189 Am J Health-Syst PharmVol 62 Jan 15, 2005

REPORTS English National Health Service hospitals

Medication management
in English National Health Service hospitals
JONATHAN COOKE, ANNE R. MASON, MICHAEL F. DRUMMOND, AND ADRIAN K. TOWSE
Purpose. The methods currently used by
English National Health Service (NHS) hos-
pitals to manage the use of medicines were
studied.
Methods. A questionnaire was mailed to
directors of pharmacy at all English NHS
hospitals in May 2001.
Results. The response rate was 57% (157/
275). Sixty-six percent of the responding
hospitals provided general acute care ser-
vices, and 34% provided mental health ser-
vices. About 1 responder in 5 (19%) was a
specialty hospital functioning either as a
freestanding institution or alongside other
hospitals. The average total expenditure by
the hospital trusts was 94 million ($175
million), of which drugs accounted for 3.5
million ($6.5 million). Many hospitals either
had formularies or were constructing them
(86%), and most hospitals used a process to
manage the introduction of new medi-
JONATHAN COOKE, PH.D., is Director of Pharmacy and Director of
Research and Development, Withington Hospital, South Manchester
University Hospitals NHS Trust, West Didsbury, Manchester, United
Kingdom. ANNE R. MASON, M.A., is Research Fellow, and MICHAEL
F. DRUMMOND, D.PHIL., is Director, Centre for Health Economics,
University of York, Heslington, York, United Kingdom. ADRIAN K.
TOWSE, M.PHIL., is Director, Office of Health Economics, London,
United Kingdom.
Address correspondence to Dr. Cooke at Withington Hospi-
tal, South Manchester University Hospitals NHS Trust, Nell
Lane, West Didsbury, Manchester, M20 2LR, United Kingdom
(jonathan.cooke@man.ac.uk).
The National Health Service personnel who helped with the pilot
survey and who participated in the survey are acknowledged.
Supported by GlaxoSmithKline UK through an unrestricted grant
to the Office of Health Economics.
Presented in part at the Annual Meeting of the United Kingdom
Drug Utilisation Research Group, Manchester, January 30, 2003.
Copyright 2005, American Society of Health-System Pharma-
cists, Inc. All rights reserved. 1079-2082/05/0102-0189$06.00.
cines. About three fourths of the hospitals
had 20 pharmacist full-time equivalents.
The implementation of national guidelines
was variable, although some of this varia-
tion may have been due to differences in
service provision. Few hospitals were ac-
tively monitoring compliance with guide-
lines (31%), but audits of current care were
common (72%).
Conclusion. A survey of English NHS hospi-
tals provided information on pharmacy
staffing, drug expenditures, and measures
taken to ensure rational medication use.
Index terms: Audits; Compliance; Costs;
Data collection; Drug use; Formularies;
Hospitals; National Health Service (Great
Britain); Pharmacists, hospital; Protocols;
Rational therapy
Am J Health-Syst Pharm. 2005; 62:189-95
E
nglands roughly 50 million
people are served by a central-
ized federal health maintenance
organization (HMO), the National
Health Service (NHS). The use of
medicines in the NHS has, as in most
health care systems worldwide, in-
creased considerably over the past
half century. The writing of a pre-
scription is one of the most common
therapeutic interventions, and the
safe and effective use of medicines is
a priority for many health care insti-
tutions. Spending on medicines has
grown at a rate outstripping that of
general NHS expenditures for a
number of years and currently stands
at around 1517% of expenditures in
primary care organizations, 45% of
expenditures in NHS hospitals, and
15% of all NHS costs.
1
Reasons for
this include greater screening of the
population, demographic changes
(with a more elderly population re-
ceiving more medications), more ef-
fective medicines with indications
against diseases that were previously
difficult to treat, and national poli-
cies aimed at developing clinical ser-
vices (known as National Service
Frameworks [NSFs]) in such areas as
mental health,
2
coronary heart dis-
ease,
3
care of older people,
4
and dia-
betes.
5
In addition, guidelines on
more than 70 new technologies have
been issued by the NHSs special
health authority, the National Insti-
tute for Clinical Excellence (NICE).
