In the first of a two-part series, Ron Batagol summarises the development and evolution of hospital pharmacy in Australia from the early years, through to the beginnings of clinical/ward pharmacy practice in the hospital setting in the 1970s
In his 1988 book, A History of Pharmacy in Australia, Gregory Haines, gives some background to the activities which took place in hospitals in Sydney in the early 1800s.
He writes that: “medicines were made in the hospital dispensary according to prescription and sent in labelled bottles to the wards for administration by nurses or wardsmen, with purgatives and emetics sometimes mistakenly interchanged!”
In Victoria, it was in the major gold-mining towns that dispensers in hospitals were first employed: Ballarat in 1856 and Bendigo in 1859.
The first dispenser in the then town of Melbourne was not employed until 1862, at The Melbourne (later Royal Melbourne) Hospital. In fact, in most hospitals of the 1850s and 1860s, the dispensing was undertaken by a medical practitioner, usually a designated Assistant Surgeon.
In 1864 the Melbourne Lying-in Hospital and Infirmary for Diseases of Women and Children opened, which later ‘morphed’ into The Royal Women’s Hospital.
Interestingly, this hospital’s first annual report stated that “A Mr. Williams, Chemist of Brunswick Street, provided a dispenser gratuitously for the first six months.”
Was this a prescient omen of things to come?
For, indeed, more than a century was to pass before pharmacists working in hospitals were able to secure something approaching the staffing and equipment required to manage the Drug Budget, the largest hospital expense outside salaries!
Hospital pharmacy practice: 1930s to 1960s
In his History of the Society of Hospital Pharmacists in Australia in Victoria, 1941–1950, Neil Naismith discusses the state of hospital dispensing practice in the late 1930s:
“Mr Victor I. Frank, who was a dispenser at The Royal Melbourne Hospital (formerly the Melbourne Hospital) to 1935), has provided the following description:
‘After the 1930s depression, the finances of the Government were in poor shape and such utilities as public hospitals were severely limited in their expenditure.
‘Positions for hospital dispensers were limited. Unless you had a steady job, you would be lucky to obtain a week’s employment every three weeks. Opportunities were controlled mostly by the drug wholesale houses.’
Formation of the Society of Hospital Pharmacists
In June 1941, the Society of Hospital Pharmacists of Australia (SHPA) was inaugurated at a meeting at The Royal Melbourne Hospital in Victoria, a state with 36 member pharmacists employed, at that time, in hospitals.
There were two prime movers behind the formation of this professional organisation, both of whom became elected officers, namely, the president, Charles MacGibbon, director of pharmacy at The Royal Melbourne Hospital; and honorary secretary, Fred Boyd, from Mont Park Mental Hospital in Macleod, an outer eastern suburb of Melbourne.
When the SHPA became a national organisation in 1961, Fred Boyd was elected its first federal president, a post he held from 1961 to 1965. Boyd was also the first editor of the Australian Journal of Hospital Pharmacy (now the Journal of Pharmacy Practice and Research).
In writing about the mid to late 1940s, Neil Naismith notes that: “perhaps the greatest achievement of this period was the contact and rapport which was established between the pharmacy staffs and the various hospitals by means of the monthly meetings and the Annual Conference that became a regular event from 1947.”
Among others who played leading roles in the formation and early development of the SHPA were Bill Hayes (Geelong Hospital) and Lance Jeffs (Royal Adelaide Hospital).
Hospital practice in the 1950s and 1960s
I recall that when I started my pharmacy apprenticeship in 1957 in community pharmacy, some of the favourite extemporaneous mixture scripts of the day were directly derived from hospitals, such as the RMH Asthma No. 1 Mixture, with aspirin, ephedrine, phenobarb and theophylline, which was cloudy white, and the Asthma No. 2 Mixture, with ephedrine, phenobarb and theophylline plus potassium iodide, with liquorice extract, which made it a black colour.
There were, of course, a variety of other favourite extemporaneous preparations, including the bane of our lives at that time, the very potent atropine and phenobarbitone mixture, used for infant colic and other infant gastro-intestinal problems.
In a historical snapshot of hospital pharmacy practice in the 1950s, Peter Featherston from Royal North Shore Hospital, Sydney, reflected on the work environment of the time:
Working conditions in the hospitals of the fifties left much to be desired. Existing equipment was, generally speaking, in poor condition, and replacement difficult or impossible to obtain.
Of course, it was also a time of ‘financial constraint’, and, as usual, the pharmacy was fairly low down on the ‘financial pecking order’ of most hospitals.
