Achieving excellence in pharmaceutical care: a strategy for Scotland

4. Enabling NHS Pharmaceutical Care Transformation

Context

The Health and Social Care Delivery Plan sets out an ambitious programme of change for health and social care in Scotland. The level of planning and delivery required through health and social care integration, improving population health, implementing the National Clinical Strategy and changing how NHS organisations work together with local authorities and with other partners, requires a different approach at both regional and national levels.

We can provide better clinical outcomes and more efficient, consistent and sustainable services for staff and service users through NHS Boards, Integration Authorities and other partners working more collaboratively and effectively to plan and deliver services. Work is already underway regionally and nationally to identify areas which would benefit from being planned and delivered on that basis. This includes the preparation of regional delivery plans and a national delivery plan.

While playing to the strengths of the pharmacy team is crucial to achieving excellence, they must also have the resilience to be able to respond and adapt to the needs and pressures facing our modern health and social care system. In order to do this we have identified three key enablers as priorities for action. These are: developing the pharmacy workforce, improving access to and use of digital information and technologies, and planning for a sustainable, flexible and resilient approach to delivery of NHS pharmaceutical care across Scotland.

It is important that as we shift the balance of care and pharmacists take on expanded clinical roles that involve providing clinics and managing caseloads or undertaking other new tasks previously carried out by another healthcare professional, people are confident that they are receiving the best NHS pharmaceutical care that is safe, effective and person-centred, and which meets their needs and wishes. Building confidence and an understanding of the enhanced role of the pharmacist is as important with the multidisciplinary team as it is with the people we support, carers and the public.

Through our programme of work we are committed to ensuring pharmacists have the necessary clinical, decision-making and digital skills needed to care for people effectively. This equally applies to other members of the pharmacy team such as pharmacy technicians, dispensers and pharmacy assistants. In addition, pharmacists will be integral members of multidisciplinary teams and will play their part in shaping local health and social care services so that they meet local needs in community health care and out-of-hours hubs.

We are already experiencing an increase in demand for pharmacists and pharmacy technicians and a number of initiatives are underway to help us understand and prepare for the expansion of the pharmacy workforce. In responding, we must ensure the stability of, and continue to improve, existing services across all community, primary care and secondary care settings. This includes recognising an increasing interest across the profession to develop a more flexible approach to their career pathway including portfolio career opportunities.

A digital infrastructure can assist pharmacists and pharmacy technicians in increasing their clinical role. For example, automated technologies being deployed in the dispensing process can release time and capacity for improving the services we provide for people. Remote and mobile working can provide the workforce with more flexibility and create improved working conditions for staff. Additionally, technology enabled approaches can support people to better manage their medication, improve adherence and support wider access to pharmaceutical care reviews for people in care homes and their own homes. Finally, improving access to electronic information and management data is critical to informed decision making and the effective delivery of services and our ambition for consistently high quality seamless care at all points of the person's journey across the healthcare system. As part of identifying the gaps in our current technology provision we have been mapping the various technology systems and how they are utilised. From this we will be able to identify improvements which will drive our digital agenda.

Our vision for achieving excellence in pharmaceutical care also necessitates changes to the planning and delivery requirements for sustainable NHS pharmaceutical care. This will be achieved by providing NHS Boards and HSCPs with the means to take a proactive approach to planning and delivery if we are to realise an integrated role for pharmacy across all healthcare settings.

"Extending the range of training and development opportunities is an essential component to delivering a modern workforce."

Pharmacy workforce

Commitment 7:

Actions

Postgraduate career framework
Pharmacy technician development
Workforce planning

Building the clinical capability and capacity of the pharmacy workforce.

Workforce planning and development

With the demand for pharmaceutical care set to increase across the board we need to strengthen our pharmacy workforce planning. Currently there are approximately 4,700 whole time equivalent registered pharmacists and over 2,000 registered pharmacy technicians in Scotland, most of whom are working in community, primary and secondary care settings. The requirement to increase pharmacist capacity in GP practices has largely been met through different models of direct employment, redeployment, secondment and contractual arrangements via NHS Boards and community pharmacy. With further increases planned in order to meet this growing demand, it is critically important that we are also able to maintain and improve NHS pharmaceutical care provision across all settings.

