Hospital Pharmacist Vol 7 No 5
p138-140
May 2000 Articles
Discovering hospital pharmacy in Guernsey
By E. Freestone, BPharm, MRPharmS
The pharmaceutical world of the Channel Islands has much in common with the UK, but the differences are surprising
The bailiwick of Guernsey is a crown dependency consisting of seven inhabited islands lying 80 miles south of Weymouth. Guernsey, which has a combined area of 24 square miles, is inhabited by 60,000 people. The seven islands are divided up into three separate political entities: Sark, Alderney and Guernsey. This division has a significant effect on the delivery of health care.
Sark has its own parliament, the Court of Chief Pleas, Taxes and Laws. It has no state-funded health care system and is not covered by Guernsey's health system. Alderney also has its parliament, the States of Alderney, and its own local laws. However, it has the same taxes and health care arrangements as Guernsey itself. Guernsey is the main island. It is governed by the States of Guernsey, which passes its own laws and raises taxes without reference to the UK.
Health care funding
In 1999, the Guernsey Board of Health was paid £48 million out of income tax for use in managing the hospitals. The hospitals are divided into the following:
Acute - 220 beds
Alderney - 24 beds
Mental Health - 100 beds
Care of the Elderly - 100 beds
The £48m also caters for community nursing and health promotion. The Guernsey Social Security Authority pays for the community prescriptions and for the contract which provides for medical cover in the acute hospital.
All general practitioners (GPs) are in private practice, and a routine consultation costs £26, for which there is an £8 grant from the States of Guernsey. The accident and emergency unit is staffed by a GP, and there is a charge of £35 or more for a consultation. Patients, if admitted to acute or psychiatric beds, receive medical and all other care free of charge for the duration of their stay. Patients in long stay care of the elderly beds pay a long stay charge. On being discharged, they are given a PS6 prescription form (similar to an FP10) to be taken to their local pharmacy. All outpatients are also given PS6 prescriptions, except for psychiatry patients, whose medicines are dispensed by the pharmacy at the Princess Elizabeth hospital which is the acute unit. The PS6, also used by the GPs in primary care, are for a maximum of 30 days and cost £1.90 per item with only children, the elderly and those on state benefits being exempted.
The hospital pharmacy
The hospital pharmacy service is based at the Princess Elizabeth hospital, which serves four hospitals on Guernsey and Alderney. The service has five pharmacists working in the hospitals and one pharmaceutical adviser. There are also four technicians, four assistants, three clerical staff and one porter.
The pharmacy strives to attain UK standards in all areas of practice. All the pharmacists are registered locally and also in London with the Royal Pharmaceutical Society. The technicians all hold the Business and Technical Education Council certificate or its antecedents. The pharmacy service participates, as an extra-territorial member, in the Wessex chief pharmacists group and its supporting committees and groups and is also part of its contracting group for pharmaceuticals. The usual external audits and monitoring for drug information and quality assurance (QA) are also carried out, as well as hospital-wide QA schemes, such as the Health Quality Survey (HQS).
An assistant "top-up" (that is, filling the stock to an agreed level) service is provided by the pharmacy to all the wards in Guernsey hospitals. The service also extends to a small 24-bed cottage hospital in Alderney, which is visited on a quarterly basis. The acute hospital wards are all visited daily by a clinical pharmacist providing the same range of functions as in the UK. However, the medical system is very different, and this places a number of challenges on the staff. For instance, there are no junior medical staff (only specialists), which means that much of the routine tasks undertaken by junior medical staff have to be undertaken by the nursing or pharmaceutical staff. Drug chart re-writes are mainly done by pharmacists, as are anticoagulation prescriptions, a significant amount of medication clerking and therapeutic drug monitoring (TDM). The absence of junior medical staff means that formulary drug changes are made by pharmacists, usually without reference to medical staff.
The drug information unit is run in line with UK Drug Information Pharmacists Group (UKDIPG) recommendations. It provides both reactive and proactive information to healthcare professionals, supports the drug and therapeutics committee and the pharmaceutical adviser. It also has to support a number of other departments not usually associated with drug information, such as the States analyst, police and customs officials (usually in the identification and legal classification of medicines). There is a contract with Southampton General hospital to provide advice and backup.
An active and well-funded training programme exists, and includes an MSc in clinical pharmacy (Belfast) for pharmacists, managerial and information technology (IT) training for all staff within the Guernsey civil service board, and a programme of UK courses, including those provided by the Guild of Healthcare Pharmacists weekend school and the United Kingdom Clinical Pharmacy Association. Each pharmacist receives on average five to 10 days for "off-island" training per annum.
The pharmacy provides a number of technical services which are organised by a senior technician with pharmacist support. The department provides a daily radiopharmacy service for the nuclear medicine department (this service is for both Jersey and Guernsey). The nuclear medicine department, which has recently moved to a new facility, has a radiopharmacy isolator in a class B room (according to the Medicines Control Agency's "The Rules and Guidance for Pharmaceutical Manufacturers"). Parenteral nutrition (PN) is prepared for patients in a separate isolator. Kabimix bags (from Pharmacia & Upjohn) containing standard regimens are routinely used, except, of course, in neonates. The same isolator used for PN is also used for preparing patient-controlled analgesia (PCA) devices (the Baxter Elastome Balloons) and centralised intravenous additive (CIVA) items that are difficult to prepare at ward level.
