Supplementary written evidence submitted by the Royal Pharmaceutical Society (PHA0066)

Dear Mr Brine,

 

Many thanks for the opportunity to speak to the Committee on 21 November as part of its inquiry on pharmacy.

 

I appreciate the session was constrained for time and so thought it may be helpful to set out some topics I would have looked to explore further.

 

The RPS is the professional leadership body for pharmacists and pharmacy students working in all areas of practice. Our members work across the whole of the health service, including in community pharmacy, general practice, PCNs, hospitals, in academia and industry, as well as other roles such as in mental health services, prisons, and the armed forces. This inquiry shows the huge range of areas where pharmacy teams have a crucial role, reducing health inequalities, managing the growing cost of long-term conditions, and delivering best value from medicines for patients and the NHS.

 

We have seen some welcome steps towards advancing the clinical role of pharmacists in the NHS, and this will accelerate with a new generation of pharmacist prescribers. But we know there are areas where the Government and NHS can go further, such as around the disappointing lack of progress in expanding access to PrEP through community pharmacy – an issue which would benefit from clearer leadership within Government.

 

Throughout our work with The King’s Fund last year, we consistently heard from health and care leaders how pharmacy has a fundamental part to play in the health service of the future.i There are some key enablers to make this a success, including workforce planning to ensure a pipeline of pharmacists for the future, making best use of skill mix within pharmacy teams, and much-needed investment in IT and interoperable patient records.

 

Learning Support Fund

 

During the session I noted that while the Government has announced that eligible students on nursing, midwifery, allied health professions, medical and dental courses will be able to claim 50% more for travel and accommodation expenses, pharmacy students on clinical placements remain excluded from this support.ii

 

As the pharmacy degree has evolved to include a greater emphasis on clinical practice, pharmacy schools are delivering a growing number of clinical placements across a range of care settings and geographies. At present there is no direct support for pharmacy students travelling to these locations and this depends on the individual university. Placing students into rural or coastal locations can help manage the health inequalities that these communities experience and generate a pipeline of future pharmacists who may wish to return to work in those locations once qualified.

 

While we would ideally look for pharmacy students to be able to access all aspects of the Learning Support Fund as part of a future review, financial support for travel and accommodation for pharmacy students on clinical placements would be a positive first step.


The NHS Long-Term Workforce Plan highlighted the inequity caused by the inconsistent way in which funding is paid to students and has proposed “to introduce a single, consistent policy for funding excess travel and accommodation costs incurred by students undertaking placements”.

 

With the NHS estimating that education and training places for pharmacists need to grow by 31–55% to meet the demand for pharmacy servicesiii, there is a clear need for pharmacy students to be included in this support.

 

System leadership

 

The introductory session heard from different sectors of pharmacy, but there is also a wider question of how pharmacy is integrated and works across the system.

 

Pharmacists play a vital role in supporting medicines optimisation – improving medicines safety and helping patients get the most benefit from their medicines. With pressures on NHS budgets, we need to ensure teams are able to continue supporting the best use of medicines for patients across the health service, not just cutting costs.

 

ICS Chief Pharmacists need the time, resource and support to lead and develop pharmacy services, working with colleagues across the system – this shouldn’t be an afterthought without additional resource.

 

We welcomed the funding for new Community Pharmacy Clinical Leads in each ICS, who are playing a key role in developing local pharmacy services, but there is uncertainty about how many posts will continue after national funding ends in March 2024.iv

 

With financial pressures across the NHS, it is vital that pharmacy teams get the funding, staff and resources they need, including in system leadership roles, to support the safe and effective use of medicines across the health service.

 

Virtual wards

 

Hospital at Home, including virtual wards, provide acute clinical care, monitoring and treatment for people at home, for a short duration. This is an alternative to care in hospital, preventing avoidable admission or facilitating early discharge. Hospital at Home services are growing at pace and scale, with the aim to support NHS recovery and enable reforms to community; and urgent and emergency care.

