pharmacy practice research in the united kingdom: which issues should shape future developments?

5
GENEKAL AK‘I’LCLES Pharmacy practice research in the _ _ United Kingdom: which issues should shape future developments? SIOBHAN M. COTl’ER and NICHOLAS MAYS Pharmacy practice research (PPR) is a developing area of research in the United Kingdom. To date, most studies have been carried out in secondary care, although efforts have been made recently to encourage studies in primary care. The quality of PPR is variable and there have been few well-performed studies. It is likely that this has resulted from the relative novelty of PPR and the inexperience of the researchers. Studies have usually been performed on services at a single site and have been carried out in isolation from fellow researchers or university departments with appropriate expertise. Initiatives have been taken within pharmacy to improve the quality of PPR but the resources that are available, and hence the potential for improvement, are limited. In contrast, health services research (HSR) is a relatively well-established area of research in which related topics in the broader areas of health care are considered. Comparable methods could be employed to examine PPR and HSR topics. It is suggested that substantial improvements may be made in the quality of PPR by fostering long-term collaborative ventures between PPR and HSR. PHARMACY practice research (PPR) is a rela- tively new development in the United Kingdom (UK). Although logically part of health services research (HSR), it has developed largely in isola- tion from HSR. Only in recent years have efforts been made to increase contact between research- ers in the two fields. Important changes have occurred in health care and in research, particularly within the National Health Service (NHS), that have impli- cations for PPR. Increasingly, health care is being provided by multidisciplinary ieams. The internal market is forcing purchasers and provid- ers to consider the need for services and the cost- effective provision of those services. The empha- sis is on moving as much care as possible to the community. Health professionals are having to grapple with issues of role demarcation since traditional roles are no longer assured in a market-driven environment where managers wield increasing power. Evidence-based care is in vogue and research monies are being directed at projects that appear to address gaps in the evidence underlying health care interventions. In the midst of this turbulent and ever-changing scene, where does, and where should, PPR fit in? This paper is based on two recent reviews of UK PPR literature. These are a personal review of all aspects of UK PPR literature’ and a criterion- based review of evaluative studies of hospital clinical pharmacy.* Our aim in this paper is to provide an overview of the history and nature of PPR in the UK and to explore its contribution to the examination of pharmacy services. We pro- vide our views on PPR’s place in health care research, examine the effects of policy initiatives on the development of PPR and make suggestions as to how policy-makers and researchers can guide progress to optimise the contribution of PPR to health care. What is PPR? A review of all the papers that have appeared in the lnternational Journal of Pharmacy Practice (IJPP) shows the diversity of topics that come under the heading PPR. These include the assess- ment of computer systems for patient education, the measurement of nurses’ views on pharmacy services and assessments of the kinetics of various novel drug preparations. Are all of these papers considered to be PPR, or is there an absence of consensus on the definition of PPR such that papers that do not lie easily within the traditional boundaries of pharmacy research, such as pharmaceutics, by default become part of PPR? In the associated field of HSR, the Medical Research Council has provided a helpful defini- tion of HSR as “the investigation of the health needs of the community and the effectiveness and efficiency of the provision of services to meet those needs.” It has been suggested that replace- ment of “health needs” with “pharmaceutical needs” would supply a workable definition of PPR.’ Another suggestion, that PPR encom- passes pharmaceutical research into patient care and behavioural research: seems to be in agree- ment. Yet these definitions, even if they were accepted widely, do not describe all studies that are currently thought to be PPR. It is possible that the confusion regarding PPR . . Department of Public Health and Policy, London 3chool of Hygiene and Tropical Medicine, Keppel street, London WClE 7HT Siobhan Cotter, PhD, MRPharmS, research fellow King‘s Fund Policy Institute, London Vicholas Mays, MA, DipSocSci & Pdmin, director of bealth services research Mr Mays is :hairman of the Royal Pharmaceutical Society of Great Britain’s task force m pharmacy wactice research md development Zorrespondence to: Dr Cotter ‘nt J Pharm Prmt L996;4:1-5

Upload: siobhan-m-cotter

Post on 30-Sep-2016

212 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Pharmacy practice research in the United Kingdom: which issues should shape future developments?

