ABSTRACTS
Guild of Healthcare Pharmacists MSD Award 1999
Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999.
Workshops
Oral Presentations
Poster Presentations
Clinical Governance, CPD and NHS Pharmacists
It would be difficult to exaggerate the importance for the future of hospital pharmacy of the Government's agenda for the New NHS. There has never been such a wide-ranging programme of changes and initiatives that has such significance for our profession. Clinical governance is central to the Government's key strategy to set, deliver and monitor high standards of patient care. In response to the development of clinical governance pharmacists will have the opportunity to demonstrate that they can make a positive and effective contribution to the delivery of high quality patient care in a multidisciplinary environment. This presentation will explore the steps that hospital pharmacists will need to take to ensure that they adopt proactive, timely and appropriate approaches to such a challenging and formidable agenda. The key areas to be addressed will be:
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NICE, the First Year
The National institute of Clinical excellence (NICE) was set up as a special Health Authority on 1st April 1999, It's overall objectives are to promote high clinical standards in the NHS, by developing or commissioning guidance on clinical and cost effectiveness and disseminating this guidance to clinicians, patients and commissioners.
Anne-Toni reviewed the Institute's first year, its work and development to date. She also described how the Institute operates, the ongoing work programme and provided an insight into plans for the next year.
Current Developments at the Department of Health
The title I was given for my presentation is "Current Developments at the Department of Health". An alternative title might be "A year in the life of two civil servants". I say that because, as many of you will know, it is Keith Ridge who deals with many of the issues concerning hospital pharmacy and so some of the initiatives I'm going to be talking about Keith is involved in and, for some of them, I am leading on. The other reason for this alternative title is that I thought Keith and I would do a double act. I will give the presentation and then Keith will answer any questions. (Don't worry Keith - I'm only joking!) More seriously, though, when we do get to the questions, I'll ask Keith to join me. Within my talk, what I plan to do is to set out the policy context using the Priorities Guidance and the announcements following this year's Budget statement. And then to use this as a framework to refer to some of the developments.
National Priorities Guidance Modernisation is the theme running throughout this Government's policies for the public sector. The National Priorities Guidance - "Modernising Health and Social Services" - is no different. It sets out thirteen priorities for the next three years. The first three, within the theme "improving health and tackling health inequalities", are smoking, drug misuse and teenage pregnancy. As well as national initiatives, local action should be planned as part of the HiMP development process to encourage smoking cessation, improve services for drug misusers and prevent teenage conceptions The next group of priorities, under the theme "saving lives", are focused on the big killers: cancer, coronary heart disease and stroke. They pick up two of the National Service Frameworks. The third group is about ensuring that people receive fast access to the care they need, delivered in a way that is responsive to their needs. The two priorities under this theme are "waiting lists and times" and "modernising primary care". The next theme, "caring for vulnerable people", requires health and local authorities to work together to tackle three priority areas: mental health, children's services and older peoples' services. And, of course, the first and the last are also the subjects of National Service Frameworks. The final theme, "modernising strategies", includes three priorities which will support the delivery of the other ten. They are quality, staff and information technology. The Priorities Guidance also identifies three "must-dos", which underpin the delivery of improvements in all the thirteen priority areas. They are: 1. Careful management of NHS resources 2. Strengthening services to prevent and control communicable diseases.
Budget announcement In terms of resourcing those efforts, as we heard in the Budget announcement a couple or so weeks ago, the NHS is to receive significant extra investment. NHS funding will grow by over 6% a year from now to 2004, over and above inflation. If the extra investment is to make a real difference, how it is spent will be very important. Two conditions need to be met. Firstly, the service must be organised efficiently; and secondly, it must deliver preventative, as well as sickness services. To do this, the NHS must modernise, to deliver better, faster, fairer and more convenient services. Prime Minister's Challenges Following the Chancellor's Budget announcement, the Prime Minister made a personal pledge to modernise health and social services. He laid down five major challenges to improve the NHS. These are: Partnership Performance Professions and the wider NHS workforce Patient care Prevention Six Modernisation Action Teams Subsequently, the Secretary of State announced that he is setting up National Modernisation Action Teams to decide how best to meet these challenges. The partnership team will be considering how to make all parts of the health and social care system work better together and ensuring the right emphasis at each level of care. The performance team will focus on improving both clinical performance and health service productivity. The professions and wider NHS workforce challenge is about increasing flexibility in training and working practices and removing demarcations, in the context of a major expansion in the healthcare workforce. Patient care - has two components and therefore two modernisation action teams - the first will look at ensuring fast and convenient access to services; and the second will consider how we can better empower and inform patients, so that they can be more involved in their own care. The sixth team will address prevention and inequalities and how the health system can focus its contribution to tackling the causes of avoidable ill-health. Each of the teams will be chaired by a Minister, with the exception of the sixth one - prevention in inequalities which will be chaired by the Chief Medical Officer. Key stakeholders and front line clinicians and managers will work with them over a four month period to produce a National Plan for the NHS in the summer. Obviously, the thirteen priorities within the National Priorities Guidance map on to these six areas of modernisation. And I now want to use some of the modernisation themes to illustrate some of the developments we are involved in which I hope will be of interest to you. Performance Clinical governance So, under this theme of performance, the first item is clinical governance. I have really included it for completeness, because I know this will have been covered by Peter Sharott in his presentation on Friday. I am sure Peter will have talked about the medicines management performance framework, which we have developed in collaboration with our Regional colleagues. This has been piloted in across five Regions in a number of hospitals. The results are encouraging and we would hope to see it rolled out shortly. Controls assurance Clinical governance and controls assurance are two complementary elements of the local quality improvement programme. Clinical governance focuses on the clinical content of care, whilst controls assurance addresses the systems that underpin that care. Within the controls assurance programme is a chapter on the safe and secure handling of medicines. In the redraft, we have sought to ensure that the standards are in line with the Duthie Report on the safe and secure handling of medicines. We have also sought to ensure that the standards complement the medicines management performance framework and do not duplicate it. So the controls assurance chapter on medicines management addresses the safe and secure handling of medicines and the medicines management framework addresses the clinical contribution of pharmacists and others to ensuring the safe, effective and efficient use of medicines. Medication errors Medication errors is an issue, which is receiving a higher profiles - and not before time! [Press headline - "Doctors' errors wipe out hospitals bonus". Cartoon - "We'll have you up and suing in no time".] Incident reporting is covered within the Controls assurance standard on medicines. And CMO's report on "Learning from Experience" is likely to lead to further impetus. Medicines Information The next item is medicines information, which I have included to allow me to mention the strategy, which has been produced by the Drug Information Pharmacists. I am not trying to clain this as a Department of Health development, but we have had some involvement! It is due to be published very shortly. Obviously, medicines information pharmacists, as they are to be known in the future, make an important contribution to evidence-based practice and good quality care, both in supporting other pharmacists and directly. I think the process of producing a strategy may well be a model, which could be used for other specialist pharmacist groups. Hospital manufacture - risk assessment Another item I wanted to mention under the theme of performance, is the risk assessment of hospital manufacture. With growing concerns about the ability of NHS manufacturing units to secure the necessary resources to meet the standards of GMP, together with the impact of Guidance Note 14 on the manufacture of specials, we have obtained Ministerial agreement to undertake a UK-wide assessment of NHS manufacturing capacity and capability. The 125 NHS manufacturing sites will be shortly receiving a questionnaire. Although it is quite lengthy, I hope you will provide as much information as you can, as this will help us make the most appropriate recommendations to Ministers. PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
Prime Minister's Challenges Following the Chancellor's Budget announcement, the Prime Minister made a personal pledge to modernise health and social services. He laid down five major challenges to improve the NHS. These are:
Six Modernisation Action Teams Subsequently, the Secretary of State announced that he is setting up National Modernisation Action Teams to decide how best to meet these challenges. The partnership team will be considering how to make all parts of the health and social care system work better together and ensuring the right emphasis at each level of care. The performance team will focus on improving both clinical performance and health service productivity. The professions and wider NHS workforce challenge is about increasing flexibility in training and working practices and removing demarcations, in the context of a major expansion in the healthcare workforce. Patient care - has two components and therefore two modernisation action teams - the first will look at ensuring fast and convenient access to services; and the second will consider how we can better empower and inform patients, so that they can be more involved in their own care. The sixth team will address prevention and inequalities and how the health system can focus its contribution to tackling the causes of avoidable ill-health. Each of the teams will be chaired by a Minister, with the exception of the sixth one - prevention in inequalities which will be chaired by the Chief Medical Officer. Key stakeholders and front line clinicians and managers will work with them over a four month period to produce a National Plan for the NHS in the summer. Obviously, the thirteen priorities within the National Priorities Guidance map on to these six areas of modernisation. And I now want to use some of the modernisation themes to illustrate some of the developments we are involved in which I hope will be of interest to you. Performance Clinical governance So, under this theme of performance, the first item is clinical governance. I have really included it for completeness, because I know this will have been covered by Peter Sharott in his presentation on Friday. I am sure Peter will have talked about the medicines management performance framework, which we have developed in collaboration with our Regional colleagues. This has been piloted in across five Regions in a number of hospitals. The results are encouraging and we would hope to see it rolled out shortly. Controls assurance Clinical governance and controls assurance are two complementary elements of the local quality improvement programme. Clinical governance focuses on the clinical content of care, whilst controls assurance addresses the systems that underpin that care. Within the controls assurance programme is a chapter on the safe and secure handling of medicines. In the redraft, we have sought to ensure that the standards are in line with the Duthie Report on the