Hospital Pharmacist
2005;12:403-404
November 2005

Clinical governance — Career opportunities for pharmacists

By Debbie Andalo

A new career path is emerging in hospital pharmacy on the back of the Government’s clinical governance reforms. Trusts are increasingly appointing senior pharmacists to take responsibility for the wider clinical risk agenda which is taking them to the heart of policy making. Those pharmacists who have been forging this new role say it brings tremendous professional satisfaction because the top priority is improvement of patient care and safety. However, the job does not come without drawbacks. They warn that you have to be thick-skinned, prepared to be unpopular at times and not shy away from making decisions.

This is a job laden with responsibility on which some pharmacists will thrive. Liz Mellor, clinical governance lead pharmacist for Leeds Teaching Hospitals NHS Trust says: “I love the variety of the job. I enjoy seeing change occurring and that I can influence such change for the benefit of the patient.”

Background

Clinical governance first began to appear in NHS vocabulary after Labour came to power in 1997 and was one of the foundation stones of the NHS planning blueprint. The NHS Plan was published in 2000 and the policy has underpinned the government’s raft of reforms ever since. The Department of Health’s clinical governance support team defines clinical governance as “A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”

The definition clearly illustrates that clinical governance crosses the breadth of an NHS organisation, and it is this breadth which makes a job as clinical governance lead so appealing. Ms Mellor says: “It is not a clinical or operations job — it is the whole breadth of pharmacy and medicines management development.”

Nicky Thomas, clinical governance senior pharmacist for pharmacy for Sheffield Teaching Hospitals NHS Foundation Trust agrees. She says: “Before I took on this job my world was within pharmacy and neuroscience. Now I am in contact with staff of all different kinds in all different areas because clinical governance in pharmacy impacts on all these other areas.”

It was the opportunity to work trust-wide which also appealed to Stephanie Barnes principal pharmacist clinical governance (medicines) at Guys and St Thomas’ NHS Foundation Trust.

Responsibilities

Different clinical governance pharmacists have varying responsibilities according to their individual trust organisation and structures. For Ms Barnes, one of the first clinical pharmacist leads to be appointed in England, key responsibilities include medicines policy, extension of prescribing rights and the risk management of unlicensed medicines.

Narinder Bhallar, lead pharmacist clinical governance at Cambridge University Hospital NHS Foundation Trust, explains that his remit is to consider all “medicines-related risk for the trust”. He says: “I review drug incident forms and horizon scan national action from the National Patient Safety Agency. I work with the trust’s multidisciplinary medicines safety committee, which I set up, to make sure that the trust’s medicines action safety plan is pushed forward.”

The newness of the posts, most of which have only begun to appear in the past five years, has given pharmacists the opportunity to develop the job as they see fit, which for many, attracted them in the first place.

Ms Thomas was the first clinical governance lead in pharmacy in her trust when she took up the post in 2001. She says: “Clinical governance was the new buzz word. It was something which was in its infancy and our trust had demonstrated enough commitment to it for me to realise that it was something which was really going to happen and have a big impact on patient care. I had the opportunity to get involved in that right at the start and to help shape it for other leaders inside and outside the trust.”

Ms Barnes has also relished developing the parameters of the job. She says: “It is one of those roles which is not always as defined as you think. I continue to do it and develop it as I go along.”

Mr Bhallar was also attracted to being given the chance to help design and develop the role. He says: “I like the idea of building up new things which I can then develop. Typically, I change job every three years. I am just at that point now when, normally, I start to think that I have done as much as I can and should pass it on to somebody else.” But contrary to his former career decisions, he has no plans to look for a new job at the moment. “I am still really enjoying it. Perhaps I have another two years here. I have not decided yet.”

Experience

Clinical governance lead pharmacists are generally senior pharmacists with years of experience. It is not a role which, according to those in the post and those involved with professional training, is suitable for those who are newly qualified or have less than seven or eight years’ experience. Ms Thomas’ job description calls for a senior pharmacist with 10 years’ experience, some of which should be in management.

Mr Bhalla, on the other hand, also believes a minimum of seven or eight years experience in necessary to be eligible for such a job role He points out that pharmacists need to have a broad medical background and clinical experience. One problem, however, which may deter those who are most suitable for the level of responsibility and vision required for the senior management role, is grading inconsistencies between trusts for clinical governance leads posts.

