Clinical governance, the Crown report and the concept of pharmaceutical care mean that hospital pharmacists will be even more accountable for their actions. However, these developments also present new opportunites. How do pharmacists find the time and resources to meet the new challenges? The new responsibilities and ways in which they might be tackled - including an American perspective - were discussed at the hospital pharmacy sessions
The ward pharmacy model was outmoded and must be changed to allow pharmacists to respond to the demands of a modern NHS, said Mr Keith Farrar (chief pharmacist, Wirral hospital NHS trust).
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Keith Farrar: pharmacists must focus on service provision, not on their own convenience |
Doctors communicated with primary care when patients were discharged from hospital but pharmacists rarely did. Although he admitted there were obstacles to communication between community and hospital pharmacists, Mr Farrar said they must be overcome, as it was important that there was continuity of pharmaceutical care between hospitals and the community.
Hospital pharmacy would continue to change and should develop more of a patient focus. It should increase its partnerships with health authorities, primary care groups (PCGs), community pharmacists and commercial organisations. There would need to be changes in the skill-mix of hospital pharmacies and automation would have to be accepted, as pharmacists could not be expected to do everything.
The forces for change that were affecting pharmacy included the publication of "The new NHS — modern and dependable", which introduced the unified drugs budget and "A first class service", in which clinical governance was outlined. Both meant increased responsibility and accountability for pharmacists in the provision of quality care. Others were "Information for health", which specified that all hospitals should be prescribing electronically by 2005, and the devolution to Scotland and Wales.
Mr Farrar said that clinical governance provided a framework for quality care. Pharmacists were good at auditing the work of other professions but had done relatively little to audit their own profession. It was time to take responsibility for the clinical care that pharmacists provided. Pharmacists should look beyond money when managing medicines and begin to use existing information more effectively. Medication errors cost the NHS a lot of money and information gathered about the type of errors that occurred could allow changes to systems to be made that would prevent them happening again. Currently this information was largely unused and errors continued to occur. Non-compliance had not been investigated properly and medicines that were not taken by patients represented an enormous waste of money.
The increasing demands on the profession would be particularly hard to meet because of the current shortage of pharmacists brought about by the four year degree course and the loss of hospital pharmacists to positions in PCGs.
Mr Farrar offered possible solutions to such challenges. These included the full use of IT by all pharmacists, who should stop feeling threatened by it and start to use it to their advantage. Pharmaceutical care should become related to need, not supply. The skill mix of hospital pharmacies must be reviewed, with greater use of technicians as checkers and as clinical support (which meant that they had to be registered). Automation should become more widespread, and pharmacists should make more of existing information and be more proactive.
By 2001, he thought that pharmacists would be initiating treatment on admission and would be monitoring and amending prescriptions, as appropriate, during admission and on discharge.
He put forward a theoretical model for the future, in which patients' prescriptions were initiated by hospital pharmacists, dispensed by machines that were supervised by technicians and the medicines returned to the patient. He speculated that the entire process could take 15 minutes.
Electronic prescribing
In a further presentation, Mr Farrar reviewed the topic of electronic prescribing. The culture of reluctance, or even refusal, to use computer technology was the biggest obstacle in the way of the new NHS information technology (IT) strategy. This must change, particularly in the wake of "Information for health", he said.
The strategy mentioned two new electronic records that were in development - the electronic patient record (EPR) and the electronic health record (EHR). The EPR would be a complete record of the care given to a patient by a particular hospital, whereas the EHR would contain the entire health record of a patient. "Information for health" specified that all hospitals must have level 3 EPRs by 2005.
In order for electronic hospital systems to succeed, computers had to have a rapid response time. "A week may be a long time in politics but a second is a long time in computing", Mr Farrar said. There must be local flexibility and changes should be made rapidly, otherwise people tended to lose interest in the process. It was also essential to have local support staff for computer systems, rather than remote support staff who did not understand the local situation. He added that it was helpful if the computer support staff were also health professionals employed in the hospital, as it was easier for them to understand computing than it was for computer experts to understand medicine and health care.
The implementation of electronic prescribing systems had to be a hospital initiative, as it would not succeed if it was seen as a departmental project. There had to be strong champions for the electronic cause in order to bring all departments on board. When looking for suitable systems, it was important to see them operating in another hospital, a demonstration version was not adequate.
