The drive to improve quality is a key element of the Government's agenda for the National Health Service. The principles of clinical governance mean that all health professionals working in primary care need to address the quality of services they provide to patients.
Clinical governance has been defined as "a framework through which NHS organisations are accountable for continuously improving the quality of services and safeguarding high standards of care, by creating an environment in which excellence in clinical care will flourish". Health authorities, NHS trusts and primary care groups and trusts all now have a statutory responsibility to deliver clinical governance.
Clinical governance has been part of the NHS vocabulary for about two years. However, there is still only limited evidence that the pharmacy profession has grasped this important opportunity to demonstrate and promote, to a wider health care audience, our potentially large contribution to delivering the quality agenda, especially through effective pharmaceutical care.
A survey of a sample of primary care groups undertaken by the National Primary Care Research and Development Centre (NPCRDC) and the King's Fund towards the end of 1999, clearly shows that managing prescribing is currently at the top of the clinical governance agenda and is likely to stay there.
Although the survey highlights considerable variation in the way that PCG advisers and community pharmacists are being used to provide prescribing support, overall, 87 per cent of PCGs are now employing or remunerating pharmacists to provide prescribing advice. Of these PCGs, 68 per cent are directly employing pharmacists to provide prescribing advice, while 38 per cent are funding community pharmacists to provide input on a sessional basis. These findings are reinforced by information contained in the comprehensive rolling database of prescribing advisers, maintained by the National Prescribing Centre (NPC).
The apparent inertia in developing pharmacists' roles within multidisciplinary clinical governance and pharmaceutical care might stem from a number of misconceptions or feelings.
First, as there is so much change occurring, with so many competing priorities for professionals, multidisciplinary clinical governance is not considered to be of highest relevance to pharmacists. Second, clinical governance is primarily targeted at, and therefore the concern of, the medical profession. Third, the pharmaceutical profession should get involved in the clinical governance and other agendas only if the Government provides full central funding, in advance, for pharmacists to develop and undertake such activities. Finally, if we ignore it long enough, it may just go away.
Allowing ourselves to be swayed, and therefore delayed, by such misconceptions or feelings means the opportunities may be lost. It is clear that, with the development of PCGs and primary care trusts, important strategic decisions, including issues on quality, service delivery and funding, are increasingly going to be made at a local level, and soon.
Clinical governance can either be predominantly driven by a top down (management/organisational) approach or by a mixture of a top down and a bottom up (professionals on the ground) approach.
With the management approach alone, there is a danger that the agenda will be primarily to make sure that uniform, minimum standards are met, procedures and checks are in place, and that budgets are adhered to. Adding in the bottom up, professional approach should also encourage the development of both individuals and the teams within which they work, plus a broad improvement in the quality and nature of health care that patients receive.
The culture within which clinical governance is delivered will also be a major influence on its success, or failure. It will thrive in an organisation, and indeed a profession, which is proactive, open and participative, where ideas and good practice are shared.
Another barrier to delivering the clinical governance agenda is the perception of some health care professionals that it is too big and time-consuming. Although this new terminology may seem a little unfamiliar, the fact is that the pharmacy profession is already well-versed in, and regularly delivering, many of the key components of clinical governance.
Pharmacists have, for many years, quite rightly referred to themselves as "the experts on medicines", yet this expertise is only rarely referred to outside of the profession and is certainly not used to its full potential.
The President of our Society has recently expressed, in her vision for the millennium, that "when medicine is discussed, there is an immediate association with the pharmacy profession" (PJ, January 1, p13). Harding1 has previously argued that "the failure of pharmacists to capitalise on their unique drug knowledge may threaten their professional status". This threat to the profession remains and, clearly, we are some way yet from achieving the President's vision.
Schools of pharmacy and other providers of education, training and professional development, spend much of their time ensuring that the pharmacists of today truly are medicines experts. The breadth and unique blend of pharmacists' pharmaceutical knowledge and skills mean that they understand medicines from scientific, clinical, managerial, social and behavioural perspectives. Who better, then, to develop and implement pharmaceutical care, medicines management and the related clinical governance agenda?
Quality assurance of prescribing and safe and effective systems of supply and administration to patients are at the heart of pharmaceutical care. Its main objectives are to improve the quality and cost-effectiveness of medicine usage and thereby improve the overall clinical care of, and its convenience to, patients.
Recent "Broad Spectrum" articles have also highlighted the potential that clinical governance holds for the profession. These, too, argued that the current health reforms offered a golden opportunity for pharmacists to take a lead in medicines management.
As with any new task or situation in life, often the hardest part is getting started. To help this process, the NPCRDC and NPC have collaborated to produce a handbook* specifically for pharmacists entitled "Improving quality in primary care: supporting pharmacists in primary care groups and trusts". The effort invested in this collaboration represents a clear statement by these two centrally funded, national organisations of their belief that pharmacists are key to the delivery of clinical governance and medicines management. Both the NPCRDC and the NPC have an ongoing remit to monitor and support the development of prescribing support provided to health authorities, PCGs, PCTs and GP practices. The handbook contains information and ideas about a range of prescribing issues and can be used as a starting point for individual pharmacists to get involved in multidisciplinary clinical governance. It also provides ideas around expanding existing practice and sets out some of the ways that quality in medicines use may be assessed, and some of the ways in which it should not be measured.
Our aim is to provide a framework through which all pharmacists, wanting to become more involved in the quality agenda around medicines management, can start "singing from the same hymn sheet".
*Copies are available, free of charge to pharmacists working within the NHS, by contacting the NPCRDC: e-mail communit@fs1.cpcr.man.ac.uk or telephone 0161 275 7126.
Ms Cantrill is from the school of pharmacy and the National Primary Care Research and Development Centre at Manchester university. Dr Devlin is from the NPCRDC. Mr Jackson and Dr Queenborough are from the National Prescribing Centre
| 1. Harding G, Taylor K. Responding to change: the case for community pharmacy in Great Britain. Sociol Health Illness 1997;19:60. |