safe and secure handling of medicines. We have also sought to ensure that the standards complement the medicines management performance framework and do not duplicate it. So the controls assurance chapter on medicines management addresses the safe and secure handling of medicines and the medicines management framework addresses the clinical contribution of pharmacists and others to ensuring the safe, effective and efficient use of medicines. Medication errors Medication errors is an issue, which is receiving a higher profiles - and not before time! [Press headline - "Doctors' errors wipe out hospitals bonus". Cartoon - "We'll have you up and suing in no time".] Incident reporting is covered within the Controls assurance standard on medicines. And CMO's report on "Learning from Experience" is likely to lead to further impetus. Medicines Information The next item is medicines information, which I have included to allow me to mention the strategy, which has been produced by the Drug Information Pharmacists. I am not trying to clain this as a Department of Health development, but we have had some involvement! It is due to be published very shortly. Obviously, medicines information pharmacists, as they are to be known in the future, make an important contribution to evidence-based practice and good quality care, both in supporting other pharmacists and directly. I think the process of producing a strategy may well be a model, which could be used for other specialist pharmacist groups. Hospital manufacture - risk assessment Another item I wanted to mention under the theme of performance, is the risk assessment of hospital manufacture. With growing concerns about the ability of NHS manufacturing units to secure the necessary resources to meet the standards of GMP, together with the impact of Guidance Note 14 on the manufacture of specials, we have obtained Ministerial agreement to undertake a UK-wide assessment of NHS manufacturing capacity and capability. The 125 NHS manufacturing sites will be shortly receiving a questionnaire. Although it is quite lengthy, I hope you will provide as much information as you can, as this will help us make the most appropriate recommendations to Ministers. PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
Performance Clinical governance So, under this theme of performance, the first item is clinical governance. I have really included it for completeness, because I know this will have been covered by Peter Sharott in his presentation on Friday. I am sure Peter will have talked about the medicines management performance framework, which we have developed in collaboration with our Regional colleagues. This has been piloted in across five Regions in a number of hospitals. The results are encouraging and we would hope to see it rolled out shortly. Controls assurance Clinical governance and controls assurance are two complementary elements of the local quality improvement programme. Clinical governance focuses on the clinical content of care, whilst controls assurance addresses the systems that underpin that care. Within the controls assurance programme is a chapter on the safe and secure handling of medicines. In the redraft, we have sought to ensure that the standards are in line with the Duthie Report on the safe and secure handling of medicines. We have also sought to ensure that the standards complement the medicines management performance framework and do not duplicate it. So the controls assurance chapter on medicines management addresses the safe and secure handling of medicines and the medicines management framework addresses the clinical contribution of pharmacists and others to ensuring the safe, effective and efficient use of medicines. Medication errors Medication errors is an issue, which is receiving a higher profiles - and not before time! [Press headline - "Doctors' errors wipe out hospitals bonus". Cartoon - "We'll have you up and suing in no time".] Incident reporting is covered within the Controls assurance standard on medicines. And CMO's report on "Learning from Experience" is likely to lead to further impetus. Medicines Information The next item is medicines information, which I have included to allow me to mention the strategy, which has been produced by the Drug Information Pharmacists. I am not trying to clain this as a Department of Health development, but we have had some involvement! It is due to be published very shortly. Obviously, medicines information pharmacists, as they are to be known in the future, make an important contribution to evidence-based practice and good quality care, both in supporting other pharmacists and directly. I think the process of producing a strategy may well be a model, which could be used for other specialist pharmacist groups. Hospital manufacture - risk assessment Another item I wanted to mention under the theme of performance, is the risk assessment of hospital manufacture. With growing concerns about the ability of NHS manufacturing units to secure the necessary resources to meet the standards of GMP, together with the impact of Guidance Note 14 on the manufacture of specials, we have obtained Ministerial agreement to undertake a UK-wide assessment of NHS manufacturing capacity and capability. The 125 NHS manufacturing sites will be shortly receiving a questionnaire. Although it is quite lengthy, I hope you will provide as much information as you can, as this will help us make the most appropriate recommendations to Ministers. PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
Clinical governance So, under this theme of performance, the first item is clinical governance. I have really included it for completeness, because I know this will have been covered by Peter Sharott in his presentation on Friday. I am sure Peter will have talked about the medicines management performance framework, which we have developed in collaboration with our Regional colleagues. This has been piloted in across five Regions in a number of hospitals. The results are encouraging and we would hope to see it rolled out shortly. Controls assurance Clinical governance and controls assurance are two complementary elements of the local quality improvement programme. Clinical governance focuses on the clinical content of care, whilst controls assurance addresses the systems that underpin that care. Within the controls assurance programme is a chapter on the safe and secure handling of medicines. In the redraft, we have sought to ensure that the standards are in line with the Duthie Report on the safe and secure handling of medicines. We have also sought to ensure that the standards complement the medicines management performance framework and do not duplicate it. So the controls assurance chapter on medicines management addresses the safe and secure handling of medicines and the medicines management framework addresses the clinical contribution of pharmacists and others to ensuring the safe, effective and efficient use of medicines. Medication errors Medication errors is an issue, which is receiving a higher profiles - and not before time! [Press headline - "Doctors' errors wipe out hospitals bonus". Cartoon - "We'll have you up and suing in no time".] Incident reporting is covered within the Controls assurance standard on medicines. And CMO's report on "Learning from Experience" is likely to lead to further impetus. Medicines Information The next item is medicines information, which I have included to allow me to mention the strategy, which has been produced by the Drug Information Pharmacists. I am not trying to clain this as a Department of Health development, but we have had some involvement! It is due to be published very shortly. Obviously, medicines information pharmacists, as they are to be known in the future, make an important contribution to evidence-based practice and good quality care, both in supporting other pharmacists and directly. I think the process of producing a strategy may well be a model, which could be used for other specialist pharmacist groups. Hospital manufacture - risk assessment Another item I wanted to mention under the theme of performance, is the risk assessment of hospital manufacture. With growing concerns about the ability of NHS manufacturing units to secure the necessary resources to meet the standards of GMP, together with the impact of Guidance Note 14 on the manufacture of specials, we have obtained Ministerial agreement to undertake a UK-wide assessment of NHS manufacturing capacity and capability. The 125 NHS manufacturing sites will be shortly receiving a questionnaire. Although it is quite lengthy, I hope you will provide as much information as you can, as this will help us make the most appropriate recommendations to Ministers. PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
Controls assurance Clinical governance and controls assurance are two complementary elements of the local quality improvement programme. Clinical governance focuses on the clinical content of care, whilst controls assurance addresses the systems that underpin that care. Within the controls assurance programme is a chapter on the safe and secure handling of medicines. In the redraft, we have sought to ensure that the standards are in line with the Duthie Report on the safe and secure handling of medicines. We have also sought to ensure that the standards complement the medicines management performance framework and do not duplicate it. So the controls assurance chapter on medicines management addresses the safe and secure handling of medicines and the medicines management framework addresses the clinical contribution of pharmacists and others to ensuring the safe, effective and efficient use of medicines. Medication errors Medication errors is an issue, which is receiving a higher profiles - and not before time! [Press headline - "Doctors' errors wipe out hospitals bonus". Cartoon - "We'll have you up and suing in no time".] Incident reporting is covered within the Controls assurance standard on medicines. And CMO's report on "Learning from Experience" is likely to lead to further impetus. Medicines Information The next item is medicines information, which I have included to allow me to mention the strategy, which has been produced by the Drug Information Pharmacists. I am not trying to clain this as a Department of Health development, but we have had some involvement! It is due to be published very shortly. Obviously, medicines information pharmacists, as they are to be known in the future, make an important contribution to evidence-based practice and good quality care, both in supporting other pharmacists and directly. I think the process of producing a strategy may well be a model, which could be used for other specialist pharmacist groups. Hospital manufacture - risk assessment Another item I wanted to mention under the theme of performance, is the risk assessment of hospital manufacture. With growing concerns about the ability of NHS manufacturing units to secure the necessary resources to meet the standards of GMP, together with the impact of Guidance Note 14 on the manufacture of specials, we have obtained Ministerial agreement to undertake a UK-wide assessment of NHS manufacturing capacity and capability. The 125 NHS manufacturing sites will be shortly receiving a questionnaire. Although it is quite lengthy, I hope you will provide as much information as you can, as this will help us make the most appropriate recommendations to Ministers. PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
Medication errors Medication errors is an issue, which is receiving a higher profiles - and not before time! [Press headline - "Doctors' errors wipe out hospitals bonus". Cartoon - "We'll have you up and suing in no time".] Incident reporting is covered within the Controls assurance standard on medicines. And CMO's report on "Learning from Experience" is likely to lead to further impetus. Medicines Information The next item is medicines information, which I have included to allow me to mention the strategy, which has been produced by the Drug Information Pharmacists. I am not trying to clain this as a Department of Health development, but we have had some involvement! It is due to be published very shortly. Obviously, medicines information pharmacists, as they are to be known in the future, make an important contribution to evidence-based practice and good quality care, both in supporting other pharmacists and directly. I think the process of producing a strategy may well be a model, which could be used for other specialist pharmacist groups. Hospital manufacture - risk assessment Another item I wanted to mention under the theme of performance, is the risk assessment of hospital manufacture. With growing concerns about the ability of NHS manufacturing units to secure the necessary resources to meet the standards of GMP, together with the impact of Guidance Note 14 on the manufacture of specials, we have obtained Ministerial agreement to undertake a UK-wide assessment of NHS manufacturing capacity and capability. The 125 NHS manufacturing sites will be shortly receiving a questionnaire. Although it is quite lengthy, I hope you will provide as much information as you can, as this will help us make the most appropriate recommendations to Ministers. PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
