Optimising and strengthening capacity in IBD pharmacy

To ensure best possible outcomes in IBD treatment, we need to define quality practice, embed quality improvement, share good practice, raise the political profile of advanced pharmacy services and monitor progress. Using national service standards and a benchmarking tool to facilitate these goals is an effective way to enable, mandate and commission advanced pharmacy practice

In 2016 the World Health Organization (WHO) published the Global Strategy on Human Resources in Health: Workforce 2030¹ to enable the vision that by 2030, all communities will have universal access to health workers, without stigma and discrimination. The document estimates that 40 million new jobs in health are needed globally to obtain Universal Health Coverage (UHC) by 2030, requiring countries to develop national plans for the health workforce development. This fits in with 9 of the 17 Sustainable Development Goals² set by the United Nations General Assembly in 2015 for the year 2030 and health policy makers will have to refer to both these documents when developing strategies for health services in their country.

Objective

The objective of the WHO Health Workforce strategy is to describe policy levers to shape health labour markets. These are:

Optimise the existing workforce in pursuit of the Sustainable Development Goals and universal health coverage (for example, education, employment, retention)
Anticipate and align investment in future workforce requirements and plan the necessary changes (for example, a fit for purpose, needs-based workforce)
Strengthen individual and institutional capacity to manage human resources for health policy, planning and implementation (for example, migration and regulation)
Strengthen data, evidence and knowledge for cost-effective policy decisions (for example, labour market analysis, National Health Workforce Accounts).

The question to answer now is: How do we ‘optimise’ pharmacy practitioners, align investment and develop the capacity in practice?

We have made progress in developing advanced specialist practitioners in some countries reported in a global report³ in 2015 by the International Pharmaceutical Federation (FIP). The subsequent FIP document describing Education in the Context of Workforce Development⁴ in 2017 states: the continued development of pharmacy services and the pharmaceutical sciences relies on a well-educated, competent, sufficient and well-distributed pharmaceutical workforce.

Achieving the 13 ambitious goals set out in the FIP document⁵ will require country-specific solutions, and to enable this transformation of the workforce, we need to look at the behaviour change model.

As a profession we need to develop:

Capability through education and describe clear development pathways from foundation to advanced practice
Motivation through professional and financial recognition (credentialing)
Opportunity through inclusion of well described pharmacy services in policies and mandate the commissioning of services.

This might feel new for a majority of the pharmacy workforce but we would not expect other medical practitioners to stay static in their competencies.

The common competencies

The strategy highlights the common competencies needed for all pharmaceutical practitioners irrelevant of area of practice to be developed to ‘optimise the workforce. In the UK, the Royal Pharmaceutical Society (RPS) has set out in the Advanced Pharmacy Framework (APF) of the RPS Faculty the six clusters of competencies advanced practitioners need to demonstrate to be credentialed as stage 1 or stage 2 Faculty Members or Faculty Fellow. These are:

Expert professional practice
Collaborative working relationships
Leadership
Management
Education, training and development
Research and evaluation.

National service standards are currently set for a range of disease areas, and the case study of pharmacy services in inflammatory bowel disease (IBD) demonstrates how advanced specialist practice can be enabled, promoted and recognised. Through embedding advanced pharmacy practice in the 2019 UK IBD Standards,⁶ we are optimising the pharmaceutical workforce in IBD, aligning the IBD pharmacy services to national standards and mandating the commissioning of expert pharmacy skills in each IBD service.

Pharmacy and the UK IBD standards

The first national IBD standards were developed in 2009 describing minimal pharmacy input. Pharmacy was recognised only once in the IBD team requiring ‘One pharmacist with special interest in IBD’ without any description of the required competencies or service parameters.

In 2018, a multidisciplinary alliance of 17 organisations and patients (IBD UK) was convened to update the current IBD standards. To inform the development of medicines optimisation-related standards, IBD units with developed expert pharmacy services were surveyed through the UK Clinical Pharmacy Association network to identify quantity and quality of advanced practice requesting information about service provision and the relevance of the RPS Framework for Advanced Practice. An e-Delphi consensus process was undertaken over three rounds by IBD UK to refine a set of evidence- and expert opinion-based recommendations for optimal service delivery across the patient journey with 80% agreement required for statements to be retained.

The new standards identified informed the development of a benchmarking tool to enable self-assessment supporting quality improvement and additional resources requests where needed. Descriptors were developed in two consensus workshops by IBD UK with expert pharmacy representation. Due to development of IBD pharmacy services⁷ in the intervening years it has been possible to achieve a consensus on pharmacy as an integral part of the IBD services. Four units, two teaching and two district hospitals with developed IBD pharmacy services were surveyed, informing four relevant standards key to pharmacy leadership, medicines expert roles and multidisciplinary team (MDT) working for patient from diagnosis to long-term care. Proposed standards were submitted to the Delphi process and IBD UK agreed 59 standards in total. All four (7%) describing expert practice were incorporated with 100% agreement.

IBD UK defined 0.6 WTE MDT expert pharmacist (Faculty stage 2 or above) per 250,000 population based on the pharmacy survey results. It was agreed to define high quality practice through the Royal Pharmaceutical Society Framework for Advanced Practice.