Whilst pharmacy workforce planning data for the managed service is readily available the real gap is that there is no robust baseline data on the number of pharmacists and pharmacy technicians working in our network of community pharmacies, of which there are over 1,250. This will continue to present a challenge until we can reach a pragmatic solution with the community pharmacy sector and persuade them of the benefits that sharing such information can bring for both community pharmacy contractors and health service planners. In the future, this information could also be sourced from a Performer's List for Pharmacists.

Extending the range of training and development opportunities is an essential component to delivering a modern workforce and ensures that extended multidisciplinary teams have the skills, confidence and capacity to work to the full range of their competencies. Our vision and current work towards integrated pharmaceutical care to support a shift in the balance of care is already increasing the demand for pharmacists and pharmacy technicians with greater clinical capability. Supporting an increased demand for care in community pharmacy, in GP practices through access to pharmacists and pharmacy technicians and in hospital pharmacy is already driving a need for pharmacists and pharmacy technicians with the right clinical skills. Combined with the appropriate digital skills, this will lead to greatly enhanced delivery of pharmaceutical care.

Action:
We will work in collaboration with NES and other key stakeholders to understand and address future pharmacy workforce requirements in order to inform the national workforce plan and the educational needs of the profession.

Independent prescribers and advanced clinical skills

Prescription for Excellence made a clear commitment to ensuring people had access to pharmaceutical care which was delivered by pharmacist independent prescribers across all care settings. Significant progress has already been made to build a complementary mix of skills within the pharmacy team, including independent prescribing, communication skills, history taking and advanced clinical assessment skills. Since 2013 there has been an increase in the number of pharmacists with independent prescribing and advanced clinical skills and just over a quarter of all pharmacists practicing in Scotland are currently qualified as independent prescribers. In addition to this, NES has developed and is delivering a comprehensive education and training programme, focused on providing enhanced clinical skills training for pharmacists and technicians. A further drive to recruit more pharmacists to undertake these programmes, along with an increase in training places and additional financial resources, will be needed to support the planned capacity increase in pharmacists with advanced clinical skills to meet the needs of the service.

NES Advanced Clinical Skills Programme

The award winning NES Advanced Clinical Skills Programme for Pharmacist Independent Prescribers course represents a unique collaboration between NES Pharmacy, three Scottish Schools of Medicine, Glasgow Caledonian University and the two Schools of Pharmacy in Scotland. The course comprises a mix of mandatory and elective modules covering core clinical skills such as consultation, physical examination and assessment skills as well as a range of condition specific modules including diabetes, coronary heart disease, respiratory, musculoskeletal and common clinical conditions. The course has been developed and delivered through a multi-disciplinary team of clinicians, including doctors, nurses, physiotherapists and pharmacists.

Undergraduate education

We have already indicated our intention to strengthen pharmacy undergraduate education with a commitment to move to a five-year integrated initial education programme for pharmacists in Scotland. This will also help to ensure that the university curriculum is aligned to prepare newly qualified pharmacists for the changing roles we have described by ensuring those graduating from the new five year integrated programme will have all the digital skills and underpinning knowledge and clinical skills for taking on a prescribing role. We will also continue to encourage a focus on interprofessional education, building on the work undertaken by the School of Medicine at the University of Dundee and the School of Pharmacy and Life Sciences at Robert Gordon University, in order to support future collaborative practice.

Postgraduate education and continuing professional development

New vocational training programmes have recently been launched to better prepare pharmacists for more clinical roles at both the early and developing stages of their careers. Foundation Training aims to equip pharmacists early in their career with a broad range of general skills and provide them with a foundation on which they can develop further. Expert Professional Practice modules aim to equip them with a range of specialist skills, after they have completed their Foundation Training. There is also a General Practice Clinical Pharmacist Competency and Capability Framework which characterises core roles and responsibilities and identifies any learning and professional development requirements to support pharmacists working as advanced practitioners.

