Hospital Pharmacist
Vol 9 No 4 p90
April 2002

Take a spoonful of sugar with salt

By Anthony R. Cox, BSc, MRPharms and John F. Marriott, BSc, PhD

One interpretation of the "Spoonful of sugar" referred to by the recent Audit Commission report is that it reflects the song immortalised in the film Mary Poppins.¹ This is a well crafted work; the sweetness of the film allows the audience to swallow its ideological messages by the spoonful, instructing them to find new roles for themselves and asking to focus more on shopping and entertainment than on work. This message has some bearing on the desire for a 24/7 medicines management culture contained in the report. An alternative view is that "Spoonful of sugar" refers to the amelioration of painful procedures by pre-dosing with sweet substances. Achieving the laudable aims formulated in the report will inevitably involve experiencing both corporate and professional "pain".

When the report was launched, the media latched on to the reported 500 per cent increase in the number of medication-related deaths from adverse drug reactions (ADRs) and medication errors over the past 10 years. For example, the BBC web-site stated that a "Prescription drug deaths surge" had occurred. This increase was based on an analysis of International Classification of Disease (ICD) codes. Previous reports of increases in medication-related deaths using ICD codes have been criticised due to uncertainty of coding classification. In 1995-96, the ICD-9 coding system was changed to ICD-10, raising the possibility that coding changes have contributed to the observed increase in deaths. The incidence of ADRs in the literature has also remained reasonably level over a number of years, so the evidence that there has been an explosion in the number of medication-related deaths should be taken with a pinch of salt.

Nevertheless, ICD codes poorly detect ADRs: diagnoses can be inaccurate and physicians may consider them an administrative burden.² Therefore, the incidence of medication-related deaths in the Audit Commission report may be a severe underestimate. Medication errors are thought to kill 7,000 patients a year in the US; an equivalent figure for the UK would be 1,500 deaths. This is about seven times higher than the number in the Audit Commission report. Lack of adequate definitions for medication errors makes all calculations little more than guesswork.

The greater toxicity and complexity of modern medicines is blamed for the steep rise in medication deaths, but the majority of medication-related admissions to hospital are caused by well-established medicines, and crop up with depressing regularity in studies: drugs such as warfarin, diuretics, non-steroidal anti-inflammatories and beta-blockers. The relatively small number of deaths and the seemingly rapid rise in their occurrence that the report describes may suggest that a quick and easy solution exists. One of the report’s authors stated that the problem was "relatively straightforward to fix". There is reason to doubt this assumption.

Doubt has been cast on the extent of preventability of medication errors and finding models of care that have actually caused preventable deaths may be hard. Even baseline information is difficult to obtain. Only 6 per cent of ADRs are reported to the Committee on Safety of Medicines. Reporting of medication errors will suffer from similar under-reporting, even before the fear that staff will be blamed is introduced; and the NHS is some way from a no-blame culture.

Information technology (IT) and automation will help reduce risks, but will not prevent all errors. Government investment on IT in the NHS is low, being about 1.5 per cent of the health budget, compared with the 6 per cent spent in the US. The re-engineering of pharmacy services may potentially reduce risks, although these changes can also introduce new risks. Care must be taken to ensure new systems are safe and are monitored to uncover any new risks.

The report has overt messages for the direction and future of pharmacy in the NHS. It underpins the need to invest in medicines management in order to improve standards of patient care. Not surprisingly, one key element necessary for the delivery of the objectives within the report is the availability of suitably trained and experienced pharmacy staff. However, reliable projections for pharmacist numbers required to satisfy a higher profile 24/7 patient-based medicines management system are lacking. At present, 60 per cent of pharmacy departments already report that they cannot offer the services they wish to, and there is a worrying trend of rising vacancies of technician support staff (NHS Pharmacy Education and Development Committee vacancy survey 2001).

Given any amount of exposure to inspirational and motivational management, how attractive is a 24/7 service to the majority of the pharmacy profession? Will a young working mother consider the opportunity to labour in the small hours gives her "flexibility"? Indeed, some work, as yet unpublished, shows up to a 10-fold difference between the numbers of pharmacists who believe that services should be available at night and those who are prepared to participate.

Even with suitable personnel, the spectre of funding remains. The report recommends that consideration be given to the virement of cash from non-pay budgets to fund any extra staffing, but pharmacy will be competing with other pressures, sometimes in trusts with mounting financial difficulties. Previous protracted pay negotiations and a failure to uplift the emergency on-call payment nationally do not provide confidence that the Government is willing to pay the price required to fix recruitment problems and fund a 24/7 pharmacy service. The recent pay settlement for hospital pharmacists, in line with other pay review bodies, may give some hope.

Clinical pharmacy already plays a role in the safe use of medicines and may do more with increased resources, but the reality is that a reduction in medication-related morbidity and mortality will be hard won and will require the close and equal involvement of all health professionals. Hospital pharmacy should not underestimate the challenge and difficulties it faces, and despite the Audit Commission’s strong focus on pharmacy they will not be able to deliver alone. A mere spoonful of sugar may well not be enough to help the medication errors go down.

Mr Cox is the ADR pharmacist at the West Midlands Centre for ADR reporting, Birmingham, and teaching fellow, pharmacy practice research group, Aston University. Dr Marriott is senior lecturer, pharmacy practice research group, Aston University