From autumn 2015, the way pharmacists engage with patients will change. This is because the government has decided to give community pharmacists and pharmacy technicians in England read-only access to the summary care record (SCR), an electronic patient record derived from patients’ GP records, if the patient gives consent.
Access to the SCR, announced on 23 June 2015, has long been an ambition by the pharmacy sector as it advances clinical pharmacy practice, and has been applauded by representative organisations, including the Royal Pharmaceutical Society (RPS) (The Pharmaceutical Journal is owned by the RPS). It will mean community pharmacists and pharmacy technicians will have 24-hour access to important medicines information relating to their patients, including details of the drugs they are taking or have recently taken, allergies and any adverse reactions. Hospital pharmacists, generally, already have access to SCRs.
It is not expected that pharmacists would access the SCR for every patient or for routine dispensing. “It is based on a clinical need at the time decided by the pharmacist or pharmacy technician,” says the government agency, the Health and Social Care Information Centre (HSCIC), which ran a pilot study to assess pharmacy use of the SCR over 2014–2015, and which has been given responsibility for the implementation of pharmacies accessing the SCR. “You must only access the record when you have a patient’s permission to view it,” the HSCIC adds. Along with the patient’s name and address, the SCR also includes the patient’s date of birth and personal NHS number.
Patients have the option to add other relevant medical information — such as diagnoses and personal preferences — to the SCR in consultation with their GP. In England, 96% of the population has an accessible SCR.
“There has long been a consensus across the [pharmacy] profession that widening access to health information to community pharmacy will enable safer, better and more accessible care,” say the RPS, Pharmacy Voice and the Pharmaceutical Services Negotiating Committee in a joint statement.
But some stakeholders suggest the move does not go far enough. Sir Kevin Barron MP, chair of the newly reconstituted All-Party Pharmacy Group, hopes the decision will lead to full read-write access to the care record for pharmacists. “We’d like to see that in place by April 2017.”
Mimi Lau, director of pharmacy services for Numark, a member organisation for independent pharmacists, agrees. “It is a great announcement but it mustn’t stop there,” she says.
“Pharmacists need to be able to have ‘write’ access,” says Lau. “When this happens, pharmacists will be able to view and update medical records, making sure that the GP knows the outcome of each and every consultation.”
While pharmacy organisations welcome the move, others are pointing out that pharmacists should be aware of some legal risks.
Noel Wardle, partner at London law firm Charles Russell Speechlys, warns that if a patient comes to a pharmacy for the first time with a prescription that has an error, and the only way the pharmacist would be able to identify that error would be by reference to the SCR, the pharmacist may be held responsible (or at least partly responsible) if he or she does not spot the error and the patient suffers harm as a result.
“It may not matter whether the pharmacist actually knew about the information on the SCR, because the pharmacy may be deemed to have that information purely because he has access to it.”
Wardle stresses that it will be important for pharmacies to have robust procedures that ensure the pharmacist’s clinical assessment is based on information contained within both the patient’s SCR and the patient medication record (PMR) — the pharmacy’s patient records.
“It will be even more important for pharmacists to be able to demonstrate that such procedures are in place… and to document (in the patient’s PMR) any interventions.”
Joy Wingfield, honorary professor of pharmacy law and ethics at the University of Nottingham, advises pharmacists to record everything. “Doctors have learned over the last several decades that if you don’t make a record, it didn’t happen – or more accurately you cannot show whether it did or not. In court, no records tends to mean no defence.” She suggests that the PMR could be used to record this information.
Wingfield says that any new professional responsibility will be accompanied by heightened professional liability for the consequences of any act or omission which leads to patient harm.
“Failing to check a record could give rise to an attempt at a civil action for compensation if harm resulted. However, that is a long way from saying that it would — or that such an attempt would be successful.”
For a civil action to succeed, three things have to be proven on the balance of probability. Firstly, there has to be a duty of care, second there has to be a failure to meet the expected and reasonable standards of care, and third, a failure to meet the standard has directly caused harm to the patient.
If pharmacists and their supervised staff assume access and read patient’s records then they will automatically assume a duty of care in this activity, she says.