To win acceptance from staff, the first part of a system to become available should provide convenient, rapid access to useful services, such as laboratory results and the ordering of x-rays and ECGs. Prescribing should be activated later as this part of the system was harder to learn and staff were less willing to use it. When such a system has been put in place at the Wirral hospital NHS trust, the number of complete and correct dosages charted increased from 17.7 per cent to 100 per cent
Problems that arose from the implementation of an electronic hospital and prescribing system included the fact that the computer system generated a great deal of paper. Also, while lap-top computers were ideal some staff preferred static terminals; The issue of security was a high priority for staff and patients alike. He said that a nurse had once used a doctors password to prescribe illegally but had been arrested the next day because the information provided by the system showed that it had could not have been the doctor who had used the terminal. Locums presented another problem, as they were unable to use the system because they were at the hospital for only a short time and were not included on the system. Stat doses could be confusing, as doctors often wrote up stat doses but did not record whether they were given.
Despite these problems, computerised systems could improve the quality of prescribing, made it easier to monitor prescribing, minimised omission of doses by nurses , allowed use of formulary drugs only, minimised risk and provided good clinical audit (and eventually clinical governance) data. They were a useful tool for the pharmacy service and increased the need for pharmacists as they uncovered medication-related problems that had previously gone unnoticed.
The purpose of the "Information for health" strategy was to put in place, over the next seven years, the people, resources, culture and processes necessary to ensure that NHS clinicians and managers had the information they needed to support the core purposes of the NHS. According to Dr Peter Drury (head of information policy, NHS Executive), the better use of information and information technology (IT) would support fast, convenient and dependable services to patients and health professionals. It was important that the uptake of this technology took place in a co-ordinated fashion. The main focus of the strategy was to put patients and their needs first.
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Peter Drury: information technology would allow better patient care in the NHS |
It was hoped that all hospitals would have level 3 EPRs in place by 2005. Level 3 implied that the following would be electronic - order entry, result reporting, prescribing and integrated care pathways. However, the really big step would come when trying to implement further levels, Dr Drury said.
By 2005, primary care would be expected to have achieved full implementation of EHRs.
Local implementation of the strategy would allow integration of information to support treatment and care, analysis and the provision of seamless care. It would result in a single, cohesive, community-wide system, which would link up to provide a functioning national framework.
The implementation had three phases - from 2000 to 2002, a pilot scheme was currently testing the feasibility of electronic prescribing in the community by general practitioners. The main problems that had to be dealt with were maintaining the security of information, a lack of record structures and a lack of clinical information standards.
The guidance that provided the blueprint for this local action, over the period 2000 to 2005, was HSC 1999/200. This looked at the NICE, Prodigy, national service frameworks and clinical governance, which were hugely important to the collection of data. It contained an annexe that discussed prescribing issues and linking patient-specific disease areas with prescribing data. Collaborative working would be vital for the successful implementation of the strategy.
Dr Drury said that information on the policy could be found on two websites - www.doh.gov.uk/nhsexipu/index.htm and www.nhsia.nhs.uk.
The need for "pre-digested", unbiased drug information could be met by use of a website, Mrs Margaret Hewetson (director, South Thames drug information centre) suggested.
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Margaret Hewetson: the website could help health professionals keep up to date |
Shapour Hariri: training needed to change current NHS culture |
Automated pharmacy systems reduced costs and allowed hospital pharmacists to concentrate on pharmaceutical care, provided the systems were introduced in an organised fashion. This was the main message of Ms Pat Lee (practitioner in residence, American Society of Healthcare Pharmacists).
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Pat Lee: an American perspective on electronic prescribing and dispensing systems |
It was decided that the system should provide an electronic medical record for patients that would be shared by all of the health professions involved in a patient's care. Part of this would be electronic prescribing, an automated pharmacy system, documentation, and a pharmacy procurement system running in parallel. The doctors and pharmacists on the multidisciplinary team collaborated to develop templates for electronic prescribing for almost all disease states. It was agreed that any drug orders not covered by these templates would be dealt with by the pharmacists, who would be available on the wards for consultation.
The automated pharmacy system was located on every ward. It contained 97 per cent of all the drugs that would be needed on that ward, dispensed into individual dosage boxes for each patient. The boxes were bar-coded and the system contained all the information on each patient - a full medication profile, information on medicine use and stock control. It was linked to the clinical support system and the documentation system. The documentation system was designed to provide such information as the prescribed dose, time of dosing, missed doses, site of any injection to be given, the name of the nurse that was giving medication, together with that of a witness.