Medicines Information The next item is medicines information, which I have included to allow me to mention the strategy, which has been produced by the Drug Information Pharmacists. I am not trying to clain this as a Department of Health development, but we have had some involvement! It is due to be published very shortly. Obviously, medicines information pharmacists, as they are to be known in the future, make an important contribution to evidence-based practice and good quality care, both in supporting other pharmacists and directly. I think the process of producing a strategy may well be a model, which could be used for other specialist pharmacist groups. Hospital manufacture - risk assessment Another item I wanted to mention under the theme of performance, is the risk assessment of hospital manufacture. With growing concerns about the ability of NHS manufacturing units to secure the necessary resources to meet the standards of GMP, together with the impact of Guidance Note 14 on the manufacture of specials, we have obtained Ministerial agreement to undertake a UK-wide assessment of NHS manufacturing capacity and capability. The 125 NHS manufacturing sites will be shortly receiving a questionnaire. Although it is quite lengthy, I hope you will provide as much information as you can, as this will help us make the most appropriate recommendations to Ministers. PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
Hospital manufacture - risk assessment Another item I wanted to mention under the theme of performance, is the risk assessment of hospital manufacture. With growing concerns about the ability of NHS manufacturing units to secure the necessary resources to meet the standards of GMP, together with the impact of Guidance Note 14 on the manufacture of specials, we have obtained Ministerial agreement to undertake a UK-wide assessment of NHS manufacturing capacity and capability. The 125 NHS manufacturing sites will be shortly receiving a questionnaire. Although it is quite lengthy, I hope you will provide as much information as you can, as this will help us make the most appropriate recommendations to Ministers. PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
PPRS and hospitals One of the "must-dos", which is also relevant to performance and productivity, is the careful management of NHS resources. The recent PPRS agreement is important here. For the first time with this settlement, the Department of Health has taken action to ensure the hospital sector benefits from that agreement where possible. We have undertaken a survey of a sample of fifty acute and community NHS Trusts to obtain information on price changes resulting from the PPRS settlement. This has involved a great deal of time and effort by pharmacy staff, for which we are very grateful. We undertook the first survey towards the end of last year and we will be repeating it shortly. This information not only gives us data on how hospital prices have been affected, but will also inform our discussions with pharmaceutical companies. Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately. Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site. Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data. Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem. Table 1. Pharmacy Contribution to Patient Care on PTWR
Professions Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds Ruth Bednall, Duncan McRobbie & Tony West, Pharmacy Department St. Thomas' Hospital, London SE1 7EH
Pharmacists prescribing One of the developments which would remove demarcations and lead to more flexible working practices, and assist in meeting the Prime Minister's challenge for professions, is the implementation of the two Crown Reports. Ministers announced recently that this will be tackled in a step-by-step approach. The legislation is already in place to enable the expansion of nurse prescribing. Pharmacist prescribing requires primary legislation and must await a slot in the Parliamentary timetable. However, in the meantime, I think the profession needs to continue to develop its contribution and demonstrate its capability within existing arrangements, such as managing the continuation of medicine supply for patients leaving hospital, and through, for example, pharmacists-led anticoagulant clinics. Patient Group Directions, which I will come to later, will also help. Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone. Reasons to avoid the use of concurrent typical drugs: EPSE may emerge or worsen (and therefore worsen secondary negative symptoms) Symptoms of hyperprolactinaemia may emerge or worsen May increase incidence of TD Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK. Method Pharmacists with responsibility for psychiatry were identified from a previous survey In May 1998, 229 requests for information were sent out to pharmacists identified Pharmacists collected data in one week of June Reminder letters were sent out in the second week of June Results Response rate of atypical prescribing survey 62% > 6 weeks therapy Cloz Risp Sert Olan Quet Amis Number of patients 800 646 48 892 124 56 Mean dose (mg/day)Dose range (mg/day) 483.412.5 - 950 6.30.25 - 16.0 17.14.0 - 25.0 15.61.6* - 45.0 524.225 - 750 727.7100 - 1200 N (%) patients on atypical alone(no regular or prn other antipsychotics) 450(56.3) 178(27.6) 13 (27.1) 169(18.9) 12(9.7) 4(7.1) N (%) patients on atypical and prn typical 233(29.1) 256(39.6) 23(47.9) 377(42.3) 64(51.6) 31(55.3) N (%) patients on atypical and regular typical (+/- prn) 104(13.0) 204(31.6) 12(25.0) 329(36.9) 47(37.9) 21(37.5) N (%) patients on atypical and another atypical 13 (1.6) 8(1.2) 0 17(1.9) 1(0.8) 0 Use of anticholinergics N (%) pts on reg. antich. and atypical alone 118/683(17.3%) 101/434(23.3%) 5/36(13.9%) 53/546(9.7%) 7/76(9.2%) 9/34(26.5%) N (%) pts on reg. antich. & atypical& reg. typical 48/117(41.0%) 122/212(57.5%) 7/12(58.3%) 155/346(44.8%) 23/48(47.9%) 13/2259.1%) Chi-squared test(df = 1) p P< 0.0001 P< 0.0001 P=0.002 P<0.0001 P<0.0001 P=0.015 Note. Amis = Amisulpride Olan = Olanzapine Risp = Risperidone Cloz = Clozapine Quet = Quetiapine Sert = Sertindole Conclusions Atypical drugs are prescribed as the sole antipsychotic in only a minority of patients The co-prescription of typical drugs makes the use of regular anticholinergics significantly more likely (indicating the emergence or worsening of EPSE)Z The use of "PRN" typical antipsychotics is widespread despite being illogical Some atypical drugs (e.g. olanzapine) are used in higher doses than those recommended by manufacturers The quality of prescribing practice with atypical antipsychotics is exceptionally poor judged by evidence-based criteria References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82. ......................................... back to top 'Making a Difference' - Pharmacy Contribution to Medical Post-Take Ward Rounds
Primary care pharmacists With the spot-light on primary care, the number of pharmacists working on prescribing, medicines management and pharmaceutical care within GP practices, PCGs, PCTs and Health Authorities is increasing significantly. The rapid pace of NHS reform and the new emphasis on quality mean that all professionals have to reappraise and realign their skills and knowledge within this new environment. This is particularly true of primary care pharmacists. Through a joint initiative between the NHS Executive and the National Prescribing Centre, in association with the Pharmaceutical Advisers' Group, we are about to launch a core competency framework to help pharmacists, working in primary care, identify and address their continuing professional development needs. Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom Taylor D, Mace S, & Mir S Pharmacy Department,Maudsley Hospital, London
Workforce Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%) Managers' perceptions of the roles of pharmacy technicians in 2 years' time Increased involvement in clinical trials, self-administration and patients' own drugs schemes; developing financial information, drug bulletins, and formularies; filing, data input, and query answering in drug information; audit, patient counselling, and final checking of dispensed and compounded items Decreased involvement in dispensing, distribution, compounding and stores No change in the involvement in quality assurance / control, computer support, attending external meetings, prescription monitoring, and the education and training of other pharmacy staff The level of support for a national register of technicians 410 technicians (77%) and 36 senior pharmacy managers (78%) supported a national register 16 technicians (3%) and 1 senior pharmacy manager (2%) did not support a national register 94 technicians (18%) and 8 senior pharmacy managers (17%) said they didn't know 14 technicians (3%) and 1 senior pharmacy manager (2%) did not answer Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians. Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff. Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires. References Thompson L, Lockwood J, Freeborn S. Pharmacy technical support focus group North West - mapping exercise. Pharmacy Management 1999; 15: 9-13 Hospital group chairman calls for technician registration. Pharm J 1999; 263: 732 http://www.formic.co.uk ......................................... back to top A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom
Recruitment and retention Workforce, or the lack of it, is probably the number one issue on the minds of hospital chief pharmacists and their staff at the moment. How to attract new staff? How to retain the staff they have? How to make best use of the staff they have? And this is all the more frustrating because of the huge agenda I have outlined and the real opportunities for pharmacy. There is light at the end of the tunnel, with a 20% increase in the number of pharmacy students since 1993. But, in the short to medium term, there will be recruitment and retention difficulties for the hospital pharmacy workforce. And I realise it is not only in respect of pharmacists, but also pharmacy technicians, because there too there are sizeable vacancy rates. The Pharmacy Workforce and Training Working Group report, published in 1997, stimulated a great deal of positive action. However, as we enter the first of the two fallow years - firstly, few preregistration trainees and then, in 2001, few newly qualified pharmacists, continuing action is required. Locally, I know there is much good practice and many creative approaches. And these can be shared with other pharmacy managers. However, we also need to ensure that pharmacy is stitched into national workforce initiatives. Although the current focus nationally, just now, is on nurses, the general approaches are also being applied to other NHS staff groups. One of these is the new approach to NHS Careers. The new "Join the Team", NHS Careers campaign, whilst recently focusing on nursing, does so in such a way to promote all NHS careers. I am sure you will have seen the advert about Joe who, 18 months ago, was knocked down by a car. 34 people picked him up, including a pharmacist. This means that the campaign draws attention to other NHS staff groups, whilst it focuses on one particular group. It also means that, in the future, the campaign can be easily adapted to promote other particular groups, like pharmacists. It also targets returners, as well as newly qualified staff (hospital pharmacist case study). A new NHS Careers Service has also been launched with a single telephone number. Again, it is currently dealing with nursing, but will shortly be extended to other professions, including pharmacy. As well as a job that is rewarding, flexible employment arrangements are also important. The "Improving Working Lives" campaign is proving quite successful and new national standards are about to be launched. Pharmacy has developed a number of creative approaches (refer to tool kit), but I am sure can do more. Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2. Objectives To identify the career expectations and aspirations of pharmacy technicians in 5 years' time To identify managers' perceptions of the roles of pharmacy technicians in 2 years' time To identify the level of support for a national register of technicians Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis. Results 534 technicians (40%) and 46 managers (60%) returned their questionnaires. The career expectations and aspirations of pharmacy technicians in 5 years' time Expectation Aspiration Working as a technician 437 (81%) 339 (64%) Training to be a pharmacist 5 (1%) 19 (4%) Working in a non-pharmacy related job 43 (8%) 75 (14%) Not working / career break / retired 30 (5%) 74 (14%) Not answered 19 (4%) 27 (5%)
