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The Pharmaceutical Journal
Vol 268 No 7195 p587
27 April 2002

Council presentation

Getting the "Spoonful" message across

Pharmacy needs to consider how to get the messages of the Audit Commission report, "A spoonful of sugar", into the domains of those with the power to make decisions within hospitals, Nick Mapstone (public services research directorate, Audit Commission) told the Royal Pharmaceutical Society's Council in a presentation on 9 April. The report offers compelling evidence to promote the role of pharmacy services within hospitals, but although pharmacists tend to know about it, National Health Service trust boards do not.

Mr Mapstone said that over many years at the commission, he has looked at many topics in the hospital sector. Of all of them, hospital pharmacy is the most straightforward because of the vast amount of literature that existed, often buried away in professional pharmaceutical journals.

The message that the commission tried to get across in the report is that medicines are a good thing. They improve the quality of health care, and there have been dramatic strides forward in the past 10 years. But they are becoming increasingly powerful, and if things go wrong the consequences are serious for the patient.

Research in other high-risk industries, such as aviation and oil, has found that people are likely to make mistakes if they are tired, are making multiple decisions and are working in unfamiliar circumstances. That is almost a caricature of the way in which doctors worked in hospitals, said Mr Mapstone.

Something the Audit Commission tried to convey to the media is that it is not just an NHS problem. It is a problem internationally, as was shown in a recent report in the BMJ, which looked at autopsies and demonstrated that in half the cases the wrong drugs had been prescribed or wrong dose form used.

Maintaining the status quo is not an option. In 2001 a BMJ article by Dr Charles Vincent illustrated the extent of the problem by showing that more than 10 per cent of patients experienced an adverse event with their medicines. A third of adverse events led to greater illness or even death. Each led to an average of an extra 8.5 days in hospital.

Influencing trust boards

How did one get NHS trust boards to take those issues seriously, Mr Mapstone asked. Trust boards are primarily interested in three things: balancing budgets, their star rating, and delivering targets against the NHS plan. Getting a matter on to the agenda is hard unless it can be shown to have direct impacts on costs, organisational capacity and waiting time. Tactically that is the way pharmacists have to think to get across some of the messages in "A spoonful of sugar".

Currently £500m a year is spent treating people who have been made sicker than they otherwise would have been as a result of medication received in hospital. A typical hospital has five beds blocked by patients suffering in that way. Data produced last year showed something like 1,200 deaths due to medication errors in hospitals, but that figure was probably understated significantly. So there is a huge challenge there for both the cost and the quality of health care.

Evidence from the United States has suggested that electronic prescribing systems eliminate 75 per cent of errors, offering a fast opportunity to improve quality of care and to make big inroads into that £500m. Case study evidence indicates that automation of dispensing reduces errors to about 2.5 per cent of all medicines issued — as well as releasing scarce pharmacy staff resources.

A front-line clinical service

"A spoonful of sugar" is really about changing the way in which trust boards look at pharmacists. The paper is trying to get across the message that pharmacy is a front-line clinical service and not just a drug buying and dispensing service.

Original pack dispensing, said Mr Mapstone, is a good thing because it reduces risk and adds to patient convenience. It helps with self-administration of medicines, which is a concrete way of improving compliance.

Of course, there are opportunities to make savings through the use of drugs that patients bring into hospital with them. As the divide between them is becomes increasingly blurred, there is scope for joint protocols between primary and secondary care.

The problem is that, because other things drive trust thinking, delivery in all of those areas is slow, particularly over electronic prescribing systems. The Government has set a target, but the reality is that few trusts will achieve the 2005 deadline for electronic health records and prescribing systems.

One problem is that original packs, medication review, self-administration schemes, etc, knit together and need to be considered as an overall strategy for medicines management within hospital. If all the pieces of the jigsaw are in place, then benefits will flow. A complication is that it does not just involve working with one staff group. It involves a significant redesign of the work of pharmacists, doctors and nurses, and the attitude of patients as well.

The report's main recommendations include a national standard for error reporting in hospitals. Currently, there is no standardisation, although the Department is developing it. The pressure on capital resources faced by NHS trusts suggests that virtue in a standardised specification for automated dispensing. Once again, the Department is thinking about it.

When every NHS trust has to introduce a system of electronic prescribing, it seems hard to understand why no national coding system is being introduced. Without it, purchasing is fragmented and problems are created for hardware and software suppliers. The commission wants greater direct leadership from the Department on electronic prescribing — but that is a battle it will lose.

Although there is a huge problem with recruitment and retention of pharmacists throughout the NHS, the service needs to move away from its traditional dispensing and purchasing functions and into patient-centred activities. There are major systemic problems in the way health care is delivered. Many prescribing decisions are made by those who are least qualified and understand drugs least — junior doctors. They need support from pharmacists.

What might the recommendations for the Society be? The formal registration of technicians is already on the "to do" list. The Society needs to maintain pressure on government on the recruitment and retention crisis that faces many hospitals. In particular, suggested Mr Mapstone, hospital pharmacists' salaries are inadequate. It says much about society's values that auditors who go round ticking boxes are paid more than people who have others' lives at stake.

Much closer links are needed between primary and secondary care. That distinction is getting blurred. Hospital pharmacists strongly hold the view that perhaps the Society did not give them the support they would like. Since most of the Society's members are community pharmacists, hospital pharmacists feel slightly left out. Steps to put that right would be welcome.

Data on pharmacists' activities have been collected from 200 acute hospitals, and the commission now has a full picture of what is going on in acute hospitals in England and Wales. The database is a rich resource but would be more powerful if it could be maintained in a time series so that people could calibrate progress over time.

The signs are promising

The agenda is huge, but the signs are promising, Mr Mapstone said. Electronic prescribing systems will arrive. The clinical governance agenda will not go away. Those things together create the right environment, so that pharmacists may be pushing at an open door to a certain extent. Most important of all, pharmacists need to push themselves to establish a more prominent role and get across the idea that pharmacy is a front-line clinical service.

The real pressure has to come from chief pharmacists. The question will be asked: where is the money coming from? It will come from eliminating the half a billion pounds currently being spent treating people with adverse drug reactions. It is a question of getting that message across. It is not some peripheral issue that the Audit Commission chose to look at. It is central to all the things that are driving trusts forward.

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