The journey towards dedicated pharmacy support for all emergency departments

Ten years ago, a pharmacist working in an emergency department (ED) would have been a rarity. But, with patients spending more time in EDs, pharmacists are now viewed as an essential part of the team.

In December 2023, the Royal College of Emergency Medicine (RCEM) and the UK Clinical Pharmacy Association (UKCPA) called for more involvement of pharmacists and pharmacy technicians in EDs, saying they would support “the safe and efficient delivery of care to patients”. In a joint statement, the two organisations set out seven standards for the level of support needed (see Box 1)^​1​.

According to David Webb, chief pharmaceutical officer for England — who gave evidence at a House of Commons Health and Social Care Committee inquiry into pharmacy in March 2024 — “about 45% of hospitals who responded [to an NHS Benchmarking Network project] said that they had a clinical pharmacy service in emergency departments”.  

However, an investigation by The Pharmaceutical Journal suggests that, although 43% of NHS trusts in England have a dedicated pharmacist for their ED, only 15% are meeting the standards for pharmacist and pharmacy technician support set out by the RCEM/UKCPA.

In response to a request made under the Freedom of Information (FOI) Act in October 2024 to 201 NHS trusts running one or more EDs in England, data reveal that 22% of trusts that responded (22 of 98 trusts) had a 0.1 whole-time equivalent (WTE) dedicated pharmacist for each resuscitation bed, plus a 0.05 WTE dedicated pharmacist for each high-acuity bed (see Box 2 for limitations).

The data also show that 27% of trusts that responded (26 of 98 trusts) had at least 1.0 WTE pharmacy technician dedicated to the ED.

Only 15% of trusts that responded (15 of 98 trusts) met the standards for both pharmacist and pharmacy technician support.

Adrian Boyle, president of the RCEM, describes it as “concerning” that the majority of EDs still do not have a dedicated pharmacist and calls on trusts to implement its guidance.

 “This role is increasingly pertinent as people are enduring extremely long stays in EDs, unable to be admitted into an inpatient ward due to the lack of capacity. And some of these patients will be reliant on time critical medications, which, if missed or delayed, may lead to serious patient harm,” he adds.

However, Kunal Gohil, a specialist clinical pharmacist working in the EDs at Nottingham University Hospitals Trust — which met the RCEM/UKCPA standards — says the results suggest the RCEM recommendations are having an effect. Speaking on behalf of the UKCPA emergency care committee, Gohil says the committee is seeing a lot more requests for sample business cases and service specification examples that can be adapted to argue the case for an ED pharmacist.

“As a specialist pharmacist body, we’re pragmatic in terms of managing our expectations of allocating new pharmacy resources into EDs, particularly given the current economic climate and competing priorities in secondary care,” he says.

“However, these results would suggest trusts are taking the first steps and identifying the potential benefits of having increased pharmacy presence in EDs, which includes pharmacists and pharmacy technicians.”

Whether the data show an improvement on the position a few years ago is difficult to demonstrate since there has been relatively little research into the extent and roles of ED pharmacists. Gohil believes it probably is an increase but suggests benchmarking exercises on how pharmacists’ workload is split between clinical and non-clinical tasks would give a greater understanding of compliance with the recommendations.

Dan Greenwood, associate professor of clinical pharmacy at the University of Leicester, looked at pharmacy input in EDs for his doctorate in 2020. He discovered that 14 out of 25 EDs (56%) that he looked at had a pharmacist working in them at some point and 19 out of 25 EDs (76%) had pharmacy “facilities” — although this may have just been a place to store medicines.

“I suspect a lot of places are not far off [the standards] … the main thing is that at least we do now have standards and they seem reasonable. It gives us a target to work towards.”  

He adds that he is now seeing more advertisements for ED pharmacists and is also involved in an ED pharmacist social media group, whose membership has increased significantly — both of which he feels indicate increased interest in the roles.  

