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Report makes many recommendations about future pharmacy services
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Cost-effective prescribing is a recurring theme in Audit Scotland’s
report, “A Scottish prescription: managing the use of medicines
in hospitals”, published last week (PJ, 30 July, p129).
It is no surprise, therefore, that pharmacy features heavily.
Audit Scotland interviewed staff, including pharmacists, managers, senior
medical staff, junior doctors and nurses, at hospitals and NHS boards
in mainland Scotland. It also reviewed relevant data and documents from
the NHS bodies and interviewed staff from the Scottish Executive Health
Department (SEHD) and other national bodies.
The key message in the report is that medicines need to be better managed
in Scotland’s hospitals in order to ensure that patients are getting
the most benefit from money spent in this area. The report makes recommendations
and gives examples of best practice across Scotland, many of which involve
pharmacy initiatives.
An important recommendation for pharmacy is that pharmacists should be
represented at senior levels of decision-making in NHS boards and divisions.
The report highlights that NHS boards need to have a full understanding
of medicines issues when making decisions on medicines budgets and managing
risk and says that pharmacists have this knowledge but are often only
indirectly represented at a senior level.
Norman Lannigan, chief pharmacist, NHS Lothian University Hospitals Division,
and a member of the review advisory group, told The Journal that he has
three levels of management between him and the chief executive of his
NHS board. “The problem is that by the time my message reaches
the top it is diluted or the message has changed.” He adds: “My
view has always been that the risks associated with the use of medicines,
both financial and clinical, are such that we deserve a place at the
table, and this report confirms that.”
David Thomson, director of pharmacy, Primary Care Division, Greater Glasgow
and member, for Scotland, of the Royal Pharmaceutical Society’s
Council, also supports the recommendation: “I would recommend that
these opportunities are realised during the current round of health board
redesign and restructuring in Scotland.”
Changing the delivery of care
The emerging role of pharmacist supplementary prescribers and the consultation
on proposals to introduce independent pharmacist prescribing are acknowledged
in the report. It says that all NHS boards have plans to implement
the national pharmacy strategy with regard to extended clinical roles
for pharmacists and have made progress. However, it points out that
only two-thirds of hospitals currently have a clinical pharmacy service
and in those that do there are still gaps in the service.
The report says that although hospitals have taken action to release
pharmacists and technicians from the dispensary this change has been
limited in some areas and it is unlikely that the timescales specified
in “The right medicine” will be met in all hospitals. Vince
Summers, chief pharmacist, NHS Borders, and a member of the review advisory
group, puts this down to a disparity of pharmacist resource across different
boards in Scotland, as well as varying levels of progress towards changes
in skill mix. “Different hospitals have managed to obtain budgetary
resources for different reasons in the past and we do not have any standard
way of ensuring that departments have a right and reasonable level of
staffing for their service.”
Lyndon Braddick, director of the Scottish Department of the Royal Pharmaceutical
Society, comments: “We firmly support the report’s recommendations
that clinical pharmacy services should be extended and that pharmacy
managers should be represented on key decision-making groups at NHS boards
and operating divisions. The current shortage of pharmacists and pharmacy
technicians may delay implementation of some of the recommendations,
but the Society is working with the Scottish Executive Health Department
to address this situation.”
Mr Summers agrees: “The shortage of pharmacists will definitely
slow progress — it is already doing that. A lot of places struggle
to provide their current service because of the national shortage and
the inability to recruit.” He says that often, even if a department
gets funding for posts, it cannot fill them. “ The only way we
are going to be able deal with the shortage of pharmacists is to alter
skill mix.” However, he believes the shortage of technicians is
something that can be tackled at a local level. “In our area, we
are already ramping up the numbers of technicians that are being trained
in hospital and community.”
Recruitment and retention of pharmacy staff is addressed in the report.