GENEKAL AK‘I’LCLES

Pharmacy practice research in the _ _

United Kingdom: which issues should shape future developments? SIOBHAN M. COTl’ER and NICHOLAS MAYS

Pharmacy practice research (PPR) is a developing area of research in the United Kingdom. To date, most studies have been carried out in secondary care, although efforts have been made recently to encourage studies in primary care. The quality of PPR is variable and there have been few well-performed studies. It is likely that this has resulted from the relative novelty of PPR and the inexperience of the researchers. Studies have usually been performed on services at a single site and have been carried out in isolation from fellow researchers or university departments with appropriate expertise. Initiatives have been taken within pharmacy to improve the quality of PPR but the resources that are available, and hence the potential for improvement, are limited. In contrast, health services research (HSR) is a relatively well-established area of research in which related topics in the broader areas of health care are considered. Comparable methods could be employed to examine PPR and HSR topics. It is suggested that substantial improvements may be made in the quality of PPR by fostering long-term collaborative ventures between PPR and HSR. PHARMACY practice research (PPR) is a rela- tively new development in the United Kingdom (UK). Although logically part of health services research (HSR), it has developed largely in isola- tion from HSR. Only in recent years have efforts been made to increase contact between research- ers in the two fields.

Important changes have occurred in health care and in research, particularly within the National Health Service (NHS), that have impli- cations for PPR. Increasingly, health care is being provided by multidisciplinary ieams. The internal market is forcing purchasers and provid- ers to consider the need for services and the cost- effective provision of those services. The empha- sis is on moving as much care as possible to the community. Health professionals are having to grapple with issues of role demarcation since traditional roles are no longer assured in a market-driven environment where managers wield increasing power. Evidence-based care is in vogue and research monies are being directed at projects that appear to address gaps in the evidence underlying health care interventions. In the midst of this turbulent and ever-changing scene, where does, and where should, PPR fit in?

This paper is based on two recent reviews of UK PPR literature. These are a personal review of all aspects of UK PPR literature’ and a criterion- based review of evaluative studies of hospital clinical pharmacy.* Our aim in this paper is to provide an overview of the history and nature of PPR in the UK and to explore its contribution to the examination of pharmacy services. We pro- vide our views on PPR’s place in health care research, examine the effects of policy initiatives

on the development of PPR and make suggestions as to how policy-makers and researchers can guide progress to optimise the contribution of PPR to health care.

What is PPR?

A review of all the papers that have appeared in the lnternational Journal of Pharmacy Practice (IJPP) shows the diversity of topics that come under the heading PPR. These include the assess- ment of computer systems for patient education, the measurement of nurses’ views on pharmacy services and assessments of the kinetics of various novel drug preparations. Are all of these papers considered to be PPR, or is there an absence of consensus on the definition of PPR such that papers that do not lie easily within the traditional boundaries of pharmacy research, such as pharmaceutics, by default become part of PPR?

In the associated field of HSR, the Medical Research Council has provided a helpful defini- tion of HSR as “the investigation of the health needs of the community and the effectiveness and efficiency of the provision of services to meet those needs.” It has been suggested that replace- ment of “health needs” with “pharmaceutical needs” would supply a workable definition of PPR.’ Another suggestion, that PPR encom- passes pharmaceutical research into patient care and behavioural research: seems to be in agree- ment. Yet these definitions, even if they were accepted widely, do not describe all studies that are currently thought to be PPR.

It is possible that the confusion regarding PPR

. .

