Hospital pharmacy
Medicines management, NICE guidance, medication error research, continuing professional development and the Commission for Health Improvement were among the topics discussed at hospital pharmacy practice sessions on 16 September. Gareth Jones, editor of Hospital Pharmacist, reports £ 20m saved by medicines management
Michael Scott: medicines management can reduce length of hospital
stay |
Introducing a medicines management service involving a pharmacist and
a technician on each ward could save a trust £20m, said Dr Michael
Scott, chief pharmacist at United Hospitals Trust in Antrim, Northern
Ireland. The running costs of the additional service have been estimated
to be around £1m. Savings can be achieved through more efficient
use of junior doctors’ time, improving bed use through reduced
length of stay and reducing readmission rates.
Dr Scott introduced a medicines management service on five wards across
hospitals in the trust in May 2001. Patients on these wards were allocated
to either an intervention or control group. Patients allocated to the
control group received standard care, and a junior doctor took their
medical histories without pharmacist intervention. The intervention group
patients received a full medicines management service from the pharmacist
and technician. This included an assessment of appropriateness of medication
at admission, inpatient monitoring, pre-discharge preparation, and communication
with primary care health professionals at discharge. Community pharmacists
received a faxed discharge letter. Over 1,000 patients were reviewed
as part of the research.
The length of hospital stay of patients in the intervention group was
significantly lower than that for the control group. Hospital stay reduced
from 17 days to 13 days. Hospital readmission at 12 months was also significantly
reduced in patients in the intervention group. A saving in drug costs
was achieved in patients in the intervention group due to reuse of patients
own drugs. Dr Scott described an example where the nursing time spent
on drug administration had been reduced by a third in the intervention
group.
The time that patients waited for their discharge prescriptions was also
reduced. The average waiting time was 35 minutes in the intervention
group and 135 minutes in the control group.
Questionnaires returned from patients, general practitioners and community
pharmacists showed wide support for the new service.
Savings would be achieved through better use of drugs, and through reducing
nursing time. Dr Scott said that an expansion in the service may need
to be funded from the current nursing budget.
Collaboration to allocate funds for NICE guidance
Trevor Beswick: collaborative approach |
To deal with the allocation of funds needed to implement NICE guidance,
Bristol, North Somerset and South Gloucestershire primary care trusts
(PCTs) have formed a “National Institute for Clinical Excellence
college”, said Trevor Beswick, head of medicines management at
Bristol South and West PCT.
The previous approach to funding NICE guidance followed by the former
health authority involved a funding estimate being made, followed by
a transfer of funds to the provider trusts. There was no follow-up or
monitoring of how the money had been spent or whether it had been spent
on the appropriate appraisal. There were mismatches between what the
trusts said they were spending and what NICE had said they should be
spending, and there was a recognition that there were huge potential
cost pressures from NICE guidance if the previous approach was continued.
The NICE college was established to provide a common approach to NICE
guidance in the region, reduce duplication of work across PCTs, co-ordinate
local implementation work and establish processes for making allocations.
Technology appraisal guideline are identified by the NICE manager. Costs
are then calculated to include resources required for monitoring therapy.
Estimates are also made about the proportion of the funds that will be
given to primary and secondary providers. The college, which meets monthly,
consists of a manager, two representatives from the PCTs, two representatives
from the local NHS health care provider trusts, a finance lead and representation
from out-of-area trusts as required.
Four PCTs, three acute providers, one mental health partnership trust
and two out-of-area trusts provide care for 900,000 patients who live
in the area covered by the college.
Setting a prescribing policy before the issue of new NICE guidance, the
shifting timetable of NICE and reconciling cost estimates with final
expenditure are some of the challenges that still face the NICE college.
According to Mr Beswick, in the 18 months since it became established,
the NICE college has achieved its aims of providing clarity to working
processes, strengthening working relationships between the trusts and
PCTs, and among the PCTs, and tightening financial control. It is hoped
that, in the future, financial estimates, planning, audit and follow-up
will improve further.
Lessons from roll-out of CPD
Different approaches to supporting continuing professional development
have been pursued in three regions where roll-out of the Royal Pharmaceutical
Society's CPD programme has happened, said Lynne Bollington, All-Wales
Principal Pharmacist, Training and Personal Development.
Ms Bollington summarised the lessons learnt. The biggest barrier to acceptance
of CPD is understanding what it is. Peer review meetings are a time-effective
method of sharing records and building confidence, whereas one-to-one
mentoring is not feasible. Someone should be identified at regional and
trust level to take the lead, and support networks should be built to
enable sharing of experiences and develop confidence. There are unresolved
issues with CPD, and Ms Bollington wondered how CPD could develop measured
outcomes, and how it would fit with the knowledge and skills framework
and wider NHS agenda.
Pharmacists should contribute to medication error research by submitting
ideas, says PSRP director
Pharmacists should send ideas for medication error research to the Patient
Safety Research Programme (PSRP). This was the request made to participants
at the conference by the director of the programme, Richard Lilford,
professor of clinical research at the University of Birmingham.
