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The British National Formulary: past, present and future

JOY OGDEN

Since it was first published in 1949, the British National Formulary (BNF) has been the lead authority on the selection and use of medicines for health professionals in the UK. Here, Joy Ogden discusses how the BNF has evolved, from its first inception to the modern age of digital publishing.

Figure 1. The BNF app gives clinicians quick and easy access to BNF content from their tablet or

mobile phone. Copyright © The Royal Pharmaceutical Society 2017, reproduced under licence any have said of alchemy, that Since then, pharmacists’ practices have “Mit is for the making of gold and changed beyond recognition. Figure 1 silver. For me such is not the aim, but depicts the BNF now adapted to the dig- to consider only what virtue and power ital age – but in the early 20th century, may lie in medicines.” Paracelsus (1493– the pharmacist’s job mainly involved mak- 1541). ing their own stock medicines, pills and Paracelsus, Swiss physician and potions (with the help of recently-devel- alchemist, was reportedly one of the oped hefty pharmacopoeias) and advis- most influential medical scientists in ing on drugs. early modern Europe1 but he was by no Doctors, too, have confronted chal- means the first. If you Google “history of lenges in a changing world. In the first pharmacy”, you will find many references half of the 20th century – faced with pre- to its ancient origins, including those to scribing appropriate, effective medica- cuneiform tablets recording prescribed tions from an increasingly complex range medications from around 2000 to 1500 of drugs produced by an expanded and BC2 and further back to Sumerian times. influential pharmaceutical industry – that Pharmacy is truly an ancient art and doctors realised they needed independ- science and its development has taken ent, high-quality advice. many centuries, during which time drugs In 1941, the National War Formulary were being dispensed by doctors or phar- (NWF) was established to provide a list of macies and apothecaries with no reliable selected and trusted products to respond way of ensuring quality or dosage, making to an urgent need for strict economy in it very risky for patients. prescribing during the Second World War,

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together with a “select range of medic- to create consistent clinical guidelines. • Summaries of product characteristics aments sufficient in range to meet the NICE has now taken over the responsibil- • Consensus guidelines from NICE, the Scottish ordinary requirements of therapeutics for ity of purchasing print editions of the BNF Medicines Consortium (SMC) and the Scottish doctors in the community and in hospital.”3 for distribution to NHS health profession- Intercollegiate Guidelines Network (SIGN) als in England (one issue annually) and • Systematic reviews databases, including the Founding of the BNF its guidance is included within the BNF. Cochrane Library Following the end of the war and the • Medical and pharmaceutical research papers founding of the NHS in 1948, the British What does the BNF now provide and reviews Medical Association (BMA) and the Royal and how is it created? • Expert advisers Pharmaceutical Society (RPS) wanted to The BNF provides validated information • References sources, such as Martindale: The continue publication of a formulary for gen- on drugs and their indications, dosages, Complete Drug Reference eral use and the British National Formulary contraindications, side-effects, interac- • Statutory information, eg Home Office (BNF) arrived on the scene in 1949. tions and pricing, as well as consensus controlled drug regulations, MHRA, Drug Tariff The first BNF series was updated guidelines and evidence-based advice • Pricing information provided by NHS every three years until 1976, when the from a wide range of information sources Prescription Services rapid appearance of new drugs rendered (see Table 1).6 Figure 2 shows the journey 6 it quickly out of date. The Department of of new BNF content from source to pub- Table 1. BNF sources of information Health and Social Security (DHSS, now the lication. Hundreds of changes are made now published annually. Department of Health) negotiated with the between print editions and published The BNF is also used as the basis of British Medical Association (BMA) and the monthly online, with the most clinically national formularies in countries other Royal Pharmaceutical Society (RPS) to pro- significant changes listed separately. than the UK, where for many (includ- duce a new-look BNF, and it was agreed The Joint Formulary Committee ing in some European, African and that an updated edition would be published (JFC), which is responsible for signing Commonwealth nations) it is a well-used, every six months, which the DHSS would off the BNF’s content, oversees policy highly regarded resource. The BNF says distribute free of charge to all doctors and matters and reviews BNF amendments that, via both the BMJ and the RPS, it pharmacists. Negotiations with the BMA in the light of new evidence and expert is exploring relationships – some at a led to a promise to allow doctors freedom advice. It includes doctors appointed by national level – to make access easier in to prescribe drugs not included in the BNF, the British Medical Journal (BMJ) Group, other countries at the point of care. which continues today. pharmacists appointed by the RPS and In 2013, NICE praised the BNF’s suc- The new BNF was launched in 1981 representatives from the Medicines and cess in “addressing high-level questions and included drug monographs for all Healthcare products Regulatory Agency of drug safety, effectiveness, appropriate- licensed medicines, as well as a few that (MHRA) and the Department of Health. ness, dosage and adverse effects for all were not licensed. According to a member The BNF editorial team’s clinical writ- medications covered,” and for their clear of the Joint Formulary Committee involved ers have all worked as pharmacists, are presentation of advice and the variety of in its production, its initial reception by employees of the RPS and have a sound support tools to aid their implementa- “the media and the pharmaceutical indus- understanding of drug use in clinical tion. However, NICE expressed concerns try was hostile and unpleasant”; very practice. Each is responsible for edit- about “the lack of stakeholder involve- different to the reaction of “doctors and ing, maintaining and updating content. ment… [and] evidence of a process for pharmacists… [who] found it useful and Draft amendments are referred to a pool systematically assessing the strengths, were pleased with it.”4 However, writing in of expert advisers and clinical special- weaknesses and areas of uncertainty in 2006, one critic said that this early edition ists where their particular expertise is the evidence, or an external peer review.” did little to identify the best treatments or required. The text is then presented to In 2014, following public consul- the cost-effectiveness of choices.5 members of the JFC, who give it the final tation, NICE’s Accreditation Advisory By the early 1990s, it became obvi- approval. Depending on the content’s Committee decided that accreditation ous that local NHS managers needed impact on practice, it will then be shared could not be granted for the processes help in deciding which drugs to include with a peer review group, publicly on the used to produce the BNF and the BNFC in their local formularies, and finding BNF website, or sent to a separate set of because more work needed to be done ways to encompass both cost-effective- professionals for comment. on appraising the strength of evidence, ness and the inclusion of new treatments In 2005, the BNF team combined increasing stakeholder involvement within the limits of NHS funding. forces with Medicines for Children to and improving the peer review process. In 1999, the National Institute launch their British National Formulary However, following a reworking of the pro- for Clinical Excellence (NICE, now the for Children (BNFC), in recognition that cesses and a resubmission of the BNF’s National Institute for Health and Care babies and children were at risk from application, NICE accredited the editorial Excellence) came on the scene with its doctors prescribing drugs not licensed processes used to produce the BNF and original brief to reduce the “postcode for use in children or the use of off-label the BNFC publications from September lottery” of NHS treatments and care and medicines. A new print edition of BNFC is 2016 to September 2021. prescriber.co.uk Prescriber December 2017 ❚ 21 ■ ANALYSIS l BNF

