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House of Lords Hansard
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Clinical Pharmacologists
12 September 2016
Volume 774

Question for Short Debate

Asked by

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To ask Her Majesty’s Government what assessment they have made of the impact of the decline in the numbers of clinical pharmacologists practising in the National Health Service and teaching in universities on treatment and research capacity.

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My Lords, this debate was organised at a very late stage on Wednesday evening so I am most grateful to all noble Lords who are taking part in it, and indeed to the Minister who will respond.

Most of the major advances in medicine in the past 50 years are related to the better use of better medicines. That is what makes this debate so important. Clinical pharmacology is the study and use of drugs in men, women and children. Clinical pharmacologists are to be found in hospitals and teaching settings, employed by the NHS and the university sector, with many employed by both. Clinical pharmacologists teach clinical pharmacology at undergraduate and postgraduate level, and provide training and support for other healthcare professionals in hospital settings. They practise those branches of medicine where drug treatment and the safer medicines agenda are pre-eminent. They can help other doctors who practise in other branches of medicine to learn about dose response, inter-individual differences in drug response and drug-to-drug interactions in order to improve patient care and prescribing practice.

By working with and training healthcare professionals, clinical pharmacologists can save the NHS money by stopping unnecessary drugs and using cheaper, more appropriate and equally effective alternatives. This is particularly pertinent given recent discussions about the NHS drugs bill; medicines spending accounts for around 10% of the overall NHS budget and costs in the region of £16 billion.

In addition to playing a valuable role in the NHS and teaching in medical schools, clinical pharmacologists are researching pioneering medicine in British universities and the UK biopharmaceutical industry. They are experts in experimental medicine, designing early-phase clinical trials, establishing NHS clinical research facilities and providing overarching clinical support. The specialty provides leadership in the use of medicines, and the benefit is felt across the broader NHS—in primary and secondary care and in areas such as regulation and medicines assessment.

Clinical pharmacologists hold a number of strategic posts within the UK healthcare and regulatory environment, so they can make decisions with widespread impacts. The National Institute for Health and Care Excellence, the Scottish Medicines Consortium and the All Wales Medicines Strategy Group have all been led by clinical pharmacologists to ensure the best use of NHS resources. They hold and have held a number of key posts within the Medicines and Healthcare Products Regulatory Agency as well. The MHRA’s yellow card scheme, which collects information on side-effects, has centres led by clinical pharmacologists across the UK. Consultants in clinical pharmacology lead the National Poisons Information Service. They have jointly led the development of the prescribing safety assessment with the UK Medical Schools Council, an innovation in medical education that aims to increase prescribing competence among newly qualified doctors.

The past 50 years have seen a huge use of this highly specialised group of clinical doctors. Looking to the future, the question is: do we need them? Indeed we do. Thinking about personalised medicine as a new frontier, clinical pharmacologists can play a crucial role in refining the use of currently available medicines and developing and pioneering the medicines of tomorrow. With an ageing population and many people with multiple illnesses who use multiple medicines, the potential of the clinical specialty is very great.

There can be no argument about either the past contribution of clinical pharmacologists or their potential contribution in future, but here is the rub. At a time when we need more of them, actual reductions in their numbers are taking place. This is affecting clinical posts as much as university teaching opportunities and it is producing a vicious circle. Changes in teaching at medical schools mean that many students pass through their training without ever hearing the term clinical pharmacology. In addition, the British Pharmacological Society has found that there is about one consultant in clinical pharmacology to 500 undergraduates, compared to one cardiology consultant to only 40 undergraduates. That means the specialty has low visibility among students and trainees, so there are few role models. Indeed, many medical students can go through the whole of medical school without even hearing of the specialty. Furthermore, the low number of consultant posts can be a deterrent in itself. Unsurprisingly, trainees are unwilling to start training in a specialty where local consultant jobs are at best uncertain, at worst unavailable. There is therefore compounded uncertainty, which makes it difficult to fill trainee posts.

