This paper reflects on the results of a study validating a clinical pharmacy workforce calculator, the questions that the use of such a tool raises for the profession more widely and how it might support the challenges of delivering pharmacy services in a changing healthcare arena environment
Clinical pharmacy was first described in the seminal paper by Hepler and Strand,1 where it was defined as the provision of ‘pharmaceutical care’, that is, ‘the responsible provision of drug therapy for the purpose of achieving definite outcomes which improve the patient’s quality of life’. Since the publication of this paper, the provision of pharmaceutical care has advanced in countries such as the UK, USA and Australia. However, whilst clinical pharmacy ward-based services are well established in modern healthcare environments and the benefits of this approach to providing safe, effective and cost-effective use of medicines are known,2–4 the workforce required to deliver these services has not been well described or standardised. In the UK, this has resulted in what has been described as ‘unwarranted variation’ in staffing levels.5 Subsequently, annual data collection by the NHS Benchmarking Network further identified apparent variation in service delivery,6 but does not identify the the associated variation in patient outcomes.
The pharmacy profession does not have a mandated approach to staffing levels such as that seen in other professions, for example, nursing.7 A team in Stoke-on-Trent, England, developed a Clinical Pharmacy Workforce Calculator (CPWC) to standardise the way in which they requested workforce resource when clinical pharmacy services were requested for new or changed ward environments.
The methodology used in the development of this tool was that provided by the World Health Organization’s Workload Indicators of Staffing Need (WISN).8 This is an established approach to identifying health care staffing resources and has been applied to a variety of settings and professions globally.9–11
The WISN approach calculates staffing requirements from the equation shown in Figure 1.
Furthermore, WISN suggests that the ‘activity standard’ is to be identified by consensus from ‘experts in the field’. In the initial development of the CPWC, the activity standard was developed by the local clinical pharmacy leaders who confirmed the required task list according to local policy and timings from time and motion observation of staff activity. This reflected the traditional ‘peripatetic’ lone practitioner delivery of pharmaceutical care common in UK hospitals. The generalisability of this approach to clinical pharmacy in other settings in the UK was explored in a validation study.12
With expert consensus as the explicit source of the activity standard in WISN, a two-round Delphi consensus study was run. Hospital pharmacy managers from across Great Britain responded. The ‘activity standard’, as identified in Stoke-on-Trent was confirmed by strong consensus of national peers
for its application to acute hospital inpatients and the tool was demonstrated to be used reliably by multiple operators. A small number of pharmacy managers in community and mental health settings also responded to the study. Their numbers were not large enough to generate a consensus view on pharmacy activity in these different environments, though the small amount of data provided suggested there would be some differences in the activity standard, driven by tasks mandated in the Mental Health Act,13 or lower patient pharmaceutical acuity.
The study delivered on its objectives of confirming the activity standard for in-patient clinical pharmacy services in the UK, and therefore the validity of the calculator based on this algorithm and the transferability of the tool between operators. The application of the WISN approach to identifying staffing requirements to hospital pharmacy has proved a methodology which could be adapted to a variety of pharmacy services. Leaders in different settings, or with more specialist patient needs, could replicate this approach to confirm their activity standard and develop a standardised algorithm for identifying pharmacy staff resource requirements.
Reality of practice
As with much research, the study generated further questions that remain unanswered and warrant further investigation.
The strength of the consensus with which the ‘activity standard’ was confirmed suggests that many hospital pharmacy services are established to deliver the same set of care tasks for their patients. However, in reality, this will simply not be possible for all patients, given the range of staffing levels available to deliver these services. NHS benchmarking data (Figure 2)6 suggest that the average number of patients reviewed by each pharmacist each day is 55, whereas the ‘activity standard’, strongly confirmed by the consensus, would suggest that this number should be nearer to 17. This lower value is supported by other studies (see Table 1).14,15 Patient care cannot, therefore, be equivalent. The first set of questions raised here is to what extent does the activity standard described impact positively on patient outcomes? Is the evidence base that drives this consensus still valid? It should be noted that in the survey of hospital pharmacy conducted by the European Association of Hospital Pharmacists in 2010, UK hospital pharmacist staffing levels were around three-times higher than in other European countries.16 The same challenge is raised – what is the difference in impact on patient care?
