The Pharmaceutical Journal
Vol 269 No 7213 p274-275
31 August 2002

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Accrediting community pharmacies: a way of bringing in quality standards?

Some primary care trusts in England have introduced accreditation schemes for community pharmacies in their areas. These schemes could be the forerunners of national quality standards. Jonathan Buisson (on the staff of The Journal) looks at what is involved in three different areas

One problem with the current National Health Service contract for community pharmacies is that it does not include many specific quality standards. Pharmacies must dispense accurately and with reasonable promptness, but primary care trusts, through which the payments for pharmacy services pass, have few levers to pull to enforce standards which might be thought appropriate.

One way round this, pending a new national pharmacy contract, is the use of local accreditation schemes. Some of these schemes have more than one level, with pharmacies receiving additional payments for reaching and maintaining higher levels; others have only one level but use the incentive of saying that accredited pharmacies will be first in line when new schemes, potentially attracting additional funding, are being considered by local PCTs.

Going for gold in Stockport

One of the more established accreditation schemes is the Stockport "Going for gold" scheme. Started in 1998 by Stockport Health Authority and Stockport Local Pharmaceutical Committee, it has three levels — bronze, silver and gold.

Hazel Evans, community pharmacy development facilitator to Stockport Primary Care Trust, which now runs the scheme, told The Journal, that when the scheme started around a quarter of the 62 pharmacies in the area expressed an interest in taking part and began working towards the first level. However, all had difficulties they could not overcome and, as a result, the HA appointed a part-time community pharmacy facilitator working eight hours a week to support the scheme. Two facilitators now work 24 hours a week between them.

Mrs Evans says: "One of the first tasks was to tone down what had been held to be too prescriptive, removing requirements to provide confidential business information and to make reports to the authority which were not seen to be for the benefit of pharmacy. In addition, guidance issued by the Royal Pharmaceutical Society on clinical governance was taken into account. This included topics such as continuing professional development, evidence based practice and audit, and risk management through written protocols. Requirements for staff training were introduced."

To date, there are 20 pharmacies working towards the bronze level and a further 25 that have already achieved it. Of these, six are working towards silver level. Five pharmacies have achieved silver and two of these are going for gold. Accreditation visits normally take place in the quieter, spring and autumn, months.

Incentives for taking part in the accreditation scheme are two-fold. First, pharmacy staff have access to free training courses provided by Stockport PCT. Forthcoming courses include diabetes, health and safety and fire training, first aid, and updates for pharmacy support staff on the PCT's non-prescription medicines formulary. In addition, there is the support offered by the scheme's facilitators. Secondly, there are financial benefits — £750 for bronze, £1,000 for silver and £1,500 for gold. Payments are made annually if reaccreditation is achieved.

"Accreditation has led to real job satisfaction for pharmacy staff involved, and for me," Mrs Evans says. "Some pharmacies have moved on from auditing dispensing procedures to [developing] clinical standards such as monitoring patients' inhaler technique."

Committed to quality in Sheffield

The four PCTs in Sheffield jointly run an accreditation scheme for pharmacies known as "Commitment to quality" which was launched in November 2001. This is based on an accreditation scheme of the same name which has been running for general practitioners in the area for some time.

There are three levels — basic (red), intermediate (green) and good practice (blue). Pharmacies in the area are invited to decide for which of the three levels they wish to apply. Of 106 pharmacies in Sheffield, three have so far achieved accreditation: two branches of Lloydspharmacy at basic level and Associated Chemists (Wicker), which went straight in at good practice.

Susie Coates is pharmacy development manager at South East Sheffield PCT, which administers the scheme on behalf of the four PCTs. She explains that those pharmacies seeking accreditation receive funding (£200 for basic, £400 intermediate and £700 good practice) which they can spend on training or preparing documentation. Alternatively, it can be used to provide locum cover to allow contractors to spend time preparing for an accreditation visit. Pharmacies are provided with a toolkit of documents which covers the required standards and gives templates which can be used in preparing documentary evidence. Copies of these have been placed on the Sheffield LPC website (www.sheffieldlpc.demon.co.uk) in its archive section.

Once pharmacies indicate that they are ready for accreditation, they are visited by a team of pharmacists, PCT staff and a member of the community health council.

Ms Coates says: "The visits take about half a day during which the team examine documentary and physical evidence of compliance with the standards. They also interview the pharmacy staff and observe the pharmacy team in action."

Following this there is an official report and a meeting for pharmacy staff. Once granted, accreditation lasts for three years.