The use of medicines has come
under considerable scrutiny within
the past decade. While more than
80% of NHS spending on medicines
is incurred in primary care, the use of
medicines in NHS hospitals is highly
relevant for several reasons. First, a
patients hospital stay is often depen-
dent on the appropriate selection of,
timely administration of, and effec-
tive response to medication. This will
REPORTS English National Health Service hospitals
190 Am J Health-Syst PharmVol 62 Jan 15, 2005
often determine the duration of stay
and the setting within which a pa-
tient receives treatment (e.g., an in-
patient or outpatient setting). Fur-
thermore, general practitioners in
primary care are often reluctant to
change a drug that was started in the
hospital. Medicines initiated in hos-
pitals can therefore have a consider-
able impact on expenditures and
clinical practice in primary care. Sec-
ond, there is concern about the num-
ber of medication errors in NHS hos-
pitals. Medication errors can lead to
increased morbidity and mortality
and often contribute to expensive lit-
igation against NHS institutions.
Such cases divert funding from the
direct treatment of patients. The De-
partment of Health recently estab-
lished the National Patient Safety
Agency and issued targets to NHS
hospitals for reducing the number of
serious medication errors by 40% by
2005.
6
Finally, studies of the clinical
efficacy and cost-effectiveness of
medicines are frequently conducted
or coordinated by NHS hospitals.
The English NHS operates like a
very large HMO with 50 million en-
rollees. There is, therefore, consider-
able emphasis on management pro-
cedures aimed at improving the use
of resources. Medication manage-
ment in hospitals encompasses the
entire way that medicines are select-
ed, procured, delivered, prescribed,
administered, and reviewed to opti-
mize drugs contribution to produc-
ing informed and desired outcomes
of patient care.
7
We report here a survey to docu-
ment the methods currently used by
English NHS hospitals to manage the
use of medicines, with a view to in-
forming future practice in the United
Kingdom and beyond.
Methods
In England, hospitals are grouped
into organizations known as hospital
trusts, which may occupy more than
one site. In this article, the word
hospital refers to hospital trusts.
We surveyed directors of pharma-
cy to ascertain the development of
medication management and hospi-
tal pharmacy in England. The survey
was pilot tested at six sites in various
English NHS regions, modified ac-
cording to the responses, and sent to
chief pharmacists at all NHS hospi-
tals in England in summer 2001.
Hospitals in Scotland, Wales, and
Northern Ireland were excluded
from the survey because these coun-
tries have different organizational
structures from those in England.
Survey questions addressed the
type of hospital, the number of phar-
macists employed, the total annual
hospital expenditure and the propor-
tion spent on medicines, the types of
services provided by the hospital, the
use of electronic facilities, the hospi-
tals medication management com-
mittee and other committees, pre-
scribing policies, formularies, and the
response to NSFs and to guidance
from NICE. Questions were also asked
about how medication management
services had developed, including the
use of patients own medicines, pa-
tient self-administration of medi-
cines, and prescribing arrangements
by pharmacists and nurses.
We sent reminders to nonre-
sponders over a three-month period.
Respondents were promised an ad-
vance copy of the report and given
the opportunity to participate in a
prize drawing. Differences between
the responders and all NHS hospitals
in England were tested with the chi-
square test (StatsDirect statistical
software, version 2.2.5, Cheshire,
United Kingdom). The a priori level
of significance was 0.05.
Results
Two hundred seventy-five ques-
tionnaires were sent out and 157
were returned, yielding a response
rate of 57%. Some returned ques-
tionnaires did not have a response
for each question. The response sam-
ple was broadly representative of the
population of hospitals in England in
terms of regional distribution (p =
0.89, chi-square test).
Description of responding hos-
pitals. Two thirds of responding
hospitals (103/154) provided general
acute care services. Over half of these
acute care hospitals (59/103 [57%])
provided other services, including
emergency care (39%), mental
health care (21%), community care
(19%), and tertiary care (17%). One
third of the hospitals (53/154) pro-
vided mental health services, and
most of these (87%) provided at
least one other service, such as com-
munity care (55%), acute care
(42%), and emergency care (25%).
