Prescription for Excellence - the future of pharmaceutical care: vision and plan

Chapter 3 Safety in pharmaceutical care and medicines

In this Chapter we will set out our aims and related work programme to deliver safety in pharmaceutical care and medicines. This will focus on developing approaches to:

• Review of the governance arrangements for the safe delivery of pharmaceutical care and use of medicines in the community.
• Implementing clinical guidelines and Monitoring of the use of Medicines.
• Implementing Scottish Patient Safety & medicines reconciliation Programme across pharmacy practice in primary care & secondary care.
• Introducing patient level risk assessments.
• Introduce a framework for the use of patient identifiable prescribing data to monitor changes in prescribing.
• Extend access to patient information systems and enable the sharing of information between pharmacists, GPs and other healthcare and social care practitioners.
• Establish a Performers List for pharmacists to provide NHS Pharmaceutical Care. All pharmacists delivering clinical services will be independent prescribers.

Delivery of treatments, interventions, support and services so that NHS pharmaceutical care is delivered in a safe environment preventing injury or harm to people from medicines, advice and support.

3.1 Introduction

3.1.1 Safety in pharmaceutical care and medicines is uppermost in ensuring optimum benefit from the therapy patients receive. Building on our quality ambitions, this Chapter will focus on our actions/strategy to help ensure that there will be no avoidable injury or harm to people from medicines, or from the advice or support they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.

3.1.2 A study undertaken for the Royal Pharmaceutical Society of Great Britain^[30] found 3.3% dispensing errors, 5% of medicines prescribed at outpatient appointments not added to GP records (13% of consultations were not added to GP records). In hospital they also found 18-60% discrepancy in medication with 1.5-9.2% prescribing errors, and 11% discrepancy in discharge medication. Using NHS accredited clinical pharmacists in the community to support medicines reconciliation as patients move between different care settings will improve care and safety for patients.

3.1.3 The Public Bodies (Joint Working)(Scotland) Bill to integrate adult health and social care services is currently before Parliament and is designed to integrate health and social care. This Action Plan recognises the importance of delivering NHS pharmaceutical care to recipients of local authority community care services in a way which best meets the needs of those individuals. This is entirely consistent with the integration agenda. If passed by Parliament in its current form, the Public Bodies (Joint Working)(Scotland) Act will require Health Boards and local authorities to work together to plan the delivery of certain functions within their area and it is envisaged that this would include the delivery of pharmaceutical care services in care homes. Within care homes, consistent clinical input from suitably qualified NHS accredited pharmacist prescribers is recommended, working in partnership with GPs, nursing and social work staff, patients and their carers to ensure appropriate clinical governance in reviewing prescribing. The same would apply for patients living in their own homes with supported care. It will be essential to ensure that there is consistency of service standards for delivery.

3.1.4 The Vision and Action Plan proposes that it is essential that NHS Boards ensure all patients have access to NHS pharmaceutical care from a pharmacist so that where the population is served by a dispensing doctor then clinical pharmacist input is also available to the population. Pharmacists delivering this would need to be prescribers and on a NHS Board's NHS Pharmaceutical Care Performers List like other healthcare professionals in primary care to ensure standards of care.

3.1.5 The Vision sets out to address key issues highlighted in the Francis report^[31] such as patient safety and consistency and quality of care.

3.2 Governance arrangements for the safe delivery of pharmaceutical care

3.2.1 The pharmacists that will be delivering the pharmaceutical care in the community will need to ensure that when they manage patients, they work with medical and nursing colleagues to implement clinical guidance and undertake the relevant monitoring where appropriate. They will need to ensure they work closely with the NHS Board's governance structure for utilisation of medicines.

Scottish Government will consider approaches to implementing clinical guidelines and monitoring of the use of medicines in all care settings.

3.2.2 The development of new medicines is essential for advancing therapeutics. This is a dynamic process which aims to improve clinical responses, whilst reducing harm and/or side effects. However, not all new medicines represent a significant improvement over existing medicines in the same therapeutic class.

3.2.3 Medicines are the most common intervention in healthcare. The Audit Scotland Report on Prescribing in General Practice suggests that NHSScotland spends close to £1.4bn a year on medicines. Of this expenditure, almost £1bn (70%) is spent on medicines dispensed in primary care. Territorial NHS Boards spend around 10% of their budgets on GP prescribed medicines. NHS clinicians have evolved processes such as Area Drug and Therapeutics Committees (ADTCs) and the Scottish Medicines Consortium (SMC) to ensure that the medicines they use represent value for money.

3.2.4 The ADTC functions support and help deliver the three quality ambitions, particularly around patient safety and provision of the most appropriate treatments at best cost. SMC accepted medicines are considered by local ADTCs for inclusion on their formularies.

Scottish Government will consider the review of the clinical governance arrangements for the safe delivery of pharmaceutical care and use of medicines in the community.