Martin Bennett of Associated Chemists (Wicker) says that the accreditation process was "interesting rather than difficult". When he started the accreditation process, he found that the pharmacy met many of the necessary standards but this compliance was not written down anywhere.

"We started in January 2002 and it took around two to three months to get everything together. It seemed to me to be easier to go for the top level and cover everything in one go."

He says that the accreditation inspection visit, and the subsequent feedback meeting, have helped the pharmacy staff to feel more involved. "I meet people from the PCT all the time, but the staff do not — they now realise that we are part of the NHS, rather than working alone."

Mr Bennett says that the accreditation process has been beneficial: "It has enabled us to tidy up our arrangements. Most of the stuff we were already doing, but we just did not document it properly. It also highlighted a few areas where we had to do things better or where we had stopped doing things and we needed to start doing them again."

Accreditation in Kent

Nine PCTs in the Kent and Medway area jointly run a single-level accreditation scheme. The scheme is based on work started by the former East Kent and West Kent health authorities.

Jackie Giltrow is pharmaceutical adviser to Swale PCT, which administers the scheme. She explains that the accreditation scheme is part of the local clinical governance agenda. "Clinical governance sets a framework of standards — if these are achieved then you are accredited."

The scheme uses an incentive to encourage participation, rather than a specific reward. "We agreed that these were basic standards so no one should receive extra money for meeting them — but those who are accredited can join the queue for other PCT schemes that might be funded. They will be first in line for consideration."

A series of evening meetings was held at the end of 2001 and beginning of 2002 to explain the clinical governance framework and its accompanying file of documentation. Some pharmacies started working towards accreditation then but had problems producing the required standard operating procedures. As a result, Ms Giltrow and her colleagues produced a series of templates and held a further meeting in July.

"At the meeting we asked pharmacies to say when they felt they would be ready for accreditation — now, soon or later. We are now following up those at or near the accreditation stage."

Accreditation visits are made by the pharmaceutical adviser together with a non-pharmacist representative of the appropriate PCT. The adviser looks at the standard operating procedures, both in writing and in practice, other documentation and dispensary equipment. Pharmacists' CPD portfolios are examined.

Meanwhile, the non-pharmacist conducts a small customer survey and looks at the pharmacy from the public's point of view. The appearance of the pharmacy, the provision of relevant information and the manner of staff with customers are observed. The PCT representative also checks whether the pharmacy's designated quiet area offers adequate privacy for confidential discussions. Accreditation visits are arranged in advance with the pharmacy.

If the standards are deemed to be met then the pharmacy is informed in writing within 28 days and given a certificate to display. Accreditation lasts for two years because, with 265 contractors in the area, Ms Giltrow says that one-year approval would result in her doing nothing but accreditation visits.

"Even though we have only done a few visits so far, we have seen people change their practice in order to comply with SOPs they have written themselves. Even in my former role as one of the Society's inspectors, I found it difficult to get people to change their practices before."

Those pharmacies that do not meet the standards can either provide subsequent evidence that they have rectified any problems within 28 days or agree on a later date for another visit. Appeal is possible to a steering group which consists of PCT, LPC and patient representatives.

Five visits to date have resulted in three accreditations, one pharmacy being given a list of improvements to make and one turned down.

National accreditation

The Pharmaceutical Services Negotiating Committee's community pharmacy services database, accessible through its website holds details of six other local accreditation schemes in England, as well as the Stockport one.

The negotiation of the new community pharmacy contract offers an opportunity to introduce new quality standards, probably linked to some form of accreditation. Among the issues that will have to be discussed are whether it is better to have single national standards, allow local flexibility or bits of both. The bodies doing the accrediting, probably PCTs, and the methods for doing it also need to be agreed. The incentives for taking part, financial or otherwise, will have to be determined. Work on all of this is still at an early stage.

Even the most well established schemes have only been through one or two cycles and do not yet have all the pharmacies in their areas taking part. If these schemes are to be extended further, or form part of the new national contract, then a number of major issues will have to be discussed and decided upon.

First among these is what it is that gets accredited. Should it be individual pharmacies, individual pharmacists or teams of pharmacy staff? This leads on to linked issues about what happens when pharmacies change ownership or there are major staff changes. The status of locums in such schemes is also problematical. Should they be accredited separately?

There will be a need to balance any national standards that may be introduced with local priorities and with the abilities of pharmacies to take part in or achieve different standards, due to constraints of time, space or staffing.

There is also the question of incentives. Is it better to offer straight cash payments or to make participation in future schemes dependent on accreditation? If cash is to be offered then who pays, to whom and how much?

Finally, what is it that accreditation schemes are trying to achieve and who will benefit most from them; pharmacy, PCTs or the public?