Department of Public Health and Policy, London 3chool of Hygiene and Tropical Medicine, Keppel street, London WClE 7HT Siobhan Cotter, PhD, MRPharmS, research fellow

King‘s Fund Policy Institute, London Vicholas Mays, MA, DipSocSci & Pdmin, director of bealth services research

Mr Mays is :hairman of the Royal Pharmaceutical Society of Great Britain’s task force m pharmacy wactice research md development

Zorrespondence to: Dr Cotter

‘nt J Pharm Prmt L996;4:1-5

Page 2: Pharmacy practice research in the United Kingdom: which issues should shape future developments?

exists to some extent because it is a new and developing area with few boundaries. In contrast, the core purpose of many PPR studies is very similar and centres around the protection, devel- opment and justification of pharmacy roles and services. Despite differences in the ‘areas sur- veyed, and in the review methods used, both recent reviews of UK PPR literature’.’ show this to be the case.

Furthermore, the emergence of PPR was linked closely with the takeover by the pharmaceutical industry in the 1960s of pharmacy’s role as the main compounder of medicines and its concomi- tant need to retain its professional status by adopting-other roles. Much PPR in the hospital sector has sought to justify the existence and extension of clinical pharmacy services’ while much of that in community pharmacy has sought to support the development of the “extended role”.’ Such pragmatic reasons for performing PPR may have clouded thinking on the definition and boundaries of PPR.

However, consideration of the historical con- text of PPR development reveals a patchy ap- proach by the profession to the area. This, rather than the profession-centred reasons for perform- ing practice research, is more likely to have been the major determinant in the delayed maturation of PPR as an area of scientific inquiry. The dominance of the scientific (physical science) base of pharmacy training and the location of most departments of pharmacy within university facul- ties of science are likely also to have influenced the profession’s view as to what constitutes good research. The dominance of the physical sciences in pharmacy has probably retarded the introduc- tion of social science approaches in PPR.

Historial context

Some of the earliest PPR papers in the UK appeared in the late 1960s. They focused on hospital pharmacy, describing problems in the use of drugs on hospital wards and pharmacists’ approaches to providing a solution. The develop- ment of various pharmacy services, particularly hospital clinical pharmacy services, were chroni- cled in PPR publications throughout the 1970s and 1980s. In the UK this mainly took place in the Pharmaceutical Journal and, later, in the Jour- nal of Clinical Pharmacy and the British Journal of Pharmaceutical Practice. Few PPR publica- tions appeared on community pharmacy in this period despite the fact that the overwhelming majority of pharmacists practised in primary care.

As early as 1977, a PPR section was introduced into the programme of the British Pharmaceutical Conference in recognition of this developing area of research. The need to improve the skills of practice researchers was one of the reasons for the inauguration of the College of Pharmacy Practice under the auspices of the Royal Pharma- ceutical Society of Great. Britain (RPSGB) in 1981 and its subsequent provision of short courses in research methods. Scholarships were established

/

to help fund and train practice researchers in the early 1980s. Yet by 1986, when the Nuffield Report into Pharmacy was published: still rela- tively little PPR had been performed. Based on the recommendations of the report, academic pharmacy practice units were established to pro- mote the growth of PPR and to enable pharma- cists to develop research skills while maintaining their clinical practice base. These units often linked hospitals with schools of pharmacy.

A major stimulus for PPR was the Department of Health’s creation of the Pharmacy Practice Research Enterprise Scheme in 1990. This scheme was initiated to train pharmacists in research skills normally used by non-pharma- cists, such as those used in the evaluative social sciences. A key feature of the scheme was the placement of researchers in non-pharmacy insti- tutions where they would encounter researchers from other backgrounds and gain valuable in- sights into unfamiliar research techniques.

In 1992, the lack of a widely-indexed journal in the UK for the publication of high quality practice research papers stimulated the creation of the ZJPP. This is published by the RPSGB. It pro- vides an alternative publication forum to The Pharmaceutical Journal. Despite its title, most ZJPP publications originate in the UK, rather than from the international community of phar- macy practice researchers.

While there has been increasing support within the profession for the development of PPR over the past 30 years, and latterly financial support, the quality of UK PPR remains poor. Based on the two recent reviews of PPR referred to above,l.’ in the next sections we summarise the current state of PPR and discuss mechanisms that could facilitate future developments.

