The Guild of Healthcare Pharmacists welcomes the opportunity to make a submission to the NHS Plan for Scotland, and looks forward to being closely involved in its implementation. We would hope that the Plan would acknowledge the part that the pharmaceutical profession can play in improving and developing the NHS in Scotland, thus patient care, and that it would be followed by a resolve to ensure the service is able to contribute fully.
In addition to the central role of responsibility for pharmaceutical services such as purchasing, dispensing and clinical services, hospital pharmacy operates within a number of other areas. These include -
In recent years, though, it has become increasingly difficult to fulfil these roles due to shortages of staff and problems in recruiting and retaining pharmacists at all grades in the hospital service. The expansion of primary care pharmacy, where the skills of hospital trained pharmacists are highly valued, is one cause of retention problems. Higher salaries and increasingly lucrative packages in community pharmacy have meant that many newly qualified pharmacists choose to pay off their student loans earlier by working in the community. Once there, the perception is that pharmacists can never return to practice in hospitals. This means the potential to contribute as fully as possible in these areas cannot be realised.
- Aseptic services
- Multidisciplinary care teams e.g. oncology, nutrition, critical care etc.
- Strategic groups at Trust and Health Board levels e.g. Drug and Therapeutic Committees, Infection Control Committees and Quality Assurance Groups
- Medicines information teams whose remit is now extending outwith the hospitals e.g. supporting NHS Direct.
- Research teams
The NHS Plan for England refers to a new Market Forces Supplement to enhance the salary of staff in geographical areas where there are labour shortages. We would support this development, but would suggest that, if incorporated into the Scottish Plan, it could also be applied to disciplines in which there are shortages.
Although we realise that the NHS Plan for Scotland will be quite different from the Plan recently published for England, we understand that a lot of the main themes will be similar. It is understandable, therefore, that some of the comments in this document echo parts of the English Plan, and we hope that these areas are included in the Scottish Plan.
We note in the NHS Plan for England that "Our vision is of an NHS where staff are not rushed off their feet and constantly exhausted; where careers are developed, not stagnant; where staff are paid properly for good performance; and where childcare is provided in every hospital." and hope that the NHSiS shares this vision.
We would also hope that the aim of modern IT in every hospital and surgery is mirrored in Scotland, but would wish that it be extended to include every pharmacy. Such inclusion would help ensure that all parts of the NHS could properly contribute to improving healthcare.
Lifelong Learning / Education / CPD
There are significant pharmacy staff training requirements if the suggestions made in this document are to be progressed. There are major shortages of both pharmacists and pharmacy technicians at all grades, and an increase in training posts throughout the service is essential. Many of the areas in which pharmacists could make major contributions have already been tried and tested around the United Kingdom, so the evidence is available, and would not require new projects or reinvention of the wheel. Currently, these systems are not in routine practice, and so extensive training would need to be provided and funded.
There is a requirement in the English Plan for NHS employers "to empower appropriately qualified nurses, midwives and therapists to undertake a wider range of clinical tasks .", and we would maintain that pharmacists should be included in such statements. Further training may be necessary to achieve the appropriate qualifications, but experienced pharmacists, building upon accumulated knowledge, have the abilities to embrace many new roles in a developing NHS.
In order that pharmacists are able to take on the proposed new duties, it is vital that pharmacy technicians and Assistant Technical Officers (ATOs) expand their roles into new areas. Teaching programmes for these grades need to be developed, as provision of such teaching is patchy at best, and non-existent in many areas, although efforts to correct this are being made by the Association of Scottish Trust Chief Pharmacists (ASTCP). One problem which must be tackled is the lack of proper career structures for technicians and ATOs. The 'glass ceiling' for these grades is considerably lower than for other professions. Increased responsibility must be matched by an increased grade and remuneration.
Pharmacists are well established educators of patients and professionals on issues related to medicines and should be more involved in medical/nursing teaching at all stages i.e. from undergraduate to postgraduate. It has been shown that if the different professions start working together at undergraduate level, there is a reduction in professional jealousies and rivalries and it leads to better understanding of each others role in the care of the patient. Increased involvement should improve healthcare in the long term and reduce risk management problems.
