Pharmaceutical Journal Vol 263 No 7066
p570
October 9, 1999 Broad Spectrum
Clinical governance and pharmacy: is there a place for policy in our profession?
By Catherine Duggan and Soraya Dhillon
In recent years, the philosophy behind service provision in the National Health Service has changed. We have seen a move from a secondary care dominated service to a primary care focus, a move from a reactive medical service to a proactive health service, and a change in emphasis from treatment to prevention. There has been a focused shift toward the application of evidence in practice, both prescribing and service development, and a movement from individualised working to development and nurturing of joint partnership working.
Recent White Papers have described the current Labour Government's ideals behind the new style NHS aimed at improving the quality of care at all levels of health care provision. The introduction of clinical governance, which has evolved from corporate governance, is by far the most ambitious quality initiative ever implemented in the NHS. This extension of corporate governance, from financial to clinical matters, is one of the most fundamental and radical of the Government's proposals. For the first time in the NHS, monitoring and ensuring quality of care is a statutory responsibility with chief executives being held personally accountable. All health organisations have a statutory duty to seek quality improvement through clinical governance, and well-managed organisations will be judged as those in which financial control, services performance and clinical quality ae fully integrated at every level.
In pharmacy, too, we have seen a move from reactive to proactive professionals through initiatives such as the extended role and Pharmacy in a New Age. But are we really keeping up with the pace of current changes? Are we talking the same language as policy makers at the Department of Health? And, if not, how else can we as a profession be central to the evolving NHS. How does clinical governance fit into pharmacy? How are we continuously seeking to improve the quality of our services? How are we actively seeking to measure our professional performance and against what baseline data? Within the profession, we need to discuss the interplay between the evolving health service in the United Kingdom and the potential roles for pharmacy, and raise issues surrounding why pharmacy is not more inherent to these developments.
Clinical governance is expected to address how good practice can be recognised in one service and transferred to others. The Commission for Health Improvement will address both the quality of care and the issue of professional accountability, while the National Institute for Clinical Excellence aims to promote clinically effective and cost-effective care by producing research-based guidelines. National service frameworks set out the patterns and levels of service which should be provided for major care areas and disease groups, and, locally, the purchaser organisations - the newly established primary care groups - will include explicit quality standards in their service agreements with provider trusts. It is clear that these evidence-based guidelines will both contribute to a clinical decision and allow doctors clinical freedom to exercise their professional expertise and judgment. Problems with the ethics of adapting a population perspective to an individual patient will become the dilemmas facing a clinician.
Rising to the challenge
Since April 1 this year, all trusts, health authorities and primary care groups have appointed a lead to be responsible for clinical governance and every health professional is expected to take part. The development of the professions within the NHS will be the key to how it rises to the challenges of the NHS agenda - recruitment and retention, skills training, and access to information - while participating in quality strategies within existing processes of care. Where is pharmacy? Have we exploited these developments within our profession? Have we established our role in disease and medicines management within the process of clinical governance?
At the same time, health authorities have evolved in the changing primary care sector: the roles of the medical and pharmaceutical advisers are no longer focused on budget setting and implementing rational prescribing, as each PCG is now responsible for its own performance. Health authority personnel now need to be equipped with skills that enable them to link prescribing issues across the health care interface. Their roles include removing the boundaries that exist across the health care sector and facilitating the closer working of primary and secondary care - the delivery of truly seamless care. Any mistrust between primary and secondary health care professionals can no longer exist. It is the management of the patient and his or her disease that is the focus, not dumping prescribing costs across the interface. The advisers and PCG pharmacists need to provide strategic vision development of new models of pharmaceutical care. Are they ready for their new roles?
The increased focus on primary care means a greater specialism in the community: a knowledge of chronic illness and the concepts of disease and medicines management need to be promoted to other health care professionals. Pharmacists are the professionals who can deliver high quality expertise on these issues. Where are the pharmacists willing to take up the gauntlet? Are they based in hospital or community? Wherever these primary care pharmacists come from, we need to break down barriers and allow new methods of professional practice to emerge. We need to do more in targeted areas, thus ensuring the emergence of primary care pharmacy expertise. We need to adapt professionally in order to adopt these newly evolving, often more eclectic, more challenging roles. We can see that pharmacy needs to develop through the initiatives from the Royal Pharmaceutical Society but, most of all, the changing world of the NHS should provide us with the impetus to take these issues further and wider.
We need to reinforce the value of the profession of pharmacy to ourselves and to others. We should focus not just on dispensing prescriptions, but move towards the holistic role of medicines management, which is integral to the process of dispensing, not an add-on. Surely, pharmacists, as the supposed experts on drugs, should be the experts on medicines management. Doctors have to have a broad knowledge base while establishing and maintaining specialism and expertise - why cannot pharmacists? Pharmacy now faces a dilemma: we can either refocus our services and target those issues in medicines management which are pertinent to high quality provision of pharmaceutical care, or we can try to salvage the number of staff we employ at the expense of focused services. For example, should we not focus on developing high quality pharmaceutical care across the interface, ensuring that information is consistently transferred to GPs and community pharmacists, rather than routinely providing outpatient dispensing services?
We need the evidence from which to develop medicines management further, in both hospital and community practice. We should establish "beacons of good practice" and set standards by which professional practice can be measured. We need to increase our profile throughout the NHS with support from the Society, and demand that our professional development be led by the professional body. However, we should remember that professional developments should not deter the development of professionalism. We need to foster a broad-minded culture throughout the profession that is receptive to evolving roles, and to increase the value of the profession inside and outside pharmacy. Let us take up the gauntlet of developing within the evolving NHS rather than evolving without it.
Dr Duggan is teaching and research fellow and Dr Dhillon is director of taught postgraduate education at the School of Pharmacy, University of London