Services provided by the 30 specialty
hospitals included care of the elder-
ly, treatment of learning disabilities,
neurology, obstetrics, oncology,
ophthalmology, orthopedics, pediat-
rics, renal care, and care of spinal
injuries. The remaining 21 hospitals
included emergency, community,
tertiary care, primary care, and
teaching hospitals.
Table 1 depicts pharmacist em-
ployment in the hospitals, and Figure
1 shows annual drug expenditures by
the number of pharmacists em-
ployed in 2001.
The median total annual hospital
expenditure was 94.1 million
($157.3 million) (semiinterquartile
range, 30.8 million [$51.5 million]).
The median annual expenditure on
medicines was 3.5 million ($5.9
million) (semiinterquartile range,
2.1 million [$3.5 million]), repre-
senting around 4% of all hospital ex-
penditures. In 81% of the hospitals,
drug budgets were controlled by the
clinical divisions or directorates
rather than by the pharmacy.
Developments in information and
communication technology (ICT)
are important components of a mod-
ern health service. Table 2 shows the
ICT facilities available in the 156
hospitals responding to this ques-
tion. At the time of the survey, most
departments had Web-enabled access
from within the pharmacy, but only a
191 Am J Health-Syst PharmVol 62 Jan 15, 2005
REPORTS English National Health Service hospitals
Table 1.
Pharmacist Workforce in English Hospitals (n = 157)
31 (20)
28 (18)
60 (38)
20 (13)
14 (9)
2 (1)
0
2 (1)
0
15
610
1120
2130
3150
5175
76100
101150
>150
No. (%) Hospitals
with Indicated Workforce
No. Pharmacists
(Full-time Equivalents)
small number had fully integrated
information technology systems in-
corporating electronic prescribing
and decision support.
Hospital committees. Ninety-
seven percent of the respondents
(149/153) had a pharmacy and thera-
peutics (P&T) committee (or a medi-
cation management committee) that
covered the whole hospital. The
committee met monthly in 35% of
the hospitals (53/153), whereas in
other hospitals it met every two
months (42%) or every three months
(20%). Membership on the P&T com-
mittee is shown in Table 3. On aver-
age, seven types of representatives sat
on the committee (range, 211).
Drug-use policies. Seventy-eight
percent of the hospitals (123/157) had
a hospital formulary in use, and a fur-
ther 8% (12/157) had one under con-
struction. Seven percent of the hospi-
tals (8/120) said that their revision
process was ongoing (continuous).
Where formulary revision was not an
ongoing process, the average (median)
date of the last revision was September
2000, about 15 months before the sur-
vey was sent. One hospital had not up-
dated its formulary in nine years.
Ninety percent of the hospitals (142/
157) had a formal scheme for manag-
ing the introduction of new medicines,
and another 6% (10/157) reported
that their scheme was currently under
construction or review. Ninety-four
percent of the schemes (143/152) took
the impact on primary care into ac-
count, and 77% (115/149) were in-
volved in decisions in conjunction
with primary care representatives. Of
the hospitals with a scheme for man-
aging the introduction of new medi-
cines (including a scheme under re-
view), 23% (35/152) did not name the
products currently being managed by
the scheme. Most of the nonre-
sponders (30/35) did not provide gen-
eral acute care services.
Only 3% of the hospitals (5/157)
had no scheme for managing new
medicines. All of these hospitals
employed 10 or fewer full-time-
equivalent pharmacists. Only one
provided general acute care services,
three provided mental health and
community services, and one was an
eye hospital.
Specific policies that were in place
in the fiscal year 20002001 are listed
in Table 4. These were identified as
areas that were being highlighted as
good practice in national guidelines
recently issued in the United King-
dom.
7,8
Respondents were given the list
and asked whether these policies were
current practice in their hospital. Un-
der patient group directions, nurses or
pharmacists may facilitate the supply
and administration of medicines to
defined patient groups without a pre-
scription; the survey revealed that
nurses are more likely to undertake
these activities than pharmacists.
Response to national guidelines.
NICE was set up as a Special Health
Authority for England and Wales on
April 1, 1999, to provide guidelines
on clinical and cost-effective practice
for the NHS.
