Guild of Healthcare Pharmacists
Submission to the
National Pharmaceutical Forum

This submission was formulated in discussions with Council of the Guild of Healthcare Pharmacists and from comments received from members of the organisation working in Scotland.



Introduction

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 -

  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/NHS24.
  Research teams

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.

back to top

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 reference in 'Our National Health' to the intention of the Scottish Executive Health Department to "support arrangements to allow pharmacists to prescribe a broader range of medicines, conduct medication reviews and monitor certain treatments.". This is presented in the context of community pharmacy and we would maintain that hospital pharmacists should be similarly empowered. 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.

back to top

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. We would expect that NHS Scotland would provide the same, if not better, support as that specified for England in 'Pharmacy in the Future'.

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. It is to be hoped that this can be addressed in the Scottish Pharmacy Strategy.

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.

back to top

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. The vision of electronic prescribing and transfer of prescription data in 'Pharmacy in the Future' is somewhat limited to reproducing a paper system electronically. We would suggest that the scope should be expanded to give proper links from secondary care to G.P.s and community pharmacists records and similar access to secondary care records for G.P.s and community pharmacists. This should prevent medication errors on admission to, and discharge from, secondary care.

back to top

Changing roles

We recognise that there is tremendous pressure for changing roles and more flexible services and working patterns. What is not clear is how these can be matched up with the new Staff Governance Standard and best practice guidance on family-friendly policies. Some indication of current thinking would be useful.

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. This is recognised within 'Pharmacy in the Future' and should also be part of the Scottish Pharmacy plan.

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. 'Our National Health' mentions an integrated patient record in G.P. practices and health centres and electronic transmission of prescriptions between G.P.s and pharmacists. Again, we would maintain that his should also encompass secondary care. However, we would hope that access to the electronic patient record would differ from that announced by Mr. Alan Milburn in February, where pharmacists were not included in the 'clinical staff' within the NHS.

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.

back to top

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.

back to top

Other points

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.

 

Colin Rodden
Secretary for Scotland
Guild of Healthcare Pharmacists

back to top