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

Chapter 5 Making it Happen: Infrastructure to deliver pharmaceutical care

In this Chapter we set out our aims and related work programme to develop the infrastructure that supports pharmaceutical care. This will focus on developing approaches to:

• Ensure a workforce that is fit for purpose by implementation of NHS standards of practice for pharmaceutical care are attained through working with the NHS, Schools of Pharmacy and Medicine, NES and the professional and regulatory bodies.
• Ensure education and training meets the needs of patients and the NHS.
• Provision of NHS Clinical and Professional Leadership.
• Implementation of primary and secondary care configured systems to allow electronic information sharing contributing to pharmaceutical care and electronic prescribing for all prescribers including pharmacist prescribers.
• Implement HEPMA to allow for electronic capture of prescribing data in secondary care.
• Develop and implement a modern framework for planning NHS Pharmaceutical Care Services.
• Ensure that pharmacy premises are suitable for the delivery of pharmaceutical care.
• Support the use of action research, practice research and clinical research that enables development and evaluation of pharmaceutical care.

Development of infrastructure that supports pharmacy practice development, education, training, research and electronic sharing of information for the development of pharmaceutical care

5.1 Introduction

5.1.1 In this Chapter we focus on how we will put in place the foundation blocks for making our Vision and strategy happen from pharmacy practice development, education, research and electronic sharing of information, to medicines supply and premises.

5.1.2 This Action Plan acknowledges the important and effective role that is played by the network of pharmacies across Scotland in the provision of medicines and access to healthcare advice.

5.1.3 The legislation needed to reconfigure all aspects of how we plan, contract and deliver NHS Pharmaceutical Care and Services will be considered. Particular consideration will be given to the increased focus on the clinical aspects of pharmaceutical care and how this might be delivered in the future.

5.1.4 Prime responsibility for delivering the Vision locally will rest with NHS Boards and their Directors of Pharmacy working with others, and will take into account any new approaches resulting from the integration of health and social care.

5.2 Workforce, Education and Training

5.2.1 The Vision proposes that pharmacists in 2020 would be released from routine dispensing to work as NHS accredited clinical pharmacist independent prescribers delivering pharmaceutical care. In order to achieve this, the Wilson and Barber report recommends developing a framework to ensure a workforce that is fit for purpose to deliver pharmaceutical care for the 21^st century, reviewing all aspects of pharmacy workforce and associated education, training and professional attainments of standards. There is currently no central locus for pharmacy national workforce planning in Scotland. NHS Education for Scotland (NES), working with key stakeholders such as the Schools of Pharmacy and the NHS Boards, should be commissioned to undertake data collection and trend analysis to lead to better supply and demand forecasting, and capacity planning for the pharmacy workforce.

5.2.2 In addition, by 2020, the accredited clinical pharmacists delivering pharmaceutical care would need to be independent prescribers that would work in partnership with GPs and have case loads to manage.

5.2.3 The undergraduate pharmacy programmes in Scotland needs to ensure that graduates are fit for the future requirements of the NHS with the right balance of clinical, supervised practice and interdisciplinary experience, taking into account future workforce needs of the NHS and the regulatory framework.

5.2.4 Education and training in multidisciplinary team based practice at both undergraduate and postgraduate level would be critical to develop more collaborative methods of working. This would be led by the Scottish Government and NES, working in partnership with the Schools of Pharmacy and Medicine in Scotland and professional and regulatory bodies.

5.2.5 Work is already underway with a scoping exercise of what the educational requirements of such an approach might be. In addition, joint post-graduate training is currently being facilitated by the relevant professional bodies.

5.2.6 NES which currently administers and funds the Pre-registration Pharmacist Scheme (PRPS) would work with the Scottish Government, Schools of Pharmacy and the NHS to advance to a more integrated academic and clinical undergraduate programme, including a planned and co-ordinated supervised practice through undergraduate placements. In addition, consideration should be given to a NES Deanery structure for pharmacy similar to medicine to enhance educational quality assurance and appropriate training environments for the future pharmacy workforce. The quality management of the learning environment of both placement and the pre- registration year for pharmacy trainees, including formal tutor appraisal, could be assumed by NES, in line with other professional groups in the NHS.

5.2.7 A significant part of formal post-graduate training is focused on hospital based pharmacists, linking to potential career development. This needs to be further developed into a structured career framework for hospital and community pharmacists which introduces NHS accredited clinical pharmacist independent prescribers and also accommodates other new and innovative models of practice. Further consideration should be given to how the newly-launched Royal Pharmaceutical Society (RPS) Faculty for Professional Career Assessment could support the NHS to facilitate a robust career framework suitable for the needs of the NHS in Scotland.

Scottish Government will establish an early review of all aspects of pharmacy workforce and associated education and training involving NES, Schools of Pharmacy, Schools of Medicine, NHS Boards and the professional and regulatory bodies to develop an integrated approach to ensure a workforce that is fit for purpose and that meets the future service needs of NHSScotland.

5.3 Clinical and Professional Leadership

5.3.1 The provision of NHS pharmaceutical care is the responsibility of the NHS Board working with the Scottish Government. NHS Boards would take the lead in creating professional and clinical networks to support all pharmacists providing care to the NHS patients. These would need further strengthening through professional recognition and identification of professional leaders and clinical leaders within each NHS Board. This will be supported by NES, HIS and the professional and regulatory bodies. These leaders should also work with pharmacy owners and employers of pharmacists to ensure a common understanding of the importance and requirement of the professionalism of individual pharmacist and the creation of systems to support this.

Scottish Government will work with NES, HIS and professional and regulatory bodies to develop Clinical and Professional Leadership in a multi-disciplinary environment.