Workforce planning review Many of the best services in the NHS are delivered by teams of doctors, pharmacists, nurses and other health professionals, working together across traditional professional boundaries. Workforce planning - which today looks at each NHS profession in isolation - needs to plan and train staff for a modern NHS by breaking down traditional barriers between different staff groups. A consultation paper A Health Service of all the Talents: Developing the NHS Workforce was published on Thursday. It sets out proposals for the review of workforce planning, including: Establishing a national workforce planning board to take a strategic role in staff planning and development; Establishing a single source of NHS funding for undergraduate and postgraduate training and education, so that resources can be used more flexibly; and Developing more flexible training arrangements, so that NHS staff can switch between different professions during their training without having to restart training from scratch. The report recognises the growing demand for pharmacists to support the developing prescribing and medicines management agenda and the work in hand to tackle recruitment and retention difficulties. It also highlights the need to build on this work to recognise the clinical expertise of pharmacists, to enhance career opportunities and to ensure that there are sufficient pharmacists with the necessary skills to meet the needs of both primary and secondary care. Work is already in hand to develop new human resource strategies for nurses and PAMs. Making a Difference - the strategy for nursing - is an exemplar. Work is also being initiated to develop a parallel strategy for scientists and technicians, which will include pharmacists. I know some of you will say why are we being included in this group? We're clinical! This group also includes clinical psychologists. Pharmacists need to be included in one of the groups and inclusion with the PAMs can be viewed equally inappropriate. Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours. Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes: To maintain the strong training component of the basic grade rotation To reduce the length of the working week to comply with WTR To address the length of each shift and ensure appropriate compensatory rest. Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included: A 1 in 8 resident commitment (equating to 47.25 hours per week), which required an increase of 4 residents in establishment with some annual leave would be covered by back up pharmacists in order to ensure the 48 hour working week was not exceeded Each shift would be reduced to 24 hours and followed by a whole day compensatory rest A continued commitment to the basic grade training programme. A commitment to ensure that the maximum 48 hour working week and minimum break between shifts were achieved and appropriate. A collective agreement with the current residents to vary requirements for the24 hour shift required and to extend the period of reference form 17 weeks to 26 weeks as this fitted more appropriately with the operational rotations Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements. Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future. ......................................... back to top Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames Laura M. O'Loan *, MSc, MRPharmS, Diane M. Evans **, DMS, MSc & Angela M. Alexander ***, BPharm, MSc, PhD, FRPharmS, MCPP * Principal Pharmacist, ** Technician Training Co-ordinator, North Thames Pharmacy Education & Training, *** Consultant in Pharmaceutical Research and Education, Maidenhead, Berkshire
Job evaluation One of the elements of Agenda for Change to underpin a new pay system is job evaluation. Having looked at a number of job evaluation schemes and found them wanting, in terms of the needs of the NHS, an NHS job evaluation scheme is being specifically developed. Job evaluation addresses the issue of equal pay. It allows new jobs to be designed more flexibly to meet patient needs. And it allows new qualifications, continuing professional development and increased responsibility to be recognised more easily. As Ron Pate indicated in his recent paper in Pharmacy Management, the implementation of job evaluation presents an opportunity to modernise the career structures within pharmacy. So that they support the future development of hospital pharmacy services, and facilitate careers within pharmacy management, as well as clinical practice. But also, so that they properly reflect the roles of pharmacists employed by the NHS in primary care and Health Authorities, as well as secondary care, and also the prison service. Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames "Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications. NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally. Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda. The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support. The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following: How should enquiries for information or advice about medicines be handled, given that both community pharmacists and DI pharmacists answer these types of enquiries from members of the public at the moment? How should pharmacists contribute to the development of NHS Direct plans to provide disease management type services over the telephone? How might pharmacy wish to contribute to the NHS Direct web site - what topic might be appropriate for briefings? In what other areas might pharmacy wish to contribute? ......................................... back to top Oral Presentations
Patient care (speed of access) NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence. It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim. Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other. In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care. Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance. ......................................... back to top Information for Health - one year on Margaret Hewetson Director of Drug Information South Thames
NHS Direct NHS Direct is one of the Government's "big ideas" for the health service. By the end of the year, everyone in England will be able to contact NHS Direct and obtain advice about health, illness and the NHS over the telephone. Pharmacy is playing its part here too, through the involvement of Drug Information - or should I say Medicine Information - Pharmacists handling difficult medicine queries and through the pilot in Essex where patients are referred to a community pharmacist, alongside the other three options of self-care, GP consultation and accident and emergency. Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing. ......................................... back to top Developing a Pharmacy Intranet system Dr Shapour Hariri IT Project Manager Regional Drug Information Centre Guy's Hospital In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget. Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available. This workshop will focus on the following: What is an Intranet? Advantages of having an intranet? Intranet Vs Internet What content to publish Technologies involved Cost and time implications Maintenance of the data Electronic formularies (inc WeBNF) Future possibilities? ................................... back to top Litigation and clinical governance Dr Peter Harrowing Solicitor The United Bristol Healthcare NHS Trust
Walk in Centres In the same vein, pharmacists also need to get involved with walk-in centres. They need to ensure that there are safe and secure systems for handling medicines, in keeping with the controls assurance standard. They need to oversee the supply of medicines to walk-in centres, so that they are appropriately presented and risk is minimised. Pharmacists may also be one of the team working within walk-in centres. There's an example of this being developed in St Helen's and, of course, there is the walk-in centre based within a Boots pharmacy at Birmingham New Street Station. Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex. Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur. The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas. ......................................... back to top Working with biotechnological products Dr Cathleen Sass Clinical Science Liaison Gilead Sciences
Patient group directions Pharmacists also need to get involved with the establishment of patient group directions, formerly known as group protocols, for use in walk-in centres, as well as elsewhere. We are currently consulting on changes to the legislation, which will clarify the law on the use of patient group directions. The consultation document, MLX260, was disseminated by the MCA in the middle of March. If you haven't already seen it, you can get hold of a copy from the MCA web-site and have a look at it, along with the draft Health Circular. Pharmacists will of course be among professions that will be able to work within patient group directions. Patient care (empowerment) And the final three topics I want to touch on are: Concordance; The Expert Patient Task Force; and Professional training. The theme, running through these, is patient empowerment and involvement. Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust
Patient care (empowerment)
Concordance and medicine taking Concordance and medicine taking are increasingly on the agenda. They were referred to in the recent Watchdog Feature on Waste Medicines and they were also addressed at a conference run by the Promoting Excellence in Consumer Medicine Information Group earlier this week, at which Lord Hunt spoke. I am sure you are all aware of the "From Concordance to Compliance" document produced by the RPSGB in association with MSD, from which the concept of "concordance" originates. That document was published three years ago. It always takes time for new ideas to catch on, but I am fairly certain in the next year the agenda around medicines will move to address appropriate medicine taking, as well as appropriate prescribing. Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops Fit for the future? Training the next generation Graham Davies Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care. Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision. The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders. ......................................... back to top Advances in HIV therapy Rosy Weston Principal Pharmacist GUM/HIV services, St. Mary's NHS Trust
Expert Patient Task Force An initiative arising from Saving Lives: Our Healthy Nation, which is very relevant to concordance is the Expert Patient Task Force. This group will design a programme to help people with chronic conditions take the lead themselves in managing their condition, with appropriate support from the health service. It will build on existing work, which indicates that not only does the approach help patients better know and cope with their condition, it also can enable them to understand and manage their prescribed medication better. Self-management programmes give patients the skills to communicate more effectively with healthcare professionals. And everyone gains, because it leads to more productive consultations. There is pharmacy input to both the main task force and its sub group. And I expect the patient and professional-led self-management programmes, which result from this work, will provide a major push for concordance in prescribing and medicine taking. Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999. A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester. The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit. Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home. 13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital. Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit. The OP costs were found to be approximately half of the IP costs. We conclude that OP delivery of the deGramont regimen is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance. ......................................... back to top Workshops
Professional training Not only can expert patients play an important part in self-management programmes, but they can also make a valuable contribution to the training of health professionals. I believe that patients should be involved in the design and delivery of training programmes for pharmacists. This is particularly important in respect of the development of effective communication skills. CPPE is looking to make further progress with this approach. Conclusion I have set the policy context, using the 13 priorities in the National Priorities Guidance and the Prime Minister's five challenges. I have then use these to outline some of the developments at the Department of Health, relevant to pharmacy. ......................................... back to top A Vision for the Future Naaz Coker, Kings Fund Fellow The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on: Leadership, accountability and governance Pharmacy's values, core beliefs and behaviors The new demand for strategic thinking Separating strategy from exhortation ......................................... back to top Guild of Healthcare Pharmacists MSD Award 1999. An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh. All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal. To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented. ......................................... back to top Guild of Healthcare Pharmacists Baxter Healthcare Intravenous Therapy Award 1999.