However, Wingfield believes that it is difficult to say what standards of care should be exercised before the practice of pharmacy using patient records becomes widespread and established. This is usually achieved over time and through the development of guidelines, which in due course may be refined by case law in the event of a dispute.
For example, a prescription for penicillin may necessitate a check for possible allergies every time. While a check for a repeat supply of blood pressure tablets may only be “desirable”.
“It is always worthwhile checking one’s insurance arrangements when taking on new duties, ensuring that the insurer accepts the risk associated with them, and to keep up to date with the latest standards of practice generated by the professional body or elsewhere,” Wingfield says.
Proof of concept pilot
The decision to allow pharmacists and pharmacy technicians access to the SCR follows a pilot project launched in April 2014 involving 140 community pharmacies across England. The pharmacies involved are located in West Yorkshire, Sheffield, North Derbyshire, Northamptonshire and Somerset.
A report of the pilot, published on 23 June 2015 by the HSCIC, reveals that by accessing information contained within the SCR, pharmacists were able to avoid having to refer the patient to another health service in 92% of cases. Of these cases, 56% would have been advised to see a GP, 22% referred to an out-of-hours GP service or NHS 111, and 1% to a hospital accident & emergency department. In 18% of cases, having access to the SCR meant a prescribing error was avoided, says the report.
Providing an emergency supply of medicine out of hours was the most common reason, cited in 29% of cases, for a pharmacy accessing a patient’s SCR. “Whilst this is the highest single use, it is not as high as originally expected by the industry. This could indicate that use of the SCR in this scenario is not being maximised,” say the report’s authors.
The pilot also found that 72% of cases in which the SCR was accessed involved identifying a medicine that the patient was unsure of. The pilot project also found that, on average, over a six month period, 2.9 SCRs were accessed per month per pharmacy. If this was applied to all pharmacies in England, this would represent more than 400,000 accesses per year.
Stewart Kelly, from the Woodhouse Pharmacy in Sheffield, and one of the pharmacists involved in the pilot, says having access to the SCR prevented one of his patients from being dispensed an antibiotic that they were allergic to.
“Had the patient not contacted the pharmacy, and had I not been able to access their SCR, a significant patient safety incident could have occurred,” he says.
Support for the move
The announcement to roll out the scheme to the rest of England was made by community and social care minister Alistair Burt, who describes pharmacists as an “untapped resource”.
“As experts in medicines, they can help people to manage their conditions and take some of the pressure off our GPs,” he says. “That’s why it makes complete sense to give them the ability to access patients’ summary care records, where appropriate.”
The government intends to use money from its primary care infrastructure fund to help train pharmacists to access and use the SCR.
“I encourage all community pharmacists to get involved and further improve the care we can give people in their communities,” Burt adds.
Britain’s pharmacy regulator, the General Pharmaceutical Council, is also supportive of the move. “Pharmacy professionals in other settings, including hospitals and GP surgeries, are already accessing records and using this information and their expertise to improve the health and well-being of their patients,” says Duncan Rudkin, the GPhC’s chief executive. He adds that professional standards already exist that govern the holding of secure patient information, obtaining patient consent and patient privacy.
Pharmacists in England who would like to access SCRs would need a NHS smartcard, along with specific SCR roles assigned to it. They will also need to be on the N3 network (the national broadband network for the NHS) and be able to access the NHS Spine web-portal, known as the Summary Care Record Application (SCRa).
The HSCIC says there will be controls in place to monitor access, with patients being able to make requests to see who has accessed their SCR.
Pharmacies must have clear and robust standard operating procedures in place as part of their approach to information governance, the HSCIC adds.
The decision is being supported by patient groups. Katherine Murphy, the chief executive of the Patients Association, says pharmacists can provide person-centred services for the patients they serve by having access to a patient’s SCR.
Caroline Abrahams, charity director at Age UK, says community pharmacists can play a vital role in ensuring people in later life are using their medication safely and effectively.
“The SCR could help community pharmacists to do even more, but it is vital that before any data are shared there must be a full and open conversation about what this means to an individual and on this basis, their clear consent,” she adds.
When someone is taking a large number of different medications, it can sometimes be difficult to remember all the potential side effects, or how and when to take treatments.
“When time with a GP can often be short, this support offered by pharmacies can make a significant difference to the health and wellbeing of older people,” she says.