Furthermore, as recounted by Featherston in the early 1950s, there were no such things as prescription pads and it was common practice for the prescribing medical officer to give the outpatients their medical records. Within these were interposed, jumbled haphazardly with clinical notes and prescribers’ comments, their prescriptions.
This prevailing situation in many hospitals was also noted by Naismith, in his history of the SHPA:
‘During that period there was a huge proliferation in the use of large-volume intravenous fluids in public hospitals and the greater number and variety of such formulations that were required, had a tremendous effect on hospital practice’.
Some standard formulae were commercially prepared, but a large proportion were prepared, and would continue to be made (for many years) by pharmacy departments in-house.
Indeed, as Featherston noted (and I can also verify from my own introduction to hospital pharmacy practice in 1973):
‘Up until the mid-to-late 1970s , hospital pharmacy departments were set up with autoclaves and other required equipment, to routinely prepare a wide range of water for irrigation, dextrose, saline and assorted other intravenous and large volume sterile solutions on-site, as well as eye drops, inhalations and other small volume products.’
He also commented that:
‘Up until the mid-1960s, the majority of all prescriptions issued by private GPs and hospital medical officers, were for extemporaneous preparations; (mixtures, creams, lotions, ointments, nosedrops, eyedrops, suppositories).
As far as supply to the wards and other medical treatment areas within the hospital, bulk medication supplies prepared by the pharmacy department, often located in the basement, were placed into ward baskets and delivered to the wards and other clinical areas by pharmacists or support staff, and there was little if any clinical role for pharmacists at the ward level.’
The next stage
Setting the stage for the future involvement of hospital pharmacists within the ward/clinical management areas were three significant ‘preludes’:
1. Implemention of the Imprest system for ward supplies
In 1952, the Imprest system for the supply of drugs to wards was established in NSW by the chief pharmacist at Canberra Hospital, Enid Barnes, and was an important milestone in the development of hospital pharmacy.
For the first time, pharmacists were provided with an entry into wards.
As noted by Jill Mobilia, pharmacy director of the Royal Children’s Hospital in the late 1950s, this provided a mode of formal entry of pharmacists onto the wards, to work with nursing and other ward staff on medication supply management.
2. Pharmacy involvement in the development of hospital‑based pharmacopoeias
Another important development in the evolution of hospital pharmacists having input into clinical decision-making had actually commenced back in the 1940s, when some major teaching hospitals developed their own pharmacopoeias.
In Victoria, these pharmacopoeias included those from The Royal Melbourne, The Alfred, The Royal Childrens, St Vincent’s,Prince Henry’s, Eye and Ear, and Queen Victoria hospitals.
Neil Naismith noted that these pharmacopoeias were prescribed texts for medical staff and medical students, providing a set of established formulae, to facilitate the work of both medical and pharmacy staff, without lessening therapeutic efficiency. Preparation and maintenance of these pharmacopoeia involved a committee which included input by the chief pharmacist.
3. The formation of drug subcommittees in hospitals
Commencing in the late 1940s and through the 1950s, with the epoch-changing transition to medications prepared by drug manufacturers in tablet and capsule form, hospitals set up ‘drug subcommittees’ to monitor and evaluate new drugs, including the cost-benefits, and to make recommendations regarding their use or otherwise.
“Again, within hospitals, the Chief Pharmacist was an integral part of these Committees,” Naismith wrote.
During my apprenticeship years in community pharmacy in the late 1950s, I experienced first-hand the ‘explosive’ increase in the availability of proprietary preparations coming on to the market, winning the favour of prescribers.
Following on from this transition to medications prepared by drug manufacturers in tablet and capsule form, in March 1960, arising from an existing “emergency-only drugs” list, the Pharmaceutical Benefits
Scheme was introduced throughout the country. Initially for a list of drugs, including some extemporaneous and proprietary products, to be used for an expanded, but still limited, number of designated medical conditions.
These were to be dispensed at community pharmacies with a small patient co-payment (5 shillings, or 50 cents in today’s terms).
The 1970s: Initiation of hospital-based clinical pharmacy services
In 1973, after four years of undergraduate study, followed by 11 years of full-time practice as a community pharmacist, I commenced my hospital pharmacy career at The Royal Melbourne Hospital (RMH), a major teaching hospital in Melbourne.