Performance / Accountability Framework
The majority of pharmacists agree that there needs to be a framework to assess competence and fitness to practice. Records of CPD can contribute to this, which is why portfolios are becoming more widely used. In general, assessment should be carried out by ones peers. However, it can be extremely difficult to accurately assess the competence of specialists. As pharmacy becomes more specialised, the number of individuals with the knowledge and expertise to competently assess a specialist is reduced.
It has been demonstrated in the past that, whereas many aspects of hospital pharmacy can be measured against statutory or regulatory standards, there is no clear and nationally acceptable definition of competence or practice for clinical pharmacy. This makes it very difficult, if not impossible, to achieve professional self-regulation for clinical pharmacy. This can easily be demonstrated by inspection of the clinical service in any acute trust. The gradings attached to clinical posts range from B to F. It is extremely unlikely that all of the post holders will be providing expertise, services and care to the same level.
The career progression within the medical profession is obvious, and dependent upon academic qualifications, duration of training and recognised training places accredited by the Royal Colleges. Accreditation can be removed if the training places fail to meet the necessary criteria. Clinical pharmacy has none of these, and no equivalent accrediting body to the Royal Colleges. Career progression is based on definitions, agreed in 1989 by the Pharmaceutical Whitley Council, which mainly reflect budgetary and managerial control and responsibilities, with some vague references to `specialist' duties. It can be extremely difficult to fit clinical pharmacists into these definitions and frequently the `glass ceiling' is reached fairly early in a pharmacist's career. The only options then available are progression into management or into primary care.
Equity of access should mean that all patients, irrespective of the speciality into which they are admitted, receive the same level of pharmaceutical care, although some may need more input than others. This is impossible to achieve with current levels of staff. Comparing pharmacy with medicine, there is no equivalent of the consultant/junior doctor relationship. Junior pharmacists will be trained by a senior colleague, but will then rarely have regular discussions with senior colleagues about their patients. There are no clearly described levels of accountability, exposing patients to unacceptable risks and junior pharmacists to unacceptable pressure. The debate on grading structures being changed to properly reflect accountability for patient care has already opened, as has that on the competencies required for each grade. What must also be made clear for each grade are the professional responsibilities commensurate with it.
Strengthening and integrating different sectors
Pharmacy, both hospital and community, is currently an under-utilised resource. Proper investment could result in greatly improved patient care and be cost neutral. Investment in additional staff has been shown many times to be repaid by savings to the service, whether through reduced drug costs, earlier discharge or avoided litigation. Increasingly, pharmacists are working with general practices in roles ranging from the review of individual patients' medication to supporting the formulation and implementation of prescribing policies.
Specialist pharmacists should be employed as part of multidisciplinary teams, working in both secondary and primary care for the common good of patients with chronic diseases. Perhaps employed by the Health Board, the team would be seen as neither secondary nor primary care based, but their remit would encompass both.
Similarly, appropriate staff should be employed to co-ordinate the supply of drug delivery equipment such as syringe pumps and nebulisers across Health Boards, Trusts and LHCCs to ensure access is equitable.
Globally, there needs to be greater investment in clinical pharmacy services, which are very patchy in some areas, especially hospices, mental health, community and learning disabilities. There is a need to improve the quality and actual staff complement in these areas, which have traditionally been under resourced through either bad management or failure to invest. Clinical pharmacy has developed primarily within the hospital service and it is only in recent years that significant developments have taken place within primary care.
Domiciliary pharmacy services are another area where significant expansion would be of benefit to the patient, but where more investment is required. Visits to elderly or other patients deemed 'at-risk' to review medication or advise the patient could significantly reduce the number of hospital admissions connected with adverse drug events or drug wastage due to the patient using medicines improperly.
Investment in the above areas would lead to improved patient care, optimisation of medication use and, ultimately, savings to the NHS and patients.