9
We asked pharmacy
directors about their hospitals re-
sponse to a sample of recent NICE
guidelines on proton-pump inhibi-
tors,
10
rosiglitazone,
11
and taxanes.
12
A
summary of these guidelines appears
in Appendix A, and the hospitals re-
sponses are presented in Table 5.
When hospitals took no action in
response to guidelines, this some-
Figure 1. Annual drug expenditure in English hospitals, grouped by number of pharmacists.
0
A
n
n
u
a
l

D
r
u
g

E
x
p
e
n
d
i
t
u
r
e

(

1
0
0
0
)

1
0
0
0
)

1
0
0
0
)

1
0
0
0
)

1
0
0
0
)
30,000
25,000
20,000
15,000
10,000
5,000
15 610 1120 2130 3150 >50
No. Pharmacist Full-time Equivalents
Minimum
Lower quartile
Median
Upper quartile
Maximum
REPORTS English National Health Service hospitals
192 Am J Health-Syst PharmVol 62 Jan 15, 2005
times reflected the types of services
provided. For example, a hospital
providing only mental health servic-
es would not need to respond to
guidelines on taxanes for the treat-
Table 2.
Information and Communication Technology Resources in English Hospitals (n = 156)
a
a
One hundred fifty-six responses to this question were received, but not every respondent answered each part of the question. Percentages may not therefore total 100.
b
EDI = electronic data interchange.
7 (4)
11 (7)
18 (12)
23 (15)
22 (14)
12 (8)
17 (11)
21 (13)
7 (4)
64 (41)
68 (44)
92 (59)
112 (72)
127 (81)
127 (81)
135 (87)
63 (40)
57 (37)
32 (21)
20 (13)
4 (3)
Intranet access within the pharmacy
Internet access within the pharmacy
EDI
b
ordering of medicines from suppliers
Pharmacy Web site on intranet or Internet
Intranet or Web-enabled formulary
EDI invoice processing
Electronic prescribing
Partially Present Not Present Present
No. (%) Hospitals Giving Indicated Response
Resource
ment of advanced breast cancer.
When hospitals did respond to NICE
guidelines, the response was margin-
ally greater for rosiglitazone (median
number of responses, three; range,
one to nine) than for proton-pump
inhibitors (median, two; range, one
to eight) or taxanes (median, two;
range, one to nine), although the dif-
ference was not significant (p =
0.7374, d.f. = 2, analysis of variance
[ANOVA]). Passive types of respons-
es, such as circulating the guidelines
(73% of hospitals did this for at least
one topic), were more common than
active responses, such as monitoring
compliance (14%) or auditing cur-
rent practice (49%).
NSFs are one of a range of mea-
sures designed to promote quality
nationwide and to decrease geo-
graphic variations in service.
9
NSFs
set national standards and identify
key interventions for a defined ser-
vice or care group. We asked hospital
pharmacists about the action taken
Table 4.
Drug-Use Policies in English Hospitals in Fiscal Year 20002001
a
All respondents answered this question, but not every respondent answered each part of the question.
b
PGDs = patient group directions.
130 (83)
114 (73)
105 (67)
97 (62)
107 (68)
43 (27)
Nurse authorization of supply of medicines
through PGDs
b
Reuse of patients own medicines
28-day, original-pack, outpatient
dispensing
Self-administration of medicines
28-day, original-pack, one-stop discharge
dispensing
Pharmacist authorization of supply of
medicines through PGDs
No. (%) Hospitals with Policy in Operation
or Being Implemented (n = 157)
a
Policy
Table 3.
Membership in Pharmacy and Therapeutics Committee in English Hospitals
a
Only 72 of the 154 respondents specified the number of members on the committee.
b
PCO = primary care organization.