The supply chain was automated and controlled stock automatically, adjusting it as necessary and thereby controlling costs. The drug procurement system placed orders for new stock directly with the distributor.
When the system was put in place, the results were assessed. It transpired that following the implementation of the system, pharmacists moved away from their supply role and were providing more pharmaceutical care to both inpatients and outpatients. They had developed a major role as teachers of both doctors and patients. Drug expenditure was reduced, as was the time taken by nurses to complete a drug round. Technicians had taken over the distribution role of pharmacists and documentation had improved - 97 per cent of drugs were being correctly written up instead of 63 per cent. Statistical reports on drug usage could be provided and there was greater accountability, security and control of drugs.
The aim was to continue to monitor and control the system, Ms Lee said. In particular, the treatment templates were to be monitored to see whether desired outcomes were being achieved.
In summary, Ms Lee said that the key to successful implementation was achievement of the following - clear, consistent direction of the project, a high level of support throughout the hospital, organisation and planning, thoughtful analysis and participation by all parties affected. In addition, it was vital to be clear about the outcomes that were to be achieved before bringing in technology.
Draft standards for effective medicines management had been proposed by the College of Pharmacy Practice. They would have far-reaching consequences for hospitals, if they were adopted, said Dr David Cousins (director of pharmacy, Southern Derbyshire acute hospitals trust).
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David Cousins: nine quality standards proposed by College of Pharmacy Practice |
It was proposed that for successful implementation of such standards, the entire hospital would have to agree to be accredited. It would need to prepare for accreditation, submit evidence supporting its application, undergo a two or three day inspection visit and receive an accreditation report. This would indicate either that the hospital had been successful or the areas of improvement required before resubmission would be possible. This process would require a new infrastructure of personnel, who would perform a quality assurance role similar to that seen in manufacturing departments but for the entire medicines management process. They would have to inspect practices within the pharmacy service on a regular basis and use a systematic approach.
The proposed standards
Draft standards had been proposed by the college and could become the "orange book" for medicines use. There were nine standards - first, the trust board would have a written medicines strategy that made clear their commitment to safe, effective and economical use of drugs. Secondly, the chief pharmacist would be designated as the person in the hospital responsible for medicines management within the trust.
There would be explicit, written, quality standards for all stages in the prescribing process, which would be used regularly to audit the quality of prescribing. These would include standards for use of patient's own medicines, discharge medication and the appropriateness of prescribing for patients (including adherence to recognised guidelines). Other standards would relate to the adjustment of medicine to patient parameters and use of unlicensed medication. Preparation of parenteral formulations in both ward and pharmacy areas, including the environment that they were made up in, would be covered, as would record keeping, training and competence measures for the pharmacy service as a whole. The administration of medicines (from dispensing to ingestion by the patient), discharge medication, counselling and reporting medication errors would also have standards that must be met. The draft standards were to be piloted in four hospitals in 1999 and, after amendment, would be issued in their final form next year.
Dr Cousins suggested that it might be more appropriate, in some cases, for pharmacists to participate in nurses drug rounds rather than doctors ward rounds, although he acknowledged that this was "less sexy".
In future, it was possible that inspectors would pay impromptu visits to ensure that standards were maintained at all times.
With appropriate training, pharmacists might soon be able to prescribe medicines that were currently prescription only, said Mrs Helen Remington (chief pharmacist, Addenbrooke's hospital, Cambridge)
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Helen Remington: pharmacists may be given prescribing rights after appropriate training |
The review began in April, 1997 and published its final report in March, 1999. A second phase of consultation on the recommendations of this report began on June 7, the outcome of which was not yet known. The responses to the consultation were to be sent to Frank Dobson and the government would then take steps to implement the agreed recommendations.
Patient safety was paramount when considering who should prescribe. It was essential that all staff were fully qualified, were registered and had undertaken post-qualification training. In addition, new prescribers should only work within their level of competence. A general practitioner or consultant would retain the lead role in a patient's treatment and would be kept fully informed about that particular patient. Full, integrated, confidential patient records should be kept, and prescribing and dispensing should remain separate.
Two basic prescribing models had been formulated - dependent prescribing and independent prescribing.
Independent prescribers would take responsibility for clinical assessment of patients and for the appropriateness of any prescription issued. The current systems for prescribing by doctors and dentists, as well as over-the-counter prescribing by pharmacists, were existing models of independent prescribing.
