The Pharmaceutical Journal Vol 264 No 7092 p600-602
April 15, 2000 Forum

Guild of Healthcare Pharmacists

Self-regulation, clinical governance and a vision for the future

Self-regulation - a privilege that might not continue

Good self-regulation systems and clinical governance were the "key to the future" of improved care for patients, said Baroness AUDREY EMERTON (chairwoman, Brighton Health Care NHS trust), who gave the opening address. All health care professionals were accountable for ensuring a high standard of practice. In the case of pharmacists, the basis of this was the Royal Pharmaceutical Society's Code of Ethics. This provided a framework for clinical governance, which, in turn, allowed a systematic approach to peer review. However, health care professionals were "not good" generally at external scrutiny and there had been much discussion in government about the wisdom of continuing to allow self-regulation. The pattern of self-regulation might be changed by government in the near future. It was a privilege to be a professional and to be allowed self-regulation but cases of misconduct that had been reported widely in the media had all focused a spotlight on the fact that poor practice had been neither spotted early enough nor dealt with adequately. There had only been a few incidents but they simply should not have happened, Baroness Emerton said. Prevention of poor performance should be high on the agenda of all health care professionals. This was made easier by ensuring that there was clear understanding throughout the profession of the standards expected of an individual, with support provided for those who were not achieving them. Baroness Emerton said that a part of the process of setting standards and ensuring quality service provision was clinical governance. At the Brighton Health Care NHS trust, a number of quality issues had been identified, which aimed to tackle clinical governance. These included the setting up of goals that all staff in the trust were expected to be familiar with, the collection of data and the audit of the quality of services provided. Alongside this, the practise of evidence-based medicine, risk assessment and risk reduction were crucial.

Audrey Emerton: prevention of poor performance must be high on the agenda

Clinical governance and pharmacists

Hospital pharmacists must adopt a proactive and timely approach to clinical governance and demonstrate that that they could make a positive and effective contribution to the delivery of high quality patient care, Mr PETER SHAROTT (regional pharmaceutical adviser: secondary care, NHSE London) said. The current problems with recruitment and retention were an obstacle to this goal. However, they would not go on for ever and the clinical governance programme allowed 10 years in which to achieve targets. In addition, hospitals that provided high quality services would be attractive places for pharmacists to work. Clinical governance was central to the government's strategy for the modernisation of the NHS, as it provided the framework for the programme both nationally and locally. Mr Sharott added that the setting, delivering and monitoring of standards was vital. The London region clinical governance reference group, which was responsible for assessing the capacity and capability (in terms of clinical governance) of trusts and health authorities, had put together success criteria. However, trusts and health authorities were at different stages with regard to meeting them. In the NHSE London, regional pharmacy services represented the profession and responded to central bodies, such as the National Institute for Clinical Excellence (NICE) and the Centre for Health Improvement (CHI). They also helped with benchmarking of pharmacies and investigating untoward incidents. They had developed clinical governance action plans for dealing with audit, complaints, continuing professional development and adverse drug reaction reporting. However, it was crucial that local standard operating procedures and protocols were in place. Using the Chelsea and Westminster hospital as an example of the efforts of an individual hospital, Mr Sharott said that, within pharmacy, the directorate structure was being used to put clinical governance into practice. The directorate pharmacists sat on directorate boards and were involved in projects, such as the setting up of clinical trials and Crown protocol development. In addition, individual pharmacists got involved in more specific enterprises within their directorates.

Enjoying a joke at the evening reception in the Royal Pavillion: (left to right) Roger Kline (Manufacturing, Science and Finance union), Ivor Caplin (MP, Lab, Hove), Jenny Langston (mayor, Brighton and Hove) and Peter Cooke (president, Guild of Healthcare Pharmacists)

Identifying non-compliance with drug treatment of transplant patients

Measuring patient compliance had not yet revealed information that might help pharmacists to predict which patients would not comply, said Miss CLAIRE HODGKINSON (clinical pharmacist, Royal Infirmary of Edinburgh). Presenting the 1999 MSD award lecture, she said that compliance with drug therapy after renal or liver transplant was vital as it prevented organ rejection and death. However, patients were not always compliant with their treatment, despite being a motivated group. She described how she undertook an evaluation of compliance with tacrolimus therapy. Patients were asked to bring their tacrolimus supply into the outpatient clinic, where it was repackaged into a bottle with an electronic drug event monitoring (eDEM) lid. This contained a microchip that recorded each time the bottle was opened by the patient. The number of times a day that the bottle had been opened and the times of opening could then be plotted to give an estimation of the patient's compliance. Out of a total of 138 patients, 56 per cent had a greater than 90 per cent compliance rate, and 19 per cent had less than 90 per cent compliance. The remainder either lost their eDEM bottle, did not use it correctly or another factor interfered with compliance. Miss Hodgkinson said that, surprisingly, no patient factors correlated with compliance, including the total number of tablets in their regime, the patient's age or the incidence of adverse events. However, male patients were less likely to comply with their drug therapy than females and there was a "big difference" between the compliance of patients who had received a cadaveric kidney compared with those who had had a live one (86 per cent versus full compliance). However, the assessment was still ongoing and further results could be expected in the future, she said.