6 (121)
1 (12)
2 (16)
1 (15)
1 (14)
2 (16)
1 (16)
1 (12)
1 (12)
1 (13)
1 (16)
1 (11)
1 (11)
2 (22)
152 (99)
147 (95)
141 (92)
122 (79)
105 (68)
104 (68)
101 (66)
59 (38)
51 (33)
50 (32)
37 (24)
5 (3)
3 (2)
3 (2)
Consultant (including medical director)
Chief pharmacist
Other pharmacist
Nurse
Primary care physician
PCO
b
prescribing committee representative
Area prescribing committee representative
Finance manager
Clinical governance committee representative
General manager
Junior physician
Chief executive
Regional prescribing committee representative
Patient representative
Median No. (Range) Members
with Indicated Title on Committee
(n = 72)
a
No. (%) Hospitals Whose Committee
Included Member with Indicated Title
(n = 154) Title
193 Am J Health-Syst PharmVol 62 Jan 15, 2005
REPORTS English National Health Service hospitals
by their hospital in response to the
first two NSFs published, namely
those for coronary heart disease
3
and
mental health
2
(Appendix B). Over-
all, 74% of the hospitals (111/150)
responded actively to the NSF for
coronary heart disease, compared
with 45% (68/150) for the mental
health NSF (Table 6). This is unsur-
prising, given that two thirds of our
respondents provided no mental
health care. However, 24 hospitals
with no formal mental health care pro-
vision did respond to the NSF for
mental health, typically by circulating
the guidelines (16/24), establishing a
subcommittee (12/24), or auditing
current practice (11/24). Although
the number of positive responses by
individual hospitals for both types of
NSFs ranged from one to nine, the
median number of responses was
slightly higher for the NSF for coro-
nary heart disease (four) than for the
mental health NSF (three). However,
the difference was not significant (p
= 0.1484, d.f. = 1, ANOVA). Active
responses, such as monitoring com-
pliance (done for at least one NSF by
23% of the hospitals) or auditing
current practice (54%), were less
common than passive responses,
such as circulating the guidelines
(67%) or reviewing disease manage-
ment guidelines (59%), although the
difference was not as marked as that
for the responses to NICE guidelines.
Discussion
The vast majority of all health care
provision in the United Kingdom is
undertaken through the NHS, which
is a state-run, free-at-the-point-of-
need care provider funded by federal
taxation. It is not surprising, there-
fore, that pharmacy services in the
hospital sector have evolved from
national directives in a uniform fash-
ion. The most significant of these di-
rectives appeared in 1988 after the
Nuffield Foundation report on U.K.
pharmacy
13
and provides a prescrip-
tive blueprint for clinical pharmacy
services.
14
A significant further mod-
ernization of hospital pharmaceuti-
cal services was described in Phar-
macy in the FutureImplementing
the NHS Plan
15
and A Vision for
Pharmacy in the New NHS.
8
These
documents highlighted the changing
a
P&T = pharmacy and therapeutics committee.
Table 6.
Responses of Hospitals to National Service Frameworks (NSFs) (n = 150)
37 (25)
47 (31)
18 (12)
34 (23)
12 (8)
27 (15)
49 (33)
7 (5)
10 (7)
82 (55)
63 (42)
61 (41)
41 (27)
67 (45)
27 (18)
53 (35)
84 (56)
12 (8)
30 (20)
28 (26)
Audited current practice against NSF
Established subcommittee to move recommendations forward
Made submission to P&T
a
committee; P&T committee
recommendations modified
Reviewed disease management guidelines
Identified indicators for monitoring compliance
Requested funding for drug use
Circulated guidelines
Issued specific directive
Modified formulary
No action taken
Mental Health Guidelines Coronary Heart Disease Guidelines
No. (%) Hospitals with Response
Response
Table 5.
Responses of Hospitals to National Institute for Clinical Excellence Guidelines for Selected Drug
Groups (n = 140)
a
P&T = pharmacy and therapeutics.
33 (24)
10 (7)
21 (15)
21 (15)
11 (8)
55 (39)
75 (54)
10 (7)
18 (13)
43 (36)
17 (12)
5 (4)
71 (51)
29 (21)
7 (5)
15 (11)
91 (65)
15 (11)
61 (44)
30 (22)
60 (43)
15 (11)
33 (24)
40 (29)
14 (10)
3 (2)
92 (66)
16 (11)
43 (31)
37 (16)
Audited current practice against guidelines
Established subcommittee to move
recommendations forward
Made submission to P&T
a
committee; P&T
committee recommendations modified
Reviewed disease management guidelines
Identified indicators for monitoring compliance
Requested funding for drug use
Circulated guidelines
Issued specific directive
Modified formulary
No action taken
Taxanes Rosiglitazone
Proton-Pump
Inhibitors
No. (%) Hospitals with Response
Response
REPORTS English National Health Service hospitals
194 Am J Health-Syst PharmVol 62 Jan 15, 2005
role of pharmacy in general and hos-
pital pharmacy in particular and ad-
dressed such issues as medication
management services, nonmedical
prescribing, automation, informa-
tion technology, and reduction of
medication errors. Our survey exam-
ined some of these areas.