Conclusion
A Vision for the Future
The session addressed the changing context for health care delivery and the challenges facing health care professionals in the future. The emphasis was on:
An evaluation of qualitative analysis and feedback sessions in achieving concordance and hence optimal therapy in liver and renal transplant patients. Claire Hodgkinson Clinical Pharmacist, Renal and Renal Transplant Units, Royal Infirmary of Edinburgh.
All liver and renal transplant recipients attending the outpatient clinic at the Royal Infirmary of Edinburgh from 27th July 1999 on tacrolimus therapy were approached, the one exclusion criterion being if the patient used a form of medication compliance device routinely. Patients were phoned the evening before their clinic appointment and asked to bring in their tacrolimus from home. At their clinic visit written consent was obtained before repackaging 28 days supply of their tacrolimus into a bottle with an electronic Drug Event Monitor (eDEM) lid (Aardex, Zug, Switzerland). At 28 days the device was retrieved for downloading of data, and the patient asked to complete an EPQ-R and a SF45 questionnaire. Qualitative analysis was performed to see what patients felt about taking medications, whether they had any problems with this and whether they felt that they experienced any side effects from their medications. Patients with compliance outwith 90-110% completed a second 28 day period with eDEM surveillance on their tacrolimus bottle. These patients were randomised to three groups: group 1) patient not informed of surveillance and function of eDEM bottle lid; group 2) patient informed that compliance to tacrolimus therapy being monitored via eDEM device; group 3) patient informed that compliance being monitored via eDEM device plus feedback session on results from previous 28 day period plus qualitative analysis. Data was analysed to see what effect, if any, the feedback session had on concordance. Results from the EPQ-R and SF45 questionnaires were compared to see whether it was possible to target patients whose compliance would be suboptimal.
To date 59 patients have been recruited to stage 1. Of these, 6 patients have had compliance out with 90-110%. Further results will be presented.
A feasibility study to compare the possibility of patients receiving out-patient (OP)deGramont chemotherapy for metastatic colorectal cancer rather than in-patient (IP) deGramont chemotherapy. Michelle Rowe Chief Technician The Christie Hospital, Manchester.
The deGramont chemotherapy regimen of 5-Fluorouracil(5Fu) and calcium folinate (FA) is widely used for the treatment of metastatic colorectal cancer. Commonly six or twelve cycles of treatment are given over a three or six month period, consisting of a 48 hour infusion, repeated every two weeks. This regimen currently requires the patient to be hospitalised. Was this necessary as these patients are otherwise healthy? It was recognised that if it could be given as an OP procedure both patients and health budgets could benefit.
Three requirements were identified to convert the regimen from an IP to OP procedure. These requirements were enacted under the co-ordination of a pharmacy technician: nursing staff trained to insert central venous catheters(CVC); filled disposable elastomeric infusion devices were obtained; patients and/ or carers were trained to change their own devices at home.
13 patients were enrolled into each arm. Quality of life(QOL)data and face to face interviews were conducted by the technician at each patient visit to the hospital.
Results: All OP received treatment on expected days, however 54% IP received less than 6 cycles due to the gruelling treatment schedule. All the IP had treatment delays each visit.
The OP costs were found to be approximately half of the IP costs.
We conclude that OP delivery of the deGramont regimen
is practical, cost effective and offers considerable QOL benefits, in turn leading to greater patient morale and compliance.
Predicting the future is always a risky business. One of the few certainties in life is that experience can teach us how to deal with the challenges that lie ahead. As health care is continually evolving, the challenges faced are often difficult and frequently encountered, so that evaluating the type of care provided, how it is delivered and by whom, is essential. Predicting the training needs of pharmacists, based on some future model of health care is therefore difficult and best approached by examining the processes currently adopted. Carrying out such an appraisal may provide some indication of the structure and process needed to ensure that future training models produce pharmacists capable of delivering pharmaceutical care.
Let us first review the issue of competency. Although the profession has made attempts to ensure that its workforce is competent by introducing a skills based pre-registration training programme, this approach fails to evaluate the ability of individuals to undertake certain tasks to a required, pre-defined standard. In fact research evaluating the competency of pre-registration pharmacists suggests that a significant number are unable to perform some of the basic tasks required of a clinical pharmacist, to the desired standard. Furthermore, once an individual has passed the pre-registration year he/she is never required to demonstrate their competency again; the expectation being that all pharmacists can provide the same level of service, regardless of the training they have received or their prior experience. The introduction of clinical governance is likely to influence the general quality of the pharmaceutical service provided and specifically the "fitness for purpose" of those practitioners responsible for its provision.
The session will highlight the problems associated with the approaches currently used to produce practitioners "fit for purpose" and the resulting consequences. The workshop will then deal with the key ingredients of a future training strategy in line with the requirements of the NHS. Particular emphasis will be placed on the relationship between a competency based training programme and the career of a professional; the need for succession planning; the relevance of accredited tutors and training sites in maintaining standards of delivery and its relationship with continuing professional development. It is hoped that the issues and solutions raised in discussion will serve to inform the deliberations currently being undertaken by key stakeholders.
Advances in HIV therapy
The ultimate goal of therapy for an illness is to improve length and quality of life. In HIV-1 infection, the currently believed route to this goal is to suppress the level of virus to as low as possible for as long as possible. Over the last 4 years significant developments have occurred in the understanding of viral replication, improved diagnostic and monitoring techniques, in conjunction with a wider range of therapeutic interventions. Whilst this has resulted in a dramatic reduction in mortality and morbidity due to HIV in the developed world, these developments have made the management of HIV infection even more complex.
Clinicians and patients are faced with frequent changes in what is regarded as the current standard of care as new data emerges on new drugs, new combinations, new treatment strategies and increasingly recognised difficulties with drug-drug interactions and unexpected toxicities. Adherence issues leading to sub-therapeutic drug levels and development of drug resistance further complicate therapy, and are likely to limit the potential benefit, which might otherwise occur. Other major concerns include the increasing cost of long-term management of HIV, as more patients live longer, requiring more aggressive therapy, whilst new infections continue to occur.
The aim of this workshop is to provide participants with a brief overview of new drug developments through a mini lecture and handout and to meet the objectives through group discussion. Participants do not need to have experience in working in this area of medicine, as they will be expected to draw from their experiences in other clinical areas.
Working with biotechnological products
Biotechnology has improved the treatment of many diseases and provides options for previously untreatable illnesses. There are more than 30 agents available on the U.S. market including vaccines and drugs to treat anaemia, growth hormone deficiency, transplant rejection, cancer and multiple sclerosis. The high cost of biotech drugs requires proper handling and the minimisation of waste. Biotech drugs are protein based and require special care. Points to be considered include: shipping, handling, storage, shelf life, timing of reconstitution, adsorption, glycosolation and denaturing.
Developing a Pharmacy Intranet system
In any hospital the pharmacy is a core central service. Almost all patients admitted to the hospital will interact with pharmacy at least once during their stay. All doctors and nurses and the majority of other healthcare professionals also use the service almost every day. Use of appropriate drug therapy is one of major components of the clinical governance philosophy adopted by the NHS and spending on drugs is approximately 10% of the NHS budget.
Efficient flow of information and effective management of knowledge is crucial to the workings of any pharmacy department. Large amounts of information is exchanged within pharmacy and also with its customers. Information technology and in particular internet technology could be used to streamline this information flow and making knowledge more readily available.
This workshop will focus on the following:
...................................
Litigation and clinical governance
The increasing role of pharmacists in clinical pharmacy and their involvement in new areas of practice such as anticoagulant clinics together with the development of specialist services exposes pharmacists to an increasing risk of facing a claim for clinical negligence.
It is important to understand what is meant by clinical negligence and the various features of it that must be proved by the patient in order to found a claim against an individual pharmacist. Whilst in most cases a claim will be bought by the patient against the pharmacist's employer it is necessary for the pharmacist to understand all the important elements of negligence so as to protect their professional reputation. Those elements of breach of duty, injury to the patient and the causation of the injuries alleged all must be proved by the patient in order to be successful in their claim.
Many professionals recognise when something has possibly gone wrong in their care of a patient, but they are often hesitant in seeking to discuss this with the patient and it can be difficult for those in such a position to understand important differences between an apology and an expression of regret on the one hand and the admission of liability for negligence on the other.
In many such cases there can be a certain amount of anger on the part of the patient and their relatives and a desire for an explanation of what has happened. In such a case prompt action on the part of the pharmacist can improve the situation and promote confidence on the part of the patient. A well-planned strategy can help all those involved cope with the inevitable anxieties and worries that arise at such a time. It is important that pharmacist develop safe systems of work in order to avoid or at least minimise the risk of claims being pursued. The concept of risk management and the introduction of clinical governance should not only help to protect individual pharmacists and assist in the identification of those whose performance is failing below recognised professional standards, but perhaps more importantly lead to excellence in patient care.
Whilst risk management and clinical governance may be viewed as a threat these concepts are very much based on the identification of problems before any patient is harmed and helping those professionals who are not performing well to identify their weaknesses and to improve their performance.
Information for Health - one year on
"Information for Health" was published in 1998. It outlined the development of the Electronic Patient Record (EPR), Electronic Health Record (HER), electronic prescribing and the computerisation of GP surgeries. These initiatives impact on the type of pharmaceutical services that health care professionals require. It is therefore important for pharmacists to understand the strategic direction of these developments and to explore their implications.
NHS Direct was also part of the strategic direction for information services described in "Information for Health". Because of enormous political pressure and also because of its involvement of the professions, particularly nursing, NHS Direct has developed very quickly and has been particularly successful. In user surveys 97% of those asked were either satisfied of very satisfied with the service they received. NHS Direct now covers 60% of England and will cover 100% by the end of 2000. Pharmacists as the North and Yorkshire (Newcastle) Regional Drug and Therapeutics Centre were involved with one of the first three wave sites. Since then pharmacy services to NHS Direct have developed rapidly and pharmacy is viewed very positively by NHS Direct nationally.