We then come to the NHS and its employment of consultants. The problem is exacerbated by Health Education England’s workforce plan approach, which is an aggregate of local plans. Inevitably, those local plans are focused on immediate pressures related to targets and waiting times, so the decision-making of Health Education England operates on a demand and supply model. It asks NHS trusts what they need, collates those requirements and that essentially becomes the strategy. As most NHS trusts do not have a clinical pharmacologist consultant, they will never ask one. Hence, Health Education England states that there is no demand and therefore no need to increase supply. This is a problem for all small specialties. What we need, above all else, is strategic thinking at national level for these very important, small-number specialties. It needs to be multifaceted because we need to increase visibility to the next generation, supporting training and securing more consultant posts.

In many cases, even more worryingly, the problem has spread to industry. A shortage in clinical pharmacological skills in the UK biopharmacological industry was highlighted last year as part of a call for urgent development of a skilled workforce by the Association of the British Pharmaceutical Industry. We have traditionally enjoyed a very high reputation in this field: we can think of eminent people, such as Sir Michael Rawlins, now the chairman of the MHRA, previously the chairman of NICE, or Sir Alasdair Breckenridge, former chairman of the MHRA. Alongside these global leaders in thinking in this area is a pharmaceutical sector that is hugely important to Britain, given the scale of R&D investment and the consequent developments that take place in the UK. That is important not just to patients but to the UK economy.

Some of this is at risk because the people who make the key decisions are essentially NHS bodies and universities who do not have the strategic picture. Indeed, at the moment there are only 72 consultants in post in the NHS, despite a recommendation from the Royal College of Physicians that there should be about 440. Over the past 10 or 15 years we have seen a huge increase in the consultant workforce, but in terms of clinical pharmacologists there was a massive increase in the last 12 years from 72 to 77. These gains have not been protected and my understanding from the British Pharmacological Society is that the number has now gone to 72 consultants.

The case I want to put to the Minister is that we need some action. The British Pharmacological Society is calling for more investment by the organisations responsible for workforce management in the four UK nations—this is a UK issue as well as an issue for England—to provide a minimum increase of 78 consultant posts to bring the total up to 150 by 2025. It also wants to provide clear career pathways with associated career support and development.

How is this to be done? I hope that this afternoon the noble Baroness will signal her support for some action to be taken. I hope she will recognise the fundamental contribution of clinical pharmacology to the NHS and the safer medicines agenda and, as importantly, its potential pivotal role in maintaining the UK’s leading international academic and industrial position in the pharmaceutical sciences. I hope she will agree to meet the British Pharmacological Society with Health Education England, NHS England and the NIHR to agree workforce numbers, and to discuss what can be done in terms of a high-level strategy for clinical pharmacology. I also hope she will urge the British Pharmacological Society to work with the ABPI, the Medical Research Council and other employers and training providers on developing joined-up careers and training pathways as part of this strategy.

We are all aware of the financial pressure on the NHS at the moment, but I just point out that the clinical pharmacology specialty delivers essential cost savings. Indeed, work for the society to be published shortly by PWC estimates that for every pound invested in clinical pharmacologists, £5 can be saved through more efficient use of medicines and fewer adverse drug reactions.

This country has a pre-eminent role in the field of clinical pharmacology. It is very clearly at risk and I very much hope that the Minister will signal that the Government are prepared to take action to reverse the very worrying trend we are seeing at the moment.

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My Lords, almost all my working life, I was involved in the National Health Service and in general dental practice for over 35 years; also, I had the privilege of serving as a member of various health boards. It is because the NHS means so much to me that I put my name down to speak in this debate.

Noting that the subject was “clinical pharmacologists”, I realised that I did not know precisely what they were and what they did. Although I asked the party Whips’ offices of Government and Opposition to provide me with their definition, neither did so, so I had to have a good look at Wikipedia, which was a great source of information. I know that this debate happened at very short notice, so I am not blaming anyone that only the weekend intervened between the time that we heard about it and now.

Wikipedia makes it clear that clinical pharmacology,

“is the science of drugs and their clinical use. It is underpinned by the basic science of pharmacology, with added focus on the application of pharmacological principles and quantitative methods in the real world. It has a broad scope, from the discovery of new target molecules, to the effects of drug usage in whole populations. Clinical pharmacology connects the gap between medical practice and laboratory science. The main objective is to promote the safety of prescription, maximise the drug effects and minimise the side effects. It is important that there be association with pharmacists skilled in areas of drug information, medication safety and other aspects of pharmacy practice related to clinical pharmacology. In fact”,

in some countries people,

“train to become clinical pharmacologists. Therefore, clinical pharmacology is not specific to medicine”.

