The
Pharmaceutical Journal Vol 266 No 7129 p5-6
The Primary and Community Care Pharmacy (PCCP) Network held its annual conference in Wolverhampton on October 2 and 3, 2000. Speakers discussed where pharmacy is now and where they hoped it would be in the future. Jane Swan reports
The future - changes in prescribing
Primary care group to trust transitions
Merck award for head lice researcher
Ethical issues and an increase in negligence claims
The future
New regulations for care services
The changing face of immunisation
Information sources
Mrs Swan is head of pharmacy services, Nottingham community health NHS trust
The issues affecting the development of electronic prescribing were described
by Miss ANN SLEE (principal pharmacist, Wirral hospitals).
“Information for health” (an information strategy for a modern National Health
Service, 1998–2005) set out a framework for the full implementation of electronic
patient records (EPR) in primary care and in acute hospitals. It required that
by April, 2005, there would be electronic transfer of patient records between
general practitioners (GPs) and 24-hour emergency access to patient records.
Substantial progress towards this target was required by April, 2002. There
were several drivers for change:
EPR would result in the journey of a prescription from prescriber to the Prescription
Pricing Authority becoming more streamlined with EPR at the centre and links
to other agencies.
The level of access to EPR had to be decided, particularly who could initiate,
amend or discontinue prescriptions. EPR could help with the administration of
protocols, eg, formulary control, but protocols would need to be relevant to
all needs across primary and secondary care. Decision support elements could
be built into the system, eg, correct dosing, correct drug choice and checking
for interactions.
The challenges for remodelling prescribing included a need for a common drug
dictionary and systems to meet users’ needs. An additional challenge was the
utilisation of information to meet patients’ needs.
Mr STEPHEN LUTENER (head of pharmacy law, Royal Pharmaceutical Society) highlighted
the legal issues affecting prescribing, including the legal framework to allow
nurse prescribers and the nurse prescribers formulary.
He described the legal background for the supply of medicines under patient
group directions (PGDs) — articles 12A, 12B and 12C of the amended Prescription
Only Medicines (Human Use) Order, 1997 [see PJ, August 12, 2000, p219]. These
gave an exemption for health professionals to supply or administer a prescription-only
medicine under a PGD in order to assist doctors and dentists in providing National
Health Services. He listed the requirements for constructing a PGD and the persons
authorised to supply medicines under a PGD. The NHS recommendations [see PJ,
August 19, p255] suggested that PGDs should be reviewed every two years, that
the appropriate person to sign PGDs on behalf of an NHS organisation was the
clinical governance lead, and that all professionals involved in PGDs had to
work within their profession’s code of practice. The recommendations also stated
that a senior person in each profession had to ensure that only fully competent,
qualified and trained staff acted under PGDs and that extra care was taken with
antimicrobials and “black triangle” drugs. The Council of the Royal Pharmaceutical
Society had set a six-month target to provide a resource pack on PGDs, Mr Lutener
said. A working party had been set up to identify opportunities for the profession
to supply medicines under PGDs, to prepare information, advice and standards,
and to propose mechanisms for dissemination to support pharmacists in developing
and utilising PGDs.
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What pharmacists were doing in the transition between primary care group (PCG)
and primary care trust (PCT) was discussed by Mrs LARAINE TUPLIN (prescribing
manager, Central Derby PCT).
She outlined the structural changes that had been undertaken to form Central
Derby PCT. It now had a full-time prescribing manager and a prescribing support
pharmacist. Their time was divided so that they spent half on projects, PACT
and strategy and half supporting individual practices. There were also five
practice pharmacists who each worked for one day a week split into a half-day
in two practices. These practice pharmacists were either community or hospital
pharmacists.
Mrs Tuplin outlined the pharmaceutical needs of the PCT. These were:
Strategy - contributing to the health improvement programme (HimP), formulating policies and implementing national service frameworks and guidelines from the National Institute for Clinical Excellence
Advice - need for prescribing advisers, drug information and evaluation, and expertise in specialist areas, eg, family planning or writing patient group directions
Pharmacists could specialise as PCT clinical, public health or community health
pharmacists. There were challenges because PCTs had a number of problems to
solve; they still did not have all the answers but were willing to listen to
anyone who could help. She concluded that pharmacists had the expertise that
was needed, so should “contact your PCG/T and get in there!”
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The Merck Award was presented to Mr DAVID MORGAN (director of pharmaceutical
public health, North Wales health authority) for his research paper “A comparison
of wet combing with malathion for treatment of head lice in the UK: a pragmatic
randomised controlled trial” published in the Lancet (2000;356:340-4).