The expertise, experience and professional judgement of advanced clinical pharmacy practitioners is demonstrated through the depth of their knowledge in areas such as diagnostics and therapeutics, their enhanced skills in consultation, critical thinking and clinical decision-making, research outputs and their leadership role within their teams. However there is currently no corresponding advanced pharmacy practice programme.

As a result we have recently commissioned NES Pharmacy to review postgraduate programmes to help align to the future needs of the workforce with a view to developing a Postgraduate Career Framework for pharmacy in Scotland. To take this forward NES will establish an expert educational group to provide advice on the future options to develop this Framework. This will include areas such as support for early level careers, advanced practice level careers, consultant level careers and clinical and professional leadership. It will also need to be able to sustain a flexible and capable workforce which will allow recognition for career advancement of current professionals as well as provide supportive professional development and recognition of the future pharmacy profession in early careers, advanced and specialist practice and consultant pharmacist level.

The Career Framework will need to be applicable at all levels of development, to all specialties (clinical and non-clinical, generalist and specialist), all sectors of care and will need to allow for recognition and transferability across all UK nations. It will also need to take cognisance of any other frameworks currently in use across GB, such as the Royal Pharmaceutical Society ( RPS) Foundation and Advanced Pharmacy Framework ( APF) and the guidance for NHS consultant pharmacists. It will need to encompass the future digital skills requirements of pharmacists, technicians and others.

Action:
We will introduce a Postgraduate Career Framework for pharmacy in Scotland which will include a consultant pharmacist role.

Pharmacy Technicians

With the increasing prominence of the role of pharmacy technicians it is also important that their education and training needs are reviewed in light of this. Whether working on our hospital wards, providing supported discharge processes into the community setting or working in community pharmacies, pharmacy technicians have an important role in improving safety, addressing compliance problems and reducing waste. One example of this is the East Renfrewshire HSCP Medication Support Service which employs the services of pharmacy technicians who provide personalised support regarding people's medication as part of the local discharge programme. Their role is invaluable to other members of the health and social care team.

Action:
We will commission NES to develop a work programme with the Further Education Colleges in Scotland in line with the General Pharmaceutical Council's regulatory requirements to consider the future education and training requirements for pharmacy technicians.

Mentorship

Consideration will be given to the opportunities to develop GP mentorship for pharmacists undertaking new roles in GP practices by creating capacity to support this as part of their role for developing the wider multidisciplinary team through their leadership and development role. The implementation and further expansion of independent prescribing to other professional groups across recent years offers opportunities for pharmacists, with their expertise in the safer use of medicines, to also provide support and mentorship to the growing number of new prescribers. Partnerships like this also provide possibilities to explore future collaborative practice models.

Leadership development

Leadership, whether individual or team-related, at all levels, is fundamental to the delivery of high quality, safe and person-centred healthcare. We know that leadership is most effective when it is appreciative, supportive and sustained, enabling teams and individuals to deliver high quality care. The Kings Fund describes the leadership task as ensuring direction, alignment and commitment within teams and organisations. This requires leaders who continually nurture a culture that ensures that safe, high quality compassionate care is the top priority. Key to this are leaders who promote a shared sense of purpose, foster an enabling culture and help others achieve their full potential. We have benefited over the years from having an integrated approach to pharmacy leadership within our NHS Boards, with Directors of Pharmacy having a direct responsibility for the managed service and an indirect one for the local community pharmacy network. This has served the public, the local health and social care system and the profession well and we will continue to encourage and strengthen this leadership role. We have been investing in professionalism and leadership development across the profession over a number of years and will continue to make this a focus of our Postgraduate Career Framework for Pharmacy.

In addition the NHS is investing in a comprehensive programme to consider leadership and talent management development within NHS Scotland to ensure that both current and future leaders are equipped to drive the changes needed in health and social care and identify the next cohort of future leaders of NHS Scotland. This provides an opportunity for pharmacists with wider leadership ambitions to come forward and enroll on this interdisciplinary programme.

" NES has developed and is delivering a comprehensive education and training programme."