Claire Hodgkinson: no way of predicting compliance

1999 Baxter award - outpatient chemotherapy for colorectal cancer

The deGramont regime of fluorouracil and calcium folinate can be administered on an outpatient basis, which offers considerable benefits to patients, said Ms Michelle Rowe (chief technician, the Christie hospital, Manchester).
Ms Rowe explained that she had overseen a project to quantify the benefits of home administration via a central line. Patients were selected on the basis of their ability to cope, psychological status and support network. They were trained to look after their central line and administer their own infusions. When they returned home, they were given an information booklet and a hotline number to ring for support from hospital staff. When asked which treatment they preferred, most chose outpatient because it was less tiring, had less impact on their life and there were fewer delays to treatment. However, a few patients preferred inpatient treatment because it gave them the opportunity to talk to other sufferers, which they felt was important. All of those treated as outpatients received treatment on the expected days. In comparison, 54 per cent of the inpatients received fewer than the scheduled six cycles because they found the regime too gruelling, she said.

A vision of the future

The context in which pharmacy services operated was changing rapidly. It was nonsense to imagine that it was possible to predict a particular future and move towards it using fixed goals and objectives. So said Mrs NAAZ COKER (King's Fund fellow). Traditional compartmentalised thinking was too limiting. It was important to work within a context of collaboration and co-operation while remaining extremely flexible. Mrs Coker reminded those who had known her when she worked in pharmacy that she had never believed in a single grand vision, only in grand possibilities.
There were now new challenges. Questions were being asked about the moral authority of health professionals. Scandals highlighted by the media had raised issues about accountability and leadership within the clinical professions. She stressed that there was a growing mistrust of scientists generally, following scare stories in the media relating to food and nuclear power stations. However, good health and health care were about partnerships. These partnerships were based on valuing experience, as well as on scientific knowledge and, therefore, on recognising the contribution that so many people made to health. This raised questions for pharmacists: what was the purpose of a pharmaceutical service? What did they acquire scientific knowledge for? Was it for the blind pursuit of knowledge or was there a moral purpose? What were the values underpinning a pharmacy service? How did pharmacists connect with their values in practice? These were the questions that had to be addressed when thinking about the future.
Mrs Coker went on to say that what was present, in reality, was a National Disease Service, since the money spent annually on the NHS had little impact on the overall health of the nation. She had been part of a group set up by the Royal Pharmaceutical Society, which had included a diverse group of pharmacists and hospital managers. The remit of the group had been to develop a strategic direction for hospital-based pharmacy services and values. Mrs Coker continued by stating that the thinking of pharmacists in relation to strategy had been rather impoverished because planning had been, and continued to be, mistaken for strategy. Although pharmacists planned strategies for the future, they had to act in the present. She said that she was working with two acute trusts that were planning for new hospitals in about five years time. The trusts had ambitions for developing new services once they moved to new premises but had relatively poor services at present. However, it was important to start the improvements in service today so that they would be in place before the move.
The challenge for the future was effective leadership. She stressed that leadership could be learnt. It was different to management in that it required a development of emotional intelligence and existing talent. It was also about supporting decisions rather than imposing them. Mrs Coker concluded that the challenge of leadership was to find ways to inspire and excite young pharmacists to enter and stay in the profession.

