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In Denmark, the Ministry of Health is responsible for legislation on health care, including legislation on health provisions, personnel, hospitals and pharmacies. The Ministry also sets up overall guidelines and quality goals for health care services. The next political and administrative level is the five regions, and they run the 10 hospital pharmacies in Denmark. All hospital pharmacies are publicly owned. In 2009, 18303 hospital beds were recorded (http://www.sst.dk/Indberetning%20og%20statistik/Sundhedsdata/Sengepladser.aspx), and the average admission time was 4.2 days (http://www.regioner.dk/%C3%98konomi/ ~ /media/Filer/%C3%98konomi/Analyser/Styr%20p%C3%A5%20regionerne%202010/Styr%20p%C3%A5%20regionernes%20%C3%B8kono_Kap_6.ashx).
Three of the regions have only one hospital pharmacy, each delivering medicinal products and services to all hospitals within the region, while two regions have several hospital pharmacies. There is great variation among the size of the pharmacies, with the hospital pharmacy in Copenhagen having more than 500 employees and the smallest pharmacy having about 20 employees. Approximately 1500 people work in hospital pharmacies in Denmark. The largest group of staff consists of pharmaconomists, with a 3 year education (http://www.pharmakon.dk/Pages/International.aspx?PageID=152), followed by pharmacists (http://www.sdu.dk/en/uddannelse/kandidat/farmaceut, http://www.farma.ku.dk/index.php/BSc-and-MSc-programmes-in-Dani/4638/0/) and locally trained people. Despite variations in size, all hospital pharmacies have similar tasks and pursue goals within the same three areas:
Meeting special hospital needs by manufacturing, preparing and developing medicinal products.
Safe and efficient supply of medicine by optimising logistics including, IT systems.
Rational pharmacotherapy by developing and implementing clinical pharmacy.
The pharmacies have a variety of functions to fulfil in order to meet these goals. All pharmacies buy, store and distribute medicine, and they all use the same ERP system, Apovision. They deliver profound top-up service and participate in drug and therapeutic committee work, including the elaboration and implementation of recommendations and drug use monitoring. Many pharmacists perform medication reconciliation and medication reviews, and participate in different national or local quality programmes and patient safety initiatives. The pharmacies all have central intravenous additive service (CIVAs) on a small or large scale. Four hospital pharmacies produce medicine licensed for use within hospitals (SAD products), and even more participate in clinical trials.
Back in 1990, some of the regions formed a common organisation, Amgros, to support the regions and hospital pharmacies. Amgros is owned by the five regions, and the board consists of seven regional politicians (http://amgros.dk/en/about-amgros/about-amgros.aspx). The professional inspiration and strategies are carried out in close collaboration with the hospital pharmacy managers. The initial and still the main task of Amgros is to ensure that the public hospitals receive the necessary quantity of medicine purchased at the lowest possible price through tendering. Recently, the tasks were extended to include the elaboration of national treatment guidelines for expensive products by formation of the Danish Council for the Use of Expensive Hospital Medicines (RADS). Since 2007, all regions are stakeholders in Amgros, and today Amgros is also the Marketing Authorisation Holder of SAD products and in general supports the manufacturing of medicine. Amgros runs and develops different IT solutions to support both pharmacies and the complicated tendering processes, from budgeting of EU tenders to following up on consumption. Amgros also holds a lot of R&D projects to support the development of Danish hospital pharmacy and the hospital pharmacies in reaching their goals.
Profound national cooperation to achieve common goals
As both all pharmacies and Amgros strive to deliver safe medicine to public hospitals by optimal use of resources, a profound collaboration has developed over the years. The intention is to share and utilise resources such as specialised knowledge, economy and staff in order to identify and implement solutions for the benefit of all hospital pharmacies and Amgros. To achieve this, a comprehensive voluntary cooperation structure exists.
In 2011, the 10 hospital pharmacies and Amgros formed a coordination group (SAK) to set the common strategic goals for the profound collaboration between the 11 organisations. SAK consists of one hospital manager per region and the director of Amgros. SAK has three standing advisory groups: preparation of medicine (F3), procurement, logistics and tenders (FILU) and clinical pharmacy, research and development (KFFU).
Each of these has the possibility to establish close working groups and networks, depending on need, for common task solution and sharing of knowledge between the hospital pharmacies. The working groups and networks are staffed with employees from the hospital pharmacies and Amgros. If larger projects are initiated by SAK or the advisory groups, a project plan and budget is prepared (for large projects a business case is also prepared), and if the project is approved by SAK or the advisory group, a project organisation, including steering committee, project leader and relevant project groups, is formed. Some of the projects are described in the other Country focus articles in this issue. The shared projects aim at different aspects of hospital pharmacy, including logistics, clinical pharmacy, preparation and IT solutions. Along with these projects, the hospital pharmacies and Amgros run local minor projects to support and develop their own businesses.
