interviews

Moving forward with pharmacy after Carter

Lord Carter’s efficiency review, which shed light on significant variations across NHS pharmacy services, was pivotal in paving the way for new standards. Andrew Davies, director of pharmacy at North Bristol NHS Trust, who helped shape the Carter report as part of the pharmacy team, tells NHE’s Luana Salles what these new targets and benchmarks will mean for hospitals.

Pharmacy services did not escape the magnifying glass of the much-anticipated Carter Review which, after nearly two years of investigation, published its final report in February on how the NHS can save £5bn through widespread efficiencies. 

In terms of pharma, Lord Carter recommended a Hospital Pharmacy Transformation Programme (HPTP), with plans to back this up required by April next year in order to ensure hospital pharmacies can achieve benchmarks by April 2020. By then, pharmacists and clinical pharmacy technicians must spend more time on frontline, patient-facing medicines optimisation activities. 

These targets may seem overly ambitious in a health service that, according to Lord Carter, still has significant variation in pharmacy and medicines costs. For instance, across the different approaches to deliver medicines optimisation, the Carter team detected a variation of between 2.5% and 71% in the rates of prescribing pharmacists as a proportion of total hospital pharmacists. 

But Andrew Davies, director of pharmacy at North Bristol NHS Trust, who led on all the information, data and intelligence elements as part of the ‘Hospital Pharmacy & Medicines Optimisation’ team within the Carter Review, is optimistic about the future. 

“Realistically, it’s going to be challenging, but there’s going to be lots of good stuff going on and we have until 2020 to implement the plans,” he told NHE, adding that there are ongoing discussion nationwide to support developing these changes. 

“Local discussions in trusts have also started and it’s now about saying we’re building up this model, the governance structure within our organisation to do this, and then as we get the further details [when the model hospital framework is published], we can evolve the HPTP, submit the plans and get them approved. That’s what everybody has started working towards.”

The model hospital 

Pharmacy services and medicines optimisation are key elements of the wider Carter Model Hospital, which will also provide a single integrated performance framework that all hospitals will have to mirror by the end of the decade. This framework is expected start rolling out from this summer, with hospital pharmacists currently “in the middle” of these discussions. 

“There is a lot of engagement with the Royal Pharmaceutical Society (RPS), the pharma industry, and the providers of wholesale distribution services, to actually say: ‘What should be in the Model Hospital? What should the metrics be?’” Davies explained. 

Collaborative working 

These collaborative models should permeate the entire pharmacy landscape. In the Carter Review, for example, the Hospital Pharmacy & Medicines Optimisation team identified that infrastructure services are “most efficiently delivered when undertaken through collaborative or shared service type-models, at local, regional and national levels” – whether these are delivered by NHS-employed staff or not. 

In practice, this means finding the model that is right for each area. “It might be collaborative working within a local NHS organisation that has a similar service and your elements are much smaller, therefore leading to economies of scale by working with somebody,” he explained. “It might be about using a hub-and-spoke type arrangement – so larger automated facilities somewhere – and that might be an NHS-provided one or a commercially-provided one.” 

Community pharmacy providers 

Changing working models will also be particularly relevant to how trusts dispense medicines, with some across the country now outsourcing patient dispensing to community pharmacy providers – a model Lord Carter hailed as a cost-effective way of freeing up clinical pharmacy staff to focus on clinical services. 

Davies highlighted the benefits of this model in terms of complex patient flows. For example, community pharmacists usually focus on supplying medicines as soon as possible: “Due to the complexity of some of the medicines used in hospital community pharmacies don’t necessarily have to undertake the level of checks that we would have to do in a secondary care perspective,” he said. 

They also don’t have the added complexities of inpatients, day case patients, and requests to get patients discharged as quickly as possible to free up beds for new patients to be admitted, or clinical teams requesting to get a specific drug checked urgently because there’s a very sick patient in the operating theatre. Outsourcing the out-patient supply or even some discharge medicines can support faster turnaround times and improved patient services. 

Patients also get the majority of their routine medicines from their local community pharmacy as prescribed by their GP, rather than the hospital. Sometimes these multiple supply routes can make it confusing and difficult for the patient to safely take their medicines.

“It is key to ensure that information flows between the hospital and any community pharmacies supplying medicines for that patient to ensure that interactions etc can be checked,” he added.

 Enhancing information flows 

Pharmacists are currently looking at how they can improve that communication gap and information flow around patients, but it is already clear that the only way to do that is by turning to modern IT solutions – “because you can’t keep phoning up somebody or using faxes”. 

In hospitals, pharmacists have had access for several years to the Summary Care Record, a resource that allows them to see a patient’s prescribed medicines from in their GP record – but at the moment, this information one flows one way from the GP system without any information moving from the hospital systems. Community Pharmacists across England are now starting to get access to this same system, further supporting safe use of medicines. 

One way of sharing medicines-related information is through the use of ‘e-referral tools’, such as the Refer-to-Pharmacy & PharmOutcomes systems which are based on the RPS e-Referral toolkit standards. These systems allow hospitals to send information to a patient’s regular community pharmacy sharing critical clinical information – such as the fact that a patient is struggling with their inhaler or that their medicines aren’t optimised. 

“The community pharmacist can then get really involved and have that conversation with the patient – each time they come, even, because they’re seeing the patient more regularly than we are,” said Davies. “The community pharmacy team are then ideally placed to help patients take the medicines in a better way. It’s about joining up around the patient – that’s what medicines optimisation is.” 

GS1 and dm+d 

Another major piece of tech work endorsed in the Carter Review and currently being tested across six demonstrator sites is the global GS1 coding standard and its important sidekick, PEPPOL. According to Davies, full GS1 implementation is “something for the future”, with hospitals mostly focusing, over the next 12 months, on moving to use the dictionary of medicines and devices (dm+d). This has to be implemented by the end of June next year, meaning any IT system in a hospital or pharmacy will have to use dm+d as the coding structure for their medicines. 

“This means you can then start looking at that information being transferred as codes rather than having to translate descriptions, because if you have to translate it from every single hospital system to other hospital systems, you end up increasing the risk of errors,” explained Davies. 

While the more immediate dm+d is a complicated set of coding structures that allows hospitals to identify products, packs and suppliers, GS1 is “much more about being able to track and trace products, people and locations through the system” – pinpointing purchased products, their buyers, their suppliers, where and which patients are using them through barcoded-based system. “All those things will evolve, so NHS organisations are assessing their digital maturity and GS1 is part of that digital maturity,” said Davies.

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