Hospital Pharmacist
2006;13:218-220
June 2006

GHP/UKCPA joint conference

Moving patient care forward in the face of financial and political obstacles was a key theme at this year’s UKCPA/GHP joint conference. Hannah Pike reports

This article as a PDF (80K)

Delivering the future for pharmacy in stormy weather

The past ten to 20 years have seen a steady acceptance that pharmacy has much to offer, in terms of the Government’s recognition that pharmacists have the potential to deliver good patient care, Keith Ridge, chief pharmaceutical officer for England, told delegates. Referring to current milestones such as pharmacist independent prescribing, Dr Ridge questioned whether it was the beginning of a new era for pharmacy and for patients. “In many ways it is the culmination of many years hard work by practitioners who want to push the boundaries and who want to utilise their skills fully to deliver good care. So perhaps really it is the end of the beginning,” he said.

He gave examples of areas of good practice, such as the diabetes primary care team in Eastern Hull running pharmacist-led clinics for newly diagnosed patients, and a multidisciplinary crisis team within the mental health trust in East Kent NHS and social care partnership.

Dr Ridge turned to the audit of medicines management recently carried out by the Healthcare Commission in England, the results of which are due to be published in the next few months. “Given that there have been two earlier medicines management frameworks, a Spoonful of Sugar and the collaborative, there will inevitably be an expectation of progress in hospitals,” he said.

Using the analogy of trying to build a house during a storm, Dr Ridge asked delegates: “How can you possibly begin building the house at any time, but particularly when the short term forecast is for stormy weather?” He said that an element of calm is needed, but warned: “That does not mean retreating into your bunker to weather the storm.”

Dr Ridge went on to say that he has been surprised how low some clinical pharmacists put cost-effectiveness in their priority list. “For some, money does not seem to be a priority at all,” he said. He said that he is not suggesting pharmacists put cost-effectiveness above all else, but that they should use their skills to achieve a balance between cost and clinical effectiveness, bearing in mind that safety must be paramount.

Dr Ridge urged pharmacists not to forget their essential, traditional skills as new roles emerge. Referring to the £46m that was invested in modernising the network of NHS manufacturing facilities in hospital pharmacies in England, he said it is important that the units work together to rationalise the range of unlicensed products used in the NHS. “I know there has been some progress in clinical rationalisation of products, particularly through some good work with the Royal colleges. However, the implementation of that work needs to step up a gear.” He said that strong leadership and collaboration is required, not just between NHS units, but also with clinical practitioners.

Dr Ridge urged pharmacists to grasp the opportunity to become independent prescribers, but acknowledged that it may be difficult in terms of time. He noted that many hospitals have implemented automated dispensing to help free pharmacists’ time, but suggested that pharmacists need to think of more radical solutions. “You should not, in my view, be afraid to consider how best the private sector can be used in freeing up pharmacy staff to do things like prescribe, while still retaining value for money and a secure supply of medicines,” he said. “Clearly this type of thing needs to be thought through very carefully. However, what we cannot have is clinical and cost effective improvements in patient care being held up by a reluctance to think differently or create innovative solutions.”

Medicines management in Northern Ireland

Placing a medicines management team of pharmacists and technicians in hospitals in Northern Ireland has brought about benefits including reduced length of hospital stay, decreased rates of readmission and reduced drug wastage. Mike Scott, chief pharmacist for United Hospitals Trust in Antrim, described the integrated medicines management project carried out in 2001-04 with the £600,000 funding that was provided by the DHSSPS.

A team of five pharmacists and five technicians was put into five wards — three pairs at Antrim Area Hospital, one pair at Mid-Ulster and one at Whiteabbey Hospital — to focus on medicines management including medicine reviews, monitoring and education.

The results showed that length of stay was reduced by two days (from 9.77 to 7.84, P<0.03), and readmission rates decreased by 20 per cent (P<0.02). In terms of financial benefit, a return of £4.80–£8 was yielded for every £1 invested. Other benefits included improved stock utilisation, better use of use of nursing and junior doctor time, and improved accuracy of discharge prescriptions.

The project is now being rolled out across Northern Ireland, with £4.6m being invested in pharmacy staff over 2004-2008.

E-learning is effective for medicines safety

The evaluation of an internet-based educational programme on medication safety was presented by Bryony Dean Franklin, principal pharmacist, clinical services, and director, academic pharmacy unit, Hammersmith Hospitals NHS Trust.

The programme consisted of 11 training modules on topics such as using the drug chart, one-stop dispensing and drug calculations, designed to take 30 minutes each. The modules were written by trust staff and commercial software was used to deliver the package.

The incidence of medicine administration errors was measured on one ward before and after nursing staff had used the package, during observed ward rounds. A questionnaire was also sent to the staff after they had accessed the modules to gain feedback.