The Government's priorities for health care

Mrs JEANETTE HOWE (acting chief pharmacist, Department of Health) gave a broad picture of the Government's proposals for health. She began by describing the document "Modernising health and social services" which set out 13 priorities for the next three years.
The first three were smoking, drug misuse and teenage pregnancy, which had the theme "improving health and tackling health inequalities". The next priorities, were "saving lives", and related to the major killers - cancer, coronary heart disease and stroke. The third group were about fast access, prioritised waiting lists and times, and the modernisation of primary care, which had to be delivered in a way that was responsive to patients' needs. Under the theme of "caring for vulnerable people", Mrs Howe said that health and local authorities were required to work together to tackle dealing with children, mental health and older people. The theme of "modernising strategies" included three priorities to support the delivery of the other 10 and these were quality, staff and information technology. The delivery of these improvements was to be underpinned by careful management of NHS resources, strengthening services to prevent and control communicable diseases and purchasing and providing safe and secure services through local health authorities. Pharmacists had to focus their efforts in all these areas.
Turning to the Budget announcement, Mrs Howe stressed that in order to make a real difference, the way in which the extra investment given to the NHS was spent was vital. The Prime Minister had laid down five major challenges to modernise, to organise efficiently and to deliver preventative, as well as sickness services. They were: partnership, performance, professions and the wider NHS workforce, patient care and prevention. Modernisation action teams had now been set up to decide how best to meet these challenges.
Mrs Howe then talked about performance, which encompassed many areas and included: clinical governance; controls assurance, which addressed the systems underpinning clinical governance and ensured a standard consistent with the Duthie report on the safe and secure handling of medicines; medication errors, since they received a high profile in the media; medicines information, in which Mrs Howe acknowledged that drug information pharmacists had contributed by producing a strategy which was to be published very shortly; hospital manufacture; risk assessment, where there were concerns about the ability of hospital manufacturing units to meet standards; the Pharmaceutical Price Regulation Scheme (PPRS) and hospitals.
Discussing the developments taking place within the profession, Mrs Howe said that pharmacist prescribing had been put on the agenda by the two Crown reports and required a step-by-step approach towards legislation. Meanwhile, pharmacists had to prove their ability, for example, by leading anticoagulant clinics. In addition, primary care pharmacists were becoming increasingly involved in medicines management. With the rapid pace of NHS reform and the new emphasis on quality, all pharmacists had to reappraise and realign their skills and knowledge. Another area of concern was the workforce, or lack of it, and Mrs Howe recognised that it was probably the number one issue in pharmacy as well as other health care professions. She knew that, with the huge agenda that the Government wished to implement, the lack of staff was all the more frustrating. However, she hoped that the difficulties in recruiting not only pharmacists but also pharmacy technicians, would only be apparent in the short to medium term.
Mrs Howe concluded by discussing patient care, which was all about empowerment. She touched on: concordance and medicine taking, which were increasingly on the agenda; the expert patient task force, which was a group given the task of designing a programme to help patients manage their condition, and understand and manage their medication, leading to more productive consultations; and the professional training of health professionals. Mrs Howe thought that expert patients could make a valuable contribution in this last area and should be involved in the design and delivery of training programmes for pharmacists.

Medeva medal winners Mr Chris Cairns was awarded the 1999 Celltech Medeva gold medal for outstanding contribution to hospital pharmacy. He was president of the guild from 1996 to 1998 and recently moved from St George's hospital in Tooting to take up his present position as director of pharmacy and dietetics at the University hospital, Lewisham. The silver medal for contribution to hospital pharmacy locally was given to Mr Paul Gurnell (principal pharmacist aseptic dispensing services, Northern General hospital, Sheffield). Mr Gurnell has been a representative of the guild for over 25 years. He was a national member on the council for eight years and was on the pharmaceutical Whitley council during the 1980s regrading exercise.

The picture shows (left to right) Chris Cairns, Pam Lewis (marketing director, Celltech Medeva), Peter Cooke (president of the Guild of Healthcare Pharmacists) and Paul Gurnell

Oral and poster presentation winners

The prize for the best poster presentation was won by Mr Duncan McRobbie (principal clinical pharmacist) and Miss Audrey O'Reilly (resident pharmacist) at Guy's and St Thomas's hospital for "A review of the appropriateness of the prescribing of HMG CoA reductase inhibitors prior to and post coronary artery bypass grafting". The winner of the oral presentation prize was Mrs Ruth Bednall (medical admissions pharmacist) from the same hospital. The title of her paper was "Making a difference - pharmacy contribution to medical post-take ward rounds".

Communicating NICE-ly

The National Institute for Clinical Excellence (NICE) expected to use a number of ways to disseminate the information that it produced and it hoped to assist companies that were required to submit data to it, said Mrs ANNE-TONI RODGERS (communications director, the NICE). The methods proposed were electronically, by e-mail and via its website (www.nice.org.uk), using six-monthly paper update documents, through meetings and professional journals and by establishing partnerships with the pharmaceutical industry. In addition, it was hoped that, eventually, companies would be given six years' warning when an appraisal of a product was to be done by the NICE. This would enable them to build the NICE requirements into trial programmes prior to the launch of new products.
It was hoped that guidance produced by the NICE would drive good practice through the health care system and pharmacists could contribute to this, she said.