The Pharmaceutical Journal
Vol 275 No 7366 p306
10 September 2005

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Thinking the unthinkable — pushing the boundaries of pharmacy skill mix

By Steve Acres

Most people working in hospital pharmacy will have heard of skill mix but the issue is certainly not limited to the hospital environment. In the most simple terms, skill mix is about having the right grades of staff with the right levels of competence to complete all the required tasks in the working environment.

A number of overarching NHS and Department of Health publications talk about using people’s skills appropriately, and competence is the key to understanding exactly what those skills are. Competence may best be described by the acronym SKATE (skills, knowledge, attitude, training and experience). We perhaps all know from observation whether or not a person is capable of doing a particular job but how do we measure this or train the person to become competent? Knowledge and Skills Frameworks (KSFs) will allow us to describe what competence looks like for posts within the NHS. KSFs are being applied to current job descriptions and will allow the description of competency for new roles as they develop.

At the University Hospitals of Leicester the pharmacy team has developed a strategy which includes the development of “directorate pharmacy teams”. Comments often received from ward pharmacists and technicians indicate that they spend a substantial amount of time chasing lost medicines and becoming involved in supply chain work. This is clearly not an appropriate use of their hard earned clinical skills. Understanding what happens to medicines at ward level is key to identifying solutions.

As a starting point we asked our medicines management technicians and pharmacists exactly what tasks they did on the ward and recorded these on a spreadsheet. We also added some basic housekeeping jobs that often do not get done. These included ensuring patients’ medicines went with them when they were transferred to another ward, moving patients’ drugs from the drop-off point into their locker and reviewing returns to ensure that patients no longer need them.

Having completed the list, we then added columns for each grade and asked if each grade of staff was, or could be, competent to complete that task. If the answer was yes, then it got a tick in the box. This stage requires an objective viewpoint and the ability to challenge the status quo. In the same way that technicians can perform a final check if they have proven competency, there is no reason why assistant technical officers working at ward level cannot do a number of housekeeping tasks (beyond topping up). These tasks are, after all, an integral part of medicines management. A section of the simple spreadsheet is illustrated in the Table below.

Although the spreadsheet is beneficial in its current state, this is certainly not the end of the story. Add an extra column and calculate average time taken for each task plus another column for cost (this could be further broken down by staff group), and yet another to record the added-value that pharmacy brings to the patient journey. In doing so you can begin to see that this would be a tool for calculating staff levels, building business cases and defining the impact on the clinical service brought about by a lack of pharmacy staff.

Benefits

So, back to the issue of skill mix at ward level, what benefit has this produced for us? On the four wards where we piloted assistant technical officers as part of the directorate team, the results have been encouraging.

The value of returned medicines increased during the first month as staff sorted through stock and got the housekeeping under control. Although some returns are non-avoidable there are many that are; in the
second month returns have dropped significantly, because of better housekeeping, and should remain low. This is a good indicator that we have also got duplication under control, since many returns are generated by duplicated prescriptions and dispensing.

Stock requisitions from wards have reduced by between 50 per cent and 84 per cent. There is anecdotal evidence that we have achieved a reduction in missed doses as a result of better stock availability. Ward staff time has been freed to focus on appropriate duties. Pharmacist time has been freed to focus on clinical duties. We now have better organised stock cupboards (tidied up every day), where ward staff can actually find things. The staff involved have a sense of achievement, motivation and job satisfaction. There has been a huge improvement in multidisciplinary working and communication.

Although this model has been developed within the hospital setting, the principles of staff mix are applicable across all of pharmacy. In community pharmacy, freeing pharmacists’ time to take part in new initiatives, as required under the new contract, can only be achieved if some of their current workload can be moved. This is clearly an opportunity to review all tasks within the pharmacy and to invest in staff development so that staff are competent to take on new roles. It is understood that there will be some roles carried out by a pharmacist which cannot be redistributed but reviewing all tasks and challenging the status quo objectively will identify those that can. It is also an opportunity for staff development for all grades of staff whether they be pharmacists, technicians or dispensing assistants.

There may be some who will see this development as a further erosion of both pharmacist and technician roles. We all face significant problems in recruiting pharmacists and technicians; to employ this valuable and expensive resource on inappropriate duties is simply inexcusable. What this initiative has achieved is better value for public money and better job satisfaction for all grades of staff. It also fits neatly into the medicines management agenda, workforce development and the NHS plan.

Horizon scanning for new opportunities to push the boundaries even further should always be on the agenda. For example, the introduction of automation brings on a whole range of possibilities, such as completing much of the dispensing process at ward level with stock held in the dispensary and using an air tube to deliver medicines to the ward. This, in turn, will require a deeper look at who does what, where and how and will, almost certainly, lead to new ways of working. So, come on: be brave and think the unthinkable. You could be surprised by the results.