State of nractice research in the UK t

Most studies have been hospital based although community based studies have recently increased in number. As one would expect in a relatively new area, most studies are descriptive, eg, of the usefulness of videos for postgraduate pharmacist education5 and of a card system to improve communications between general practitioners and community pharmacists.6 Descriptive data are often not exploited fully because of the absence of well-constructed research questions.

Evaluative studies have begun to appear but are few in number, usually single-site and often of dubious quality. With a few exceptions, data collection has been performed by the pharmacist providing the service under study and design features that might have controlled for bias and confounding have not been considered. These include the blinding of assessors to control and test groups and the measurement, or control, of extraneous factors in “before and after” studies. Feasibility studies and studies that purport to be evaluations but are, in reality, descriptions, are common.

Pharmacists have carried out the vast majority of studies in isolation from other health services

Much PPR in the hospital sector has sought to justify the existence and extension of clinical pharmac y services while much of that in community pharmacy has sought to support the development of the “extended role”

THE I \ T E R \ A T I O I A l . Jot R Y A L OF P H A R M A C Y P R A l : T I l : E , M A H l : H 1996

Page 3: Pharmacy practice research in the United Kingdom: which issues should shape future developments?

researchers. In a small number of instances non- pharmacy health professionals and, more recent- ly, a few social scientists have been involved.

The nature of published PPR studies is partly related to the lack of funding for PPR in the past and the underlying reasons for pursuing such studies, namely, to support the development of new services and the maintenance of established ones at individual hospital or community pharma- cies. Descriptive PPR has had a major role in cataloguing and publicising service developments and encouraging the provision of novel services. However, the continued pursuit of such studies in well-described areas, such as pharmacists’ inter- ventions, is inefficient and uninformative.

That is not to say that there is no place for descriptive research. Much effort has been con- centrated on discribing clinical pharmacy while major areas of descriptive research, such as interprofessional relations, health needs, out- comes, economics and policy research, have been neglected. The pursuit of PPR by pharmacists alone has ’ also resulted in pharmacist-driven research that runs the risks of lack of rigour and objectivity. Tough questions about the accessibili- ty, effectiveness and efficiency of services have been ignored in many cases. This is unacceptable in a resource-constrained NHS. There is, howev- er, now some evidence that researchers in PPR are considering new areas and beginning seriously to evaluate pharmacy services.

Many obstacles will have to be overcome by researchers tackling pharmacy service evalua- tions. One of the main difficulties lies in separat- ing pharmacists’ contributions from those of ither health care professionals.’ This relates to the multidisciplinary nature of health care and the relative absence of records of pharmacists’ :ontributions to care in, for example, hospital 3atients’ case notes.’ This, and the relative lack of validated outcome measures, have hampered Ivell-intentioned studies on the outcomes of phar- nacy services, such as the effect on patient care of 3harmacists’ interventions to improve prescrib- ng. In addition, few practice researchers have adopted a truly multidisciplinary approach to iervice evaluation or have attempted to adopt :xisting evaluative research designs. The result is hat PPR has failed to examine most pharmacy iervices fully and it has not explored the optimal irovision of such services.

Bearing this rather damming picture in mind, what constructive steps can be taken to overcome he problems? The suggestions that follow are lased on knowledge of the systems that have ,upported the development of research in other ields in the UK and elsewhere. The types of mesearch that should be performed are examined )efore focusing on who should be involved and he structures that could support developments.

Future research directions

There remains a clear need for studies that ncrease understanding of why pharmacy is prac- ised as it is and of how to improve practice. For

example, what pharmacy-based activities are ac- ceptable to pharmacists and patients? How can pharmacists contribute optimally with other workers to the provision of health care that improves health? What are the barriers to better interprofessional collaboration and how can these be reduced? Which incentives will encourage pharmacists to provide services that are felt to be worthwhile by patients and professionals but infrequently provided, such as the provision of verbal information on medicines to patients on complex drug regimens and the improvement of communication regarding patients’ therapies be- tween professionals in primary and secondary care? Is there a need for change in the infrastruc- ture or funding of community pharmacy to sup- port new practice developments?