Digital information and technologies

Commitment 8:

Actions

ePharmacy support for primary care prescribers
HEPMA
Health information access
Technology enabled care solutions
Future hospital requirements
Clinical decision support tools
Automation

HEPMA

Hospital Electronic Prescribing and Administration ( HEPMA) systems, when fully implemented, make hospitals safer places to take medicines. Three NHS Boards in Scotland (Ayrshire and Arran, Forth Valley, and Dumfries and Galloway) have already implemented HEPMA. This has shown benefits in improving the quality of prescribing, reducing medicine information errors between primary and secondary care and reducing missed doses of medicines. It can also offer the opportunity of much better insight into prescribing and other medicine related activities through data analytics at different levels. All NHS Boards in Scotland are now developing plans to implement HEPMA to improve clinical care and service efficiencies.

Action:
We will work with NHS Boards to ensure that HEPMA is the uniform standard in hospitals across Scotland. We will ensure that pharmacy contributes fully to the multidisciplinary transformation of care that will be delivered through HEPMA.

ePharmacy

The ePharmacy Programme, which provides the technology infrastructure that underpins services such as MAS and CMS in community pharmacy, is well established and continues to introduce improvements to working practices in community pharmacy. For example, a recent pilot project to support the sharing of pharmaceutical care plans between hospital and community pharmacy at admission and discharge has been tested in NHS Forth Valley, NHS Grampian and NHS Greater Glasgow and Clyde through the Pharmacy Care Record ( PCR) held within community pharmacies. Work is underway on a full set of requirements to inform a national roll-out.

The Universal Claim Framework will allow all the community pharmacy services, such as smoking cessation, the supply of medicines under the unscheduled care Patient Group Direction ( PGD) and the Gluten Free Food Service, to be delivered harnessing the benefits of electronic support, meaning that pharmacists will no longer have to handwrite any associated prescriptions, and eventually won't need to print a paper form at all. It will also support better electronic information sharing between community pharmacists and GP practices. The transformation of primary care and the further development of services such as MAS and CMS will require enhanced information exchange between community pharmacists and other members of the multidisciplinary team, in particular GP practices and secondary care.

Electronic prescribing

There are a number of clear benefits from the introduction of further enhancements to the electronic transfer of prescriptions ( ETP) in primary care. The ePharmacy Programme has thus far concentrated on underpinning GP prescribing activity. Whilst this represents the vast majority of all prescribing activity, there are growing numbers of new prescribers in primary who would benefit from being enabled to use the ePharmacy infrastructure to support their prescribing activities. In addition, there may be further benefits to be gained from an incremental move towards paperless prescribing across primary care. This has the potential to improve productivity and efficiency by reducing the time consuming physical printing and signing of prescriptions by GPs. It also removes the need for community pharmacists to endorse and claim both electronically and on paper. A fully paperless service, relying on technology only, is also less susceptible to most elements of fraud. Paper prescription forms, however, are currently central to a number of established processes involved in providing medication to people and a move to paperless prescribing will necessitate process changes across the board, including the use of Advanced Electronic Signatures ( AES), robust systems for the clinical check on the appropriateness of the prescription request, adjustments to community pharmacy workflow and changes to NSS payment processing. Some of these require legislation changes and new IT functionality.

Action:
We will extend ePharmacy support to all key prescribers in primary care. We will commission the ePharmacy Programme to scope and test an incremental move to paperless prescribing across primary care.

Access to healthcare information

The current limitations surrounding community pharmacist access to electronic information and records such as the Emergency Care Summary, the Key Information Summary and Anticipatory Care Plans still require to be resolved. A Short-Life Working Group ( SLWG) has been convened, with membership including the Information Commission Offices ( ICO), Information Governance specialists, Caldicott Guardians, the Scottish Government, the BMA and RCGP with GMC and public representation invited. This SLWG will work together to create a Scottish Code of Practice between Health Boards and GP practices to promote the safe sharing of information across boundaries in healthcare and within the multidisciplinary team, in accordance with the Data Protection Act ( DPA).

Action:
We will consider how the pharmacy profession can safely access and share appropriate health information in light of the guidance contained in the future Scottish Code of Practice.