Proper funding of the palliative care facilities traditionally provided by charities is essential if these are to be considered core services instead of the 'added-bonus' status they presently hold.
Proper communication and involvement in patient care between secondary care, Primary Care Trusts, LHCCs and community pharmacists is vital if the patient is to receive the best possible care. Such involvement is significantly lacking in some areas, but easily achieved through investment in IT.
We recognise that there is tremendous pressure in the English Plan on changing roles and more flexible services and working patterns. What is not clear is how these can be matched up with family-friendly policies. If the Scottish Plan is similarly focussed, it would be very helpful to have this omission addressed. We realise it is not possible to give detailed proposals on how it would be achieved, but some indication of current thinking would be acceptable.
It is fairly well accepted that reviews of both skill mix within individual departments, and the roles of individuals within the uni/multi-professional setting are required to move hospital pharmacy forward, and many departments have done so, prompted by recruitment difficulties.
Improvements in support services e.g. technical and IT are required to free time for secondary care pharmacists to carry out a more appropriate medicines management role, but also to allow them study time to keep up to date. Advances in medicine are being made more rapidly than ever before, and it is vital that pharmacists are able to keep abreast of new developments such as gene therapy.
Proper medicines management would benefit the patient clinically, the Trust financially, and considerably reduce litigation risks. The Chief Pharmacist must be responsible not purely for the pharmaceutical service within the Trust, but for all aspects of medicines management throughout the organisation, encompassing purchase, preparation and supply of medicines as well as advice on the medicines on the patient's admission, stay in hospital and discharge.
Probably one of the biggest improvements to the patients stay in hospital would be the implementation of fully decision-supported electronic prescribing throughout Scotland, spanning primary, secondary and tertiary care. Automation of the medicines prescribing process in this way would provide a major backup for the clinical process, ensuring that prescribing decisions are based upon best clinical practice, rational and cost effective and that transcription errors, made when prescriptions are rewritten, are all but eliminated. Although we realise this is not a panacea, it would certainly improve on the current situation.
Linking together all the disparate electronic systems throughout the NHSiS would reduce duplication of effort and make it easier for community pharmacists and G.P.s to have accurate information. It is not uncommon for a G.P. to supply a list of prescribed medication on patient admission which differs, sometimes markedly, from that provided from the community pharmacists' medication records and from what the patient is actually taking. Where the patient uses only one community pharmacist on a regular basis, the medication record can be augmented with knowledge of medicines purchased 'over the counter' to give the most accurate picture of current medication. However, the lack of a network linking community pharmacists with G.P.s, or primary, secondary and tertiary care centres, means that this information is one aspect of an under-utilised resource which, if it were harnessed properly, could significantly streamline hospital admissions.
A central, electronic patient record, accessible to all health professionals who are involved with the care of the patient would be a major advance. Full information would be available for the first time, with all hospital and G.P. case notes and pharmacy patient medication records incorporated. Errors due to poor handwriting would disappear and duplication would be minimised. The inclusion of pharmacy contributions in case notes, practised in some areas, should be extended throughout the NHSiS and form part of the electronic patient record.
The use of patients own medication during hospital stay has been found to reduce medicines wastage, save money, be one way to reduce delays in discharge from hospital, and can be coupled with individual patient medication on the wards to improve the process further. Proper involvement of the pharmacist in the discharge process has been shown to reduce the time taken between the decision to discharge the patient and the patient leaving the ward. A common cause of patient complaints is the time taken by the pharmacy to provide discharge medication. However, the number of complaints is misleading, since pharmacy is constantly being unfairly used as a scapegoat for problems which occur on the ward with the discharge.
Pharmacists should take responsibility for optimising drug therapy for individual patients by means of therapy choice, patient education, concordance and ensuring that the information is automatically available to the patient's G.P. and community pharmacist; especially where specialist advice is required. The Crown Review support for independent and dependant prescribing by pharmacists will be an important future step in achieving this goal. Access to a central electronic patient record will ensure that prescribing can be carried out safely, with the pharmacist in full possession of any relevant data. The pharmacist should be much more involved in adverse drug reaction monitoring and protocol development. Proper technical support and appropriate investment in storage boxes for patients own drugs would allow self-medication schemes to be introduced more widely. Again this would facilitate prompt discharge.