Concern about the effectiveness and toxicity of insecticide lotions had led
to the promotion of mechanical methods of removing head lice. Mr Morgan compared
the effectiveness of “bug-busting” with malathion lotion.
The results, from a sample of 72 primary school children, showed that malathion
lotion was twice as effective as bug-busting, even in an area of intermediate
resistance.
Policies advocating bug-busting as first-line treatment for head lice in the
general population were inappropriate, he said. Assessment of the outcome of
treatment one to two weeks after its completion was essential for successful
management, he added.
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Litigation and ethical issues were discussed by Dr PETER HARROWING (consultant
pharmacist and solicitor, United Bristol Healthcare NHS trust). He asked: “Where
do I stand? Do I know what I am doing? Does anyone know the answer? Can I sleep
at night?”
He divided legal and ethical risks into those for pharmacists and those for
patients. For a pharmacist, the important issues to consider were civil liability
(negligence, breach of contract), criminal liability (Medicines Act 1968, Health
and Safety at Work Act 1974), the Consumer Protection Act 1987, disciplinary
procedures, clinical complaints and the Statutory Committee.
Risks for the patient included adverse reactions, short-term and long-term effects,
a missed opportunity of a cure and death, he said. The NHS had 100,000 outstanding
claims for clinical negligence and £2bn outstanding liabilities. Most claims
had to be paid from individual trusts’ budgets but there was a clinical negligence
scheme for trusts.
There had been an increase in negligence claims which could have resulted from
an increase in public awareness, media hype or because of developments in medicine
that had led to an increased expectation of a cure. The doctor or professional
was no longer “infallible”.
For a patient, negligence might mean additional pain and suffering or the loss
of opportunity for a cure. This led to a sense of grievance and a desire for
compensation, Dr Harrowing said.
For pharmacists, an allegation of negligence would lead to a loss of confidence
in his or her own professional competence, anger at a lack of gratitude, frustration
at an inability to satisfy a patient and a loss of confidence in the system,
he said. Emotions such as guilt, worry and bitterness would occur. Fears of
criticism by the court, media and peers and of unemployment were also likely.
Dr Harrowing discussed sources of negligence, standards and issues raised by
a claim. Consent was a difficult area and special care in obtaining consent
was needed for particular groups of patients such as the elderly, mentally ill
and children, he added.
He gave advice on how to avoid a negligence claim. This included having good
relationships with others, proper procedures, audit, training, risk management,
clinical governance and controls assurance. It was also important to know when
to ask for help, to seek advice before mistakes occurred, to maintain good records
and to share information.
If something did go wrong, pharmacists should inform others, offer an explanation
to the patient or relatives, make notes about the incident (but not “make up”
notes) and make sure that members of the health care team learned from the situation.
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The keynote speaker was Professor ALISON BLENKINSOPP (department of medicines
management, Keele University). She asked: “What does the future hold for pharmacy
in the new NHS?”
The policy background for the new NHS modernisation programme included the five
“Ps” which were prevention, patient care (access and empowerment), professions
and workforce, performance and partnerships. There was an implementation and
modernisation board, NSFs (eg, for older people and diabetes), an expert patient
taskforce and self management programmes. NHS Direct and walk-in centres had
been developed.
There were roles for pharmacists in medicines management, medication review
and, in the future, prescribing, eg, of discharge medication. Medicines management
included monitoring of therapy, repeat dispensing and medication review. All
PCGs and PCTs would commission pharmacist input, she said. For community pharmacy,
there would be the electronic transfer of prescriptions by 2004, distance ordering
and supply of NHS prescriptions, improved out-of-hours access and an emphasis
on the pharmacist and not the premises. The recognition of medicines management,
the pharmacist’s contribution as part of a team activity and the opportunities
for local developments were important, she concluded.
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Miss DIANE HEATH (All Wales principal pharmacist, community services) introduced
the topic of “inspection in the future in registered care settings”.
Under the Care Standards Act 2000, a National Care Standards Commission (NCSC)
would be formed. The Act had two main aims: to improve the quality of care services
and to protect vulnerable people using these services. The Act covered England
and Wales and would regulate a full range of social care and private health
care. Regulation woud be through the NCSC in England and the National Assembly
for Wales (NAW). Regulation of the social care workforce would be through the
General Social Care Council (England) and the Care Council for Wales.
The NCSC/NAW would regulate care homes, children’s homes, domiciliary care agencies,
private and voluntary health care services, independent fostering agencies,
voluntary adoption agencies, residential family centres and nurse agencies.
They would also inspect local authority fostering and adoption services and
welfare arrangements in boarding schools. The Secretary of State for Health
and the NAW would prepare minimum standards for each regulated service and strong
powers of enforcement and deregulation were planned. In England, the NCSC had
an implementation team led by Mr Chris Hume (programme manager, NCSC), within
the social care policy division of the Department of Health as a non-departmental
public body, ie, it was independent. These bodies would become legal entities
from March, 2001, before becoming fully operational on April 1, 2002.
