Christine Clark PhD FRPharmS FCPP(Hon)
Healthcare in the USA is heading for a perfect storm as the demands for healthcare increase while the pool of taxpayers decreases and the supply of providers and facilities shrinks, according to Dr Dennis Tribble (Director, Medical Affairs, Pharmacy Drug Delivery, Baxter Healthcare Corporation). The underlying problem is the baby-boom generation – in the USA, since January 2011, some 10,000 people per day have retired and, as a result, the over-65s make up the fastest-growing age group. Chronic, medication-managed disease is common in this group and this will increase the demand for primary care health services, he explained. In spite of this demographic change, there has been no change in the numbers of doctors who are trained. Furthermore, fewer nurses are now being trained. However, there is no shortfall in the numbers of pharmacists. “If we are to provide primary care for chronic, medication-managed illness then the people best-suited to do that are pharmacists”, said Dr Tribble.
In 2009 the American Society of Health-System Pharmacists (ASHP) recognised that the current practice model was unsustainable and embarked on a project to devise a new practice model. One of the drivers for this was the realisation that good quality services and cost-savings go hand-in-hand. For example, medication errors cost on average $8000 and so avoidance of such errors is worthwhile. Savings on the drug budget are generally modest but measures that reduce the length of stay in hospital or reduce the 30-day readmission rate produce significant savings, said Dr Tribble. In some schemes, routine follow-up of patients by pharmacists had reduced the 30-day readmission rate by 50%, he noted.
ASHP went through a lengthy process to build consensus and then to formulate recommendations. These included recommendations that:
- All patients should have a right to receive the care of a pharmacist
- Hospital and health-system pharmacists must be responsible and accountable for patients’ medication-related outcomes
- Every pharmacy department should develop a plan to reallocate its resources to devote significantly more pharmacist time to medication management services
- Pharmacist-provided drug therapy management should be prioritised using a patient medication complexity index
- A patient medication complexity index should be developed that includes factors such as severity of illness, number of medications and comorbidities.
Many people struggle with the idea of being accountable for patients’ medication-related outcomes, commented Dr Tribble.
ASHP has provided a number of resources on its website to support hospital pharmacists in developing their services and the organisation is still working on the development of a gap analysis tool (to assess current readiness for a new practice model) and the medication complexity index.
In the process of developing the practice model, a sizeable evidence base has been reviewed. Of particular note is a 2011 report from the Office of the Chief Pharmacist, US Public Health Service to the US Surgeon General. Among other things, the report says that pharmacists are already involved in collaborative management of disease through medication use and other clinical pharmacy services. Although such programmers were successful in the federal health system, their roll-out to the private sector was impeded by policy, legislation and compensation barriers. The report describes the need to recognise pharmacists as healthcare providers and to reimburse them accordingly. Part of the reason for this is the fact that medications are provided in 80% of treatments and drug-related morbidity and mortality accounts for $200 billion in potentially avoidable healthcare costs annually. Moreover, there is already a wealth of scientific evidence that demonstrates positive outcomes from pharmacist intervention in the care of patients. Dr Tribble commented, “We don’t need more evidence – we need courage [to implement it]”. Access to care is the big issue, he added, and the report notes that this is limited more by the availability of primary care providers than it is by ability to pay [in the USA].
Dr Tribble concluded that the UK is ahead of USA in the development of pharmacy services, in some respects, and that he and his colleagues look forward to learning from the UK experience.
Modernising pharmacy careers
Overall trends in medicines utilisation – especially with respect to medicines wastage and non-adherence – do not appear to be improving, Sue Ambler (Modernising Pharmacy Careers (MPC) Programme Director, Department of Health, London), told the audience. Medication errors are at unacceptable levels in hospitals, primary care and care homes and up to 50% of medicines are not taken as intended. However, education and development of the pharmacy workforce could help to tackle these problems, she continued.