Is the BNF still meeting dence-based guidance to best practice and acute care, revealed that 100% of prescribers’ needs? in an accessible format. health professionals working with med- One of the most important roles of the The last time the BNF commissioned icines used the BNF. Asked about their BNF is to sift through the vast quantities independent market research to check use of the BNF’s various formats, includ- of data on medicines emanating from its performance on meeting these aims ing digital devices and computers, most clinical researchers, pharmaceutical was conducted by Kantar Health in 2010. respondents (68%) said they used the companies, regulators and professional The survey, which included doctors, print publication daily, whereas only 14% bodies every day and provide evi- nurses and pharmacists in primary care used the BNF online every day. Only 61% of healthcare professionals had ever used the BNF in its digital form, despite its free availability for many years on the internet. The print and digital formats were also used in different contexts: most people preferred to use the book to aid decisions, typically about doses at the point of care, whereas the BNF in dig- ital form was most often used for review, education and continuing professional development (CPD). The BNF decided to tackle the grow- ing volume of information by facilitating digital access to the print versions of BNF and BNFC – online via desktop com- puters and laptops and via an app for mobile phones and tablets (see Figure 1) – and in November 2015, the BNF was re-structured (see Table 2). The elec- tronic BNF and BNFC are now updated online monthly, via MedicinesComplete (www.medicinescomplete.com) and the NICE Evidence Search portal (www. evidence.nhs.uk) but there are aspira- tions to make that even more frequent. BNF director Karen Baxter says the change was being partly driven by the NHS’s pursuit of a digital agenda in an attempt to go paper free, but also by the need to change the BNF’s book- based structure, which was limiting its production in any other form. However, she emphasises that this does not spell the end of the print version. She says: “Rather than holding all our content as a print product, we now hold our content on a database, from which we can produce print, app and web material, or anything else that may crop up as being desirable – basically much more modern publishing.” Ms Baxter adds: “We hope it will be a much more consistent experience and much easier for users to get the informa- tion they’re looking for.”

Reaction to the revamped BNF Ms Baxter says: “I think initially there was quite a degree of shock about the