Guernsey has an active cancer service with a dedicated day hospice for the patients. All blood results are screened in the pharmacy and there is liaison with the medical staff if an adjustment is deemed necessary on the prescription. The technicians prepare the cytotoxic drugs and adjuvant infusions, which are then transported to the hospice or flown out to Alderney, if required. There is a contract with the Portsmouth hospitals NHS trust for QA and advice on technical services which enables the service to be developed so as to ensure compliance with best practice.
Pharmaceutical adviser A pharmaceutical adviser post was created in January 1999. The postholder is responsible for monitoring and changing prescribing in primary care so as to provide the best care possible within the available resources. The budget of approximately £9 million is generous by UK standards, but the amount includes what would normally be hospital outpatient and discharge medication costs. The pharmaceutical adviser works closely with the Guernsey Social Security Authority and the Board of Health so that integrated and shared care pathways can be established. It is also envisaged that a common formulary between primary and secondary care can be achieved for the island.
Procurement Perhaps it is not surprising that procurement of pharmaceuticals is a more long-winded process than it is in the UK. That is aside from the fact that some of the customer service staff forget all about the English Channel. ("Oh, give it to our van driver this afternoon", they say. Not unless he has water wings!). Orders to wholesalers are received the next day or the day after; orders from other suppliers are received weekly or fortnightly and, those from NHS Supplies, monthly. The vagaries of the weather can delay deliveries for up to 72 hours. Oxygen is supplied in cylinders (approximately 150J size per week) twice a week. A concentrator, which will replace the cylinder banks, is due to be acquired this autumn.
Pharmacy, for historical reasons, also keeps and orders items which are not routinely held in UK pharmacies, for example, hip prostheses. The total drug expenditure is approximately £1.5 million, two thirds of which is still held in the Princess Elizabeth hospital pharmacy budget. As the doctors are not employed by the Board of Health, there is no directorate structure through which the money can be passed down. (Mental Health and Community Health Services are the two exceptions.) The pharmacy is also the purchasing and distribution centre for all vaccines (childhood and travel) in Guernsey.
Since Guernsey is not part of the UK, import and export licences for Controlled Drugs (CDs) must be obtained before supplies can be forwarded to the islands. This can add four weeks to the delivery cycle, which can become a significant delay when demand soars for a low use item needed for one patient. At times, the hospital acts as a wholesaler of last resort to the islands' community pharmacies.
Chief pharmacist's role
One key area of activity in the hospital pharmacy is the role of the chief pharmacist, which encompasses far more than that of a similar postholder in the average UK district general hospital (DGH).
Guernsey is a separate jurisdiction from the UK and so the Medicines Act 1968 does not apply on the island. The control of medicines and the practice of pharmacy is controlled by the Poisons, Pharmacy and Pharmacists Ordinance 1970, as amended. This categorises all medicines as poisons in a number of different schedules. Older readers will remember this system prior to the implementation of the Medicines Act in 1977, but the Guernsey system has its own peculiarities. Paracetamol, for example, can only be sold under the supervision of a pharmacist, but aspirin can be bought by the ton from any retail outlet. The law does not require registration of premises but requires that sales of poisons take place under the supervision of a pharmacist (unless exempted) on the production of a prescription.
The law also allows the Board of Health to appoint a person to enter and inspect pharmacy premises to ensure compliance with the relevant regulations. This person just happens to be the chief pharmacist. All complaints relating to the practice of pharmacy and the conduct of pharmacists are investigated by the chief pharmacist and reported to the Board of Health. The appropriate action is then decided upon, which could be referral to the Statutory Committee of the Royal Pharmaceutical Society. (The Society's law department has no powers in Guernsey, except when a complaint is made about a breach of the Code of Ethics.) Pharmacists in Guernsey pay the overseas fee to the Society.
The Misuse of Drugs Law 1974/1997 Ordinance regulates CDs and is very similar to the UK equivalent in many ways. There is, however, an important difference: the chief pharmacist is authorised to possess classes A, B and C drugs received from patients and others for the purpose of arranging the destruction of these drugs (never mind that the law does not say how he should do it!).
The chief pharmacist is responsible, in conjunction with the administration director in the Board of Health, for drafting and correcting legislation relating to medicines, pharmacy, pharmacists, and the implications of change relating to other health care professionals having a medicinal component. In addition, the chief pharmacist has had to liaise with the Trading Standards department, the police and customs officials about direct mail order of prescription only medicines, medicinal claims for foodstuffs, internet sales of Viagra, registration of companies in Guernsey exporting medicines from India to West Africa and the list goes on. It is a varied life.
Perceptions
The different laws and organisations in Guernsey make it a real challenge to achieve the desired outcomes and means that UK practice cannot be applied directly. Many of the controls and levers that exist in the UK do not exist on the island. The hospital pharmacy is thus, for the pharmacy profession, the local DGH, district health authority, regional pharmaceutical adviser, Society's inspectorate division and the Department of Health all rolled into one entity. The small team of staff at the hospital have to provide all the pharmaceutical services that this plethora of agencies undertake in the UK. In fact, the breadth of service and knowledge required can be staggering and occasionally quite daunting. In order to improve the attractiveness of hospital pharmacy in Guernsey and also to provide a method of challenging our practices and increasing the depth of our experience, rotational posts are being established with Guy's and St Thomas' hospital NHS Trust.
Guernsey is a small, safe and very prosperous community where there is a desire to provide the best health care possible. To achieve this, the States of Guernsey has funded extensive investment in medical facilities, including the re-fitting of the pharmacy department in 2001. The hospital pharmacy service is an essential part of a single health care economy.