Clinical pharmacy – validity of the evidence base
The activity standard, as confirmed by the consensus, is largely driven by the medicines reconciliation work stream, which is heavily evidenced-based2 and monitored throughout the NHS.5 Medicines reconciliation, i.e. the confirmation of the complete list of medicines prescribed for and taken by a patient prior to their admission to a new health care setting, contributes to the majority of the staff time requirement for the delivery pharmaceutical care. This evidence strongly associated the reconciliation of patients’ medicines at transfer of care (particularly around admission to hospital) with improved patient outcomes. As staffing levels vary greatly, the same level of medicines reconciliation cannot be delivered consistently between sites and so the assumption might be that there are differences in patient outcomes which would impact on equity of care. Some components of the task must be omitted for some or all patients. Which of these are relevant in terms of impact on outcome presuming the patient cohorts are similar? In addition, much of this evidence base is 15 years old and technology advances in that time might have impacted on the association between medicines reconciliation and positive patient outcomes. Reasons for this may include the reduced need for the process of medicines reconciliation as the technology has driven accuracy of data transfer between care settings or technology has reduced the time it takes to complete medicines reconciliation. The activity standard would need to be adjusted in both scenarios. However, the evidence base that drives this activity and its associated time requires refreshing to confirm the previously identified impact.
This is necessary if we are to continue to deliver evidence-based care at the appropriate level for our patients. The staffing levels, calculated by the CPWC, driven by evidence, are more than the average seen across the UK. If adopted widely this increased requirement for pharmacist and pharmacy technician resource is identified at a time when there are substantial competing employers for this workforce within the UK.
If we are unable to staff to the identified ‘activity standard’ with pharmacists, do we need to consider the skill mix of the team delivering the service? An area of practice where consensus was difficult to achieve related to the interim review of patients between admission and discharge. At present the activity standard suggests that this should be done by pharmacists. In the UK, delivery of pharmaceutical care is already supported by registered pharmacy technicians. These vocationally trained staff support many elements of the medicines supply process and have developed a strong role within medicines reconciliation activities. Perhaps the role of the ‘clinical’ pharmacy technician needs to be considered here? The team at Royal Stoke University Hospital explored this question in an assessment of pharmacy technician clinical skills. The team of medicines management technicians at the Trust were asked to review a prescription chart to identify medicines management issues and the necessary action required to ensure the safe use of medicines. The same prescription was used as a clinical assessment of pharmacists presenting for interview for entry grade posts. The results were marked and ranked in order of success (see Table 2). The highlighted candidates were the pharmacist interviewees. As an ‘in-house’ exploration of the issue this was not subject to statistical analysis, but the data is shared for illustrative purposes.
This data demonstrated that the existing clinical knowledge of these medicines management technicians ‘compared favourably’ to the junior pharmacist cohort. These results were replicated in West Midlands study from Aston University in the UK.17 Service structures that support the extension of practice of this workforce should be considered and the activity standard could then be adapted accordingly.
Alternatively, time could be released to care by making the approach to service delivery more efficient. In the field of continuous improvement methodology, the basis of the Toyota ‘Lean’ system18 requires the removal of ‘waste’; repetition of activities not done to the correct standard the first time is one of these ‘wastes’. Much of clinical pharmacy could be deemed ‘waste’,19 and where there is insufficient staffing that valuable commodity could be better used by supporting the ‘getting it right first time’ (GIRFT) approach. The National Institute for Health and Care Excellence guidance on medicines optimisation, which superseded the original medicines reconciliation guidance, requires medicines to be reconciled but does not specify it as a pharmacy role.20 Should the profession be driving better use of technology and different use of staff to support this GIRFT agenda and release our time to support the active prescribing agenda, rather than correcting the transcription of medicines on admission and discharge?
More recently, the evidence base describing patient outcomes related to pharmaceutical care is in the area of pharmacist attendance on ward rounds.21–23 The work of Gray et al describes the deployment of individual pharmacists to single dedicated wards, facilitating the attendance on ward rounds and with time spent afterwards on the ward communicating medicines related information for onward patient care.21 This service demonstrated associations with earlier in the day discharge, reduced length of stay and reduced readmission rates. In the critical care specialty, the PROTECTED study22 also highlighted the impact of pharmacists attending ward rounds and the subsequent paper23 identified that many sites were not staffed to the recommended levels to facilitate this level of service delivery. In Australia, further evidence supporting this approach was published last year.24 Is this an additional task to add to the activity standard? Or is it simply a different way to deploy staff to deliver the same tasks? If the wards at the hospital in the paper by Gray et al are applied to the CPWC, the staff resource identified is 1.2 pharmacists per ward (accounting for the unavailable time); this matches the resource requirement used by Gray et al – and does the staff deployment in this way address the GIRFT issues, complete the task list, and allow extension of tasks due to time released to care from GIRFT?
The study by Bednall et al12 demonstrated the practicality of standardising the identification of evidence-based staffing levels for pharmacy services, which can be applied to different settings and services internationally. As a profession we should come in line with other health professions in identifying the required staffing levels for our service to remove unwarranted variation. To do so, we need to confirm the ‘activity standard’ for our services ensuring that quality outcomes for our patients are maintained. Where staffing levels cannot be achieved using existing pharmacist workforce, perhaps we need to consider changing the scope of practice for our supporting staff groups such as pharmacy technicians.