It says that “it is not clear that workforce planning and education
was integrated into the national pharmaceutical strategy despite its
implications for clinical pharmacists and for technicians working in
extended roles”. Audit Scotland expresses particular concern that
the number of vacant pharmacist posts is higher than the number of preregistration
trainee posts. It recommends: “The SEHD and NHS boards should ensure
that workforce planning includes preregistration [trainee] posts and
that sufficient training posts are available to meet the future needs
of the service.”
Professor Lannigan agrees that the number of preregistration trainee
posts needs a boost. He adds: “Training of pharmacy staff tends
to be concentrated in a few centres. We need to make sure that it is
more widely spread — more hospitals need to take on preregistration
trainees and train their own technicians.” The future
Mr Summers emphasises that “A Scottish prescription” is not
a report on pharmacy: “It is a report about how medicines are used
and the accountability for that.” However, he adds that he hopes
the report will give a lot of the issues a higher profile. “I do
not think there is anything in the report that as a board or a service
we would not want to be doing anyway. It just may change how they are
viewed as priorities [by the SEHD and NHS boards]. If it means that they
are going to deliver resources to achieve these priorities then that
may well be a positive benefit for pharmacy.”
Mr Lannigan believes that the report should be used not only to gain
more resources, but also to use those resources more wisely. “It
is good for clinical pharmacy because it realises there is a role for
clinical pharmacy. The challenge is to make sure that the variation and
availability of that clinical pharmacy service is addressed both in terms
of resources and making sure that pharmacists are doing what they should
be doing.”
The report is not as explicit as “A spoonful of sugar”, the
equivalent report in England, says Professor Lannigan, but pharmacy comes
out as something that should be valued in this process. “We do
not get many opportunities for that message to be said at the highest
level — that is the important thing about this report.”
Mr Summers warns that if a decision is taken to move on all of the recommendations
there is going to be a huge workload for pharmacy. “We have to
be careful that it does not alter the approaches and strategies of the
different pharmacy services — that they purely become to satisfy
the recommendations in this report.”
In September, the report will be presented to the Scottish Parliament
Audit Committee, which will review it, take evidence from the relevant
accountable officers and decide if it wishes to pursue the issues raised.
Audit Scotland plans to revisit the review in about two years to see
what progress has been made.
“If no progress has been made in the areas where it was felt progress
was needed, that is when the naming and shaming starts,” says Professor
Lannigan.
Other recommendations in the report
· Joint formularies The report recommends that a national framework
to guide the process for developing joint formularies is required
to ensure that prescribing is in line with best clinical practice
and is cost-effective. Eight of the 12 mainland NHS boards have
a joint formulary. However, the report highlights that only six
of these take cost-effectiveness into account and few regularly
monitor adherence to the formulary.
· Medicines budgets The report says that budget holders should
be in a position to influence prescribing behaviour and proposes
that clinical pharmacists should be involved in managing medicines
budgets. It also recommends that NHS boards should ensure that
horizon scanning information is used to inform budgets for medicines
and suggests that NHS boards should consider allocating the medicines
budget to services on an area-wide basis, for example, through
managed care networks.
· Medication incidents The review found that six of the NHS bodies
do not have well developed systems for sharing information about
medication incidents with staff. Nine bodies do not have a system
to alert clinical pharmacists about medication incidents. “NHS
boards should ensure they have robust processes to review medication
incidents and the learning points from them,” it recommends.
· Automated dispensing There are currently no automated dispensing
systems in hospitals in Scotland and no national strategy on automation,
although some boards are considering it. The report recommends
that a national strategy be developed.
· Use of IT The NHS in Scotland needs to make wider use of IT in
order to improve the use of medicines in Scotland, the report says.
For example, it recommends that the SEHD develops a clear project
plan with key milestones and timescales for procuring, developing
and implementing a national hospital electronic prescribing and
medication administration system. Ayr Hospital is the national
Scottish pilot for an HEPMA system. |
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The
Pharmaceutical Journal