Another point I must mention is how valuable the service is to general practitioners. They rely on the advice that comes through clinical pharmacologists to tell them which drugs are safe to put together and which drugs counteract or damage one another or create dangerous situations.

Another important factor is the role that they play in the national poisons centre. GPs have told me that when a patient presents and they have taken some sort of poison—or they believe that it is poison—they get on immediately to the national poisons centre, which assesses whether there is something available that could counter the poison that has been given or whether the person needs to be rushed immediately somewhere to be put on to a different type of treatment. The role that they play in the field of toxicology is extremely important.

Wikipedia lists the branches, which I shall mention by name. They include pharmacodynamics and pharmacokinetics, as well as dealing with rational prescribing, toxicology, drug interactions and drug development. So it is pretty wide-ranging—and it has been very informative. I have learned a great deal from speaking to people in the practice, who know what the position is.

However, it seems in many ways to be a very academic position, and education experts will probably know exactly what training is required. Are the facilities for training readily available? Does it require a double degree? Is the drop in numbers due to the difficulty in recruiting people wishing to be trained in this particular discipline?

From the speech of the noble Lord, Lord Hunt, it sounds as if there is a bit of a lack of interest. People may not be aware of how significant the role is and how satisfying it could be to do it well. Even the little I have found on the subject has revealed how important a part clinical pharmacology plays in the National Health Service. After listening to the speech of the noble Lord, Lord Hunt, I was better informed on that than I was just from Wikipedia, because he spoke about the very important roles that clinical pharmacologists play. But they are rather the invisible people; ordinary members of the public probably have no idea what they are—just as even I, who have worked so much in the health service, did not know exactly what it was. So we must be sure that the role is more widely recognised.

The noble Lord expressed the wish that people would be encouraged to go into it and made to feel it is worth while, and there might be more prospect of that when the subject is aired like this—then people have more idea of what they could do and how it could be a very valuable contribution. However, it requires a special temperament, because very demanding and highly skilled science is required. Their role of helping on rulings about rational prescribing—and I understand they have a place in the preparation of any new protocols for medicine—is vitally important work.

We cannot afford to lose too many clinical pharmacologists. The Government must look at ways of ensuring a continuing stream of these essential specialists for the NHS.

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My Lords, I first congratulate my noble friend on securing this short but very important debate. Like the noble Baroness, Lady Gardner, I also went to Wikipedia as well as the British Pharmacological Society. I do not think it is an academic area at all. It is a vibrant area of biomedical science that studies drug action: how medicines and other drugs work and how they are processed by the body. That affects all of us in one way or another, whether it is about taking paracetamol, the effects of alcohol and caffeine consumption, the inadvertent exposure to poisons and environmental pollutions or many other aspects of modern life, such as drug addiction and abuse and the abuse of drugs in sport.

Clinical pharmacology has added focus to the application of pharmacological principles and methodology in the clinical setting, including patient care and outcomes. It is crucial for the discovery of new medicines to help fight diseases such as cancer, depression, heart disease and infectious diseases. It is essential for improving the effectiveness and reducing the unwanted side-effects of medicines and understanding why individuals—such as women—differ in the way they respond to certain drugs. The response of children to drugs is a growing field of examination for the Pharmacological Society.

As a scientific discipline, pharmacology dates back to classical Greece and, in our country, to the Middle Ages and it lies at the heart of biomedical science. As the noble Baroness, Lady Gardner, has explained, pharmacologists work closely with a wide variety of other disciplines. Their knowledge and understanding improves the lives of millions of people across the world by providing vital answers at every stage of the discovery, testing and clinical use of new medicines. This is a unique contribution to today’s science and tomorrow’s medicines, in universities, government agencies, the health service and the pharmaceutical and bioscience industries.

The most recent example was an announcement made last week when Professor David Webb, president of the British Pharmacological Society and professor of therapeutics and clinical pharmacology in Edinburgh, said of the study of statins:

“In recent years, those of us who manage the large number of patients at excess risk of heart disease and strokes have been fighting an uphill battle to persuade them to take statins, a class of medicines that have been repeatedly shown to save lives”.

He went on to say:

“This comprehensive review, by a broad group of leading international academics, of robust and unbiased evidence from randomised controlled trials and systematic reviews, confirms that statins are both effective and cost effective”.