The benchmarking tool defined A–D descriptors for expert practice, demonstrating A as ‘excellent, proactive’ to D ‘minimal, inadequate’ care developed and agreed by IBD UK.

Agreed competencies

The four statements describing IBD pharmacy services are incorporated into the benchmarking tool to promote and mandate advanced practice developed according to Faculty agreed competencies to ensure high quality patient care. These are:

• Statement 1.5

The IBD leadership team should work with a consultant pharmacist in IBD to ensure good medicines governance, including medicines optimisation and cost-effectiveness.⁸

Does the IBD leadership team work with a pharmacist? (No = D)

Does the IBD leadership team work with an expert or consultant pharmacist in IBD (or equivalent) with annual formulary review? (No = C)

Does the IBD leadership team work with a consultant pharmacist or equivalent in IBD on annual protocol/policy review, with actions and outcomes, to actively develop pharmacy services within IBD? (No = B, Yes = A)

• Statement 3.1

All newly diagnosed IBD patients should be seen by an IBD specialist and enabled to see an adult/paediatric gastroenterologist, IBD nurse specialist, specialist gastroenterology dietitian, surgeon, psychologist and expert pharmacist in IBD as necessary⁹

Are all newly diagnosed IBD patients seen by a member of the IBD team? (No = D)

Are all newly diagnosed IBD patients seen in a dedicated IBD clinic with access to an adult/paediatric gastroenterologist, IBD nurse specialist, surgeon, dietitian, psychologist and expert pharmacist in IBD as necessary? (No = C)

Are patient-reported outcomes recorded following new diagnosis and access to the specialist team? (No = B, Yes = A)

• Statement 6.10

All IBD inpatients should have their prescribed and over-the-counter medications reviewed on admission by a pharmacist who has access to an expert pharmacist in IBD for advice, with regular review of medications during their inpatient stay and on discharge¹⁰

Does the ward pharmacist have access to an advanced generalist pharmacist to seek advice for medication review and optimisation? (No = D)

Does the ward pharmacist have access to an expert pharmacist in IBD to seek advice for medication review and optimisation and personalised consultation? (No = C)

Do the patient and ward pharmacist have access to a consultant pharmacist in IBD or equivalent on admission and during their stay for medication review, optimisation and personalised consultation? (No = B, Yes = A)

• Statement 7.3

Clear protocols should be in place for the supply, monitoring and review of medication across primary and secondary care settings?¹¹

Are shared care protocols in place for the review and monitoring of all relevant IBD medications across primary and secondary care? (No = D)

Are these agreed between primary and secondary care, with all relevant information recorded? (No = C)

Are arrangements for shared care discussed and agreed with patients, with written information provided? (No = B, Yes = A)

Conclusions

The 2019 UK IBD Standards (ibduk.org) for the first time embed and describe expert practice as an integral part of the IBD MDT managing IBD patients. The IBD benchmarking tool encourages the development of advanced competencies in pharmacy practice. This, in turn, supports behaviour change through describing competencies needed to gain required capability, enabling recognition and commissioning of advanced pharmacy practice providing motivation and opportunities.

Author

Anja St Clair Jones Dip Pharm MSc FFRPS MRPharmS (IPresc)
Consultant Pharmacist Gastroenterology, Brighton & Sussex University Hospitals NHS Trust, UK

References

World Health Organization. Global Strategy on Human Resources for Health: Workforce 2030. World Health Organisation 2016. www.who.int/hrh/resources/globstrathrh-2030/en/ (accessed September 2019).
United Nations. Sustainable Development Goals 2030. United Nations General Assembly 2015. www.un.org/sustainabledevelopment/sustainable-development-goals/ (accessed September 2019).
International Pharmaceutical Federation (FIP). Advanced practice and specialisation in pharmacy practice: Global report. Fédération Internationale Pharmaceutique 2016. www.fip.org/files/fip/PharmacyEducation/Adv_and_Spec_Survey/FIPEd_Advanced_2015_web_v2.pdf (accessed September 2019).
FIP. Transforming Pharmacy and Pharmaceutical Sciences Education in the Context of Workforce Development. Fédération Internationale Pharmaceutique 2017. www.fip.org/www/streamfile.php?filename=fip/publications/FIPEd_Nanjing_Report_2017_11.10.17.pdf (accessed September 2019).
FIP. Pharmaceutical workforce development goals. www.fip.org/files/content/priority-areas/workforce/wdgs-online-version.pdf (accessed September 2019).
IBD UK. IBD standards 2019. www.IBDUK.org (accessed September 2019).
St Clair Jones A, Smith M. Embedding pharmaceutical care into the multidisciplinary team. ECCO 2015;Abstract P306.
https://ibduk.org/ibd-standards/the-ibd-service/ibd-service-leadership-team
https://ibduk.org/ibd-standards/newly-diagnosed/specialist-assessment
https://ibduk.org/ibd-standards/inpatient-care/medication-review
https://ibduk.org/ibd-standards/ongoing-care-monitoring/shared-care