The recent Department of Health (DH) report by Lord Carter of Coles has raised the important issue of where pharmacy should focus its attention and resources in the future.
A main recommendation of the report is that NHS Improvement, a public body responsible for overseeing hospital foundation trusts and NHS trusts, should manage a hospital pharmacy transition programme. The programme should “develop plans by April 2017 to ensure that hospital pharmacies achieve their benchmarks so that their pharmacists and pharmacy technicians spend more time on patient-facing medicines optimisation activities”.
The report says more time should be spent on core patient-facing services, which it describes as “clinical services”. All other pharmacy services are covered by “infrastructure services”, such as dispensing, aseptic production, procurement and supply chain, research and development, education and training (e.g. of preregistration trainees), homecare, medicine information, clinical trials and quality control. The view of Lord Carter and the DH is that “the more time pharmacists spend on infrastructure services, the less time they have to maximise the value and outcome from complex and costly medicines and support prescribing choices across the services”. The report, in essence, suggests improvement by the use of benchmarking tools and recommends moving from the current clinical service representing 45% of the workforce to a target of 80% of the workforce. It says this is in keeping with government policy that all pharmacy services must be more clinically focused.
At first glance this strategy seems like a good plan. Clearly, the continued development of clinical services across both community and hospital pharmacy sectors is a development everyone will want in order to sustain the principles of medicines optimisation and improve patient care. But one question that arises is: at what price? On closer examination of this objective, it means that all other pharmacy services have been denigrated to the non-core “infrastructure” services. This perhaps indicates that these services, which pharmacists have always provided because of their extensive knowledge of medicines, may not be such an integral part of the profession going forward. The net impact of this may cause low morale and could have an adverse effect on recruitment and retention.
While we increase the number of pharmacists and technicians involved in clinical services as envisioned in the report, we will have to reduce our resources elsewhere or, alternatively, rely on the success of automation or centralisation to provide the service. Evidence for implementing automated hub-and-spoke dispensing is lacking (
The Pharmaceutical Journal 2016;296:222) and these alternatives strategies cannot be coordinated, planned or utilised in any meaningful way, at least not yet. It looks as if the other pharmacy services deemed by this report to be non-core infrastructure services may become neglected.
Although more clinically focused patient facing roles for pharmacy staff are a positive thing, we must not forget that pharmacists are experts in the life cycle of medicines. This goes beyond clinical patient facing roles. For example, we need robust dispensing services so patients can feel confident they can obtain a timely 100% supply without any errors. We need a robust supply chain with fewer product shortages than now. We need pharmacists in medicines information giving evidence-based advice to healthcare colleagues with medicines queries. Furthermore, we need pharmacists’ expertise in drug research, quality control, quality assurance and academia. These are not patient facing roles, but they are no less important.
If savings are to be made in the NHS, it should affect important areas, such as procurement. Pharmacists, with so much knowledge about medicines, surely have a vital role. Effective procurement leads to large savings, formulary management means that medicines are used cost-effectively, home care services deliver both savings and quality for patients, while aseptic services enable the manufacture of user-friendly products.
It seems that Lord Carter, the DH and the chief pharmaceutical officer of England (
The Pharmaceutical Journal online, 22 September 2015) are intent on throwing the baby out with the bath water. Those pharmacists involved in non-patient facing roles may take a different view.
Pharmacists are supposed to be medicines experts, not back up staff to GPs or nurses — this expertise should be applied to where medicines are created, manufactured, purchased, dispensed and managed. This is not something that, say, GPs or nurses can do. The fact that we have GP and nurse shortages in the UK should not be an argument for moving pharmacists away from their expertise and thus creating a vacuum. Pharmacists can help with prescribing and medicines management, but their skill sets need to be utilised in different capacities.
The pharmacy profession includes a range of positions around the use of medicines. All these roles are required otherwise they would not exist. If we wish to promote one role in particular, namely clinical services, then it should not be to the detriment of the others. If this happens, it will not bode well for pharmacists in other roles.