5.4 eHealth and Technology

5.4.1 eHealth plays a vital role in enabling some of the key activities set out in this Pharmaceutical Care Action Plan.

5.4.2 The eHealth Strategy 2011-17 provides the strategic direction for eHealth, with the principles of service-led change, joint governance and incremental development at its heart. eHealth in NHSScotland also provides a governance framework for technology developments, ensuring that products and approaches deliver solutions that enable and support person-centred, safe and effective practice. It also ensures that investments in IT are based on the principle of convergence, are flexible and have the ability to integrate easily.

5.4.3 A core set of technology products and services have been widely adopted across pharmaceutical services. However, the major technology solutions that are currently in place to support pharmaceutical care across NHSScotland are not fully integrated at this time. In addition, in secondary care, Hospital Electronic Prescribing and Medications Administration (HEPMA) and related electronic decision support has only been implemented in a very small number of acute hospitals, and in those cases not to its full potential.

5.4.4 Evidence from the Wilson and Barber Review recommends the increased use of robotic dispensing due to benefits in reducing dispensing errors, better use of workforce and better sharing of electronic patient data.

5.4.5 Sharing of relevant electronic patient data, for case management, is considered to be critical to ensuring delivery of pharmaceutical care both within primary care but also across secondary care. In order to optimise patient safety and to allow for appropriate monitoring of prescribing appropriateness and safety, electronic prescribing and sharing of information between primary and secondary care would need to be in place in all NHS Boards.

Scottish Government will develop approaches to implement primary and secondary care electronic prescribing configured systems to allow electronic information sharing that contributes to pharmaceutical care for all prescribers including pharmacist prescribers.

5.4.6 The eHealth strategy's aims are to use information and technology in a coordinated way to:

• maximise efficient working practices, minimise wasteful variation, bring about measurable savings and ensure value for money.
• support people to communicate with the NHS in Scotland, manage their own health and wellbeing; to become more active participants in the care and services they receive.
• contribute to care integration and to support people with long term conditions.
• improve the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality, and develop an approach to a Single Virtual Medications Care Record.
• improve the safety of people taking medicines and their effective use including the development of medications and related standards.
• to provide clinical and other local managers across the health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery.

5.4.7 Activities that underpin these six aims will have an impact on the delivery of the Pharmaceutical Care Action Plan, but the fifth aim in particular focuses on the safety and effectiveness of pharmaceutical care, irrespective of the setting.

Scottish Government will consider roll out of HEPMA to allow for electronic capture of prescribing data in secondary care.

5.5 Modern Framework for NHS Pharmaceutical Care

5.5.1 To meet rising demands, the Vision places greater emphasis on the planning, contracting and delivery of pharmaceutical care.

We will develop the new framework and requirements of the future through consultation, modelling of different methods of working and evaluating pilots.

5.5.2 The Wilson and Barber report recommends that essential to the delivery of pharmaceutical care will be the suitability of premises to ensure that patients' privacy and confidentiality is safe guarded. Pharmacy owners will need to consider how this will be achieved.

Scottish Government will work with patients and pharmacy owners to ensure that pharmacy premises are suitable for the delivery of pharmaceutical care.

5.5.3 In order to release time to allow more care it will be important to optimise the roles of the pharmacy team and automate dispensing where possible. Telehealthcare is also considered to be an important tool to help reach more patients, not just in remote and rural areas but also in urban settings.

5.6 Action Research, Practice Research and Clinical Research

5.6.1 It is important not only that any long term healthcare plan is based on evidence where possible (or best practice where there is no evidence), but also on pioneering and innovative practice which takes into account future requirements. This includes considerations of workforce, new technology, changing demographics and increasing clinical demand. This Action Plan is built on all of these but, as Wilson and Barber concluded in their report, "it is also important that any plan for future development has built into it measures for success and methods of monitoring and evaluation, so that there is a clear and demonstrable path for progress."

5.6.2 And so it is with this plan which demands new ways of thinking, new ways of working and new models of care. In testing these developments, therefore, it is proposed that the plan proposed will be dynamic and supported and informed by a programme of action, practice and clinical research:

• Action research to inform and evaluate new ways of working and logistics
• Practice research to examine new models of pharmaceutical care, partnership working, and patient and stakeholder satisfaction
• Clinical research to assess the safety and effectiveness of new services in terms of clinical outcomes.

5.6.3 This work would be undertaken in partnership with the Schools of Medicine and Pharmacy in Scotland.

Scottish Government will support the use of action based research, practice research and clinical research that enables development and evaluation of pharmaceutical care.

5.7 Making it Happen - Implementation

5.7.1 At the end of each chapter we have set out the main areas considered to deliver the vision. This work will be taken forward under a governance structure in the Scottish Government Health Directorates to consider each of the areas identified for development and to provide a detailed work programme and delivery plans.

Our work programme will explore options to provide INFRASTRUCTURE to deliver pharmaceutical care:	Years 1-3	Years 3-5	Years 5-10
1. Establish an education and training framework to help pharmacists deliver pharmaceutical care to patients in all settings
2. Develop and establish a framework for workforce development to ensure adequate resource to deliver the Vision of general practice pharmacists working in primary care
3. A framework to support clinical and professional leadership
4. Develop an integrated approach to deliver a Single Virtual Medications Care record available at each point of care
5. Support the on-going development and introduction of medications standards
6. Integrate and build on facilities already operational for the pharmacist-to-person registration service
7. Develop technology for decision support in prescribing and dispensing
8. HEPMA to allow for electronic capture of prescribing data in secondary care
9. Develop, consult on, and implement a modern framework for planning, contracting and delivering NHS Pharmaceutical Care Services considering legislative changes that might be needed supported by research