Government healthcare reforms aimed at cutting staff numbers put patients at risk. The current reforms focus on finding savings, which inevitably means reducing manpower without losing the high level of care currently being offered by the NHS. But as most of the medication checking is picked up manually in wards or clinics, any attempt to reduce staff numbers will inevitably increase the risk of wrong medicines or doses being administered.

The coming together of professionals through the proposed clinical senate groups will inevitably drive the demand for shared information between hospital and community healthcare. So far this has been sporadic at best and needs to improve. Detailed prescribing information is a must and as the groups work their way through the Commissioning agenda the safe and effective use of medication will undoubtedly be of major importance.

As more and more medications are introduced into the physician’s armoury the possibilities of adverse interactions increases. This is inevitable. Our ability to recognise these adverse interactions requires a comprehensive reporting system. This is in place through the CSM and is frequently updated in texts such as Stockley Drug Interactions. Why then does the problem continue?

Unfortunately the amount of information continues to grow at pace making it impossible for health professionals to retain and recall all of the interactions and their significance. Every time a new medication is added to a patient’s prescription there needs to be a check against existing allergies and possible drug–drug interactions. The knowledge base required to do this effectively is enormous.

E-prescribing

Plainly the use of computerised systems to enable electronic prescribing and nurse administration should be high on the agenda to help reduce adverse medication errors. But historically there has been little drive to make this happen. It is true that the computer systems that can provide all needs to all users have not been particularly up to the task. I would suggest that the IT market has now moved on dramatically and these systems and the support to run them effectively now exist.  Funding and the desire to change are the main issues facing the NHS.

NHS stakeholders

Unquestionably there are several stakeholders to consider in the introduction and maintenance of e-prescribing and medicines administration (ePMA) in secondary care. In my experience any attempt to bring in a system without the FULL involvement of clinical staff is doomed to fail. There are many examples of successful pilot schemes over the past 20 years or more and even whole hospital schemes after the Resource Management Initiative 1990-94. But these examples have not led to widespread adoption of ePMA.

One stakeholder that is often forgotten in all of this is the patient. There has been a drive over the past ten years to allow patients to carry on taking their own medications when hospitalised, which makes a good deal of sense, especially on surgical wards where patients arrive with their own medications and are happy to carry on taking them. An ePMA system needs to account for this.

Pharmacy’s role in ePMA

Pharmacy staff are a very knowledgeable and intrinsic in determining the best processes to achieve excellence in medicines management across the entire healthcare sector. Since the 1970s pharmacy has evolved from a ‘making science’ to a ‘supply science’ and latterly to an ’information science’. When ‘clinical pharmacy’ was first termed, it was unusual for pharmacy to be anywhere near the patient in hospitals other than in outpatients. It is now commonplace for pharmacy to be at the patient’s bedside and have ward responsibilities.

As an ex-chief pharmacist I witnessed many of these changes in several hospitals and have seen the benefits of this development. There is a current shift - mainly due to cost control - to push the pharmacy back to merely a stock control function. This would be a massive mistake. Stock control can be done, and is done, extremely well in many pharmacies by robotics and pharmacy technical staff. The clinical pharmacy medication decisions made by highly qualified pharmacists would be lost.  ePMA is a mechanical process but without the clinical input from professional clinicians much of the benefit would be lost. Hospital prescribing is by its nature often complex without much time to get it right before the patient is discharged into the community. The involvement of all clinical professionals to optimise treatment is paramount. If the prescribing is optimised, then good medicines management will follow.

The lack of integration between a dispensary system and ePMA often hampers progress. The main reason for integration is to maintain a controlled formulary, which makes good sense. If the Drugs and Therapeutics Committee is functioning well, an agreed hospital or hospital/community pharmacy formulary will be in operation with the vast majority of drugs and dosages for treatment will be decided on. In this case the drug database of an ePMA and pharmacy must be the same. There must however be the ability for the doctor to choose outside of the agreed formulary as long as there is good reason, in which case a full BNF-based database must be available.

Key advice

The key advice for trusts considering an ePMA system is KNOW YOUR CUSTOMERS. This not an original thought because it is the basis for all successful businesses, but it is vital that the trust knows what it is attempting to achieve on behalf of whom and for the ePMA supplier to understand these goals. The supplier too must offer ceaseless support to ensure success.

 

Stephen Freeborn -  BSc ( Hons), MSc, MRPharmS, MHSM  

1974	BSc (Hons) in Pharmacy from Manchester University, with Pharmacology as honours speciality
1975	Registered as a member of the Royal Pharmaceutical Society of Great Britain
1975	Hospital pharmacist at several hospitals across north-west England
1978	MSc in Hospital Pharmacy from Manchester University, including research into Pethidine and the Neonate, which resulted in three publications on the subject
1981	Chief pharmacist, Bolton Hospitals
1990	Project leader for £2m Resource Management Change and IT project, Bolton Hospitals
1993	Finalist in SEMA Group IT Award for the Public Sector
1994	Head of Clinical Support Services (pharmacy, physiotherapy, occupational therapy, dietetics, podiatry, orthoptics and orthotics), Bolton Hospitals
1997	Director of pharmacy, Hope Hospital, Salford Royal Hospitals Trust
2002	Director of clinical development, Ascribe plc
2003-09	Head of pharmacy division, Ascribe plc

Steve was also honorary lecturer at Manchester University from 1987 to 1997 and preceptor (clinical instructor) at Mercer University School of Medicine in Georgia, USA from 1997 to 2002. He was also a contributor to the Audit Commission’s landmark ‘Spoonful of Sugar’ report on medicines management in 2001.

Steve Freeborn is the keynote speaker at iSOFT's upcoming ePMA Excellence Forums at Wembley on 20 October and Old Trafford on 10 November.

 

 

 

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