The Pharmaceutical Journal
Vol 268 No 7180 p9-10
5/12 January 2002

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Win over hearts and minds then launch medicines management in hospitals

A central role for hospital pharmacists in managing medicines effectively is identified in a recent Audit Commission report (PJ, 22/29 December 2001, p873). What are hospital pharmacists already doing? Clare Bellingham finds out

The recent Audit Commission report, "A spoonful of sugar — medicines management in NHS hospitals", is good news for pharmacy. The report's aim is to raise the profile of medicines management in secondary care. It states that pharmacists have a central role to play in redesigning services around patients' needs and in ensuring optimal use of medicines.

Keith Farrar, chairman of the Royal Pharmaceutical Society's Hospital Pharmacist Group, commented: "The importance of the Audit Commission report is that it re-affirms pharmacy as a clinical profession and not a supply service." If pharmacy is recognised at a trust level as being essential to patient care, then pharmacy is less likely to face the same resources problems as it has in the past.

Some hospital pharmacists are already involved in activities that fit into the Audit Commission's vision of medicines management and examples of these hospitals are included in the report.

Impact of clinical pharmacy

North Staffordshire Hospitals NHS Trust provides two examples of activities: medicines management governance arrangements and the impact of clinical pharmacy.

Dr Ray Fitzpatrick, director of pharmacy, North Staffordshire Hospital, explains that the medicines management governance arrangements encourage all clinical directorates to focus on prescribing issues. "Two years ago, we decided that it was important that prescribing got a high profile. Although we had systems in place at ward and directorate level, we needed the chief executive to give the message to the board that prescribing is important," he said. As a result, quarterly reports about prescribing issues are now presented to the trust's executive management board (these had previously been presented annually). The reports include a financial summary for the trust overall, and also for each clinical division and directorate. (The trust is large and organised into six divisions within which are clinical directorates. Pharmacists work with both clinical directorate and clinical divisional management teams.) The reports also include recent decisions from two committees which consider new medicines: the drugs and therapeutics committee, which makes formulary decisions for most medicines, and the medicines management group, which considers high cost new medicines. The reports also include progress in implementation of guidelines from the National Institute for Clinical Excellence. The reports identify any overspend on specific medicines and provide an explanation where problems are identified. A recent example of this is an increase in the price of immunoglobulin because of problems sourcing it, he said.

The reports are produced by directorate liaison pharmacists. They are also presented to the public trust board which raises the profile of hospital pharmacy among the public and lay members of the board, said Dr Fitzpatrick.

He believes that this type of system could be introduced in all hospitals. "Lots of hospitals have the infrastructure and the directorate liaison structure in place but don't have the impetus from senior management." He points out that a need to increase awareness about medicines among management was highlighted in a recent Department of Health medicines management framework.

North Staffordshire Hospital has also demonstrated the benefit of employing clinical pharmacists. As a result, two senior pharmacists have been recruited to increase the level of appropriate prescribing in the medical ward.

Dr Fitzpatrick explains that to demonstrate a pharmacist's value, a pharmacist spent three months with a consultant team. Prescribing costs before and after the pharmacist's participation were compared, and with similar teams during the same period who had no pharmacist input. "This showed that having a clinical pharmacist was particularly useful and helped to manage prescribing expenditure," said Dr Fitzpatrick. The initiative demonstrated that prescribing costs were reduced by around 25 per cent.

As a result of the project, the hospital's division of medicine decided to invest money in more pharmacists on the basis that this would save money. Two pharmacists have been in position for 18 months. Have they been effective? "The division of medicine's drug budget is in balance against a background of rising medical emergency admissions," said Dr Fitzpatrick. He added that the medical division also benefited from having the pharmacists' input, an additional benefit that was not costing anything since the pharmacists' salary was covered by savings in prescribing costs.

The hospital has also created a medicines management unit and employed a medicines management pharmacist. Further details of the hospital's medicines management system can be found in an earlier article (PDF* 65K) (PJ, 28 April 2001, p585). Two technicians support the medicines management pharmacist, for example, by producing reports, and this has been a particularly successful initiative considering the current recruitment crisis in pharmacy, he added. The pharmacy department also produced evidence-based guidance and employs three people working half-time to write the guidance in three areas: adult acute, surgical and paediatric medicine.

