| · Antibiotic resistance
· Registration examination
· Registration
· Pharmacy practice
· Hospital disinfection
· Reciprocity (2)
· National boards
· Regulation of medicines
· Hospital pharmacy (2)
· New oxygen contract
Letters to the Editor
|
Hospital pharmacy
Individual patient dispensing — a blessing or burden?
From Mr R. J. Giles, MRPharmS
Did we unleash a monster? The letter from Amanda
Storey (PJ, 23 July,
p113) regarding one-stop dispensing has to be welcomed. I have been sitting
on a letter to you, wondering whether I was simply being Luddite in my
thoughts and was unsure whether to send it. Now I will.
In the early 1990s, we were privileged at Nether Edge Hospital in Sheffield
to be among the frontrunners in introducing a whole host of innovations
that are now an everyday part of the hospital pharmacy service. We took
up the baton of self-medication and developed it, introduced the reuse
of patients’ own medicines, put technicians on wards and — the
thing we were most proud of — rid ourselves of drug trolleys. Eventually
the rest of Sheffield followed suit and now it would be hard to find
a drug trolley anywhere.
Today, I have to say, that I perhaps would not be so quick to press ahead.
The whole process leaves much to be desired. Why do I say that? To answer
the question, I need to restate briefly the reasons we made changes in
the first place.
Our aims were primarily, threefold:
· To reduce wastage
· To reduce the inordinate amount of time nurses spent dealing with medicines
· To make sure patients were receiving medicines on time
To achieve this we set out to:
· Use an individual patient dispensing (IPD) system to enable patients
to reuse their own medicines.
· Break down the traditional drug round by getting rid of the drug trolley
· Encourage a lot more self-medication
This should have worked. However, what has happened in practice is that
the “patient pack initiative”, a drive to automation and
a generalised failure to make the most of self-medication schemes, have
all contributed to creating a monster that now drives us, rather than
us being in control of the changes. I may be accused of being a Luddite,
less adaptable to change in my older years, etc, but having played a
major role in introducing most of these changes, I think I have a right
to assess whether they meet the hopes and aspirations that we set out
with.
So I ask the questions for others to answer:
· Can we honestly say that, in total, nurses spend less time now handling
medicines than they did 15 to 20 years ago?
· Why is there always a large pile of medicines, returned from wards
at the back of the pharmacy waiting to be destroyed?
· Would pharmacy staff still be working late into the evenings if it
were not for IPD?
There are a lot of good things about the changes that have taken place,
but I do not believe we are making the most of them.
Aside from our failure to reduce nursing input and increase self-medication,
it is the waste of valuable resources that upsets me most. How can we
reduce the unacceptable, immoral destruction of drugs?
In my view, we have to reassess the way IPD is used or even if it should
be used. If hospitals are not going to encourage a greater use of self-medication
schemes, then what is the real use of IPD? One-stop dispensing, you might
answer. Of course, if that worked smoothly, it might be an answer. But
how many discharge prescriptions still come to the pharmacy for checking,
for changes or because the patient has got through half their patient
pack while on the ward (they insist on having at least two weeks’ supply
when they go home)?
Having witnessed the impact on the service over a number of years, I
think we have seriously to consider reintroducing drug stocks on the
wards, albeit in more locations than was the case with the single drug
trolley and not necessarily in the form of the big pots we used to have.
We can still supply the patient packs, but at least they can be shared
between patients and not thrown away when somebody’s medication
changes.
I believe we have a moral duty to conserve resources (and I do not just
mean saving money) and there are few ways to achieve this. Let the wards
have stocks in each bay, dispense with instructions for self-medicating
patients, let patients reuse their own medicines and allow pharmacy staff
to concentrate their time on dispensing discharge medicines.
IPD is not a sacred cow. And it may not be the monster I sometimes think
it is. But we should seriously consider how it contributes to the unacceptable
waste that we alone are responsible for.
Ron Giles
Retford, Nottinghamshire
One-stop dispensing from a positive perspective
From Mr R. G. Pate, FRPharmS
“Dispensing for discharge” or “one-stop dispensing” features
as a part of the Department of Health’s “Medicines management
self assessment” as a marker of performance. It has been advocated
in “Pharmacy in the future — implementing the NHS plan”,
the Cabinet Office report “Reducing burdens in NHS hospitals” and
the “Older persons” national service framework. For your correspondent
Amanda Storey (PJ, 23 July, p113) to ask whether one-stop dispensing is “not
all that it is cracked up to be” is somewhat challenging or disappointing
depending on your perspective.
Over the past three years I have seen poster displays at pharmacy conferences
which list the many benefits from one-stop dispensing schemes at a range
of hospitals (one large teaching hospital, one large acute hospital and
one relatively small specialist hospital). The advantages identified are
many and include: faster discharge (minimum of four hours saved), reduced
waste and improved quality markers, such as patients’ perception
of being better informed and involved with their medicines. Anecdotal reports
show that these successes have been replicated elsewhere. However, it is
also clear that one-stop dispensing may not be applicable to all patients
and it may be appropriate to exclude some specialties. This should be a
local health economy decision.
Your correspondent is correct that one-stop dispensing schemes are more
labour intensive for pharmacy. However the health economy efficiencies
gained (capacity improvement, waste reduction and many more) make the manpower
investment not just worthwhile but invariably self funding. Such schemes
need careful introduction with full engagement of all stakeholders. This
will require robust business planning and organisational change management
with agreement from stakeholders on associated funding changes. I would
therefore strongly recommend colleagues who have not already introduced
one-stop dispensing to visit trusts where this has been successful, learn
from their processes and examine their business cases.
Laurence Goldberg (PJ, 30 July, p139) is of course right to ask “if
hospital pharmacy services were to start with a clean sheet would anyone
come up with one-stop dispensing”. However we are where we are and
it is disappointing that so many trusts have still fully to implement a
system advocated four years or so ago — including automation. Automation
of the dispensing process has improved speed and accuracy and does not
eliminate delay in supplying discharge medicine. In my observation, hospitals
that have not implemented one-stop dispensing have invariably not implemented
(or even thought about) automation. The electronic developments which Mr
Goldberg describes as on the near horizon have seemed to me to be forever
on the horizon and to wait for these to arrive is an argument for no improvement
in the interim.
Ron Pate
Pharmaceutical Adviser (Secondary Care)
West Midlands Strategic Health Authorities |
The
Pharmaceutical Journal