We need pharmacologists to thrive and we need their futures to be assured—the whole of the NHS needs them. As my noble friend said, PricewaterhouseCoopers estimates that every pound invested in clinical pharmacologists could save £5 through more efficient use of medicines and fewer adverse drug reactions. This research, which is pending publication, has been commissioned by the British Pharmacological Society, and is in the very helpful briefing which it provided. Savings could be on a significant scale. Medicines spending accounts for around 10% of the overall NHS budget and now costs in the region of £16 billion, up from £14.3 billion since 2013. The Department of Health has estimated that £300 million is lost every year due to medicine wastage, at least half of which is avoidable, so savings could be felt across the NHS.

Surely those savings should at least justify a strategy to make sure there are enough clinicians and consultants and a better career pathway in this very important discipline. The noble Baroness, Lady Gardner, asked a pertinent question: why is there a problem? I think the answer is that, as with so many specialist areas in the NHS, no one has provided a strategy and picked it up and run with it. My noble friend has outlined the need for workforce planning. I hope the Minister will reassure the House that the Government are taking these concerns very seriously indeed and will bring forward solutions for us to consider. I very much look forward to her remarks.

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My Lords, I wish to speak in the gap.

Prescribing is one of the major roles and responsibilities of a doctor. It follows that a sound knowledge of pharmacology should be an important element in the training of all clinicians. We are now embarking on an era of medicine where treatments by drugs are becoming increasingly specific to individual patients. These developments and the application of such remedies is complex and demanding and it requires the oversight of experts.

Since the creation of the first academic departments of clinical pharmacology in the UK in the 1950s, the discipline has played a substantial role in studies in experimental medicine, and in large-scale clinical trials.

Concerns have been expressed in recent years that the number of clinical pharmacologists in the UK is falling; many of the individuals concerned are within 10 years of retirement, so there will be an even more critical shortage of clinical pharmacologists in the near future. The consequence of a dearth of specialist pharmacologists and a dearth of knowledge of pharmacology among the generality of clinicians is worrying.

Poor prescribing is one way in which patients can come to harm. A lack of knowledge can also make general practitioners vulnerable to the persuasions of drug companies that are intent on selling their remedies without regard to their efficacy or their dangers. It is difficult to estimate the cost to our health service of the inappropriate adoption of drugs that have been the subject of hard sales techniques, but it must be considerable.

What is lacking from our health service, and what it once possessed, is a facility for conducting exacting trials of pharmaceutical remedies. The decline in the number of specialist clinical pharmacologists in the health service and the marginalisation of pharmacology in medical training implies that there will be acute problems in the near future. These problems will be the legacy of a remarkable oversight on the part of the Department of Health and of the General Medical Council, over a period of more than 20 years. It is time for this situation to be amended.

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My Lords, I begin by thanking the noble Lord, Lord Hunt, for securing a debate on this important subject. He has spoken today about the vital role fulfilled by clinical pharmacologists and the contribution they make to effective treatments for the population of this country.

As the noble Lord pointed out, pharmacology lies at the heart of biomedical science, linking together chemistry, physiology and pathology. Those that take up the speciality work closely with a wide variety of other disciplines, including neuroscience, molecular and cell biology, immunology and cancer biology, to name just a few. They improve the lives of millions of people globally by providing vital answers at every stage of the discovery, testing and clinical use of new medicines.

The ability to use medicines effectively, to optimise their benefit and minimise the risk of harm to people, relies on pharmacological knowledge and understanding. We hear much about new diseases such as Ebola and Zika and their emergence and also hear much about older medicines—most notably antibiotics—no longer working as well as they did, so the contribution of pharmacology to finding better and safer medicines continues to be vital.

While it is true that there has been a decline in the number of clinical pharmacologists practising in the UK, it is important that we recognise that the fall in numbers is relatively small. Data from the British Pharmacological Society and the Royal College of Physicians show that the number of CPT consultants in the UK fell from 74 in 2002 to 72 in 2013, and that 52 of the 72 consultants were based in England, but perhaps a drop of even that amount is important.