Robotics

Automation and robotics are also being increasingly used within hospital and community pharmacy services in Scotland to dispense and distribute medicines freeing time for pharmacists and pharmacy technicians to provide pharmaceutical care and reducing the risk of error. In addition, other initiatives such as semi-automated medicines cabinets are beginning to be used in hospital wards and departments, often targeted in areas such as Acute Receiving Units and theatre wards. Benefits seen from this include releasing time for nurses to care for people and quicker access to medicines. These cabinets also provide automatic ordering of required medication and allow keyless but secure access to stored medication through fingerprint identification which also enables greater accountability and tracing of medication. We will continue to encourage hospitals to invest in these technologies.

More recently, we have invested in deploying automation in a number of community pharmacies. Testing of robotics and scanning technologies is now underway to help us understand more about the economic impact of the technology as well as how it can enable innovative workforce development in community pharmacy by releasing time for clinical care. This work is being evaluated in order that the outcomes can be used to shape future service and policy direction.

Automation in hospital pharmacy

Within NHS Greater Glasgow and Clyde (NHS GG&C) the largest hospital pharmacy robotic installation in the world exists within a Pharmacy Distribution Centre and distributes nine million packs of medicines to 4000 destination points from the eastern boundary of Glasgow to Argyll in the west Highlands. The main hospitals within NHS GG&C also have dispensing robots which dispense medicines for individual people. The use of this technology has enabled a very much smaller pharmacy to be built in the new Queen Elizabeth University Hospital than would otherwise have been required and has enabled pharmacy staff working in that hospital, freed from dispensing, to be available at the bedside to assist people to achieve the best outcomes from their treatment with medicines. In addition, semi-automated medicines cabinets are being installed within hospital wards and departments. The Golden Jubilee has recently invested in this technology for the whole hospital and the benefits include releasing time for nurses to care for people and quicker access to stored medicines meaning that people can receive for example pain relief as required more quickly. Typically wards can store 20% less medication through use of these cabinets while still providing medicines to meet the people's needs.

Action:
We will explore further options to increase the use of automation in areas where medicines are used in order to release pharmacist and pharmacy technician time to provide pharmaceutical care.

Digital integration

In parallel with this, the Integrated Digital Safer Medicines Programme ( IDSMP) has been formed to enable better information sharing for medicines information and medication-related processes between hospital, primary care and community pharmacy, as envisaged by the Closing the Loop report. The focus for this work is the development of a single, virtual electronic medicines record for every patient in Scotland, readily available to the patient and accessible to those clinicians who need it. As well as facilitating implementation of HEPMA, the programme seeks to support accurate medicines reconciliation at all transition points, improved quality of medication information, and improved patient knowledge and understanding.

Action:
We will commission the Integrated Digital Safer Medicines Programme to scope future requirements for hospital pharmacy transformation and medicines management. We will actively contribute to the development and implementation of the Scottish Government's Digital Health and Care Strategy to ensure pharmacy's needs are covered.

Technology enabled care

The Scottish Centre for Telehealth and Telecare ( SCTT), within NHS 24, supports the development and expansion of technology-enabled health and social care services in Scotland. They have a number of key programmes of work, many of which are relevant to pharmacy, including supported self-management, video consulting and home and mobile health monitoring. The development and use of technology enabled care will enable a greater reach into our local communities when delivering NHS pharmaceutical care, specifically to vulnerable people such as those who are housebound or the frail elderly. Access to pharmacy services and advice will be widened as a result, providing more equitable access to NHS pharmaceutical care and delivering improved outcomes for people from the use of medicines.

NHS Highland Technology Enabled Support

The delivery of care close to the person's own home presents particular challenges for NHS Highland. Remote delivery of care, using information and communication technologies, was seen as a solution that could enable sustainable pharmaceutical care to be provided to these remote and rural communities. As a result NHS Highland has established a remote, primary care, clinical pharmacy service to GP practices in Lochaber using a technology‑enabled care solution. The pharmacy service involves remote medication review clinics to care home residents; videoconference attendance at multidisciplinary team meetings and virtual wards; remote clinical pharmacy support to GP practices, the integrated care team, and the wider health and social care team; and collaborative videoconferencing clinics with other healthcare groups.