Excluding intravenous drugs, there was an error rate of 6.1 per cent pre-intervention and 4.2 per cent post intervention, giving a reduction of 1.9 per cent (the reduction was not found to be significant if IV drugs were included). The most common types of error were omission due to unavailability, wrong dose and fast administration of an IV bolus. More than half of the nurses responded to the feedback questionnaire and the median scores for each module were either “good” or “very good”.

The high rate of uptake of the programme amongst nursing staff suggests that this is a practical approach for routine practice, Professor Dean Franklin said.

Limitations of the study include that the sustainability of the improvement is unknown, there was no control ward and the observers were unblinded.

Professor Dean Franklin and her team were presented the 2006 Pfizer patient safety award for this work.

Medicines management gives new roles for technicians

The development of a medicines management training course for technicians was described Sheila Woolfrey, chair of the Northern Sector Clinical Pharmacy Network and lead pharmacist, medicine, at Wansbeck General Hospital, Northumbria Healthcare NHS Trust.

Dr Woolfrey described how the Northern sector clinical pharmacy network, technician CPD strategy group and the regional pharmacy education and training office designed a standardised training scheme for technicians consisting of a series of study days (involving lectures and problem-solving workshops) and ward-based activities. Technicians have since taken on new roles such as drug history taking and counselling, and both pharmacists and technicians have reported positive benefits for patient care.

Current challenges for extended prescribing

Extended prescribing is a radical and important development in health care, Tony Avery, head of division of primary care, University of Nottingham, told delegates. He said that pharmacist prescribers are well placed for this extended role, working within their competencies. However, clinical governance, including attention to patient safety, will be critical for its success and development.

Professor Avery described the current issues surrounding pharmacist prescribing. These include:

History taking and examination skills Despite a major concern expressed by the British Medical Association about pharmacists’ skills in medical history taking and examination skills, it is something that can be learnt, said Professor Avery. Pharmacists need to develop their expertise in making diagnoses, including an awareness of differential diagnoses and how to act appropriately when a patient presents with alarm symptoms.

Education and training Given the limited education and training available to extended pharmacist prescribers, it is important that they have a strong clinical background, build on any education and training with continuing professional development and mentorship, and work within their areas of competence, Professor Avery said.

Clinical governance It is important that governance arrangements are in place to assess the quality and safety of clinical care provided by pharmacist prescribers, said Professor Avery. The competencies and training required must be agreed on, as well as the scope of an individual’s prescribing. He said that this may include conventional audits, significant event audits and analysis of prescribing data, and will be facilitated by use of electronic records.

Patient safety There are already major concerns about the safety of pharmacist prescribing in all sectors and all countries, Professor Avery said, although some would argue that pharmacists might be safer prescribers than doctors. However, pharmacists still need to be aware of the potential dangers. Patient safety challenges include the need for access to accurate information about both the patient and the drug at the point of decision making. Communication with patients and with other health professionals is important, as is monitoring response to therapy and checking for adverse effects.

Professor Avery presented new data from a Department of Health funded study into the volume and type of pharmacist prescribing. The figures show that, although the volume of prescribing by community pharmacists is on the increase, numbers are still relatively low. In the last quarter of 2005 just fewer than 4,000 prescriptions dispensed in England were written by pharmacist supplementary prescribers in the community. Putting this into context, Professor Avery said that prescribing volume in his 10,000-patient GP practice alone is greater than the whole of community pharmacist prescribing in England.

Turning to the type of prescriptions written by pharmacists, the data show a clear predominance of cardiovascular system drugs. Within this category a wide range of drugs are being prescribed, including beta blockers, antihypertensives, diuretics, nitrates and anticoagulants.

“This gives the suggestion that the pharmacists who are [prescribing] in the community are getting quite involved in the range of cardiovascular prescribing and not just doing lipid lowering clinics, for example,” Professor Avery explained. Other BNF chapters from which community pharmacists commonly prescribe include the central nervous system (pharmacists involved in substance misuse clinics, for example), the respiratory system (focusing on asthma), the endocrine system (diabetes, thyroid disease and osteoporosis) and gastrointestinal system (ulcer healing and dyspepsia).

There is considerable potential for expansion of pharmacist prescribing and this could bring important benefits for the NHS, Professor Avery said, but this expansion will depend on NHS needs and the incentives provided.

A collegiate model of management

The winner of this year’s IVAX leadership award was Laura O’Loan, assistant director, London Pharmacy Education and Training (LPE&T).

Ms O’Loan described how previously the teams in the LPE&T were perceived to work in isolation. To combat this, non-senior team members were invited to a discussion forum to suggest the goals and purpose of LPE&T and subsequent meetings were held to discuss these proposals and how to achieve them.

New network teams have now been established to improve collaboration across the service. Ms O’Loan explained how involving the whole team in developing the view of the future of the LPE&T has harnessed the expertise within it.

New GHP president

Anthony Oxley, associate director, medicines management, Leicestershire Partnership NHS Trust (pictured) is the new president of the Guild of Healthcare Pharmacists (see p197).