As regards the supply of the profession, as noble Lords will be aware, from being established in 2013, it has been Health Education England’s responsibility to ensure that there is sufficient future supply of staff, including those needed in specialist fields such as this, to meet the workforce requirements of the English health system. It is the responsibility of the devolved Governments to ensure their health systems have the staff they require. Each and every year, Health Education England produces a national workforce plan for England. This is built upon the needs of local employers, providers, commissioners and other stakeholders who, as members of the local education training boards, shape their local plans.

Health Education England therefore has a responsibility for ensuring an adequate supply of trainees to provide the consultant workforce of the future, but is not responsible for setting the number of consultant posts inside the NHS. As I have just set out, this is the role of trusts, commissioners and others. HEE annually reviews the number of training places in medical specialties in response to demand expressed by the NHS. It is therefore crucial that trusts have a clear view of how they wish to utilise and promote clinical pharmacology and therapeutics positions in their hospitals.

To its credit, HEE has increased the number of training posts available. However, not all of these have been filled. Clinical pharmacology and therapeutics has suffered in terms of its fill rates against other high-profile specialties. However, as my noble friend Lady Gardner of Parkes mentioned, there needs to be more recognition of the career, more involvement with related healthcare organisations and perhaps more understanding of how fascinating and interesting this career can be, as the noble Baroness, Lady Thornton, said. In an attempt to counter this, HEE has been working to make the profession more attractive to junior doctors as they begin to specialise, including making the role more flexible to trainees, offering joint training with other specialisms and actively promoting the role at careers fairs.

The noble Lord, Lord Hunt, mentioned people not coming forward because of the uncertainty of a job. That is why some clinical pharmacologists already train towards a dual CPT, which then broadens the scope of their practice, making them more desirable to employers due to increased flexibility. I am aware that HEE has also been undertaking a review of this area and will, in due course and upon completion, share these findings with stakeholders, including the British Pharmacological Society. Leading on from that, the role has also been promoted by the chair of the British Pharmacological Society and is supported by the four UK health systems.

It may be interesting to note that the supply of clinical pharmacologists is primarily domestic, with only a very small number coming from overseas. In the three years 2012 to 2015, only one of the newly appointed consultants was trained outside the UK. Both the Royal College of Physicians and the British Pharmacological Society feel that there is a need for growth in this area and assert that current and predicted supply is insufficient to support that growth, and as such are calling for more training posts. There is, though, a lack of consensus between the Royal College of Physicians and the British Pharmacological Society about the level of future demand and the numbers required. This is perhaps an indication that it is not easy to evaluate future demand or possibly indicates a lack of understanding of these roles out in the wider health system.

Given the need to spend taxpayers’ money responsibly —and the difficulty filling the existing training posts—HEE is not able to increase the number of training positions until the demand is signalled by the NHS. At this stage, no significant increase in demand has been signalled in HEE’s annual collection of forecast demand from providers, which forms the basis for the annual training commissions for medical specialties.

In summary, I strongly encourage professional bodies with an interest in this field of medicine to actively engage locally with NHS trusts to ensure that where there is a need for additional clinical pharmacologists, they feed this in to the HEE workforce planning process. This process is the fundamental bedrock for NHS workforce planning. HEE actively engages with its stakeholders in developing its annual workforce plan, and any change in workforce planning numbers needs to be debated and resolved through this process. It is interesting that this is obviously not only a problem in the United Kingdom, because several reports have come out of the United States which show that it is having similar difficulties.

I thank the noble Lord, Lord Hunt, for giving us the opportunity to discuss this important matter.

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I am most grateful to the Minister for giving way and for the eloquence of her response. From what she said, the Government’s view is that this is solely a matter for Health Education England, and I understand that. However, does she accept that because HEE is concerned only with the accumulation of the local plans, it is not able to take any account of the national significance of this clinical speciality, and that there is a risk here because local employers do not see this as particularly important, although nationally we can see that it is vitally important? Is there a case for asking HEE to look at the national strategic importance of the professions? That would be one way of looking at this from a rather different viewpoint.

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The noble Lord stopped me just as I was about to say that very thing. This is one of the important problems. There is not joined-up thinking—certain bodies are not aware of the importance of this—so it becomes a kind of vicious circle. I was going to say that we need joined-up thinking, and I hope that debates such as this will increase awareness and get people to think further. I will be happy to meet those bodies involved; they might well prefer to meet my noble friend Lord Prior but I will be happy to accept on his behalf.

I thank all noble Lords who have taken part in this debate.