The PSRP was set up by the chief medical officer (CMO) for England, Sir
Liam Donaldson. Professor Lilford reports directly to the CMO, who set
the policy imperatives of the programme as birth asphyxia, intrathecal
vincristine, suicide in hospitals for acute mental illness and medication
error.
“
Medication error is the single greatest cause of human suffering resulting
from error,” said Professor Lilford. He also said that 4 per cent
of all hospital admissions are caused by error in medication and 1.5
per cent of all hospital prescriptions have an error that leads to harm.
Professor Lilford believes that the use of clinical pharmacists and the
use of computer systems can contribute to a reduction in error. The area
for research is therefore to find out in what way these interventions
could be used be cut down error.
Dr Jim Smith, the chief pharmaceutical officer for England, is about
to publish a list of interventions which could help to reduce errors
and will be used by the PSRP in planning research, according to Professor
Lilford. The PSRP will review the error rates in hospitals where computer
systems have already, or are soon to have, a system implemented, as well
as looking at systems in other countries.
The interface between hospital and community is an area currently missing
from the research plans. Professor Lilford would therefore be particularly
interested in receiving suggestions from pharmacists for research in
this area. Further information about the PSRP can be found on the research
programme’s website.
CHI and CHAI – implications for pharmacy
David Stead: make sure you have the evidence to support your case |
Pharmacists were encouraged to get involved with becoming CHI (Commission
for Health Improvement) reviewers by David Stead, chief pharmacist at
the Royal Bournemouth Hospital. “We deal with such a plethora of
people within the organisation on a day-to-day basis that we are ideally
suited to talking and listening to a whole range of health professionals,” Mr
Stead said, based on his experience as a reviewer.
Mr Stead offered some advice on how to survive a CHI review. “Look
at the pillars of clinical governance and make sure that you have got
the evidence to support what you are going to say,” he said. “If
you have got something to say, you have got to make sure that you say
it – it does not matter what they ask you.”
Mr Stead pointed out that although there may be a pharmacist in the team,
interviews are likely to be carried out by a non-pharmacist.
In four years, among other things, CHI has done 300 clinical governance
reviews. It is due to be replaced in April 2004 by the Commission for
Healthcare Audit and Inspection (CHAI), subject to the current legislation
being passed by Parliament. The chairman and commissioners will be appointed
by the NHS Appointments Commission and they will make an annual report
to Parliament. The closing date for applications for the post of chief
executive has passed, and an appointment must therefore be imminent.
CHAI will develop new criteria for star ratings, with the emphasis being
on what affects the patients assessment of quality. Mr Stead emphasised
that as the new CHAI organisation does not currently exist, his comments
were based on “crystal-ball gazing”. The aim of the new organisation
will be the same as that of the old organisation, and that is to bring
about an improvement in the quality of the service.
He questioned how much of the current data collected provide us with
a systematic approach to understanding and improving quality, saying: “At
the moment we have data but not intelligence.” Mr Stead then gave
an example of how this differs. “It is not about the number of
adverse events that you report; that is data. But the intelligence we
want is how organisations use that data to improve their error reporting
systems or improve their risk management processes.” There will
be a drive to obtain information on the quality of care that patients
are receiving. There will be unannounced random visits, with severe penalties
for false or inaccurate reporting.
What impact will CHAI inspections have on pharmacy? CHAI may check on
implementation of NICE (National Institute for Clinical Excellence) reviews
and national service frameworks. It is critical for pharmacists and pharmacy
organisations to tell CHAI what data to use to generate the information.
Self-assessment will become more of a norm, as will, possibly, a greater
number of visits that are focused on key areas of the service that we
deliver commented Mr Stead. These inspections may focus on coronary heart
disease, treatment of older people, children’s services and value
for money.
Case study: what happens during a CHI review
Mark Donaghy, clinical governance facilitator for community pharmacy
for Bradford South and West Primary Care Trust described what happened
when the Commission for Health Improvement visited Bradford in March
2003.
The visit involved all four PCTs in the city and the team sent many
questions to be answered in advance. A PCT review manager was identified
who would co-ordinate the visit so that it would be a positive experience
for those taking part. The local pharmaceutical committee was also
involved and newsletters and posters were sent out to encourage pharmacists
to come forward to participate. It was emphasied that the PCT as
a whole was being inspected — not individuals — and that
the review team wanted to see patients and practitioners doing good
work. The team visited three different pharmacies: one had long opening
hours, another offered an anti-coagulation service and the third
worked closely with a GP practice. Mr Donaghy was also interviewed
and was asked how a pharmacist would alert the PCT about dangerous
prescribing.
When it came to the report being published two months later CHI was
positive about pharmacy services, although it did pick up the fact
that prescribing errors are not currently reported to the PCT. Dispensing
processes, on the other hand,were not an issue. The report also applauded
South and West Bradford PCT for funding pharmacists to the tune of £200/day
for locum fees in order to enable them to particiapte in daytime
training with nurses and GPs.
According to Mr Donaghy, the review process was positive for pharmacy. |
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