The challenge for the pharmacy profession is to be agile enough to adapt our service model and staffing approach to deliver efficient care, moving away from traditional models of dispensary-based roles or peripatetic lone practitioners, correcting mistakes to a more holistic and MDT approach to care supporting other practitioners in the GIRFT agenda. We need to describe these activities clearly and staff them appropriately – and develop the evidence base that demonstrates the value added to patient care by high quality pharmacy services.
- Hepler C, Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47:533–43.
- Bond C, Raehl C. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy 2007;27:481–93.
- Gallagher J et al. Cost-outcome description of clinical pharmacist interventions in a university teaching hospital. BMC Health Serv Res 2014;14:177.
- Gammie T, Vogler S, Babar Z. Economic Evaluation of Hospital and Community Pharmacy Services: A Review of the Literature (2010–2015). Ann Pharmacother 2017;51:54–65.
- Lord Carter of Coles. Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. An independent report for the Department of Health. 2016. www.gov.uk/government/publications/productivity-in-nhs-hospitals (accessed January 2022).
- NHS Benchmarking Network. National Hospital Pharmacy Benchmarking Programme 2018-19. 2019. https://s3.eu-west-2.amazonaws.com/nhsbn-static/Pharmacy%20&%20Medicines%20Optimisation/2019/Summary%20Report.pdf (accessed January 2022).
- National Quality Board. Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time Safe sustainable and productive staffing July 2016. www.england.nhs.uk/wp-content/uploads/2013/04/nqb-guidance.pdf (accessed January 2022).
- World Health Organization. Workload Indicators of staffing need [WISN] User’s Manual. Geneva: 2010. www.who.int/hrh/resources/WISN_Eng_UsersManual.pdf (accessed January 2022).
- McQuide P, Kolehmainen-Aitken R, Forster N. Applying the workload indicators of staffing need [WISN] method in Namibia: challenges and implications for human resources for health policy. Human Resources Health 2013;11:64.
- Hagopian A et al. Applying WHO’s ‘workforce indicators of staffing need’ [WISN] method to calculate the health worker requirements for India’s maternal and child health service guarantees in Orissa State. Health Policy Plan 2012;27:11–18.
- World Health Organization. Applying the WISN Method in Practice: Case studies from Indonesia, Mozambique and Uganda. 2010 Geneva: WHO Press. www.who.int/hrh/resources/wisn_case_studies/en/ (accessed January 2022).
- Bednall R et al. Validation of a hospital clinical pharmacy workforce calculator: A methodology for pharmacy? Int J Clin Pract 2021;75(5):e13932.
- UK Government. Mental Health Act 2007. www.legislation.gov.uk/ukpga/2007/12/contents (accessed January 2022).
- O’Leary K, Stuchbery P, Taylor G. Clinical Pharmacist Staffing Levels Needed to Deliver Clinical Services in Australian Hospitals. J Pharm Prac Res 2010;40:217–21.
- Onatade R, Miller G, Sanghera I. A quantitative comparison of ward-based clinical pharmacy activities in 7 acute UK hospitals. Int J Clin Pharm 2016;38: 1407–15.
- EAHP Survey 2010. Hospital Pharmacy Practice in Europe www.eahp.eu/sites/default/files/files/EAHP%20Survey%202010(1).pdf (accessed January 2022).
- Hussain H, Lewis N. Baseline study to investigate the ability of Band 5 hospital pharmacy technicians to prioritise patients through identification of medication issues on inpatient medication charts. Pharmacy Education 2020;20(1):259. https://pharmacyeducation.fip.org/pharmacyeducation/article/view/1121/930 (accessed January 2022).
- Ohno, T. The Toyota Production System: Beyond Large-Scale Production 1988: Portland, Productivity Press.
- Green C et al. A waste walk through clinical pharmacy: how do the ‘seven wastes’ of Lean techniques apply to the practice of clinical pharmacists Int J Pharm Pract 2015;23(1):21–6.
- National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NG5 04 March 2015. www.nice.org.uk/guidance/ng5 (accessed January 2022).
- Gray A Wallet J, Fletcher N. Dedicated ward pharmacists make an impact 2017 https://hospitalpharmacyeurope.com/news/editors-pick/dedicated-ward-pharmacists-make-an-impact/
- Rudall N et al; on behalf of the PROTECTED-UK group. Clinical pharmacist interventions in the UK critical care unit: exploration of relationship between intervention, service characteristics and experience level Int J Pharm Pract 2017;25(4):311–19.
- Borthwick M et al. Critical care pharmacy workforce: UK deployment and characteristics in 2015. Int J Pharm Pract 2018;26(4):325–33.
- English S et al. Is ward round participation by clinical pharmacists a valuable use of time and money? A time and motion study. Res Social Adm Pharm 2020;16(8):1026–32.