The Modernising Pharmacy Careers Programme was set up to ensure the pharmacy workforce has the knowledge, skills and capacity to deliver the services of the future for patients and the public. One element of the programme is a re-organisation of undergraduate training such that at the end of the five-year training period a student will graduate and register simultaneously. The training will include two, six-month pre-registration training placements.
A second workstream is concerned with a review of post-registration career development of pharmacists and pharmacy technicians. The aim of the review is to provide advice and recommendations to the MPC Programme Board on developing the registered pharmacy workforce across all fields of practice, and to allow patients, the public and the NHS to benefit more completely from the unique contribution that the pharmacy workforce makes to health, well being and patient safety. Dr Ambler emphasised that this work relates to pharmacists in all areas of practice. “It is unhelpful to separate hospital pharmacists and community pharmacists in view of developments in primary care services and care at home”, she commented. One of the themes that has emerged from the review is that pharmacy staff will need to have a set of core competencies in order to underpin the delivery of clinical care and services. The recent publication of a single competency framework for all prescribers, by the National Prescribing Centre is helpful in this respect. The framework groups the required competencies into three domains – ‘the consultation’, ‘effective prescribing’ and ‘prescribing in context’. The framework applies to all prescribers in the heath service, that is, doctors, dentists and non-medical prescribers – a group that includes pharmacists who have completed the necessary training.
In future, medicines optimisation could become an important aspect of healthcare. Potentially, this is a service that could be delivered by a clinical pharmacy workforce including hospital pharmacists, community pharmacists, primary care pharmacists and practice pharmacists, said Dr Ambler.
Another important theme is the need for research to be at the core of pharmacy practice across all sectors to add to knowledge and engender a culture of lifelong teaching and learning among pharmacy professionals. This needs to start early in pharmacists’ careers, commented Dr Ambler.
Pfizer patient safety award
Implementation of a scheme to improve the management of oxygen at County Durham and Darlington Foundation Trust led to savings of £3000 per year in the medical admissions unit (MAU). David Gibson (senior clinical pharmacist) and Alwyn Foden (respiratory consultant) received the Pfizer Patient Safety Award for their project.
Oxygen is commonly perceived as simple treatment that does no harm if given inappropriately. However, in 2009 a rapid response report from the NPSA stated the underuse or overuse of oxygen could be harmful and have potentially fatal outcomes. It recommended that oxygen should be prescribed and adjusted to achieve appropriate oxygen saturations – an approach that is consistent with the British Thoracic Society guideline on emergency oxygen.
The only indication for oxygen therapy is hypoxaemia and not breathlessness, explained Mr Gibson. It should be prescribed to reach target oxygen saturations and patients should be monitored to keep their oxygen saturation within range. Special care is required in patients at risk of hypercapneic respiratory failure. He described how a hospital guideline was developed for the use of emergency oxygen in adults. This included information about which patients should receive oxygen, which devices to use and prescribing of oxygen. Doctors, nurses and pharmacists were all educated about the correct use of oxygen, and pharmacist prescribers were trained so that they would be able to adjust oxygen dosing.
Before-and-after audits of the use of oxygen in the MAU were performed. The results showed that, after implementation of the scheme, a smaller number of patients was given oxygen but a much larger proportion of these was prescribed and achieved an appropriate target oxygen saturation. In addition, there was a saving on the costs of oxygen tubing equivalent to £3000 per annum.
The next stage of the project is to maintain the improvements that have been achieved and to roll out the good practice to the rest of the hospital and beyond, said Mr Gibson.
Survival pack for directorate pharmacists
A survival pack for directorate pharmacists was launched at the GHP/UKCPA Joint National Conference. The pack, produced by the Leadership Development Group, is designed to help directorate pharmacists to understand and develop effective interpersonal skills. It includes top tips from senior managers and advice on getting a job – and what to do if unsuccessful. Details of how to obtain a copy of the pack are available on both the GHP and UKCPA websites (www.ghp.org.uk and www.ukcpa.org.uk).
The GHP/UKCPA Joint National Conference took place in Belfast, 18–20 May 2012