National, regional and local offices were planned for the organisations. The
national office would co-ordinate with other national bodies, the Social Services
Inspectorate and the Commission for Health Improvement to ensure a consistent
national approach and to report to the Secretary of State on the quality and
range of care services. It would monitor the quality of inspection, performance
of the NCSC and lead training. The regional offices would make staff appointments
and provide financial, legal and information technology support, training and
staff development. The local offices would be as small as possible with a manager,
administration team and inspectors. Their key roles would be registration, inspection,
enforcement, investigating complaints and servicing the local advisory panel.
The PCCP network had been involved in the care services developments. It had
a joint approach with the Pharmacy Community Care Liaison Group and had met
Ms Trish Davies, (project manager, minimum standards, NCSC). It had commented
on some draft standards and gained agreement that training was required for
all involved with medicines, both administration and inspection.
The PCCP had also met Mr Hume to discuss the roles of pharmacists and how to
use their expertise. It had been involved with the Royal Pharmaceutical Society
in reviewing guidance on the administration and control of medicines in nursing,
residential and children’s homes and was awaiting the final draft.
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The “changing face” of childhood immunisation was discussed by Dr MARY RAMSAY
(Public Health Laboratory Service, Communicable Disease Surveillance Centre).
Issues to be considered in vaccine policy decisions included the aim of a programme,
its cost, finding a sustainable source of vaccine and population accessibility,
she said. For each campaign, the immunisation strategy, either mass or selective
immunisation, had to be determined.
Indications for selective immunisation were risks from travel (eg, Japanese
B encephalitis), occupation (eg, anthrax), chronic disease (eg, pneumococcal
vaccine) or outbreak control (eg, hepatitis A vaccine).
Mass immunisation was used to reduce morbidity and mortality from a vaccine-preventable
disease with the aim of eradication, elimination or containment. Eradication
was defined as when the disease and its causal agent had been removed worldwide,
eg, smallpox. Elimination meant that the disease had disappeared from one region
but remained elsewhere. Containment was defined as the disease no longer constituting
a significant public health problem, eg, tetanus.
The United Kingdom mechanism for implementing vaccine policy was through a
multidisciplinary committee - the Joint Committee on Vaccination and Immunisation.
It selected vaccine policies and produced a publication of recommendations (the
Green Book). The Department of Health purchased vaccines and distributed them
via the company Farillon. The Medicines Control Agency licensed vaccines and
the National Institute for Biological Standards and Control tested the potency
and toxicity before batch release.
Several recent changes had occurred in UK immunisation. In 1996, the introduction
of a second MMR dose. In 1999, the meningococcal conjugate vaccine was introduced.
It was a polysaccharide antigen attached to a carrier protein that produced
a T cell dependent response, good antibody response, immunological memory, prolonged
protection and a good response in infancy. It was expected that a single dose
for older children and adults would provide life-long protection and lead to
herd immunity.
The control of whooping cough had changed in 2000 with a move to use of acellular
pertussis vaccine. Whole cell vaccine (which consisted of whole Bordetella
pertussis organism inactivated by formaldehyde and a range of antigens)
had been previously used. The acellular vaccine contained only the components
thought to be important for protection and was therefore less likely to cause
adverse reactions.
The acellular vaccine was currently being used to sustain a supply of pertussis
vaccine in the UK, but it was being considered for longer term use, as a booster
for pre-school children and for routine infant immunisations.
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Working with national information sources - the NICE, the Commission for Health
Improvement (CHI) and the National Prescribing Centre (NPC) - was the subject
of a presentation by Mr CLIVE JACKSON (director, NPC). He outlined the key principles
governing the environment of the modern NHS and the issues influencing the work
and responsibilities of NHS professionals. These issues highlighted the major
changes to working practice that NHS professionals now faced. Changes could
not be implemented without effective, high quality support. To reduce variability
and duplication of effort locally, there was a fundamental need for co-ordinated
action at a national level. A range of initiatives was now in place to help
deliver effective, co-ordinated information and support. These included national
service frameworks, the NICE, the CHI and the NPC.
The NPC was formed in April, 1996, following a Department of Health review.
Its aim was “to facilitate the promotion of high quality, cost-effective prescribing
and medicine management through a co-ordinated and prioritised programme of
activities aimed at supporting all relevant professionals and senior managers
working in the new NHS”. The work programme covered information, education/training
and dissemination of good practice. Core publications included MeReC publications,
new drugs scheme bulletins and therapeutic area reference sheets.
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