Changing landscape

In January 2025, a record 60,000 patients waited 12 hours or more for admission to wards from EDs in England and more than 172,000 spent 12 or more hours in the ED in total. “Ten years ago, when I started, the four-hour wait target was being met more than 90% of the time. A pharmacist’s input was considered potentially minimal as the throughput was so fast,” explains Gohil.

“Now we have 12 to 24 hour waits relatively routinely. We have had to consider medicines reconciliation more quickly, and we have an older and sicker population. A lot of people who attend A&E now are sick at baseline.”

These patients may be coming into hospital for something acute but have chronic long-term problems where the pharmacist can provide some input and a “safety net,” he adds.

National Institute for Health and Care Excellence (NICE) guidance says that all patients should have medicines reconciliation within 24 hours which, for some, will now mean this needs to be done in the ED. At Frimley Health NHS Foundation Trust, having a pharmacy team attached to the two EDs has increased the proportion of patients having medicines reconciliation done within 24 hours from 42% to 55%, says Natasha Gandhi, lead pharmacist in the ED.  

Ravijyot Saggu, a member of the Royal Pharmaceutical Society (RPS) hospital expert advisory group, emphasises that pharmacists need to use their specialist input strategically: a lone pharmacist will not be able to see every patient who passes through an ED.  “They are trying to risk stratify — they won’t see people in minors [minor injuries and illnesses],” he explains.

Gandhi adds the fast-moving nature of ED work means “you are continually having to re-evaluate your priorities”.

Time-critical medicines

However, it is not just medicines reconciliation where pharmacists can contribute their unique skills. Gandhi, for example, spends a proportion of her time teaching doctors and nurses, as well as offering advice on areas such as IV drugs or dosage. “I spend quite a bit of time in resus,” she says.    

Another area pharmacists can influence is the administration of time-critical medicines — something which can get overlooked in a busy ED.

After even a short delay in taking their medicines, people with Parkinson’s disease (PD) can find that they have an increased risk of falls and that their symptoms, such as tremors, pain and rigidity, worsen. In 2023, research published by Parkinson’s UK’s revealed that 58% of people with PD admitted to hospital in England did not receive their medicines on time every time^​2​.  

In December 2024, an investigation by the Health Services Safety Investigations Body (HSSIB) highlighted a particular case where a patient with PD who was in an ED for three days missed 7 out of 18 doses, with 3 doses given late. He subsequently died. There used to be a temporary pharmacist working within the ED, but funding for this role had been withdrawn. In its investigation report, the HSSIB called for earlier identification of patients in need of time-critical medicines^​3​.  

In 2018, looking at data from 89 patients passing through Nottingham University Hospitals ED, a paper by Gohil found that early pharmacist interventions in EDs led to fewer missed doses of PD medication and less deterioration in patients’ conditions^​4​. Dose omissions were also reduced in the 24 hours after patients moved to a ward. It also found a correlation between more missed doses in the ED and during the first 24 hours of inpatient care, and longer lengths of stay.

Medication errors

There is also research showing pharmacists in EDs have a more general impact on medication errors. A systemic review, published in Pharmacology Research and Perspectives in September 2022, found 17 studies showed benefits in terms of a reduction in medication errors and patient harm from having pharmacy input in EDs, compared with control arms^​5​. The meta-analysis put the reduction in medication errors at 70%.

The researchers highlighted how many errors occur during transitions of care — including admissions to hospitals from care homes, where data sharing may be limited. However, the research reveals areas of concern about the methodology in some of the studies, including selection bias, and measuring the severity of medication errors. All the studies were set outside the UK.   

Another role for pharmacists is in identifying any adverse drug reactions which may be behind ED attendance and admissions. More widely, many patients may have ongoing issues with medicines that are not connected with their ED attendance that, if not resolved, will put them at risk of returning. Greenwood suggests that longer waiting times in EDs mean that pharmacists have greater opportunities to solve these medicine issues.

Chronic conditions

Tom Harris, chair of the UKCPA emergency care committee and an ED pharmacist at South Tyneside and Sunderland NHS Foundation Trust, points out that many ED staff are not trained to look after patients with chronic conditions for an extended period, as is now becoming commonplace, but he says ED pharmacists can help to bridge that gap.

