What to do when an inspector calls
A visit by the Commission for Health Improvement (CHI)
was less threatening than expected, according to IAN SMALL, primary care
pharmacist, Norwich Primary Care Group. The visit was more of an information
gathering exercise, but it showed practices that clinical governance was
real, not just Government rhetoric.
The CHI's mandate is to visit every NHS trust, primary
care group and trust, health authority and local health care group at
least once every four years. Norwich had been one of the first to be visited,
so there were lessons to be learnt. The aim of the CHI was to improve
the quality of care patients received in the NHS in England and Wales.
In other words, it was not sufficient for the commission to inspect, it
also had to enable improvement.
The CHI had several functions but, at PCG, PCT and
HA visits, the clinical governance review was the most important. The
whole process took a total of 24 weeks and involved pre-visit data collection
and analysis, an on-site visit (lasting one week) and production of a
report.
For primary care pharmacists closely involved with
clinical governance, there was a great deal of work to do for CHI visits,
including a massive amount of paperwork, Mr Small said.
The 16-page pre-visit questionnaire included items
on prescribing advice, analysis of prescribing data and whether it was
shared within practices. Specific prescribing behaviour examined included
generic prescribing and the prescribing of antibiotics, benzodiazepines
and oral non-steroidal anti-inflammatory drugs.
The visits involved interviews with prescribing
advisers. Some of the issues discussed during the visit to Norwich were
the adviser's involvement with clinical governance, how advice was disseminated,
patient involvement in decision making and the primary/secondary care
interface.
Not yet at the ball
Pharmacy was “no longer Cinders, but it is not yet
at the ball,” GRAHAM BUTLAND, chief executive, South Essex Health Authority,
said.
He praised the pharmacy profession for being one
that looked for challenges rather than problems, and said that pharmacists'
traditionally underused skills now had a chance of being realised. However,
although pharmacists had significant contact with patients, the profession
had never been central to the NHS agenda, mainly because primary care
organisations were dominated by general practitioners. He then went on
to discuss one-stop primary care centres, which he said would challenge
the holistic approach to health care. They would certainly challenge medicines
management services if there was a need for a patient to see one pharmacist
on a continuous basis. One-stop centres should have a pharmacist in them,
he said.
Mr Butland acknowledged that pharmacy was probably
not on many health authorities' agendas, although it was important that
it should be. The planned reduction in the number of HAs from 99 to 30
meant that their focus would probably be on tertiary rather than primary
care and there was a need to guard against fragmentation in the system,
creating yet more geographical boundaries. Health authorities needed to
ensure that primary care organisations supported change in pharmacy. However,
there were still large numbers of primary care groups and trusts with
no pharmacy input; most had prescribing advisers, but this just reinforced
the idea of pharmacists as cost managers, and pharmacists had to be included
in the decision-making process.
Pharmacists also had to take clinical governance
seriously, and this involved, among other things, an emphasis on training
and education. But this needed more resources, an inescapable fact that
needed to be addressed for pharmacists to be truly “brought to the ball”.
Relenza PGD
JANE MOFFATT, senior pharmaceutical adviser, Brighton
and Hove primary care group, described the challenges of setting up a
patient group direction (PGD) for zanamivir (Relenza). The drive for the
PGD had been concern expressed by GPs about their workload in relation
to influenza.
Among the issues that had to be addressed in developing
the PGD included interpretation of the tensions between the Crown report
on prescribing, administration and supply and Health Service Circular
2000/ 026. Although the Department of Health's template was a good starting
point for writing the PGD, it needed modification. Patient eligibility
was an issue, despite the nature of the illness concerned, and it had
been decided that it was not enough for the pharmacist to talk to the
patient’s representative and make a supply — it was essential to talk
to the patient, and that could be done on the telephone, if necessary.
The PGD included a patient assessment tool — essentially
a two-step algorithm — which was aimed to be foolproof but not complicated.
Payment had been a difficult issue: trying to decide which elements of
the process could be viewed as standard pharmacy practice, what should
attract a payment and whether payment should be linked to supply. In the
end the decision had been taken to pay pharmacists £7.50 for assessment
of patients, a fee comparable to that paid to GPs for a similar activity
The PGD included a patient declaration form, one
aim of which was to make sure that patients realised this was a new route
of supply, and that the medicine had been given to them on the basis of
information they had given to the pharmacist.
Pharmacists had to complete a weekly returns form,
which included details not only for payment, but also to identify the
groups of patients being treated. This allowed for assessment of whether
some pharmacists were being more liberal than others in their supply and
whether National Institute for Clinical Excellence guidelines were being
followed. Concluding, Ms Moffatt said that PGDs needed to be well designed
and piloted before use, there needed to be clear routes of referral for
patients excluded from the PGD, and that appropriate training and clear
documentation were essential. — Contributed.
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