Pharmacists set up the "NHS Direct Pharmacy Support Network" (PSN) to ensure sharing of good practice, to avoid duplication and to enable pharmacist to work together across the sectors. This is proving successful and many joint working ventures are underway. The NPA, RPSGB, PSNC and DoH Chief Pharmacists Office are also very actively involved in steering the way pharmacy contributes to the strategic agenda.
The "Core principles of pharmacy support to NHS Direct sites" outlines support form community pharmacy, poisons information services and drug information services and states that these services should work together closely to ensure comprehensive and cohesive support.
The workshop will review achievements of the PSN and services provided by NHS direct sites by pharmacy. The workshop will debate the impact on pharmacy so far and more importantly how pharmacy wishes to contribute to NHS Direct in the future, including the following:
Meeting the Working Time Regulations for resident pharmacy services at Guy's and St Thomas Hospital Trust Duncan McRobbie* MSc MRPharmS, Peter Eley ** BSc(Hons) GIPD & Tony West *** MRPharmS * Principal Clinical Pharmacist, **Group Personnel Manager -Clinical Services, ***Clinical Director Pharmacy Department. Guy's and St Thomas' Hospital Trust Lambeth Palace Road London SE1 7EH
Correspondence to duncan.mcrobbie@gstt.sthames.nhs.uk
Introduction The Working Time Regulations (SI 1998 No. 1833) came into force on 1st October, 1998. They were intended to implement in the UK the Working Time Directive agreed by the European Union Council of Ministers in 1993, which the previous Conservative Government had requested to implement. The legislation was aimed to protect the Health and Safety of workers by placing limits on their hours of work and setting requirements on rest periods, breaks and holidays. Further clarification by the NHSE in advance letter AL(GC)3/98 significantly confirmed that all on site on call time has to be classified as within the working hours.
Guy's and St Thomas' Resident Pharmacy Service The Working Time Regulations(WTR) had significant implications on the way that our Residency service was being provided and also coincided with a transfer of acute medical & surgical services onto the St Thomas' site. We had to review whether a system of (12)basic grades providing a comprehensive out of hours pharmacy service as a resident on each site remained a viable option. Our initial work highlighted the vital importance of residency posts and set out 3 key targets of any changes:
Changes to Practice In order to meet the above targets proposed new rosters were designed and discussed between Pharmacy Managers, Personnel Manager and the residents. These included:
Consultation and Implementation We first consulted with Resident staff, and MSF representatives on the above changes. When agreed, the changes were implemented through a collective agreement signed by MSF full-time officer and Pharmacy Clinical Director with an agreed monitoring period to review the effectiveness of the new arrangements.
Conclusion The changes have ensured compliance with the WTR. We are continuing to monitor whether the current configuration of our Residency meets the needs across both Trust sites and this likely to mean further changes in future.
Hospital pharmacy technicians in the 21st century - expectations and aspirations in North Thames and South Thames
Introduction Hospital pharmacy is undergoing rapid change in response to NHS developments, and recruitment and retention issues. This is forcing trusts to review the roles of pharmacy staff1. The knowledge and skills of pharmacy technicians must be developed and used to enable hospital pharmacy to have a future2.
Objectives
Method This survey was carried out as part of a wider evaluation of technician self development and training. In November 1999, structured questionnaires were sent to all qualified pharmacy technicians (n = 1320) in trusts in North Thames and South Thames. A different questionnaire was sent to their senior pharmacy managers (n = 77). The survey was designed using Formic software3, which enables automatic data capture and analysis.
Results
534 technicians (40%) and 46 managers (60%) returned their questionnaires.
Discussion 81% of technicians expected to be working as a technician in 5 years' time, but only 64% wanted to, preferring instead to train as a pharmacist, work in a non-pharmacy related job, or not work. In 2 years' time, managers expect a decrease in technicians' roles in traditional manipulative tasks and an increase in tasks that involve data gathering and audit. Tasks with patient contact (but not contact with other health care professionals) are expected to increase. Both technicians and managers appeared to support a national register of technicians.
Conclusion Although most technicians expect to continue to work as a pharmacy technician, some would rather not. Managers expect the role of technicians to change. Technicians need to be well trained and motivated for this to occur. These changes will have implications for the roles and training needs of other pharmacy staff.
Acknowledgements Members of the North Thames Pharmacy Technician Self Development group, technicians and senior pharmacy managers in North Thames and South Thames, Devina Khambhaita for scanning the questionnaires.
References
A prescription survey of the use of atypical antipsychotics for hospital in-patients in the United Kingdom
Introduction Probable advantages of atypical drugs include superiority over typical drugs in treating negative symptoms and a lower incidence of extrapyramidal side effects (EPSE) (Kerwin & Taylor, 1996; Thomas & Lewis, 1998). Atypical antipsychotics are difficult to define clearly and show important individual differences. Nevertheless, as a group, these drugs appear to offer improved efficacy and, perhaps more robustly, better tolerability. Available efficacy data for atypical antipsychotics relate specifically to the use of atypicals alone.
Reasons to avoid the use of concurrent typical drugs:
Aim of the study We sought to investigate the prescribing of all atypical antipsychotics to in-patients in hospitals throughout the UK.
Method
Results Response rate of atypical prescribing survey 62%
Use of anticholinergics
Conclusions
References Taylor, D., Drummond, S., Pendlebury, J. Olanzapine in practice. Psych Bulletin 1998; 22: 552-554. Thomas, C.S., Lewis, S. Which atypical antipsychotic? B J Psych 1998; 172: 106-109. Kerwin, R., Taylor, D. New antipsychotics: a review of their current status and clinical potential. CNS Drugs 1996; 6: 71-82.
Background The end of 1999 saw a major step in the reconfiguration of the Guy's & St.Thomas' Hospital Trust. Acute Medical and Surgical Services transferred to the St. Thomas' site and the A&E department on the Guy's site became a Minor Injuries Unit, with all emergency admissions managed by an extended A&E service at St. Thomas' Hospital. Reduction in bed numbers (a net loss of 60 medical beds) and the predicted increase in patient numbers, required more efficient working methods to be implemented to increase throughput, if patients at St. Thomas' were to be managed appropriately.
Audits conducted within the hospital had demonstrated that prescription of medicines on the admissions ward were frequently inaccurate and that reported delays in discharge associated with medication were often caused due to medication discrepancies not clarified earlier in the admission. The benefits associated with pharmacists attending ward rounds is well documented and the personal success of a pharmacist attending post-take ward rounds (PTWR) at Guy's hospital promoted the need for development of a consistent, sustainable post-take ward round pharmacy service on the St. Thomas' site.
Process To facilitate this service, funding was sought and secured for pharmacists' time, equivalent to two WTE D grades. It was considered that attendance at twice daily (8am and 6pm) and weekend (8am) PTWRs would be best facilitated by utilising the clinical skills of the practitioners already within the service, but co-ordinated by a dedicated Medical Admission Pharmacist. ('D' grade). Peer review sessions amongst the practitioners we held to ensure consistent and appropriate advice and identify process issues. Data collection forms were designed to enable efficient hand over of on-going pharmaceutical care problems to ward pharmacists and to record pharmacist contribution to patient care. Contributions were categorised to facilitate quantitative analysis of qualitative data.
Results Between 1/11/99 and 30/1/00 149 PTWRs were attended. During this period 1911 medical patients were review and 1953 pharmacy contributions to care were recorded (see Table 1). Fifty three percent (1035) of these were made on the 'out-of-hours' ward rounds (6pm weekdays, at weekend and Bank holiday). Pharmacists' contribution was required for a mean number of 66.5% of patients. Ninety five (5%) admissions were identified as being due to a drug related problem.
Table 1. Pharmacy Contribution to Patient Care on PTWR
Discussion
Conclusions Improvements have been demonstrated in quality of prescribing, timeliness of pharmacy intervention and efficiency of provision of pharmacy services to acute medical patients at St. Thomas' Hospital - pharmacist attendance of PTWR has made a difference to the standard of patient care.
Impact of a high level clinical pharmacy service on prescribing costs.
Background There has been a dramatic rise in prescribing costs in the NHS over the last five years. Factors include the introduction of high cost drugs, the increase in the numbers of elderly patients, and the high expectations of the general public with regards to outcomes of therapy. This has not been matched by a similar rise in resources and there is therefore a need for prudent prescribing. In 1996 the Division of Medicine of North Staffordshire Hospital Trust was 30% overspent on a drug budget of £1 million. At this time there was a limited clinical pharmacy service to the Division with some wards not having a daily visit and there was no pharmacist regularly attending consultant ward rounds. It was hypothesised that the greatest impact on prescribing costs and quality would be achieved using an educational outreach model at ward level, delivered by an experienced clinical pharmacist. Therefore a pilot study was undertaken to assess the impact of a high-level clinical pharmacy service. This led to a successful business case and the appointment of two additional senior pharmacists to extend the clinical pharmacy service to the whole Division of Medicine.
Method Each pharmacist was responsible for a clinical directorate within the Division of Medicine. Messages of good prescribing practice were issued to consultants and ward sisters which were reinforced by pharmacists at ward level. A pharmacist was present on all consultant ward rounds, attended directorate meetings with the clinical director, directorate manager and the divisional accountant, and contributed to the audit program. In addition a pharmacy action plan was agreed with the divisional general manager with set targets for savings in therapeutic areas. This was reviewed at quarterly meetings. Key messages were printed onto "post-it" notes1. A prescribing link nurse was identified for each ward who received training in the background to the key messages and supported the directorate pharmacist. Cost comparison sheets were attached to all notes trolleys to be accessed by the doctors as they prescribed. Three of the key areas targeted were choice and route for antibiotics, nebuliser and inhaler costs, and appropriate use of nutritional supplements.
