Hospital Pharmacist
Vol 9 No 3 p80
March 2002

Review of circulars and official publications
by Alex Bower, MRPharmS

The document, "Shifting the balance of power: the next steps" which applies to England and Wales, was issued by the Department of Health on 7 January. It confirms that the new strategic health authorities (StHAs), each with a maximum of 75 staff, will have three key functions: creating a coherent strategic framework; ratifying annual performance agreements and performance management; building capacity and supporting performance improvement.

There will be four directors of health and social care, and their offices will each have a maximum of about 40 staff. National Health Service trusts will be accountable to the StHAs but will work closely with primary care trusts (PCTs). There will be an increased emphasis on delivering services through clinical networks which span institutional boundaries. Local pharmaceutical committees should now be thinking about how they will relate to PCT boundaries. Hospital pharmacy managers will need to monitor developments and form appropriate links with new players to ensure that service development plans are optimised.

"Clinical governance in community pharmacy: guidelines on good practice for the NHS" was issued by the Department of Health in December 2001. PCTs are asked to undertake a range of actions by April 2002, including the following:

• Identify a lead person who will be responsible for integrating community pharmacy into local clinical governance arrangements
• Identify a community pharmacy clinical governance facilitator
• Undertake a baseline assessment
• Arrange training
• Develop a strategy for the local implementation of community pharmacy clinical governance

This is a pivotal document for the future development of community pharmacy but there is a danger that it will not receive due attention at the present time, and the actions will not be achieved in the timescale indicated. This is because the organisational changes taking place in the NHS mean that some PCTs are only in the process of formation, health authorities are being dissolved, new strategic health authorities are being formed and full accountability for community pharmacy services cannot be transferred to PCTs until legislation is in place in October. The document does not make any reference to funding to support the initiatives and this will also prove to be an impediment to progress. Encouragingly, however, the report notes that a national training programme for community pharmacy facilitators will be developed in 2002 and that community pharmacy will be included in general guidance on processes for clinical governance in the NHS which is expected to be issued soon. The guidance will be of particular interest to hospital pharmacists who work at the interface or who have joint primary/secondary care roles.

This document applies to England only.

The National Institute for Clinical Excellence (NICE) issued Technology Appraisal Guidance Number 32 on "Beta interferon and glatiramer acetate for the treatment of multiple sclerosis" in January. This was quickly followed by Health Service Circular (HSC) 2002/004 issued by the Department of Health on 4 February and entitled "Cost effective provision of disease modifying therapies for people with multiple sclerosis".

The NICE document concluded that the drugs were not cost-effective and they were not recommended for the treatment of multiple sclerosis (MS) in the NHS in England and Wales. It recommended, however, that consideration be given to mechanisms that would secure the drugs in a way that would make them cost-effective. The circular indicates that a "risk sharing" scheme has been agreed with manufacturers, and all patients with relapsing-remitting MS and those with secondary progressive MS in whom relapses are the dominant clinical feature will be eligible for treatment if they meet criteria developed by the Association of British Neurologists. Treatment must be initiated only by specialist MS centres. Treatment costs for England and Wales for the estimated 7,500–9,000 eligible patients will be about £50m. Outcomes for patients entered into the scheme will be monitored. If there is a shortfall in actual outcomes, payments to the company concerned will be reduced from that point to restore the average cost per quality adjusted life year (QALY) to an acceptable level of cost-effectiveness. The circular indicates that, for the purposes of the scheme only, a cost per QALY will be set at £36,000.

"The right medicine: a strategy for pharmaceutical care in Scotland" was issued by the Scottish Executive on 4 February. This is an important document in setting out a strategic direction for the profession. The focus on actions needed is particularly strong and it is interesting to note the intention to establish implementation groups, through the Scottish Executive, to ensure that actions in the strategy are put into practice. The strategy identifies a number of new initiatives, such as the establishment of a Scottish Centre for adverse drug reaction reporting and a system to collect information on misadventures with medicines. It also proposes that all pharmacies be encouraged to display the NHSScotland logo as a way of emphasising their role as part of the wider NHS team.

Hospital pharmacy managers will note that there are a number of recommendations which relate to the need to develop across the hospital and community interface. These include the development of a combined hospital and medicines utilisation database and the formation of pharmacy locality groups within local health care co-operative boundaries. Specific recommendations for hospital pharmacy relate to ensuring that every patient has their medicines reviewed before discharge, that original packs are used and that self-administration schemes are implemented. Although the document will be of particular interest to hospital pharmacy managers in Scotland, it should also be of interest and prove useful to other pharmacists who wish to establish a strategic direction for pharmacy services.

Mr Bower is assistant director of strategic development at Wakefield Health Authority