 

It is disappointing that the CQC has found that pharmacy teams have not always been involved in setting up a virtual ward from the outset. Medicines are a key part of Hospital at Home and the RPS interim standards for virtual wards state that a senior pharmacy lead must be assigned to the service from the very beginning to design, implement and maintain pharmacy services.v

 

The CQC’s State of Care report noted:

 

“Often, pharmacy teams were not involved in setting up a virtual ward from the outset, so they had no influence in decisions on the use and supply of medicines. Sometimes there was no allocated budget for pharmacy staffing, which meant leadership often fell to a trust’s chief pharmacist without any additional resource, resulting in policy, practice, and governance of medicines being overlooked.”vi

 

The Committee may wish to consider if the role of pharmacists and pharmacy teams should be more formally strengthened in virtual wards.


Hospital pharmacy

 

As described in my oral evidence, pharmacists working in hospital are a core part of the multidisciplinary team. The demand for pharmacist expertise continues to increase as medicines use grows in scale and complexity. The Government and NHS should re-energise investment in hospitals to implement the Carter Review recommendations, creating capacity for hospital pharmacists to spend more time on clinical services, patient safety and supporting colleagues in primary care and other settings.vii

 

While robotics are already commonplace in many hospital dispensaries, there are further opportunities for using new technologies. For example, in the independent sector, the Cleveland Clinic London has implemented the first Closed Loop Medicines Administration system in the UK, delivering an entirely unique medicines supply model.viii This uses AI technology to help cut blister packs to individual patient-ready doses, and shows what can be achieved with the appropriate investment.

 

I agree with the report from the Expert Panel that there needs to be much faster adoption of electronic prescribing in hospitals and investment is needed in delivering digital maturity into these services. The lack of electronic prescribing between primary and secondary care setting represents a significant barrier to efficient service delivery, especially in the supply of homecare medicines.

 

Discharge prescriptions or To Take Out (TTOs)

 

Towards the end of the session, I responded to a number of questions about the role of pharmacy teams in hospital discharge. I referenced there has been research on this topic. For example, one audit showed that nearly 50% of TTOs contained at least one discrepancy, the most common of which was omission of a medicine. The significant predictors of discrepancies were if a TTO was written by a nurse or a doctor or if there was more than three hours between an unauthorised TTO being authorised.ix A further observational study has demonstrated that many of these errors can be addressed without need to contact the prescriberx and the incidence reduced further where a pharmacist is directly involved in the prescribing of discharge prescriptions.xi

 

As described in my evidence, the delays to discharge that exist are multifaceted, and rely on an interconnected service in a hospital, requiring efficient integration of pharmacy teams with junior doctors, portering and nursing staff. In some hospitals, such as Sheffield teaching hospitalsxii, pharmacist prescribers have been embedded into the team, and these have been shown to increase speed and accuracy at discharge. This emphasises the need to ensure that more pharmacists can become prescribers. Again, this underlines the vital role of pharmacy teams within hospitals and I would welcome support for hospitals to be backed by appropriate investment.

 

Aseptic pharmacy services

 

Pharmacy teams continue to play a key role in technical services in hospitals, and will be at the centre of developing new medicines and treatments, including unlocking the potential of personalised medicines. Technical services, including NHS aseptic pharmacy services, provide sterile, controlled environments to prepare medicines such as IV antibiotics, chemotherapy and monoclonal antibodies, as well as nutrition and cutting-edge medicines for cell therapy and clinical trials.

 

As identified in the review by the Expert Panel, aseptic pharmacy services played a crucial role during the COVID-19 pandemic and will be even more important as we move towards


individualised treatments in the field of gene therapies, advanced therapies and point of care manufacture. Pharmacists, supported by pharmacy technicians, will be central to providing the technical, logistical and governance expertise for these innovative products.

 

Speaking to pharmacists working in aseptic pharmacy services, I have heard concerns about short-term challenges as well as longer-term issues that need addressing.

 

 

 

 

Against this background, I would welcome the Committee exploring this aspect of pharmacy in more detail. Aseptically-produced injectable medicines have an annual cost of £3.8 billion representing 3.1% of the total annual budget of NHS England, and are due to grow 5% each year. Given their cost and vital importance to life sciences, clinical trials and medicines supply, I would welcome further consideration of the Government's investment in this unsung, but vitally important part of the NHS infrastructure.