The RMH director of pharmacy, Neil Naismith, was a pioneer in the development, implementation, and demonstration of improved patient medication management and, as a critical ‘selling point’, the cost-effectiveness arising from the implementation of ward/clinical pharmacy services.
While at RMH, I completed the 3–4 year post-graduate Hospital Pharmacy Fellowship Diploma, by examination, which included management and human resources, setting up a pharmacy department, and extensive study and project work in applied pharmacology, pharmacokinetics, and the consequential therapeutic applications in safe and effective medication management, focusing on collaborative strategies with medical,nursing and other health professionals.
As part of my orientation and ongoing practice at The Royal Melbourne Hospital, I worked in all areas of the department, including outpatients, inpatient and ward supply, requisition and purchasing, sterile preparation (under the watchful eye of the ‘doyen’ of sterile room activities, Beatrice Lee), and in non-sterile manufacturing.
In 1974, I was orientated through the then newly established Drug Information Service at The Royal Melbourne, the first of its kind in Australia, managed by the then deputy director of pharmacy, Elizabeth Lew Sang.
Later in 1974, I was fortunate to be appointed as a member of the initial full-time clinical pharmacy services team, introduced at The Royal Melbourne Hospital that year after a pilot program had been run in 1973.
In this program, one of the first in Australia, pharmacists worked collaboratively alongside medical, nursing and other health professional staff. They reviewed, supplied and counselled patients in specifically-allocated ward and other clinical areas, and also gave periodic lectures on medication use and safety to undergraduate nursing students.
The four clinical areas designated for this initial clinical pharmacy service at The Royal Melbourne were Coronary Care, Intensive Care, Renal, and the area that I was allocated to, the Special Haematology Unit, which managed patients with leukaemias and non-Hodgkin’s lymphomas.
The clinical pharmacist also attended and actively participated in therapeutic reviews on all ward rounds, and multi-disciplinary patient review meetings, as well as the haematology/pathology meetings.
The clinical/ward pharmacist also routinely liaised with nursing and other professional colleagues at ward level, regarding optimum medication management and safety issues.
I also operated a decentralised satellite pharmacy dispensing and counselling service to ambulatory patients attending the twice-weekly special haematology outpatients clinics.
From the late 1970s onwards, following Naismith’s ground-breaking studies on improved patient medication management and cost-effectiveness arising from ward/clinical pharmacy services, clinical/ward pharmacists became a routine feature in many hospitals.
Indeed, throughout the 1970s, many of us working collaboratively in the clinical areas of hospitals, were invited by senior medical staff and medical administrators in our hospitals to attend medical staff meetings, at which we presented a summary and engaged in a discussion of the practical application of Naismith’s ward/clinical pharmacy medication safety and cost-effectiveness research findings. Naismith’s work in this field continued for many more years.
From the mid-1970s, the SHPA held biennial federal conferences, alternating with state branch conferences, with local hospital pharmacists and invited overseas experts in the field attending and participating in workshop discussions, and hospital pharmacists presenting papers and posters on the clinical, patient care activities, and research in which they had been involved.
In 1976, after my initial introduction to clinical/ward pharmacy from 1974–1976, as the groundbreaking clinical pharmacy program was starting to be embraced in hospitals throughout the country, I was appointed as the convenor of the first working party on clinical pharmacy practice in Australia. This was established by the Victorian branch committee of the SHPA, of which I was then a member, and later, branch secretary.
I worked closely on the activities of this working party with the late Dr Ian Larmour, then chairman of SHPA, Victorian branch, who had also been involved in initiating clinical pharmacy practice at Prince Henry’s Hospital.
Subsequently throughout his career, Larmour developed and became a leading innovator of, new clinical practice pathways for of this important aspect of our profession.
In 1978, our SHPA Victorian working party produced the inaugural SHPA document Guidelines for Clinical Pharmacy Practice and we subsequently conducted workshops and presentations on this issue at SHPA conferences.
In the next article, Ron reflects on his own experiences and challenges with the profound changes in hospital pharmacy practice, which took place during his hospital pharmacy career from the 1970s to 2019.
Ron Batagol has had 47 years’ experience at all levels of hospital pharmacy practice, in addition to 18 years’ full-time, and 30 years’ part-time practice at all levels of community pharmacy. He has been a prominent voice in specialist, general and consultant pharmacy, author of the first Reference guide on drugs and pregnancy in 1980, several drugs and breastfeeding guides and, more recently in 2013, Taking medicines in pregnancy—what’s safe and what’s not, a plain English guide, as well as contributing to numerous advisory groups and committees.