Hospital Pharmacist
Vol 9 No 5 p149-150
May 2002

Hospital pharmacy and the common health gains

Showing the effectiveness of hospital pharmacy

Of what use are hospital pharmacists? Are they worth the salaries they are paid? These were some of the questions that the Guild of Healthcare Pharmacists wanted an answer to when it decided to commission research (PDF* 30K) that will appraise and document evidence to support the effectiveness of hospital pharmacy (see Hosp Pharm, February 2001, p31).

Damian Child, principal pharmacist at South Manchester University Hospitals NHS Trust is in no doubt about his worth. "I certainly think I am worth more than my salary for the job I am doing!"

Mr Child, along with Professor Judith Cantrill, School of Pharmacy and Pharmaceutical Sciences, University of Manchester and Dr Jonathan Cooke, director of pharmacy and director of research and development, South Manchester University Hospitals NHS Trust, won the guild research award and have now produced a report entitled "Effectiveness of hospital pharmacy: where is the evidence?".

Mr Child, who was speaking at the guild's annual national conference, argued that pharmacists must believe that they have an influence on patient care, otherwise there would be no point having them. He pointed out that a lot of work that had been carried out in hospital pharmacy were not accessible, as they might only have been presented at workshops or simply retained at the hospital concerned.

Mr Child and his team had gathered evidence by identifying references from 13 electronic databases, hand-searching of journals and conference proceedings, and in response to letters sent to 466 NHS chief pharmacists across the UK. By December 2001, a database of 824 UK references had been prepared and the list is growing. In addition, 324 potentially useful non-UK references were identified and added to a separate database.

It had not been easy for the Manchester team to collate their evidence. One reason for this was that many pharmacy journals, in which pharmacists would naturally have published their work, were not indexed in databases such as Medline. Mr Child said that even pharmacy databases such as Pharmline were not always useful. The response rate for letters sent out to chief pharmacists was also low (7.3 per cent) and this probably reflected the increased staffing pressures on hospital pharmacy.

In spite of these problems and the fact that pharmacy practice research was relatively new, Mr Child was confident that the project showed that considerable progress had been made. He maintained that good research required significant investment of funds. Pharmacists could improve their chances of obtaining funding by carrying out more evaluative, rather than descriptive, studies and by ensuring that their work was methodologically sound.

Mr Child appealed to hospital pharmacists to examine the report and help to identify any gaps in the evidence presented. He said that a lot of people were doing good work and urged them to "get it published because it helps the profession".

In terms of future work, Mr Child said that additional work would be carried out in areas of pharmacy practice where evidence was currently lacking.

Keith Farrar, chief pharmacist at Wirral Hospitals NHS Trust, asked how to resolve the dilemma that arose from the fact that journals which were indexed in databases such as Medline would not be widely read by pharmacists whereas pharmacy journals (which were read by pharmacists) were not indexed. Mr Child answered by saying that it was necessary to publish in the most academically credible journals. He said that if that meant that people would take the work more seriously, it could only be a good thing.

The report, "Effectiveness of hospital pharmacy: where is the evidence?" will eventually be made available on the guild's website www.ghp.org.uk

Helen Remington, the immediate past president of the guild, described the report as "an invaluable resource" and announced that it would be presented to the Council of the Royal Pharmaceutical Society at a later date. She hoped that the guild would be able to secure funds to ensure that the work could be maintained.

Medicines management review by Audit Commission

As part of the work of the Audit Commission on medicines management, NHS trusts were asked to collect data on their pharmacy services. At the Guild of Healthcare Pharmacists conference, Michael Yeats, project manager, services research directorate, Audit Commission, discussed how the findings from this data collection exercise supported the key recommendations of the report by the Commission on medicines management in NHS hospitals.

The data collection was structured around four main areas: staffing and workload, staff deployment, uptake of processes or initiatives, and expenditure and financial control.

The main finding on staffing and workload was that different staffing levels for similar workloads existed in NHS trusts. The vacancy rate was 11 per cent for pharmacists and 8 per cent for pharmacy technicians. The London and the South East regions had the worst vacancy rates. Mr Yeats proposed that the pharmacy profession needed to set standards for minimum staffing levels until clear outcome measures were developed.

On staff deployment, the review had shown that there was significant variation in the amount of time that pharmacists spent on clinical activities (defined to include clinical pharmacy and medicines information). In 2000/01, it was found that overall, about £27m was spent on dispensing and supply by pharmacists. If this was reduced by 75 per cent, the £21m saved could either pay for automated dispensing in 50 hospitals, or, free up 540 whole time equivalent (WTE) pharmacists, which compared well with the 425 WTE pharmacist vacancies as at 31 March, 2001.

Clearly, there was a case for automation and re-engineering of processes. However, Mr Yeats pointed out that this finding was not about replacing staff with automation. Rather, it had to do with a change of focus and trust boards would have to be convinced of this.

In terms of expenditure and financial control, Mr Yeats said that the impact of the National Institute for Clinical Excellence and National Service Frameworks was not yet evident and that this was a possible explanation for the 8 per cent overspend on drugs in 1999/2000 and 2000/01. He said that there was a need to budget realistically for the use of medicines. Unfortunately, even though the pharmacy department held the drug budget, it had little influence over activities that affected expenditure, such as the appointment of a new consultant, with the consequent effect on prescribing patterns and volume. Mr Yeats thus advocated a more proactive role for pharmacy.

Mr Yeats remarked that trusts demonstrating good practice tended to regard medicines management as being central to clinical risk management. He identified automation and the re-engineering of processes as being essential to any progress.

Mr Yeats concluded that carrying out the audit on medicines management was the easy part and asked delegates at the conference: "What are you going to do? How will your trust help the medicine go down?"

A national review of the findings of the data collection exercise is due to be published later in the year.

Commenting on automation, Helen Remington, immediate past president of the guild, noted that robotics and automation could seem like a huge bill (about £400,000). However, she said, it was possible to acquire automated systems on a lease basis rather than purchasing it and that this might cost only about £15,000 per annum.

Innovations: harnessing advances in technology

The conference provided an opportunity to share innovative work in the delivery of pharmaceutical services. In one of the sessions, June So and colleagues described the use of webcam and computer technology at Christie Hospital, Manchester.

Webcam screening

The hospital has a satellite dispensary located on a booked admissions chemotherapy unit. The unit serves about 40 patients per day with an average of 1,100 items being dispensed per month.

The dispensary is managed by a team of clinical technicians. Pharmacists provide clinical screening by means of a daily ward round and thereafter on an ad hoc basis when they are bleeped by the ward technician. In the latter case, the pharmacist has to travel to the satellite dispensary in order to resolve issues, mostly the screening of a prescription. This means that patients have to wait longer before they can receive their medication.

A webcam was set up in the satellite dispensary with the aim of transmitting high quality visual images of prescription charts (using the hospital intranet) to a computer that is close to the pharmacist. Special software was loaded on to the computer to enable the pharmacist to view the images. This technology thus allows the pharmacist to carry out clinical screening from a remote location.

Although the picture quality obtained was reasonable, other issues that are being resolved include: determining the best site for the camera, determining the optimum distance between the camera and the prescription chart, putting in place security arrangements so that images can only be viewed by pharmacy staff, and assessment of the impact for other users of the network.

The team at Christie Hospital have identified possible extension of webcam technology into the main dispensary as well as the out-of-hours service to reduce the number of callouts for pharmacists and technicians.

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