Hospital Pharmacist
Vol 9 No 7 p182
July/August 2002

Chief pharmacist or clinical director — what is in a title

By Tony West, BPharm, MRPharmS

Why are we discussing this you might ask? Well, the Audit Commission's "A spoonful of sugar",¹ in recommendation 29, says that NHS trust boards should consider a realignment of the chief pharmacist role. Specifically, they recommend that the role of chief pharmacist should be elevated to the equivalent of a clinical director and that the chief pharmacist should be a member of the trust management executive.

Perhaps the first question to ask is whether, with the wave of a magic wand, the universal implementation of the two parts of this recommendation would make a difference to medicines management in NHS hospitals. Somehow I doubt it; but why not, and what message is the Audit Commission giving the service? Keith Farrar, in a recent article in this column,² gave a brief overview of the report itself and some of the key issues. If there are any hospital pharmacists who have not yet read the full report, this provides a good starting point ... but it is no substitute for the real thing!

The message I believe the Audit Commission is giving is that medicines are an integral component of health care and require "attention". What they found was real variability within the service in recognising this and, as a consequence, there are clinical and financial risks that are not being universally managed appropriately. For me, this means we have a professional leadership issue and this is not just with the trust boards and their chief pharmacists. It is as much an issue for the professional organisations, academia and the Department of Health.

Before I return to the issue of the trust chief pharmacist I can not resist the opportunity to lob a few friendly grenades. The first must go to the Royal Pharmaceutical Society, and it is just the right time to do it, given the discussions now under way about the future make-up of the regulatory and other functions. Sitting, as I do, within a prestigious teaching hospital, it never ceases to amaze me how many professional bodies have input to our trust. As a clinical director, more of which later, I see reports from the royal colleges and the deanery about doctors and am aware of visits from many other professional groups for accreditation of either service or training. And what of pharmacy, you might ask ... an embarrassing silence?

It is, perhaps, a little unfair to lob the next grenade at the Department of Health, because they have provided some of the tools to try and help chief pharmacists. However, these tools may have been seen as more of a chore than help! The controls assurance standard,³ together with the risk register that goes with it, and the performance framework for medicines management⁴ provide a route for chief pharmacists to raise issues within their organisations. The real issue, though, is whether there is the necessary leadership and guidance to help chief pharmacists use those new tools effectively. With both of these exercises being "self-assessment" there were bound to be inconsistencies but the variations found in the data collection exercise undertaken by local auditors and analysed by the Audit Commission raise many questions.

The Audit Commission's findings would tend to suggest that some trusts are likely to struggle to deliver quality services, given their resource base and workload. What they have done, quite understandably, is linked their findings to the structural components they found in the trusts they visited.

The "best" trusts, whatever that might mean, seem to be characterised by the robust uptake of evidence-based practice with a culture of "can do". These trusts have systems that allow resources to grow to meet extra demand, whether driven by workload or a defined improvement in the quality of service provided. At a time when there are serious workforce problems (more, larger, grenades launched at both academia and the RPSGB!), these same trusts tend to have lower vacancy rates. Knowing many of these trusts, I think the real things that characterise all of them is that they have a strong leader supported by an excellent team of senior pharmacists and technicians. More importantly however, pharmacy is totally integrated within the operation of the trust and often leads on some issues — whether this be clinical governance, risk management, ethics committees or simply an extended operational management role in the organisation. So not a case of the title, more about what you are seen to do and deliver.

A glance at my biography box will indicate that I use two titles. This is not so much a case of one-upmanship, but a reflection that I perceive the two roles differently. My consultant colleagues also tend to use this approach, indicating that they are first and foremost consultant physicians and secondly clinical directors. For us, this is because the clinical director role is an operational management role aimed at ensuring clinicians are involved in management. Within the structures of all trusts there is another professional "representative" stream, recognised by the two posts of medical director and chief nurse. These posts are also at board level as opposed to the clinical directors, where representation is at trust executive level.

So where should pharmacy and its chief pharmacist fit in? Pharmacy is a clinical service and must sit within the clinical directorate structure, or whatever is in place to engage clinicians in management. If it does not, then I suggest that the RPSGB should be in discussion with senior managers in the NHS to achieve this. What is most important is the chief pharmacist being seen as the champion of medicines management, working with clinical and non-clinical colleagues to manage the risks medicines pose effectively.

In summary, there is nothing wrong with the title of chief pharmacist and it is one that is understood by the public, patients and our colleagues. There is nothing to gain from being equivalent to a clinical director if medicines management does not become an integral part of delivering health care in the organisation. In the terse words of George Bernard Shaw:

Titles distinguish the mediocre, embarrass the superior, and are disgraced by the inferior