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change and I think that’s probably inevi- of the help provided by the BNF. She table when you change something that’s says: “The BNF’s Nurse Prescribers’ very familiar and much loved. But as the Formulary, and the introduction of online editions have progressed, users say they access and an app, has been well-re- find it easier to find information and – ceived by nurses, particularly advanced probably most satisfyingly – some people practitioners. who hated it to begin with have emailed “To ensure evidence-based prescrib- us to say, with hindsight and a bit of ing, it is essential that information is familiarity, they actually now really like it.” available in all clinical settings, and dig- Readers are invited to browse by ital formats are often easier to use than alphabetically arranged drug mono- traditional paper copies. However, we graphs, drug interactions and treat- must remember that not all nurses will ment summaries or by type (eg wound have access to these systems, and some management, medical devices, and will still require a hard copy.” borderline substances) and to view the Dr Mark Temple is a general physi- Dental Practitioners’ Formulary, Nurse cian and renal consultant physician in Prescribers’ Formulary and Medicines Birmingham and a future hospital officer, Guidance. looking at future systems of care, mainly The BNF released a new and improved for acute medical patients, at the Royal app for the newly structured content in July College of Physicians (RCP). He, too, is (available for both iOS and Android plat- grateful for the BNF. He says it was the forms), which Ms Baxter says should make go-to reference in book form when he the user experience much better because qualified in 1982 and all that new doc- the data’s structure lends itself to creating tors had to guide them through prescrib- digital products whereas before it was wed- ing. He adds: “We all wore white coats in ded to the print structure. those days and in one pocket you’d have Figure 2. The journey of new BNF content. Copyright As the NHS Business Services your stethoscope and usually something © The Royal Pharmaceutical Society 2017, reproduced Authority used the chapter structure of like a tourniquet for taking blood – and under licence the print version of the BNF to develop its the other pocket was just completely own system of coding drugs, it left them taken up by the BNF… it was an essential Has he noticed any differences since in need of a new drug coding system once tool of the trade really.” the recent BNF restructuring? He replies: the BNF was restructured leading to poten- Now a renal consultant, part of his “The major difference is, it’s a lot chunk- tial problems for clinics, pharmacies and role is advising other doctors about drug ier. My sense is that it’s just a bit more hospitals. The BNF has retained a legacy interactions that might be relevant, or the difficult to pick out individual bits of chapter structure on MedicinesComplete side-effects and particular sensitivities of information rapidly because there’s less to support users of this system. There are renal patients to certain drugs, he says, highlighting, less bold print and fewer ongoing discussions about what should and on average he uses the print form of anchors to break up the sections.” happen across the service to replace this the BNF once a day – the latest edition What would he like to see in the system, says Ms Baxter. is in his office. Dr Temple adds that his future from the BNF? Both he and a col- What will happen with medicines most recent example of the BNF’s inval- league agree that a specialist publication information in the future? Ms Baxter uable help was in a query about a very specific to prescribing in renal failure replies: “I think, as you’d probably expect, rare condition (familial hypokalemic peri- could be a useful part of the BNF family. it’s a move to providing information more odic paralysis) treated by a rarely used He suggests it could give a broader per- in line with the clinician’s workflow. drug in a patient from outside the UK, Rather than having to stop what they’re diagnosed elsewhere in the UK. He says: • A drug-centric and treatment-centric structure – doing to look something up, information “I would challenge anyone to have that delivering swifter searches and one drug result will be provided at the point they need it. sort of knowledge in their head, so I went • New left-hand floating navigation panel – “It works to some extent at the straight to my BNF and looked up the con- helping you jump to any section you want on a moment with clinical decision support dition and the use of acetazolamide in monograph but I think there will be future moves its treatment. I find it probably quicker • New DOIs (digital object identifiers) – making it to make this much more refined and to navigate using the print version of the easier to reference any monograph, and helping patient-centric.” BNF than online but if you’re actually pre- to banish broken links to the content scribing online then I think it’s easy to get • Refreshed font and page layout – making the What do BNF users think? access to the online BNF and have that text clearer and easier to read Wendy Preston, head of nursing at the and the prescribing software open at the Royal College of Nursing, is appreciative same time.” Table 2. Improvements to the BNF after its 2015 revamp prescriber.co.uk Prescriber December 2017 ❚ 23 ■ ANALYSIS l BNF

spective on prescribing, including risks a new heaven, a new firmament, a new 2013;Chapter 26. and issues such as: “What medications source of energy, from which new arts 4. Wade OL. British National Formulary: its you might seek to stop or suspend tem- flow.” birth, death, and rebirth. BMJ 1993;306. porarily in acute kidney failure; or a listing 5. Head S. Freedom to prescribe v the for- of the top 20 interactions that are rele- References mulary. Pharmafile 2006. Available from: http://www.pharmafile.com/news/freedom- vant to renal failure.” 1. Science Museum. Brought to life: explor- prescribe-v-formulary Does he use the BNF to educate him- ing the history of medicine. Paracelsus (1493–1541). Available at: http://www. 6. BNF Publications. Available from: www.bnf.org self? He replies: “Yes, absolutely, very sciencemuseum.org.uk/broughttolife/peo- much so!” He adds: “I take the view that if ple/paracelsus Declaration of interests you’re in medicine, you’re always learning 2. Cottrell L. Lost worlds. Elek, 1964. None to declare and should always be open to learning.” 3. Griffin JP, et al. The textbook of pharmaceu- As Paracelsus said: “Thoughts create tical medicine. Wiley-Blackwell/BMJ Books, Joy Ogden is a freelance journalist

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