In Conversation with Ms Fionnuala Kennedy, President, Hospital Pharmacists Association of Ireland

Fionnuala graduated in Pharmacy from Trinity College in 1988 and has worked in hospital pharmacy since then. After her pharmacy degree, she returned to university and completed a degree in French and Economics. 1n 1994, following a period working and travelling abroad, she joined the pharmacy in St Vincent’s University Hospital, setting up the role of liver transplant and hepatology pharmacist. She was a founder member of the UK and Ireland Liver Transplant Pharmacists’ Group and contributed to the book “Drugs and the Liver” published by the Pharmaceutical Press in 2008. In 2001, she became the Chief II Clinical Pharmacy Services Manager and also continued to work clinically in hepatology, intensive care, surgery and transplantation. Clinical pharmacy was undergoing a period of rapid development during this period and she was at the forefront of developing standards for this service. She has lectured for RCSI and the MSc in Hospital Pharmacy in Trinity College.

During her time in SVUH, Fionnuala achieved two Masters: one in healthcare administration from the IPA and a second in healthcare informatics from Trinity College. Fionnuala has always been interested in healthcare informatics and in 2006 migrated the SVUH pharmacy system to Ascribe®, a first for Ireland. She also consulted on several informatic systems set up in SVUH during this period. In 2015, Fionnuala moved to the Mater Private Hospital, Dublin, taking on the role of Chief Pharmacist. Her hospital has seen a significant expansion in activity since 2015, and in May this year, the pharmacy will open a new state of the art aseptic compounding unit. Fionnuala joined the HPAI executive in 2015 and has been President since 2016, a role she thoroughly enjoys for the perspective it gives over the whole healthcare system.

How has the role of the hospital pharmacist changed over the past 10 years? Has your workload increased?
Hospital pharmacy has seen tremendous change in the last 10-20 years. The objective of the profession is to promote and ensure the effective, safe and economic use of medicines in our patients and healthcare system. Hospital pharmacists are recognised as the experts in medicines use and medicines management. 20 years ago, it was rare to see a pharmacist talking to a patient on a ward. Clinical pharmacists are now the norm on wards and in clinical areas in Irish hospitals. Hospital pharmacists increasingly work as part of the multidisciplinary team. They have become specialised in many areas such as anti-microbial stewardship, infectious diseases, intensive care, transplantation, although in many cases this remains to be formally recognised. Specialist supporting roles have evolved in areas such as medication safety, medicines information, aseptic compounding, medicines informatics, drug distribution. Resource constraints historically meant that smaller hospitals lagged behind the teaching hospitals in service development, but with the HIQA medication safety programme, this has provided hospital pharmacy with the support to improve medicines management services for our patients. Hospital pharmacy technicians have taken on increased roles, in particular, in procurement, drug distribution and aseptic compounding. As hospital pharmacy departments have increased in size, so too has the management function for the chief pharmacist. Budgets have risen significantly, and drugs are the highest non-pay spend in hospitals, reflecting the increased complexity and cost of medicines: the chief pharmacist is responsible for its management.

Can you briefly explain the role of the Hospital Pharmacists Association of Ireland (HPAI)?
The Hospital Pharmacists’ Association of Ireland exists to further the development of hospital pharmacy practices, assist in the provision of continuing pharmaceutical education, represent the views of the hospital pharmacist on issues of relevance to hospital pharmacy, and to advance the professional welfare of our members. The HPAI is affiliated to the European Association of Hospital Pharmacists, comprising members from 35 European countries.
The HPAI liaises with the Pharmaceutical Society of Ireland, the HSE, the Dept. of Health, the HPRA, the Universities and other organisations on issues relating to hospital pharmacy, as well as working with the EAHP to promote the practices of hospital pharmacy at a European level. The HPAI responds to consultations from various organizations and statutory bodies on behalf of its members, ensuring that the voice of hospital pharmacy continues to be heard.

What impact will the falsified medicines directive have on the day to day running of your pharmacy?
The implementation of the falsified medicines directive (FMD) will ensure that our patients only receive treatment with genuine medicines from authorised suppliers. It will allow us to ensure that the products we receive are verifiable as genuine and decommission them prior to use, in accordance with the directive.