The response rate for this survey is
not dissimilar to that achieved in sur-
veys of hospital pharmaceutical ser-
vices in Australia in 1998 (58.5%)
16
and surveys by the American Society
of Health-System Pharmacists in
2001 (49%)
17
and 2002 (46.7%)
18
and
might have been higher but for sur-
vey fatigue among chief pharmacists
(the profession was subject to three
major national surveys in 2001).
7,8,19
Our survey sought to ask questions
in the same way as these national sur-
veys. A number of the hospitals sur-
veyed had recently merged, so in
some cases the postal database did
not match the new structure or chief
pharmacists were not in place at the
new institutions. However, we be-
lieve that the results provide a good
indicator of the nature of the devel-
oping services in English hospitals.
The survey did not attempt to exam-
ine basic hospital pharmacy services,
such as drug purchasing, prepara-
tion, distribution, and dispensing;
aseptic services; and drug informa-
tion, but rather those services subject
to the governments modernization
agenda.
A key aspect of the modernization
agenda is the use of ICT systems. The
requirements for the NHS have been
laid down in a national strategy for
local implementation.
20
In the sec-
ond phase of implementation, sub-
stantial progress was expected to be
seen in delivering an electronic pa-
tient record and an electronic health
record. A specific target was that 35%
of all acute care hospitals were to
have implemented an electronic pa-
tient record system that included
electronic prescribing between 2000
and 2002. Our study found that few-
er than 5% of NHS hospitals had
such systems; for the subgroup of
acute care hospitals, the figure was
3%. However, most hospitals had de-
partmental or hospital access to the
Internet, so they are achieving one of
the other targets for ICT. The Na-
tional Electronic Library for Health
is accessible through intranets in all
NHS organizations.
New government guidance in-
cludes the goal that, by December
2006, prescribing catalogues must be
created and linked to local guide-
lines, national formularies, and ac-
credited pharmaceutical reference
databases. Good progress must have
been made toward real-time elec-
tronic prescribing across the health
care community.
21
Our survey showed that over 80%
of all hospitals drug costs had de-
volved to the budgets of the special-
ized clinical services. This means that
physicians, nurses, pharmacists, and
managers within these specialized ar-
eas have to account for drug use in
much the same way as any other
treatment. Furthermore, prescribers
are engaged in the future planning of
health services, particularly for new
treatments coming onto the market.
As in U.S. hospitals, most NHS
hospitals have a multidisciplinary
P&T committee that meets at least
six times a year.
17
Membership con-
sists of several clinical professionals,
as well as hospital managers. Patient
representatives are infrequently in-
volved. Of particular note is the
move toward consideration of the
use of medicines in the whole health
economy (i.e., hospital and family
physician practice).
Prescribing privileges for pharma-
cists and nurses are beginning to be
established in England, similar to the
trend in U.S. hospitals.
22
Patient
group directions are an intermediate
step toward full prescribing by these
health care professionals. Pharma-
cists and nurses are currently train-
ing for and achieving competency
under a scheme called supplementa-
ry prescribing.
23
Some nurses are also
achieving competency for indepen-
dent prescribing by using an extend-
ed formulary specifically for nurse
prescribing.
The way that medicines are issued
to patients is changing. Rather than
being issued medicines in unit dose
packs, as is common in the United
States, patients are encouraged to
bring in and, if appropriate, self-
administer their medicines. This is
seen as good practice, since it allows
patients to continue to take medicines
with which they are familiar and re-
duces medication errors. There is also
a move toward using original patient
packs for solid oral medicines.