There is also an acute need for evaluations of the effectiveness and efficiency of pharmacy ser- vices. Researchers need to answer the question “is this service effective?” and then to determine which services are the most valuable and what is the most efficient way to provide those services. Comprehensive evaluations have not been per- formed of clinical pharmacy services, even in the hospital sector, although there have been some excellent attempts. These include a small rando- mised, controlled, trial of the effects of a theophy- lline therapeutic drug monitoring (TDM) service on patient outcomes.’ This trial compared the effectiveness of individualised dosage (using a TDM service) with standard dosage regimens (no TDM service) in maintaining patients’ theophyl- line levels in the therapeutic range.

In community pharmacy, the picture is even worse. In a cost-conscious climate, the viability of services of unproven worth should be limited. Evaluations need to be multicentred to ensure that the results are applicable in a variety of situations. Sufficient numbers need to be recruit- ed to studies to ensure that they have the power to detect real differences where these exist. Safe- guards against bias should be in place; for example, the researcher should not normally be the community pharmacist who is providing the service under examination.

In all practice research studies, there should be an attempt to controLfor confounding. For exam- ple, when assessing changes in prescribing behav- iour, the possibility that alterations in the junior medical staff were the cause, rather than the influence of the pharmacist, must be consid- ered.’” Evaluations need to include economic as well as clinical and health outcomes.

Optimising PPR

How can PPR develor, to comDlement the multidisciplinary ethos of the provision of modern health care? The answer is to utilise the most suitable mix of disciplines to form teams to create and answer research questions in PPR. This may sound relatively simple, but bringing it about in practice will be far from simple.

PPR has developed in isolation from HSR. This has had several important detrimental effects. It

Tough questions about the accessibility, eflectiveness and effwkncy of services have been ignored in many cases. This is unacceptable in a resource constrained NHS

3

Page 4: Pharmacy practice research in the United Kingdom: which issues should shape future developments?

has led not only to narrowly-defined research questions and limited methodologies, but also to a relative lack of appreciation of the contribution that others can make to PPR studies. In general, there is a dearth of pharmacists who have a sound knowledge of good social science and other health services research methods. This is coupled with a general lack of acceptance of practice research within academic pharmacy. Unlike HSR, which has developed sufficiently far within medical research that the UK Medical Research Council has recently established a major initiative devoted to HSR at a number of linked universities, PPR does not seem to have gained similar standing among “mainstream” pharmacy researchers. The Department of Health’s PPR enterprise scheme has succeeded in encouraging some pharmacists to stand back from the relative parochialism of pharmacy to explore other areas of research. Although this will provide individual pharmacists with a knowledge of other research perspectives, it will not ensure that the main body of research- ers in PPR, nor pharmacy academics in general, will be encouraged to alter their practices to use social science and health services research meth- ods in pharmacy studies where such methods are appropriate. Unless there is a deliberate attempt to establish fruitful links with non-pharmacy institutions, pharmacy practice researchers will remain isolated. A minority of pharmacy institu- tions have established such links, such as the school of pharmacy at the University of Manches- ter (see below), but it is too early to judge the results.

Additionally, health services researchers have still had little exposure to pharmacists or to the research issues in pharmacy. This may have resulted in a relative lack of interest in pharmacy topics among those in HSR and, possibly, the failure to use pharmacy knowledge appropriately in “mainstream” HSR studies, such as studies that involve prescribing or medication use and more general studies in, for example, primary care. Once again, the Department of Health’s enterprise scheme may have helped to reduce this ignorance to some degree but there is a limit to the extent to which a single transitory research stu- dent can change the thinking of a long-established research institution.