Harris suggests that pharmacists can also stop unnecessary medicines, such as calcium tablets, which do not need to be taken in the relatively short time people are in an ED environment. This has a time saving for staff who would otherwise have to administer them — they can then spend their time doing something more productive. 

Offering expert advice to the rest of the ED team — such as how best to tackle paracetamol overdose reversal or the use of off-licence medicines — is another important aspect of the job, says Saggu.

She adds that pharmacist prescribers can change prescriptions when needed; for example, someone with PD who has developed swallowing difficulties might need a soluble version of their normal medicine.

Pharmacists can also influence what medicines patients are discharged with, such as encouraging EDs to discharge drug addicts with naloxone to counter future overdoses. And, as Saggu points out, they can ensure that patients who are discharged know how and when to take new medicines. They can also help patients who may not know how to use prescribed medical devices, such as inhalers.

Stock management is another important role that pharmacists or technicians have been able to take on to ensure that medicines are easily available in the ED.

Gohil explains that technicians are critical in the delivery of ED clinical pharmacy services, “both from a clinical standpoint supporting pharmacists but also importantly non-clinically in supporting general medicines management within EDs”.

“This non-clinical but active shop floor role may include real time responsibility for supply chains, overseeing restocking, antidote management and controlled drug reconciliation. These roles typically allow for pharmacists to focus more time on clinical tasks,” he says.

Career progression

It is evident that working within EDs is varied and rewarding but, similar to other hospital pharmacist posts, the starting salary is low compared with what is on offer in community pharmacy or in GP practices. Some ED pharmacist posts will be at band 6 of the Agenda for Change pay scale, meaning a starting pay of £37,338 outside of London. Pharmacists may spend two to three years at this rate before they progress.

Unlike other ED staff, pharmacists tend to work core hours only, which means they are unlikely to get any additional payments for unsocial hours (evenings, nights and weekends).

“Yet a 7-day, 24-hour, workforce would be incredibly useful,” says Greenwood. The RCEM acknowledged this when it issued its standards, stating that the ED pharmacy service should be present seven days a week.

Even at Frimley Health NHS Foundation Trust — where pharmacy staffing is probably more generous than other trusts, with medicines management technicians as well as pharmacists at both of its EDs — the service falls largely within 9–5, weekday working hours.  

Greenwood suggests the lack of opportunities to boost income past the basic pay may make ED work unattractive compared with other opportunities for younger pharmacists.

He also points to the need for workplaces to match the changing expectations of those coming out of university, with the right to prescribe from the point of registration and with extensive experience of contact with patients through placements (his students now spend 40 weeks in placement).

Harris points out that the UKCPA wants to promote advanced training and more education for pharmacists in ED. One of the RCEM/UKCPA recommendations was that ED pharmacists should be working towards or have achieved accreditation on the RPS ‘Core advanced specialist curriculum’, ‘Advanced pharmacy framework’ or similar.

He suggests this training is important to equip pharmacists for the range of cases they are likely to encounter in ED. “In an ED, you really need to know quite a lot around a lot of stuff… what you need to know is different to what you need on a base ward,” he says.

In trusts that have managed to meet the RCEM/UKCPA standards, the result can be transformative. For example, Faisal Faruqi, a senior ED consultant who has worked with Gohil at Nottingham University NHS Trust throughout the time the clinical pharmacy service has been developed, says the service has transformed medicines safety, governance, efficiency and education within the A&E department.

“By ensuring timely access to life-saving drugs, improving prescribing accuracy, and reducing medication-related risks, the pharmacy team plays a crucial role in enhancing patient outcomes and overall ED performance.”

Gohil emphasises that the UKCPA committee is continuing to work with the RCEM and the ED pharmacy community to develop standards and responsibilities for both pharmacists and pharmacy technicians.

“This will aid EDs in realising the crucial benefits of frontline clinical pharmacy services.”