What's up and coming?
Two current initiatives have the ability to change the tasks of hospital pharmacies in the near future—modernisation of the pharmacy structure and construction of new hospitals in all five regions.
The government has formed a committee of officials with the mission of preparing proposals on how to modernise the pharmacy sector, taking the use of resources, including public expenditure, into account. The committee has to focus on the following areas: current organisation and tasks of the retail pharmacies, tasks and duties of hospital pharmacies, international experiences and consideration of possible alterations.
Today retail pharmacies are owned and run by pharmacists, and the Danish Health and Medicines Authority controls the locations of the pharmacies. One of the tasks of the committee is to review the future role of the hospital pharmacies regarding the supply of medicine to citizens at discharge from hospital. Today, hospitals are only allowed to supply certain drugs for patients being treated at home under the care of a hospital doctor. These medicines have to be on the ‘free of charge medicine list’, which lists selected medicines for specific groups of patients (eg, parenteral nutrition, growth hormone and HIV/AIDS treatments). Apart from this, there is a general rule that hospitals supply nurse dispensed medicine sufficient to last until new prescriptions are redeemed at a community pharmacy. Normally up to 3 days' supply is provided by the hospital. It is expected that the committee will hand over a report to the government by the end of the year.
In 2010, an overall plan for the future structure and investments in hospital construction was adopted. The establishment of several new hospitals (one in each region) is an opportunity for Danish hospital pharmacies to introduce and implement new logistic solutions and new product concepts. The focus from the regions and the hospital pharmacies is to develop solutions that meet the requirements of this new hospital structure, which implies shorter hospital stays, more treatments being carried out at the patient's own home, more sophisticated home care treatments and comprehensive use of telemedicine.
Hospital pharmacies see delivery of ‘ready to use’ medicine as one of the solutions. This includes automated dose dispensing, expansion of the current central intravenous admixture (CIVA) services and—if cost effective—an expansion of automated preparation of CIVA products. Currently the focus is on optimising the preparation of cytostatics, and it is the expectation that the preparation in hospital pharmacies will be maintained in order to meet the special needs of hospital treatments that are not fulfilled by industry. New ready to use solutions will be developed, and the overall manufacturing setup will be further coordinated in order to ensure the supply and efficiency in manufacturing. The future need for ‘ready to use’ drugs is continuously communicated to the pharmaceutical industry, hoping that they will deliver solutions where the market is sufficient for industrial manufacturing. Also, the logistics regarding delivery from hospital pharmacy to the ward is—together with the regions' interest in implementing new technologies—interesting. Hence private companies are offering participation in different projects and thereby giving the chance to test for example, radio frequency identification tagging of medicine boxes. Other solutions, such as automated patient specific dose dispensing and electronic medication cupboards, are also being investigated.
Also, for clinical pharmacy, building of new hospitals is an opportunity to implement and extend patient specific activities. During the past 2 years, a number of acute emergency wards have been established. The intention is that all acute patients are admitted via these departments and many initiatives on medication reconciliation and medication review at admission have been made in cooperation with the emergency wards. Another possibility for clinical pharmacists is to develop services that support the wish for ‘streamlined and short’ patients stays. Apart from medication reconciliation and medication review, this could include efficient supply of patient specific drugs, patient education and other preparations needed for successful further treatment at home.
To summarise, both the operation and development of the Danish hospital pharmacy is a well balanced cooperation between 10 hospital pharmacies and Amgros—between local tasks and initiatives and national solutions and projects. This tradition has been developed during the past two decades through voluntariness and restructurings, and by the formation of one hospital pharmacy partner, Amgros, in 2007, this has been further strengthened. We believe that this profound cooperation makes Danish hospital pharmacy as a whole, as well as every individual hospital pharmacy and Amgros, able to operate and develop in all the different disciplines of hospital pharmacy quicker and in a more efficient way than if all 11 organisations were to come up with their own solutions. In the Country focus articles in this issue, a wide range of both local and national initiatives are presented.
↵1 The Danish Research Unit for Hospital Pharmacy, Amgros, Dampfærgevej 22, 2100 Copenhagen OE, Denmark
↵2 Head of pharmacy, The Hospital Pharmacy North Denmark Region, Porsvej 1, 9000 Aalborg, Denmark
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
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