One of the issues which may influence the variety of grades for the job is that there is no established educational path to its door. Although some postgraduate training does include clinical governance components, there appears to be no national qualification which will automatically open the door to this kind of career. However, that could all be about to change.

Heidi Wright, head of quality improvement at the Royal Pharmaceutical Society of Great Britain, is helping to develop a clinical governance education package. She says: “As far as I am aware there are no national formal qualifications for clinical governance. At the moment, we are looking at some training around clinical governance, working together with the NHS clinical governance support team. It will be a modular electronic programme which will be available to all pharmacists. We are hoping to get something out next year.”

Broad experience, including some management responsibility, seems to be the criterion for a clinical governance career. Ms Thomas decided to study for a postgraduate diploma in clinical audit after she realised it was an area of professional weakness. She says: “It was the thing I identified that I needed to take on for this role. At the time I went for the job, it was an area where I had no experience at all.”

The diploma has been an “invaluable” benefit on two fronts — clinical audit is a significant part of her job and she is also a tutor for preregistration trainees who have to undertake an audit as part of their training.

Pharmacist lecturer at Aston University, John Marriott, says clinical governance is included in all undergraduate pharmacy degrees and is part of the core curriculum for postgraduate courses. The School of Pharmacy is also in the process of developing a new MSc in pharmacy management in conjunction with its business school partners. He says: “We expect to take our first intake next academic year and a big element of that programme is the management issues around clinical governance.”

Rewards

Pharmacists working in clinical governance say the job drives them on because its end result is improving patient care. Ms Thomas says this was one of the factors which attracted her to the post in the first place. She says: “The appeal to me was that the job is all about improving services— everything around clinical governance is [considering] if mistakes are made, reflecting on them and finding ways of doing things better.”

Ms Mellor and Mr Bhalla were also both attracted by the diversity of the job. Mr Bhalla says: “It is an extremely varied job. Today, for example, I was working on a management of diabetes protocol, an alcohol-withdrawal audit and looking at paediatric drugs risk. There is satisfaction in seeing risk reduced, either through a reduction in errors or a department saying that they think errors are being reduced.”

Although the rewards of the job are high, those in the post admit that they run the risk of being unpopular. It is not a job for the thin-skinned or over-sensitive. Mr Bhalla says: “You have to be careful or you are seen as interfering in a lot of people’s jobs. I used to joke when describing my job that it meant interfering in everything.” Ms Mellor says: “You are solving problems all the time and I love the challenge of being given a number of disparate issues and trying to pull them together. It does make you unpopular but then there are occasions when you are popular when you solve problems. You have to be clear about what your role is, your function in that role and the outcome of your actions. You have to be a decision-maker. It is a big responsibility when you are setting standards in an organisation.”

Ms Thomas believes pharmacists must have a keen interest in solving problems to work in clinical governance. She says: “You have to be able to think around things and deal with situations when they go wrong. When something has not gone right — that is when I investigate it. Some people thrive on that, while others could feel demoralised. I do not think the job makes me unpopular, in fact, the contrary. I think staff are relieved that they have someone they can bring these issues to and that they do not have to deal with them on their own. They can bring the problem to me and get on with their own dedicated role. Having said that it is crucial, particularly in a trust of this size, that you collaborate with the relevant staff groups.”

The achievements of clinical governance pharmacists are easily exposed — either a problem has been solved and systems put in place to prevent it happening again, or a potential problem has been identified and tackled before it has the chance to occur. Those in the post can quickly real off their list of achievements which include establishing a trust-wide, multidisciplinary medicines safety committee; developing a policy on the use of unlicensed medicines and other guidelines around the use of concentrated potassium, for example.

Ms Thomas says: “The satisfaction is sometimes a long time coming. But it is when you have worked on a big project — a set of guidelines or a policy — and you have been through the research, completed the consulting, had it ratified and, finally, it is implemented; then you get positive feedback on the difference it is making and that things are so much better than before — that is when you think it has all been worthwhile.”

For Mr Bhalla the professional rewards are simple and stark. He says: “It is the satisfaction of seeing risk reduced. Basically that is enough.”