Use of technology

The Audit Commission report acknowledges that pharmacy is facing a major recruitment crisis, noting that 15 per cent of pharmacy posts are vacant. The problem is made worse by the added strain of demand from new services and the need to extend pharmacy operating hours. It suggests tackling this problem through:

• Introducing more flexible working patterns
• Re-engineering pharmacy services
• Redesigning and enriching jobs
• Introducing automation
• Providing administrative support
• Reviewing "make or buy" decisions

Automation is one method of releasing staff time, a method employed at the Wirral Hospitals NHS Trust, which has introduced a robotic dispensing system (see Panel). Keith Farrar, who is also chief pharmacist, said: "There is great potential for this, or the introduction of some other form of automation, in hospitals. We have not got enough staff in hospitals to do everything we want to do so it makes sense to take as much of the burden away through automation," he said.

Installing automated dispensing THE Wirral Hospitals NHS Trust introduced an automated dispensing system in January 2001. Keith Farrar, chief pharmacist, explains that the robot will only take original packs so the first thing that needs to be done is to introduce original pack dispensing. The robot covers 80 per cent of the dispensary's stock and has some limitations over the weight and size of items. All items are barcoded. When a label is printed, the robot picks the item from long sets of shelves and delivers it to the person dispensing. The system cost £300,000 to install. The advantages of automated dispensing include the fact that it makes the process faster, it does not make picking errors and it reduces space needed in the dispensary. It also frees staff time: the hospital has saved the equivalent of three-and-a-half whole time technicians since the system's introduction, allowing them to carry out other roles, such as ward visits. The systems does have disadvantages. As well as only taking original packs, it does not take all items. It does not eliminate mistakes: if a product is labelled incorrectly then the wrong item will be picked.

Technology can be used to increase safety, and make processes more efficient at the same time. "Computerised prescribing linked with electronic health records will radically alter the way in which care is provided and will deliver significant improvements in the quality of patient care," the report states. "The introduction of these systems, which ultimately need to be accessible by primary care and other hospitals, is vital to provide access to common clinical data." However, it admits that the introduction of these systems is one of the biggest challenges facing the NHS. By 2002, 35 per cent of trusts are expected to have installed electronic patient record systems and all trusts by 2005.

An electronic prescribing system has been introduced at Burton on Trent Hospitals and Wirral Hospitals. "Electronic prescribing is something that is quite difficult to introduce because it involves medical staff doing something new," Mr Farrar said. "In order to make it a success, you need to have a culture in the hospital that is willing to embrace change. If a number of people are keen and prepared to put the effort in then you can start proving that the outcomes of the change are better than the old system, providing evidence to win other people over."

Mr Farrar explains that the advantages of the system are:

• It results in production of legible and complete prescriptions
• Information is instantaneously transmitted
• It can be locally customised which is useful for formulary management and to reduce risks (eg, to direct prescribers to a correct dose)

The disadvantages of the system are:

• It raises expectations among nursing staff; because prescription transfer is instantaneous, staff expect an instant response from the dispensary
• It increases pressure on the dispensary because a back-log of prescriptions builds up overnight
• It is not a thinking system, ie, it does not indicate interactions (although Mr Farrar said that a filtering system on flagging interactions would be needed; if too many are given, there is potential for them to be ignored)

It is essential to have a pharmacist involved in the introduction of electronic prescribing. Mr Farrar said: "You can teach health care staff about computers but not computer staff about health care. Electronic prescribing is so crucial and care is needed. Pharmacists are suitably pedantic about safety."

When introducing a system, Mr Farrar recommends testing it many times to ensure that it is safe and to stop and rethink if it is not working.

The first thing is to deal with the culture. "Win over hearts and minds before introducing a system," he said. "And importantly, ask questions about systems and visit hospitals with systems in place.

"It is worth introducing but it is hard work. There is no reason why every hospital cannot do it: it is a case of the culture and getting the right system."

Time is right

The time is certainly right for pharmacists to be pushing for increased importance to be placed on medicines management in hospitals. The Audit Commission report states: "[Trust boards] that regard medicines management as a support service provided by pharmacy will risk failing to deliver their statutory clinical governance obligations. Managing the way that medicines are used in hospitals is the business of all clinical staff and it directly affects most patients. It is a strategic issue fundamental to the way that hospitals work, to the quality of patient care and to the delivery of the NHS Plan and Improving Health in Wales."

Pharmacists have an essential and central role in medicines management. The Audit Commission report has provided much-needed support to push for wider introduction of these roles in hospitals.