Results By the end of 1998 the overspend on the drug budget had reduced to 12.6% and at the end of November 1999 the Division was underspent by 1.5%. Savings in the key areas targeted by the project are shown below.
Conclusion The initial pilot study demonstrated the potential savings of a high-level clinical pharmacy service. This led to the development of a robust medicines management system involving doctors, nurses and pharmacists. The system operates at both ward level, with a review of individual patient's medication, and at divisional level with a divisional action plan and targeted messages. This has resulted in more rational prescribing without reducing the standard of patient care. Savings achieved over and above those identified in the cost-reduction plan have become available for re-investment in new therapies within each directorate. The benefits of the service could not have been achieved without the investment in additional staffing.
References 1. Bamford S.B. et al: Medicines Management at North Staffordshire NHS Trust - a review of macrolide antibiotics. Poster presentation, Guild of Healthcare Pharmacists Day Conference, Oxford, 26th November 1999.
Patients' representations of low dose aspirin and adherence to treatment post myocardial infarction (MI)
Background and aims There is evidence that taking low dose aspirin post myocardial infarction (MI) causes a reduction in both overall mortality and reinfarction rates. However, this depends on patients adhering to a life-long daily regime where taking less than 95% is predictive of a higher risk of MI (Glynn et al., 1994). Patients' beliefs about their treatment influence how medicines are taken (Horne and Weinman in press). This study aims to investigate the role of patients' beliefs about medicines in adherence to aspirin during the first year following MI.
Method A prospective, longitudinal study of 132 first time MI patients at four time-points (in hospital, 3, 6 and 12 months post MI) to investigate patients' representations of aspirin and other cardiac medicines (assessed using the standardised 'Beliefs about Medicines Questionnaire - Specific', Horne et al., 1999). Adherence was measured using a composite score of patients' self-reported adherence ('Reported Adherence to Medicines Scale'; Horne et al., 1999) plus a measure of prescription redemption from the GP or Pharmacy (available for aspirin in 50% of cases). High adherence was categorised as above 75% on both self-report and percentage supply measures. Differences in composite scores between aspirin and other cardiac medicines were explored using Chi-square test. Paired sample t-tests were used to investigate changes in beliefs about medicines over time and independent sample t-tests to assess differences in medication beliefs between high and low adherers.
Results Adherence scores for aspirin were significantly lower than for other cardiac medicines at each follow up phase (3 months, Chi=5.5, p<0.05; 6 months, Chi=11.8, p<0.01; 1 year, Chi=14.6, p<0.01) and decreased significantly between 6 months and 1 year (Chi=4.7, p<0.05), whereas adherence to other cardiac medicines remained stable over time. The perceived need ('necessity' scale scores) for aspirin at 3 months was significantly lower than for other cardiac medicines (t=-1.8, df=64, p<0.05) which was predictive of low aspirin adherence at 6 months (t=-2.3, df=64, p<0.05). However, the perceived need for aspirin increased significantly at 6 months (t=-2.1, df=78, p<0.05) and remained high at 1 year post MI. Patients' representations of the risks ('concerns' scale scores) of taking aspirin were significantly lower than for other cardiac medicines at each time-point (3 months, t=-6.3, df=64, p<0.01; 6 months, t=-3.0, df=84, p<0.01; 1 year, t=-2.6, df=90, p<0.01). Strong concerns about aspirin at 3 months and 6 months (t=2.6, df=64, p<0.01) were predictive of poor adherence to aspirin at 1 year.
Conclusions Following a first MI, patients may not be convinced of the necessity of taking low dose aspirin and perceive them as less important than other cardiac medicines leading to lower adherence. Misplaced concerns about aspirin (although infrequent) was another cause of sub-optimal secondary prevention of MI and death in this high-risk population.
References Glynn RJ, Burning JE, Manson JE, LaMotte F & Hennekens CH. Adherence to aspirin in the prevention of MI. Arch Intern Med 1994; 154:2649-2657. Horne R & Weinman J (in press). Patients beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal Psychosomatic Research. Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of anew method for assessing the cognitive representation of medication. Psychol & Health 1999; 14 (1): 1-24.
Poster presentations
Pharmacists as Facilitators for Changing Prescribing Practice
Introduction
Method Twelve months before the acute services were due to move to the St.Thomas' site; the SCPs identified the major prescribing areas where different practices occurred. Monthly meetings were arranged in order to debate these differences and these were attended by the six ICU consultants, the nursing director of ICU, and senior nursing representative from both sites. One or two major prescribing areas were presented by the SCPs who reviewed the subject, including the latest literature evidence to support best practice. This was compared to current clinical practice on the separate units. Meetings were not drawn to a close until consensus was achieved. After each meeting the SCP produced a policy which was ratified at the subsequent meeting. It was agreed that all policies would be subject to review three to six months after the merger.
Results The following new prescribing and drug administration policies were produced and were implemented on both ICUs in advance of the merger:
Discussion By managing the change in prescribing, the SCPs achieved full integration of different practices and this significantly contributed to the smooth transition of two separate ICUs to a single 30 bedded ICU. The evidence for drug usage in each area was reviewed and best practice assured. Where the evidence was equivocal, consensus practice was agreed between medical, pharmacy and nursing practitioners.
Conclusion Clinical pharmacists are in a key position to take the lead in facilitating a change in prescribing practice and drug administration in any healthcare area which is undergoing the process of change.
Guidelines for Drug administration via enteral feeding tubes
Introduction: Many patients who are fed by enteral tubes cannot swallow. As a result conventional dosage forms such as tablets and capsules are unsuitable. Although administration of medicines by these tubes is unlicenced and is fraught with uncertainty it is sometimes necessary.
Objective: The aim of this project was to review current practice of enteral drug administration at Derriford hospital and to develop guidelines for administration via this route.
Methods: A review of current practice was conducted by interviewing relevant nurses and by inspecting medication charts. A total of 70 enteral drug administration events were investigated. Data relevant to drugs and formulations most commonly administered through enteral tubes at Derriford hospital was compiled to give guidance on methods of administration.
Results: The snapshot review of seventy drug administration events via PEG or NG tubes carried out during 1999 showed that in 30% of cases the drug was either administered inappropriately (5 occasions) or inappropriate dosage form (16 occasions). Draft guidelines for enteral drug administration were drawn up, in the style of a decision making tree. Possible drug candidates were identified, together with their recommended dosage forms and comments about their administration. This information was then added to the algorithm to produce a quick reference source for ward staff.
Discussion: There is scarcity of published guidelines. Few well-conducted studies have been done on medicines given by enteral feeding tubes (stability, absorption etc). Administration via the enteral tube route is generally unlicensed. Liaison within a multidisciplinary term can optimise the safety and effectiveness of drug administration. The draft guidelines should improve both clinical practice and risk management as they highlight factors involved in drug administration.
Acknowledgement: We would like to thank all the staff at Derriford hospital, in particular Ms Jenny Lawrence, Miss C Chia and the entire pharmacy department along with the nursing and dietetic staff who gave support and encouragement throughout the project.
The role of medication beliefs in angina patients' use of GTN spray
Background and Aims A GTN spray is widely prescribed for patients diagnosed with angina. It is used by the patient as required for both symptom relief and prevention of angina symptoms. However, little is known about how patients use their GTN spray. This study aims to explore patients' willingness to use the spray and investigates the type of medication beliefs which may influence the way patients self-medicate.
Method The validated 'Beliefs about Medication Questionnaire (BMQ), (Horne et al., 1999) was used to assess patients' beliefs about the GTN spray in 44 hospitalised angina patients admitted to the Royal Sussex County Hospital, Brighton, January to March, 1997. A single question was added to measure patients' willingness to use the spray and a three-item scale was constructed to assess how often patients carried the spray with them when they left their home.
Results Results from the BMQ scores found that 89% believed that their GTN spray was both necessary and effective for the treatment of their angina, with most patients reporting that they carried it with them at all times (61%). However, 31% held strong concerns about the harmful effects of the spray, with 70% of subjects indicating that they tried to use as little as possible. Half of the subjects reported that they had avoided using their GTN spray in the past. Necessity beliefs correlated significantly with the likelihood of carrying the spray (rho=0.33, n=35, p<0.05). Willingness to use the spray correlated significantly with medication concerns (rho=0.36, n=39, p<0.05) in that those with higher scores on the 'concerns' scale had lower scores on the 'willingness to use' measure.
Conclusion In this small sample of patients the GTN spray was mainly viewed to be necessary for the control of their angina. These views influenced whether or not the spray was carried, but not whether it was used. Patients were less likely to use the spray if they had strong concerns about its harmful effects or felt little control over their angina. Angina patients may not be achieving adequate control of their symptoms due to under use of their GTN spray. This may partly be due to patients' misconceptions regarding its harmful effects such as fears of dependence or worries about long-term effects.
Reference Horne R , Weinman J A and Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychol and Health 1999; 14 (1): 1-24.
Health care professionals' views about medicines in general: a preliminary analysis
Background
Aims This study set out to compare the attitudes towards medicines in general among students of several health care professions.
Method A total of 1416 students from 7 health and 2 non health-related undergraduate courses were studied. The former was a proxy measure of a group of HCPs and the latter represented a vocational and non-vocational course as the control group. The standardised 'Beliefs about Medicines in General Questionnaire' (BMQ-General, Horne et al., 1999) was used to assess views about medicines. ANOVA with Tukeys Honestly Significant Difference test was used for statistical analysis of variations within HCP groups and between HCPs and control groups.