More innovative ways of providing existing and new services through technology enabled care will continue to be developed, where due consideration will be given to health literacy and person-centredness in the approaches taken. The SCTT will continue to play a key role in supporting future developments, and ensure the use of these technologies brings efficiencies for care providers and delivers an enhanced experience for people receiving care.

Action:
We will ensure the availability of technology-enabled care solutions to support the delivery of pharmaceutical care.

Decision support tools

In addition to a skilled workforce and evolving practice models, is the need for modern-day decision support tools . Realistic Medicine calls for practitioners to reduce harm, manage risk better and reduce unnecessary variation in practice and outcomes. Using the wealth of routinely collected health and social care data to understand better how the Scottish population use and respond to treatments is key to developing the clinical decision support tools that clinicians and the people they care for need to make the right treatment choices. This also includes the opportunities afforded through health and social care apps.

There are already examples of how pharmacists in collaboration with academic and NHS colleagues are driving innovations in how medicines are personalised to maximise health gain and minimise any unintended consequences from treatment. One such example is where pharmacists are using predictive analytic methods to quantify the association between exposure to different types of antimicrobials and the risk of developing a healthcare-associated infection ( HAI) to populate a clinical decision support tool.

While translating analytics into decision support algorithms is an emergent form of decision support, another more tried-and-tested approach with a strong body of evidence for benefit is translation of existing evidence-based guidance into formats that support quick and easy decision-making at point of care. This is most effective when the guidance is converted into evidence-based algorithms that process patient-specific data and offer recommendations or options specific to that individual patient. This type of decision support is already being used in the antimicrobial-prescribing app developed for the Scottish Antimicrobial Prescribing Group ( SAPG) as part of the decision support roadmap, and is also being used to support shared decision-making in the polypharmacy app.

Action:
We will ask the Digital Decision Support Programme to define a roadmap for pharmacy decision support tools that will deliver highest impact in achieving personalised care, shared decision-making and the other priorities outlined in this strategy.

"The development and use of technology enabled care will enable a greater reach in to our local communities."

Sustainable pharmaceutical care services

Commitment 9:

Actions

Contracting & funding arrangements
Planning

Improving the planning and delivery of pharmaceutical care.

Pharmaceutical Care Service Planning

To realise an integrated role for pharmacy and to embed NHS pharmaceutical care in health services in all settings, NHS Boards must be provided with the means to take a proactive approach to the planning and delivery of NHS pharmaceutical care. At the centre of this new approach will be a statutory planning framework for NHS pharmaceutical care. This will build on pharmaceutical care service planning already conducted by NHS Boards and will enable them going forward to more systematically target available pharmacy resources to the needs of local populations.

Action:
We will develop and implement a new planning framework to help NHS Boards better characterise the pharmaceutical care needs of their local populations.

Modern Contractual Framework

In order to deliver the full potential an improved planning process offers, NHS Boards must have the flexibility to enter into arrangements based upon the local population care needs identified by the planning process. We will therefore introduce a new contracting framework for the provision of NHS pharmaceutical care that will give NHS Boards the power to enter into contracts for the provision of NHS pharmaceutical care services. This will provide NHS Boards with the flexibility to ensure the provision of NHS pharmaceutical care services is appropriate and responsive to the local need identified by their planning processes. A new funding arrangement will also support the realisation of the direct care and clinical care outcomes of those services.

NHS Pharmaceutical Care Service Performers List

In addition, and in support of the new planning and contracting framework, we will introduce a Performers List for Pharmacy as already exists for GPs and other contractors. The main function of the Performers List is to provide governance for services delivered by contracts, safeguarding the quality of the services being delivered. It also has the potential to benefit workforce planning in the future.

Action:
We will develop and implement a new contracting framework for community pharmacy NHS pharmaceutical care services, underpinned by a new funding arrangement and a Performers List for Pharmacy.

"In order to deliver the full potential an improved planning process offers, NHS Boards must have the flexibility to enter into arrangement based upon the local population care needs."