Due to the large volume of medicinal products used by hospital pharmacy, most departments have elected to decommission at the point of goods inwards. This has required a review of procedures, infrastructure and resources. The consensus is that a medium sized hospital will require at least 1 person to perform this function, will have to install one of the accredited FMD software packages, and that a protected area is required to perform this task efficiently. It’s disappointing that we have not managed to integrate FMD software into existing medicines management software in our hospitals and that it exists as an entirely separate process.

It’s an immense and complex project involving all EU countries. At the time of writing (March 2019), the implementation date has passed and we are in a “use and learn” period, similar to most other European countries. As the industry learns how to manage alerts and diminish their number, and as the number of FMD packs in the market increases, it is expected that the system will bed down and become part and parcel of our daily activities. The relatively smooth implementation of the directive is testament to the inter-disciplinary cooperation during the previous 3 years, when stakeholders came together to plan FMD implementation.

In the event of a hard Brexit and given that the UK is a landing and release site for many drugs used by Irish hospitals, do you foresee any impact to the supply of these drugs after March 2019?
The HPAI has raised concerns about the security of the medicines supply chain at a national level for many years. Even without the threat of Brexit, shortages of medicines, including some non-substitutable medicinal products, are increasingly common. We welcome the HPRA shortages framework and the improved communication it facilitates. The EAHP has recently published a 2018 update of medicines shortages in Europe. See
Brexit will complicate the existing shortages situation. As a small, English-language country, Ireland shares many “dual” packs with the UK. At this time, it’s unclear if the UK will remain within the European Medicines Agency. In hospital pharmacy, we use many products which might be considered as marginal. Brexit might see these products being progressively withdrawn from the Irish market. When shortages arise, UK products are our first post of call. Many of the unlicensed products we already import are UK products. Brexit may affect their availability. Our suppliers have to ensure that they have robust routes for supplying the Irish market and that products which transit the UK do not get held up. Vaccines, thermolabile products and compounded chemotherapy are of concern. Also of concern are small volume hospital-specific medicines in specialist areas.

What preparatory plans are hospital pharmacists putting in place in the event of a no deal Brexit?
The HPAI has been liaising with other agencies in relation to preparations for Brexit and also participated in the development of the HPRA shortages framework. The national Brexit strategy promotes the development of alternate supply pathways for medicines and the maintenance of sufficient stocks in Ireland, independently of the UK supply chain. The HSE and individual hospitals have all been working on a Brexit strategy, individually and together. At this time, the future remains unknown, However the pharmaceutical business community and national bodies have been working hard to mitigate against potential negative effects on medicines supply to Irish patients.

If medicines do go short, hospital pharmacists will continue to manage supply either through the exempt medicinal product route or by liaising with our clinician colleagues to identify therapeutic alternatives. This will require significant research and pharmaceutical expertise, communication skills and will have resource implications. As experts in medicines use at all points in the medicines management process, from prescribing to logistics to therapeutic use, pharmacists are best placed to manage medicines shortages, and indeed, spend an increasing amount of time on this task.

With the amount of overspending in the HSE each year, how can pharmacists help to reduce the budget spent on drugs?
Pharmacists have expertise at all points in the medicines use process and are able to identify where savings can be made in our hospitals through:

  • economic product selection and procurement
  • effective therapeutic product selection, including of biosimilars
  • efficient distribution within the healthcare organisation, waste avoidance
  • pharmaceutical review of patients’ medicines
  • assessment of the therapeutic effect of medicine
  • avoidance, assessment and management of potential and actual adverse effects.

Pharmacists’ input into patient care can reduce healthcare costs by reducing unnecessary medicines use, avoiding costs associated with adverse events and re-admission to hospital, and by helping patients use their medicines to better therapeutic effect. Every patient in a hospital should have assess to a clinical pharmacist as part of the multi-disciplinary team, in order to achieve better healthcare outcomes and to reduce medicines costs for our healthcare system. Hospital pharmacists also detect and avoid medication errors and have the central role in medication safety, keeping our patients safe. The current WHO Patient Safety Challenge: Medication Without Harm supports this activity.