Results Pharmacy students (n=280) scored lowest on both the 'harm' (mean=8.6, SD=2.2) and 'overuse' (mean =12.8, SD=2.3) scales indicating that they perceived medicines in general to be less harmful and not to be over-prescribed. The perceived potential for causing harm was also low for students of medicine (n=313, mean=10.0, SD=2.3), physiotherapy (n=145, mean=10.1, SD=2.3), followed by dentistry (n=226, mean=10.2, SD=2.1), occupational therapy (n=56, mean=10.3, SD=2.0), environmental engineering (n=109, mean=10.6, SD=2.4), nursing (n=238, mean=10.7, SD=2.2), chiropody (n=22, mean=11.8, SD=2.4) and art (n=27, mean=12.4, SD=2.2) who viewed medicines as harmful substances. The view that medicines are overused was held strongest by students of art (mean=16.2, SD=2.6), followed by chiropody (mean=14.4, SD=1.9), occupational therapy (mean=14.3, SD=2.6), physiotherapy (mean=14.0, SD=2.1), nursing (mean=14.0, SD=2.6), dentistry (mean=13.4, SD=2.7), medicine (mean=12.9, SD=2.4) followed by pharmacy. Art students scored significantly higher on the 'overuse' scale than all other groups (F=12.9, df=8, p<0.01). Pharmacy students scored significantly less on the 'harm' scale than all other groups (F=25.3, df=8, p<0.01).
Conclusion Significant differences were found between the extent to which HCPs and the control groups felt that medicines in general are harmful and overused. Whilst pharmacists and medical students hold the most positive views about medicines, other HCPs were significantly less positive about medicines in general. Furthermore, HCPs need to recognise that lay people may not have such a 'pro-medicine' outlook as themselves.
References 1. Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of anew method for assessing the cognitive representation of medication. Psychol & Health 1999; 14 (1): 1-24. 2. Horne R & Weinman J. Cultural variation in beliefs about medicines. British Psychological Society Annual Conference of Health Psychology. University of Southampton, 13, 1997
Improving quality of prescribing through therapeutic substitution
Medicines Management
Guideline Compliance Most clinical pharmacy contributions to patient care were made after prescribing had taken place. Tradition required the pharmacist to find the doctor and persuade them to alter their prescription. Consultants see the pharmacists' role as assurance that prescribing follows their locally approved guidelines.
Multidisciplinary Continuous Professional Development Multidisciplinary team working allows experienced pharmacists and nurses to enhance patient care by applying evidenced-based medicine. Therapeutic substitution extends this process by empowering the pharmacist to make changes according to a consultant approved local protocol, consistent with the principles of the Crown reports.
Risk Management Clinical pharmacists encourage evidence based best practice and can be seen as medication error avoidance in action. It. Health economic concepts of 'best value' apply. Maximising resource use for the many whilst maintaining the quality of care for individual patients.
Results An audit of this pilot showed that 349 therapeutic substitutions were conducted in a 6-month period. 212 improved quality, 137 reduced costs. Cost reductions where made from a broad perspective, cognisant of any impact on primary care.
Conclusions Therapeutic substitution has proven that clinical governance principles can be embedded into clinical practice. It is still evolving but forms an important part of the hospital's medicines management system.
Identification of factors affecting job and career satisfaction in hospital pharmacists
Purpose The recruitment and retention crisis within British pharmacy services is recognised and is expected to worsen during the next 5 years. As retention is related to job satisfaction, a survey of job and career satisfaction was undertaken in hospital pharmacists employed within the South Thames region of the UK.
Method A questionnaire which had been previously validated to quantify job and career satisfaction was circulated to 608 pharmacists 1. Responses were assessed using a 5 point Likert scale with "1" indicating most dissatisfaction. Scoring was reversed for negatively worded statements so that a high score denoted greater satisfaction.
Results Responses were received from 232 pharmacists (38%) of whom 174 were female. The median age range was 31-40 years and most (46%) were employed at a middle management grade. Sixty eight percent of pharmacists were satisfied with their current job and 65% with their career. Highly significant relationships were identified between job satisfaction and company policies, job role and supervision at work (p<0.0001). Career satisfaction was related to company policies, compensation practices, job role and education and training (p<0.001).
Conclusions The results of this study highlight the need for employers to ensure that pharmacists are maintained in challenging roles which optimise use of their knowledge and skills. These findings will be used to inform the design of a recruitment strategy for hospital pharmacists.
Reference Barnett C.W. & Kimberlin C.L. Development and validation of an instrument to measure pharmacist's satisfaction with their j jobs and careers. Am J Pharm Educ 1986; 50: 5-14
Validation of an instrument to measure pharmacist's job and career satisfaction in british hospital pharmacists
The recruitment and retention crisis within UK pharmacy services is well recognised and it has previously been shown that turnover is affected by job satisfaction1. An existing job satisfaction questionnaire was validated with the aim of utilising it to determine which factors are most strongly associated with job and career satisfaction in hospital pharmacists in 19982.
The questionnaire used a Likert scale to quantify job and career satisfaction overall and with 11 independent variables. The original questionnaire was revised to include demographic data and a subscale on education and training and piloted on 15 pharmacists. A revised questionnaire was circulated to all pharmacists employed by hospitals within the South Thames region of the U.K. (n=600). The internal consistency reliability for dependent and independent variable subscales was assessed using co-efficient alpha. A co-efficient alpha value of 0.65 or greater indicated internal consistency.
Questionnaires were returned by 232 pharmacists (30%). Eight of fourteen subscales demonstrated internal consistency (Table 1). Of those that were shown to be unreliable, three contained only 2 variables and therefore were open to statistical misinterpretation. The remaining three, pharmacist-patient relationship, pharmacist - doctor/ nurse relationship and work schedule subscales were considered to contain statements that were not representative of current hospital pharmacy practice.
Eight dependent and independent variables were shown to be valid and reliable for use in a job and career satisfaction survey of hospital pharmacists employed by UK hospitals. The reduction in the number of subscales should abbreviate the questionnaire and hence improve response rates.
Table 1 - Co-efficient alpha values for subscales used in a job and career satisfaction survey
References 1. Ortmeier B.G. & Wolgang A.P, American Pharmacy 1991; 31: 27-31 2. Barnett C.W. & Kimberlin C.L, Am J Pharm Educ 1986; 50: 5-14
Development of Information Management Systems
The ability to input, retrieve and disseminate information in a fast and user friendly way has been the motivating force for the development of new information technology systems. The use of IT systems to address the need for up-to-date information has helped to streamline both clinical pharmacy and drug information processes. Outlined below are the systems developed by NTDIS in the past 12 months:
The further development of information technology systems represents an exciting future for improving pharmacy practice.
Ackowledgements: Systems designed by: Anita Balestrini, Judith Cope, Sarla Drayan, Stuart Driver, Caroline Edwards, David Erskine, Roy Gillman, Peter Golightly, Richard Goodman, Shapour Hariri, Julia Horwood, Rita Jones, Anne Maher, Andrea Patel and Jane Sharp
An Audit of Tinzaparin in the Treatment of Deep Vein Thrombosis and Pulmonary Embolism
Introduction Over the last four years guidelines for treating deep vein thrombosis (DVT) and pulmonary embolism (PE) have been amended to take advantage of new low molecular weight heparins (LMWHs). The original guidelines involved the use of warfarin to anticoagulate the patient whilst giving a continuous unfractionated heparin infusion. Once the patients INR was stabilised, the heparin infusion was stopped and the patient discharged on warfarin. If it was known that the patient had suffered a recent PE, streptokinase could be used to dissolve the clot before starting heparin and warfarin.
This treatment has several disadvantages. Patients on heparin infusions require daily monitoring of their activated partial thromboplastin time (APTT) and consequent adjustment of the rate of heparin administration. Previous audit had also demonstrated that an APTT within the desired range was not achieved in a significant proportion of patients, with the consequent risk of either a further clot or a bleed. If streptokinase was used, further PEs cannot be treated with the same regimen as antibodies raised to streptokinase rapidly render it ineffective on subsequent administration.
LMWHs are a better treatment option. They do not require APTT monitoring, are simpler for nursing staff and more acceptable to patients with a once a day injection rather than continuous infusion. Tinzaparin is licensed to treat both DVT and PE.
Aim of the Audit and Method New guidelines were introduced in the 1999 edition of the Trust Medicines Guide to increase the probability that patients diagnosed with DVT or PE received optimal treatment; i.e. to improve outcomes. The aim was to assess compliance with the guidelines by medical and nursing staff.
Preliminary Results The main problem areas appear to be as follows:
Which statin for a hospital formulary? economic considerations
Methods A cost-effectiveness analysis was used to compare the differential costs and outcomes of simvastatin and pravastatin based on the results from four pivotal studies. Review of published clinical trials and meta-analyses, report that simvastatin represents a more efficacious LLD in comparison to pravastatin (Illingworth and Tobert, 1994; Conroy, 1996; Kong et al., 1997). Projected cost-savings to both UBHT and the local Health Authority were hence established by replacing pravastatin 20mg with simvastatin 10mg.
Results Some 29 post-Myocardial infarction (MI) or angina patients would need to be treated according to the Scandanavian Simvastatin Survival Study (4S) protocol for 5.4 years in order for coronary mortality to be reduced by one. The incremental cost-effectiveness ratio was £58,482. On comparison with the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) trial, the cost of secondary prevention with pravastatin in post-MI or angina patients p