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NHS trusts should deploy more clinical pharmacists, including pharmacist prescribers, and use them to drive value from the £6.7bn that NHS hospitals spends on medicines every year, Lord Carter has advised in his final review[1]
of English NHS acute hospitals.
Lord Carter recommends that NHS trusts use at least 80% of their pharmacist resource for direct medicines optimisation activities, medicines governance and safety remits. However, his review, published on 5 February 2016, found significant variation in the number of prescribing pharmacists in hospitals and in the total pharmacy and medicines costs across acute trusts.
Lord Carter estimated in his interim report published in June 2015 that £5.0bn of the £55.6bn spent annually by NHS acute hospitals could be saved by reducing unwarranted variation across the workforce, hospital pharmacy services and medicines optimisation, estates management and procurement.
“If all trusts looked at how they might achieve the average [total pharmacy and medicines] cost, then the NHS could save at least £800m,” the final report says.
Lord Carter judges the delivery of hospital pharmacy services, which cost the NHS £600m, to be inseparable from the optimisation of medicines. “In hospital pharmacy we know that the more time pharmacists spend on clinical services rather than infrastructure or back-office services, the more likely medicines use is optimised,” the report says.
“Simply put, the NHS needs to focus the pharmacy workforce to drive optimal value and outcomes from the £6.7bn it spends on medicines,” says the report. “Trusts should ensure clinical pharmacists are in place, with sufficient capacity, to meet this challenge.”
Lord Carter proposes a ‘Hospital Pharmacy Transformation Programme (HPTP)’ to ensure trusts implement his recommendations, which also include the accurate cost coding of medicines and the consolidation of medicines stocks to reduce stock holding from 20 days to 15. He also wants NHS Improvement to publish a monthly list of the top 10 medicines that provide trusts with savings opportunities. Trusts will need to have plans in place by April 2017 to achieve the recommendations by April 2020, says the report.
The recommendations also say that infrastructure services should be delivered through collaborative or shared service type-models, suggesting that such services do not always need to be delivered by NHS employed staff. The report also highlights the potential of centralised dispensing for increasing efficiencies in the supply of medicines to outpatients and to patients when they are discharged from hospital. Lord Carter also recommends that every trust should adopt electronic prescribing and medicines administration systems.
The Royal Pharmaceutical Society (RPS) supports the report’s recommendation for an increased role for hospital pharmacists within clinical teams. “We agree completely that increased input from hospital pharmacists, working in teams with doctors, nurses and all other healthcare professionals, will improve patient outcomes, reduce waste, improve prescribing decisions and reduce avoidable harm,” says Sandra Gidley, chair of the RPS English Pharmacy Board, adding that the report provides “clear recognition of the vital governance and clinical leadership that hospital chief pharmacists provide”, a role that will be even more important in future.
The RPS also supports the sharing of best practice but warns that chief pharmacists will need access to high quality comparative data to allow its spread.
Vilma Gilis, president of the Guild of Healthcare Pharmacists, says the guild is pleased that Lord Carter has placed such “high importance” on clinical pharmacists but is concerned that employers may interpret the report to mean that infrastructure roles can be outsourced, saving money on staff costs and threatening jobs.
“Whilst we understand that many support functions in the pharmacy service may be suitable for outsourcing, hospital pharmacy has had to compete with other organisations which have the advantage of not having to pay VAT on medicines, which has given them an unfair advantage in the tendering process (and possible false impression of efficiency),” says Gilis.
The Healthcare Distribution Association (HDA UK) welcomed Lord Carter’s report. “Healthcare distributors can act as the stockroom for secondary care, storing supplies and delivering them to the right place at the right time, often with only 30 minutes notice,” says Martin Sawer, executive director of the HDA UK.