 

Medicines shortages

 

I understand that the Inquiry may examine medicines shortages in more detail and I would very much welcome this focus. This is a very complex area which covers issues such as manufacturing capacity and resilience, supply of key ingredients, medicines prices in a global market, and the role of the NHS and pharmacy teams.

 

We know there is a lot of important work behind the scenes by Government, suppliers and the NHS, but medicines shortages continue to be a concern for patients and take time to manage. The recent high-profile case of ADHD medicines is one of the latest examples.

 

We would welcome a Government review of the medicines supply chain and identification of where greater support is needed, including whether the current medicines reimbursement regime for community pharmacies is fit for purpose and how pharmacists can be better enabled to ensure patients can access the medicines they need. The review should also consider the tendering practices used for ensuring supplies into NHS hospitals as well as the powers that the DHSC Medicines Supply team have under Part 6 of the Health Service Products (Provision and Disclosure of Information) Regulations 2018 and how these are used.


We would welcome the opportunity to share further information on medicines shortages and the impact on patients should the Committee choose to explore this in further detail.

 

Prescription Charges

 

Lastly, while our panel was asked to focus largely on general practice and hospital pharmacy, I wanted to highlight our continued call, alongside patient groups and others, for the abolition of prescription charges in England.

 

The day after our evidence session, the Autumn Statement noted plans for a Universal Credit sanctions regime which would include the withdrawal of free prescriptions. Our England Chair has described this as a deeply disappointing move. We believe that no-one should be faced with a financial barrier to getting the medicines they need, regardless of their employment status. Prescription medicines are vital to our health service and improving our population’s health. Amid a cost-of-living crisis, evidence from Healthwatch has shown a worrying trend that people are increasingly avoiding taking one or more NHS prescriptions because of the cost. This had risen to one in ten people at the start of the year.xiii

 

Pharmacists in England want to focus on looking after patients, rather than policing prescription charges. Abolishing this complex system would free up time for pharmacy teams and remove an avoidable barrier for patients to accessing the medicines they need to stay well and out of hospital.

 

I would welcome the opportunity to take members of the Committee to visit a hospital pharmacy department or to see first-hand how aseptic manufacturing works in the NHS.

 

While the focus of my oral evidence was on hospital pharmacy, members of the RPS work across all aspects of healthcare. As the inquiry progresses, I would welcome the opportunity to provide further evidence on other areas of practice that the RPS supports.

 

Yours sincerely,


 

 

Dr James Davies Director for England

Royal Pharmaceutical Society

 

 


i Vision for Pharmacy Professional Practice in England. https://www.rpharms.com/england/vision-for-pharmacy-practice-in- england

ii  https://www.gov.uk/government/news/healthcare-studies-more-affordable-as-financial-support-increased

iii https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf (p.80)

iv  https://pharmaceutical-journal.com/article/news/nhs-to-appoint-community-pharmacy-leads-for-each-integrated-health-system

v  https://www.rpharms.com/recognition/setting-professional-standards/hospital-at-home-interim-standards

vi https://www.cqc.org.uk/sites/default/files/2023-10/20231030_stateofcare2223_print.pdf (p. 54)

vii https://www.gov.uk/government/publications/productivity-in-nhs-hospitals

viii https://www.linkedin.com/pulse/cleveland-clinic-london-pioneers-use-ai-medicines-libby-smart/

ix https://ueaeprints.uea.ac.uk/id/eprint/42406/

x Abdel-Qader, D.H., Harper, L., Cantrill, J.A. et al. Pharmacists’ Interventions in Prescribing Errors at Hospital Discharge. Drug-

Safety 33, 1027–1044 (2010). https://doi.org/10.2165/11538310-000000000-00000

xi Onatade, R., Sawieres, S., Veck, A. et al. The incidence and severity of errors in pharmacist-written discharge medication orders. Int J Clin Pharm 39, 722–728 (2017). https://doi.org/10.1007/s11096-017-0468-9

xii https://www.eahp.eu/sites/default/files/gpi_documents/cps12200_poster.pdf

xiii https://www.healthwatch.co.uk/news/2023-01-09/cost-living-people-are-increasingly-avoiding-nhs-appointments-and- prescriptions

 

Nov 2023