3.3 Scottish Patient Safety Programme

3.3.1 The Scottish Patient Safety Programme (SPSP) has started to be delivered in GP practices after the implementation in hospital settings. The programme of work for SPSP is now looking to extend utilising the role of pharmacists in primary care. Medicines reconciliation for patients post discharge would be an important development in this area. In addition, the review of high risk medicines is intended to complement the patient safety agenda in GP practices and will see inclusion of more high risk medicines. It is important to acknowledge that appropriate review of prescribing at medication review, which may or may not be to address polypharmacy should address many of the safety issues as highlighted in CEL 36 (2012).

Scottish Government will develop approaches to implement Scottish Patient Safety & Medicines Reconciliation Programme across pharmacy practice in primary care & secondary care.

3.4 Patient Level Risk Assessments

3.4.1 Patient risk assessment tools have been developed to identify people that would most benefit from interventions to ensure safe and appropriate prescribing. This approach has been applied to target polypharmacy reviews but also in Change Fund initiatives where enhanced pharmaceutical care has resulted in improved outcomes for older people including prevention of readmission. Patient support tools can also be used to help support adherence^[32]. This is important as discussed above it is estimated that up to 50% of drugs are not taken as prescribed.

Scottish Government will develop approaches to introducing patient level risk assessments for patients taking medication.

3.5 Patient Identifiable Prescribing Data

3.5.1 Patient identifiable data allows appropriate monitoring of high risk prescribing. It can be used to measure improvements in prescribing and potentially improves patient safety. Work has started with NHS Scotland Information Services Division (ISD) to build indicators that can be used by GPs and pharmacists. This data also helps improve evidence based prescribing. As part of the Vision, all pharmacists working with GP practices would be given appropriate skills to use prescribing data. Currently this role is undertaken by prescribing advisors but as the Audit Scotland report recommends, there is a need to increase the pharmacist and analytical input to practices across Scotland.

3.5.2 The development of data sets with time should also allow for the monitoring of treatments in different patient groups and this should be governed by Area Drug & Therapeutic Committees.

Scottish Government will develop approaches to introduce a framework for the use of patient identifiable prescribing data to monitor patterns and changes in prescribing.

3.6 Patient Information Systems

3.6.1 In order to deliver safe and effective care, the Vision proposes that pharmacists providing clinical care would be given access to relevant clinical data to ensure medication and care issues can be managed appropriately. Access to electronic Key Information Summary eKIS and Emergency care summaries (ECS), as well as sharing relevant information with social care and other health colleagues will be essential, as more patients with complex and changing support needs are managed at home.

3.6.2 Pilot work is almost complete in three NHS Boards to develop the Hospital Pharmacy Care Record (HPCR) and sharing of the existing Pharmacy Care Record (PCR) in the community as the individual moves between different care settings. This is of benefit as the information generated from the pharmacy shows what medicines the patient actually collects as opposed to what is prescribed. Sharing of information on patient discharge with pharmacists means that the rationale for changes in medication can be understood and implemented safely at this point.

Scottish Government will develop approaches to extending access to patient information systems and enable the sharing of information between pharmacists, GPs and other healthcare and social care practitioners.

3.7 NHS Pharmaceutical Care Performers List

3.7.1 Many primary care health professionals such as GPs and dentists have performers lists that are held with the local NHS Board. The Wilson and Barber Review recommends the introduction of a performers list (for pharmacists working in the community) that will underpin the principles of fitness to practice, professional good standing, professional standards and clinical governance which will improve safety for patients.

3.7.2 When designing services and introducing change, the design should allow for minimal disruption to the workflow^[33], therefore, working in collaboration with GPs, pharmacist independent prescribers will be able to implement change for patients without increasing the work burden for other healthcare professionals. Pharmacists will be supported to develop their skills so that they will be able to work as independent prescribers.

Scottish Government will develop approaches to establishing a Performers List for Pharmacists who provide NHS Pharmaceutical Care.

3.7.3 Pharmaceutical care planning that takes place at NHS Board level should help inform workforce planning, education and training.

Our work programme to deliver SAFE pharmaceutical care will explore options to:	Years 1-3	Years 3-5	Years 5-10
1. Review of the governance arrangements for the safe delivery of pharmaceutical care and use of medicines in the community
2. Implementing clinical guidelines and Monitoring use of Medicines
3. Establish partnerships with HIS, and the professions to mainstream the aims of the Scottish Patient Safety Programme in pharmacy and medicines practice
4. Develop and implement a framework for the appropriate use of patient identifiable prescribing data and risk assessment
5. Work with health professionals to enhance shared clinical patient information systems to support pharmacists providing clinical care
6. Develop with the professions NHS Pharmaceutical Care Performers list for patient registration to allow patients to have appropriate pharmaceutical care