In England and Wales, NICE is-
sues guidelines to the NHS on the
cost-effectiveness of pharmaceutical
treatments. Our survey showed that
hospitals responses to these guide-
lines are variable. Although some of
this variation may be due to the spe-
cialized nature of certain hospitals,
other variation remains unexplained.
One possible conclusion is that hos-
pitals are not always fully imple-
menting NICE guidelines on cost-
effective prescribing, but the reasons
for this are unclear. In Europe, health
technology assessment (HTA) agen-
cies vary considerably in the methods
they adopt to disseminate evidence
into clinical practice.
24
Although
there is no centralized HTA agency
in the United States, the Academy of
Managed Care Pharmacy (AMCP)
publishes a format for formulary
submissions.
25,26
These guidelines
aim to ensure that increased use of
medicines is appropriate and that
newer products offer clinical and
economic benefits. Although adop-
tion of the format has increased,
AMCP stresses that this will not nec-
essarily lead to a decline in the ex-
penditure on medicines.
27
The strength of this work is that it
provides a reasonably comprehen-
sive review of the state of medication
management services in English
NHS hospitals. The limitation is that
the situation is constantly changing.
195 Am J Health-Syst PharmVol 62 Jan 15, 2005
REPORTS English National Health Service hospitals
Nevertheless, the survey results offer
a useful snapshot of the British gov-
ernments initiatives to promote the
safe, effective, and cost-effective use
of medicines.
Conclusion
A survey of English NHS hospitals
provided information on pharmacy
staffing, drug expenditures, and
measures taken to ensure rational
medication use.
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Appendix ASummary of National
Institute for Clinical Excellence
guidelines on proton-pump inhibitors
(PPIs),
10
rosiglitazone,
11
and taxanes
12
PPIs for dyspepsia
1. Patients with mild dyspepsia should not
normally be treated with PPIs on a long-
term basis.
2. PPIs should not be used for patients with
confirmed ulcers.
3. Patients diagnosed with nonulcer dyspepsia
should not be routinely treated with PPIs.
4. PPIs may be used for patients with severe
gastroesophageal reflux disease or an ulcer
caused by a nonsteroidal antiinflammatory
drug.
5. If a PPI is recommended, the least expensive
appropriate PPI should be used at the low-
est dosage that provides effective relief of
symptoms.
Rosiglitazone for type 2 diabetes mellitus
1. Patients should be offered rosiglitazone
combination therapy (as an alternative to in-
jected insulin) if they are unable to take met-
formin and a sulfonylurea as a combination
therapy or if their blood glucose concentra-
tion remains high despite an adequate trial of
this combination treatment.
2. The combination of rosiglitazone and met-
formin is preferred to the combination of
rosiglitazone and a sulfonylurea, particularly
for obese patients. Rosiglitazone plus a sulfo-
nylurea may be offered to patients who are
unable to take metformin.
Taxanes for breast cancer
1. As patients reach the appropriate stage in
their treatment for advanced breast cancer,
they should be offered either docetaxel or
paclitaxel.
2. The use of taxanes for adjuvant treatment of
early breast cancer or for the first-line treat-
ment of advanced breast cancer should be
limited to clinical trials.
Appendix BSummary of National
Service Frameworks for coronary heart
disease
3
and mental health
2
Coronary heart disease
1. Standards 1 and 2 address the reduction of
heart disease in the population.
2. Standards 3 and 4 cover the prevention of
coronary heart disease in high-risk patients
in primary care.
3. Standards 5, 6, and 7 address the treatment of
heart attack and other acute coronary syn-
dromes.
4. Standard 8 covers the investigation and treat-
ment of stable angina.
5. Standards 9 and 10 address revascularization.
6. Standard 11 covers the management of heart
failure.
7. Standard 12 covers cardiac rehabilitation.
Mental health
1. Standard 1 addresses mental health promo-
tion and the discrimination and social exclu-
sion associated with mental health problems.
2. Standards 2 and 3 cover primary care and
access to services for anyone who may have a
mental health problem.
3. Standards 4 and 5 cover effective services for
people with severe mental illness.
4. Standard 6 relates to individuals who care for
people with mental health problems.
5. Standard 7 draws together the actions neces-
sary to achieve the goal of reducing suicides.