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2 Specialties Clinical pharmacology and therapeuticsAlthough the supervision and management of generalmedical patients is a major direct contribution to theNHS, most consultants in clinical pharmacology andtherapeutics take on other roles that contributeindirectly to achieving local NHS service objectivesand standards. These activities usually focus on themanagement of medicines in primary and secondarycare, eg: leading or playing an important role in the activitiesof drug and therapeutics committees and overseeingthe use of drugs in both hospitals and primary care managing a local drug formulary, which may bejointly agreed with local GPs editing and facilitating the production of localprescribing guidelines for common medicalproblems taking a lead role in reporting adverse drug reactionsand reviewing local medication errors undertaking HTA, which might involve reviewingnew and established drugs for clinical andcost-effectiveness purposes auditing and reviewing patterns of local drug use,with the aim of maximising effective and safe use ofmedicines in the NHS.All of these activities make an important contributionto achieving local objectives in clinical effectiveness,clinical risk management and clinical governance.Clinical pharmacologists are likely to play a major rolein auditing and investigating local drug-relatedincidents.Some consultants provide a drug information service,often with the support of a clinical pharmacist. Thismay include a plasma drug concentration monitoringservice, advising on the management and preventionof medication errors, and an advice service on drugoverdoses and the management of adverse drugreactions. Some consultants have a specialist interest inforensic pharmacology and provide expert advice incoroners’, criminal and civil cases. There should beadequate provision for all of these important publichealth and additional service commitments withinajobplan.6 Clinical work of consultantsHow a consultant works in this specialtyClinical pharmacologists have varied working patterns,but most NHS and academic consultants are accreditedin clinical pharmacology and therapeutics (CPT), withgeneral internal medicine (GIM) as their secondspecialty. However, the skills of clinical pharmacologyand therapeutics are generic and are fully applicable toother medical specialties. A few consultants also practisein specialties such as geriatric medicine, cardiology,paediatrics, oncology, respiratory medicine orrheumatology, and it is likely that the number of suchconsultants will increase as more varied trainingschemes are established.Inpatient workActivities will normally be devoted to supervising themanagement of acute medical patients and the specialistwork of the individual consultant. This work typicallyrequires two ward rounds per week at fixed times. 2 Thenumber of inpatients for which the consultant team isresponsible should ideally not exceed 20 patients. Partof this time will be dedicated to inpatient referrals forpatients with pharmacological or toxicologicalproblems. Consultants expect to work in an adequatelystaffed ward, with the appropriate facilities and ancillaryservices to care for a typical casemix of general medicalpatients. They should have the support of at least onejunior doctor who has completed general professionaltraining.Outpatient workTime will be allocated for seeing new patient referrals,including emergency referrals and follow-up afterdischarge from accident and emergency or a hospitalward. Consultants normally provide this service withthe support of junior staff and must allow time for theirsupervision. It is reasonable to expect that theassessment of a new patient will take approximately 30minutes and follow-up patients approximately15 minutes. Trainees require more time and should notwork in isolation. A typical clinic might include 4–6new patients and 10–15 follow-up patients. Thesesessions should include time for dictating clinic lettersand administrative matters relating to the outpatientservice. Some clinical pharmacologists also providespecialist clinics, eg in cardiovascular risk management,asthma, or epilepsy. Patients are sometimes referredwith specific therapeutic, toxicological or otherdrug-related problems.Specialist investigative or therapeutic proceduresClinical pharmacologists will not normally undertakespecialist procedures other than those that arise fromother specialty activities.C○ Royal College of Physicians 2013 75
Consultant physicians working with patientsSpecialist on callClinical pharmacologists have traditionally taken aparticularly active role as general non-organ-basedphysicians in the on-call rota for supervision ofreceiving and triaging acute emergency admissions.These duties should be undertaken with the support ofan appropriate number of junior doctors, including aspecialty registrar (StR). Acute general medicaladmissions should ideally be admitted to a medicaladmissions unit with appropriate staffing and access toemergency investigations. 3 The on-call rota should notbe more onerous than one in five. Each period of acuteadmitting must include a post-take ward round with thejunior staff who were involved in the admission process.In some services, two ward rounds may be required in a24-hour period. Consultants who are responsible forthe review of poisoned patients have more frequentpost-receiving ward rounds.A common on-call commitment of a clinicalpharmacology service is the provision of emergencyadvice about the management of poisoned patients.This activity will usually be supported by a poisonsinformation service, and clinical pharmacologists mayoffer regional advice. Some academic specialists mayhave out-of-hours commitments to subjects involved inclinical trials.Clinically related administrationClinical pharmacologists will have administrative dutiesin keeping with their clinical workload. They may alsobe called upon to write specialist reports related tomedication issues.Academic medicineThe large majority of consultants in clinicalpharmacology and therapeutics hold academic posts,which adds to the particularly diverse contributions thatthe specialty makes to the delivery of healthcare.Consultants in major teaching centres also play a keyrole in the design and delivery of teaching intherapeutics to medical students. 4 For new medicalgraduates, prescribing drugs is a major activity and onethat is associated with significant clinical risk. For thesereasons therapeutics remains an important themewithin any medical curriculum and requiresappropriate support from clinical teachers. Clinicalpharmacologists are also involved in the delivery ofpostgraduate training in therapeutics to other healthprofessionals in the NHS, including GPs, nurses andpharmacists.Research is a fundamental part of the work of manyclinical pharmacologists. It involves clinical research inpatients and healthy volunteers, and some individualslead teams of laboratory-based researchers.Drug-related research activities make an importantcontribution to local and national NHS research anddevelopment strategies, providing important long-termbenefits for patient care. The success of these activitieswill depend on the availability of suitable clinical andlaboratory areas, recognition of the need for protectedresearch sessions, and the support of appropriatelytrained clinical and technical staff. Clinicalpharmacologists often have an important role on (orchair) local and multicentre research ethics committees,because of their expertise in drug-related research.7 Opportunities for integrated careClinical pharmacologists frequently work with scientistsand technical staff in order to provide therapeutic drugmonitoring services. Close working with pharmacists isalso undertaken, running formulary and drug andtherapeutics committees. Similarly, subspecialty clinicssuch as hypertension and vascular risk clinics may beprovided, working with pharmacists and nurses whomay also prescribe. Although communication withprimary care concerning patient management isessential, clinical pharmacologists have not traditionallyprovided integrated services across primary care, butthe potential is there, particularly with regard tomedication review.8 Workforce requirements for the specialtyThe 2009 consultant census by the Federation of RoyalColleges of Physicians of the UK reported that therewere 51 whole-time equivalent (WTE) consultants inclinical pharmacology and therapeutics in England andWales, equivalent to one per 1.027 million population. 5The following calculation reflects the number ofconsultants needed to ensure that there are sufficientclinical pharmacologists to contribute to nationalbodies and to provide a high-quality local nationalservice, with particular emphasis on medicinesmanagement, toxicology, and academic activities suchas teaching and research. The workforce alsocontributes to the care of unselected acute generalmedical admissions. The calculation takes into accountseveral important trends; drugs account for anincreasing proportion of NHS expenditure (currently76 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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