Longer term links between HSR and PPR, such 8s those created by the Department of Health’s Yational Primary Care Research and Develop- ment Centre in Manchester, are essential for real progress. In Manchester, the collaboration be- tween the staff of the PPR unit and a wide variety 3f researchers from other disciplines and depart- ments, both within the University of Manchester nnd in other centres, such as the Centre for Health Economics at York University, is forma- lised. This enables recognition of the contribution made by all parties to joint research projects and promotes the bringing together of researchers with appropriate experience.

Several approaches can be considered when :onternplating how links should be fostered. In reality, much will depend on the efforts of leaders

in PPR to approach those in HSR and establish common research programmes. Most schools of pharmacy now have chairs in pharmacy practice and these people are ideally placed to make formal approaches to those in “mainstream” HSR in their universities. The NHS research and development initiative in England may provide a focus for common work but greater sharing of ideas on research in general is necessary. An enhanced understanding of HSR and PPR per- spectives may be fostered through attendance at jointly-organised local seminars on topics of spe- cific interest to both groups. This could provide a sound background against which research bids could be created, particularly if an understanding existed between the parties that formal joint research bids would result where it was advanta- geous to combine research skills. The current climate in research is highly competitive and it is unlikely that ad hoc collaborations to bid for money will be as successful as bids that emerge from an environment of on-going work and trust.

The placement of Department of Health PPR enterprise scheme students in non-pharmacy in- stitutions over the past five years has afforded schools of pharmacy easier access to those in HSR than in the past. It has allowed personal links to be developed and it may have reduced the suspi- cion which thrives through ignorance. For those in HSR, the experience with the enterprise scheme students may have provided an impetus to seek stronger links with those in PPR and the achievement of common aims through joint re- search projects. The scheme is still relatively new and few students have completed their research. It remains to be seen if the scheme has in fact engendered longer term research collaborations. When the scheme comes to an end in 199617, it must be built on by schools of pharmacy. The cohort of researchers trained under the scheme should be encouraged to pursue a career in PPR, either in posts in PPR units or in joint PPR-HSR posts: Efforts should be made by those who employ them to facilitate the maintenance of links with HSR units and to promote a multidisciplin- ary approach to research questions in pharmacy.

The above is only one model of a way forward. Others include the employment of social scientists and others with HSR backgrounds in pharmacy institutions, the formation of PPR units within existing HSR units or the de novo formation of research units that combine researchers from both HSR and PPR. However, skilled health researchers in some areas, such as social sciences, are scarce and a competitive market exists for research grants. It is likely that collaboration between established, well-staffed, PPR and HSR units will be more successful in acquiring research monies than, for example, bids by PPR units with a few additional social science researchers. The more theoretical questions of whether PPR should be performed only by pharmacists (albeit with wider research skills), whether it should be pharmacy-led, or whether it is equally well car- ried out by non-pharmacists as HSR in pharma- cy, remain to be answered. These questions are

PPR has developed in isolation from health services research. This has had several important detrimental effects

4 THE I’vTERNATIONAL JOliRNAL OF PHARMACY PRACTICI.:, MARCH 1996

Page 5: Pharmacy practice research in the United Kingdom: which issues should shape future developments?

likely to trouble pharmacists but may not be the most important issues at this stage. A consider- ation of the direction that health research policy has taken provides an indication of the likely direction of future developments.

What can policy makers do?

Policy makers have encouraged the growth of applied research to guide the efficient and effec-. tive provision of all types of health care. Several policies have had seemingly positive effects on HSR, such as the NHS research and development initiative in England. In PPR, the Department of Health’s enterprise scheme has encouraged the training of pharmacists in a variety of research areas, most of yhich are related to HSR. Policy initiatives seem to be firmly in favour of PPR operating as a sub-set of HSR. Many PPR projects are really HSR projects in pharmacy and would be appropriately carried out within HSR, although with prominent pharmacist involve- ment. Unless pharmacists become involved in the research carried out in HSR units, they are likely to lose an opportunity to influence the direction of projects that include a pharmacy dimension. In contrast, some projects are firmly within PPR and of prime interest to those engaged in PPR although they. draw on the expertise of main- stream health services researchers. This is where the pharmacy-led projects need to be focused.

