotoxics and intravenous admixtures. Not only do we need to fine tune doses for individual patients, but we need to work flexibly to meet patients’ day-to-day changing clinical needs. Looking to the future, there are also great challenges ahead with regard to gene therapy.
We do need to develop our skills to meet modern demands. Although underlying principles of patient safety and medicine quality do not change, we do need to evolve. The skills needed for plant-based galenicals do differ significantly from those needed for monoclonal antibodies. But as a profession we are good at adapting and developing. Our formulation and compounding skills will be needed for many years to come – let’s make sure we do not lose them.
Chris Cairns, Consultant Editor