Dependent prescribers were a new concept for the UK. They would adopt responsibility for continuing care and for the appropriateness of any prescription issued but they would not be responsible for the initial diagnosis. This would be determined by another clinician. Dependent prescribing would include repeat prescribing and the dependent prescriber could modify or stop therapy in the light of monitoring and review.
New prescribers would not normally have access to certain medicines but it was recognised that pharmacists would need access to a broader range, especially for repeat prescribing work. A new Prescriber Advisory Committee had been proposed, which would be independent and multidisciplinary. It would receive proposals from potential new prescribers, which would have to have the support of the relevant profession's statutory body.
The Royal Pharmaceutical Society of Great Britain and the Government had had additional, parallel meetings to discuss further extensions to the role of the pharmacist and to prescribing in primary care. The proposal was that, after appropriate training, pharmacists should have limited prescribing rights to an agreed list of medicines available on the NHS. The Government was keen that this list included a number of medicines that were currently prescription-only (ie, dependent prescribing).
Prescibing in a rheumatology clinic
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Miss Sarah Jones (lead pharmacist, rheumatology clinic, University Hospital of Wales, Cardiff), continued the presentation with a practical example of pharmacist prescribing, following the dependent model.
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Sarah Jones: currently prescribing in a rheumatology clinic |
A wide range of disease-modifying antirheumatic drugs were used at the clinic, some of which could only be prescribed by the consultant. However, the dosages of gold injections, penicillamine and sulphasalazine could be adjusted by the pharmacist, without referral to the consultant. After about three months, the patient was referred, by the pharmacist, to their general practitioner. Any interventions were documented and evaluation and feedback on the service from the consultant took place informally at monthly directorate meetings. A more formal assessment took the form of a patient questionnaire, which asked about level of satisfaction with the service provided at the clinic. Ninety per cent of patients replied that they were satisfied.
The clinic was challenging but professionally rewarding, and it had, undoubtedly, raised the profile of pharmacy within the hospital. The next challenge was to improve communication with primary care, Miss Jones concluded.
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Using information gathered on medication errors allowed systems to be amended and further mistakes avoided. However, reporting had to be a blame-free process, said Mr Don Hughes (principal pharmacist, Wirral hospital NHS trust).
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Don Hughes: information on medication errors must be used to prevent them recurring |
In the UK, few formal studies on the frequency and consequences of medication errors had been performed that looked at the overall medicines delivery process and there were only anecdotal reports of major errors. Mr Hughes speculated that this was because the emphasis of medicines management had been on value for money and evidence-based medicine.
Reporting of medication errors was low because NHS staff feared litigation and admission of liability, because resources for surveillance were lacking, reporting processes were cumbersome and there was ambiguity in the interpretation of medication errors. Once reported, there was little or no feedback to those reporting the mistakes. Mr Hughes felt that medication errors should be investigated openly and the lessons learned applied because the data that had already been collected was largely ignored and lost.
The attitude to medication errors must change, with emphasis placed on systems that might fail and the assumption that human error would occur. In addition, monitoring intervention data provided opportunities for monitoring clinical activity, peer review education. This allowed systems to be designed that would eliminate, or at least decrease, the effects of errors.
It was important to remove blame from individuals and place it on the dangers inherent in the system. Examples of procedures that might be targeted included dosage calculations and telephone/oral orders. Common errors included oral administration of drugs to patients with central lines and incorrect choice of drug from stock shelves.
Drugs that could be targeted might include warfarin, aminophylline, glucose 50 per cent, chemotherapeutic agents, heparin, insulin, neuromuscular blockers and intravenous potassium chloride. Most of the drugs listed above were stock on many wards, he said. By taking them off the stock list, the risk of error was removed (or at least reduced). Some hospitals had even taken the step of treating intravenous potassium chloride as a Controlled Drug in order to reduce errors.
At the Wirral hospital NHS trust, a no-blame medication error reporting scheme had been introduced on the neonatal ward, in which staff were encouraged to report actual or potential mistakes. All reports were anonymous and a multidisciplinary quality assurance group had been set up to review reports, identify system inadequacies and find ways of improving processes. The group was made up of two senior pharmacists, a consultant paediatrician, a junior doctor, ward manager and neonatal nurses. The scheme resulted in a five-fold increase in the number of medication error reports, and adjustment of stock or procedures took place accordingly. Mrs Jeanette Howe (acting chief pharmacist, Department of Health) commented that medication error was a topic of interest to the Department of Health that was currently under consideration.
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The joint community, industrial and hospital pharmacy session was held in the auditorium at the International Arena |