Currently in secondary care, pharmacy is usually cited as the problem if the medicines budget is overspent. In reality, their control over the budget is extremely limited, as doctors can prescribe what they want. Formularies restrict this freedom to some extent, but if a doctor decides that they wish the patient to have a particular therapy, even if it is not deemed to be best practice, they will usually get it. Enshrined in a pharmacist's Code of Ethics is the duty that they can refuse to supply medicines if they consider it is not in the patient's best interest. If proper responsibility for the drug budget was given to the Trust Chief Pharmacist, there would be more accountability. The Trust Chief Pharmacist could insist that requests for particular medicines, not part of agreed protocols or policies, be approved by Trust management before supply is made. There could also be proper managed introduction of new products or therapies. This would ensure that best practice was enforced, improve clinical governance and reduce wastage of resources. Alternatively, proper directorate pharmacist support, with the full authority of the Drug and Therapeutics Committee, could be employed to achieve the same result. However, it is important that the directorate pharmacists are given proper authority to match the responsibility, otherwise the situation will not change.
It is noted that the NHS Plan for England mentions 24 hour, 7 days a week working. While recognising the need for such a service, we consider it is not feasible with the number of staff currently employed or even with the number of graduates. Although IT might appear to help matters, this problem needs to be addressed by central government if such working is to be implemented.
Changing the remuneration system for community pharmacists would allow them to expand their roles in the areas of minor injuries and minor illnesses. Current remuneration is based on the number of items dispensed, and therefore there is a compromise between maximising this income and trying to provide a clinical service for patients and customers. We would expect that they will be asked in future to take on different services and the current payment systems will not encourage or support this. Payment for provision of a particular service may be the way forward. They should be used, and seen to be used fully, as a health care professional and not overlooked, as so often before, as a shopkeeper, only involved in the supply of medicines. There is a scarcity of pharmacists within the NHS, and therefore a need to ensure that their skills are used appropriately. Community pharmacists' skills are rarely being as fully utilised as they might be.
Leadership / Organisational Development
Leadership development is vital for hospital pharmacy. There are many skills required by a Trust Chief Pharmacist which are similar to other management posts at that level. However, there are some skills specific to hospital pharmacy.
Succession planning needs to be addressed. The degree of succession planning for Trust Chief Pharmacists is debatable, but there is little or none for specialist services such as procurement, aseptic services and quality assurance.
There have also been considerable problems caused by the inability of clinical pharmacy staff to progress without moving into management. The introduction of a consultant grade for experienced pharmacists is one solution which has been proposed for such clinical leaders.
Resources are limited, and therefore it is important that wastage is minimised. The recycling of medicines issued to wards and then returned to pharmacy is always one of the first casualties when staffing is tight and patient services must be maintained. Such medicines can account for considerable sums of money, but are not able to be utilised due to insufficient staff time to check and return them to stock.
One move which would improve staff morale considerably would be the decision to write off the major financial deficits affecting most secondary care Trusts. New money for new projects is all very well, but when staff and services have been cut back because of underfunding, morale inevitably suffers. As has been accepted on many occasions, the greatest asset of the NHSiS is its staff. We have seen many dedicated staff losing faith over the past few years and leaving the service because they cannot see a better future. Getting hospital Trusts back on their financial feet would remove a great deal of stress from the system and allow staff to consider better ways of providing the service, rather than continuous fire-fighting.
Finally, one misconception that is a major cause of poor staff morale amongst other groups, is the general public's view that the NHS is entirely run by doctors and nurses. Steps must be taken to rectify this notion and ensure that the true value of the myriad of non-medical / nursing essential staff is properly recognised publicly.
Secretary for Scotland
Guild of Healthcare Pharmacists