How does Ireland rank in its adoption of Biosimilars?
The adoption of biosimilars varies widely across Europe from country to country, from hospital to hospital and even among specialities within individual hospitals. There are significant savings possible, and there is a high opportunity cost in not switching. However, the switch to any particular biosimilar must be carefully considered by each hospital pharmacist and each clinical specialist for each patient. Hospital pharmacists are key to the assessment of the appropriate use of biosimilars for our patients.

What is the fundamental difference between working as a pharmacist in the private sector versus the public sector?
When it comes to the pharmaceutical care of the patient, there are few differences between a patient in a public hospital and a private hospital, as all patients have similar needs when it comes to their medicines. Medicines management structures are similar in both sectors. Private hospitals must be accredited, and Joint Commission International is the most common accreditation body. There are stringent medicines management standards which must be applied in order to achieve accreditation. By their nature, multi-disciplinary teams are more prevalent in public hospitals and pharmacists have a significant role in the provision of learning around medicines, both formally and informally. In our large teaching hospitals, there are many pharmacists in very specialised areas such as anti-microbial stewardship, transplantation, cystic fibrosis, cardiac medicines, renal medicine, intensive care, etc. These specialist roles should be formally acknowledged for their contribution to patient care. In the private hospitals, at a management level, chief pharmacists work closely with their management teams to ensure that insurance cover for patients is appropriate to their care plan, when it comes to medicines.

What can pharmaceutical companies do to further support the role of the hospital pharmacist and the HPAI?
Medicines use is ever more complex and the number of treatments available to patients has exploded in the last 20 years. The pharmaceutical industry, and specifically medical representatives, can help hospital pharmacists by appropriate and targeted education around medicines. Medical representatives should be expert in their product and it’s therapeutic use. The globalisation of medicines production has resulted in world-wide shortages of key medicines, including life-saving antibiotics. The industry has a role to ensure that medicines remain available for patients where possible, even in marginal markets, and that the supply chain is robust. If stock outages occur, industry has a role to play in sourcing product from other markets, with HPRA approval in relation to information supplied and over-labelling. The use of medicines for off-label indications is a fact of medicines use, and while this cannot be promoted, medical representatives should know their patient population and ensure that commercial decisions to withdraw medicines do not adversely affect patients.

How do hospital pharmacists deal with product recalls and what is the impact on patients attending the hospitals?
Hospital pharmacies deal with recalls as required by the HPRA. Fortunately, patient-level recalls are extremely rare. The increasing adoption of GS1 standards by hospital pharmacies as medicines informatics develops will assist in the recall process. Recalls of specific batches don’t cause a huge problem, unless no other batches are available in the market. The non-availability of modified release preparations which are non-substitutable, can cause problems for patients. The recent valsartan recall was the most problematic in my experience, as patients, many in the community, had to be switched to therapeutic alternatives, a very complex process, and with the potential to cause an adverse effect for the patient.

What are your thoughts on getting our hospital waiting lists down?
Clearly there are many reasons for queues in healthcare, most of which are directly un-related to medicines use. Pharmacists can play their part by ensuring that medicines use is safe and effective, avoiding medication errors and adverse events that might complicate or prolong hospitalisation. Hospital pharmacists liaise with our primary care colleagues to smooth the transition from home to hospital and back home again, as this interface is a key area of risk for medication errors. There is an opportunity cost for inefficient medicines use: pharmacists promote the economic use of medicines which does save money for the healthcare system as a whole.

What are your hobbies?
Hospital pharmacy is very consuming and between my work and family, it’s hard to find time for other activities. I am an avid reader, I love to swim and do other water activities, and heading out into the countryside is always a pleasure. In Dublin we have a great location, between the mountains and the sea. I love travelling to my homeplace, Laois, and Ireland’s hidden gem, the Slieve Bloom Mountains. Before children, we travelled a lot, and I’d like to resume this when our children are a little older and more independent. It will be great to share this experience with them. I’ve always had an interest in perusing maps and will have to settle for this for now.

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