HSR is receiving greater support in the UK than ever, but more could be done to promote the development of the relatively new, but closely related, area of PPR. To ensure that PPR matures as a research area, there is a case for earmarked funding for specialist units that carry out PPR within HSR. Such funding could derive from the NHS research and development strategy or could be provided in other ways. The Depart- ment of Health could make a valuable contribu- tion to the further development of PPR by supporting the growth of specialist PPR units that have firm links with mainstream HSR. Finally, there is ample opportunity for the Royal Pharma- ceutical Society (RPSGB) to assist in the develop- ment of PPR by lobbying on behalf of the profession for funds for research, by encouraging schools of pharmacy to invest in PPR and pursue active PPR programmes, and by helping make PPR more “respectable” among pharmacy aca- demics. The establishment of a head of practice research at the RPSGB and the initiation of a pharmacy practice research and development task force are welcome developments.

Conclusion

PPR is a developing area of research. While some confusion persists regarding the exact nature of PPR, it is clear that it is related closely to the better-established and better-funded area of HSR. Although HSR and PPR focus on research issues of similar natures, but in different fields, many research methods that have been employed successfully in HSR have not been

employed in PPR. The reasons for this include the sensitivity of key PPR questions (because they may threaten the development of pharmacy), a lack of knowledge of HSR methods among re- searchers in PPR, a shortage of suitably skilled social science researchers in PPR, and the rarity of collaboration between PPR and HSR units. Efforts have been made to encourage the develop- ment of P P R but it is too early to judge the long- term success of these efforts. Various initiatives have been suggested in this article which could promote the further development of PPR. It is likely that the findings of the recently established RPSGB pharmacy practice research and develop- ment task force will be of major importance to shaping the future of PPR in the UK.

ACKNOWLEDGEMENTS: This paper is based on a PhD project (S. M. Cotter) and on work commissioned by the Pharmacy Practice Research Resource Centre at the University of Manchester (N. Mays). S. M. Cotter thanks the Department of Health (Pharmacy Practice Research Enterprise Scheme Award) and the pharma- ceutical division of North West Thames Regional Health Authority for funding for the PhD which was carried out at the Health Services Research Unit, Department of Public Health & Policy, London School of Hygiene and Tropical Medicine.

References

1. Mays N. Health services research in pharmacy: A critical personal review. Manchester: Pharmacy Practice Research Resource Centre, 1994. 2. Cotter SM, McKee M, Barber ND. Hospital clinical pharmacy research in the UK: A review and annotated bibliography. London: London School of Hygiene and Tropical Medicine, 1995. 3. Booth TG. Milestones in the development of practice research. Proceedings of a conference on Pharmacy Practice Research. London: Royal Pharmaceutical Society of Great Britain and the Department of Health, 1991. 4. Pharmacy. The report of a committee of inquiry appointed by the Nuffield Foundation. London: The Nuffield Foundation, 1986. 5. Mottram DR. A viable alternative in postgraduate continuing education. Pharm J

6. Blenkinsopp A, Jepson M, Drury M. Using a notification card to improve communications between community pharmacists and general practitioners. Br J Gen Pract 1991;41:116-8. 7 . McKay AB, Hepler CD, Knapp DA. How to evaluate progressive pharmaceutical services. Bethesda: ASHP Research and Education Foundation, 1987. 8. Cotter S, McKee M, Barber N. Pharmacists and prescribing: An unrecorded influence? [editorial]. Quality in Health Care 1993;2:75-6. 9. Fitzpatrick RW, Moss-Barclay C. The effectiveness of drug level monitoring and pharmacokinetics in individualising theophylline therapy. J Clin Hosp Pharm 1985;10:279-87. 10. Taylor D. Changing habits within a mental health unit. Br J Pharm Pract 1989;11:224-5.

1991 ;245:E12-14.

5