The Benefits of a full in-house Pharmacy Service to a Mental Health and/or Community NHS Trust

STARTER OR SAMPLE FOR YOUR OWN DOCUMENT

The UKPPG is aware that throughout the country there major changes to Trusts occurring over the next year or so. For example, a new mental health Trust is being formed in Bristol and Trusts are merging in London, Suffolk and elsewhere. There are many other examples. The major concern to the Group is that pharmacy services in the new set-ups may become marginalised. Trusts may be constituted with an under-funded pharmacy service, possibly being supply only from another Trust. Expertise will be lost. Opportunities for service developments lost, pharmacy may be downgraded, with non-dedicated staff drifting to acute services etc. In short, our chosen speciality may disappear as a clinical speciality in these areas.

Recent case examples have shown that the case for an in-house pharmacy service to a reasonable size mental health/community Trust is overwhelming, once all aspects have been considered.

This document has been prepared by the UKPPG (principally Stephen Bazire and Dr Dave Branford) and it may be able to help you. Broadly speaking, it is in two sections. Firstly, the "Strategic" arguments, which could be used to persuade a Trust Board to consider an in house service, including risk assessment, drug cost management, clinical governance (the other name for corporate responsibility), case studies, options etc. Secondly, the "Operational" aspects of setting up a new service or adapting the present one e.g. staffing, purchasing, clinical etc.

Any action must be initiated by yourselves, so you will need to get your act together as soon as possible. However, committee members are available to help in the early stages. If Trusts were interested, some Committee members may be available to act as consultancy service if required.

Part one - strategic aspects

Introduction:

Many models of pharmaceutical services to Mental Health and Community Trusts currently exist. These range from a total in-house pharmacy service through a single pharmacy to a totally contracted out pharmacy service. In between are a multitude of arrangements usually involving more than one supplier (Branford 1997), which have have arised for historical reasons.

Examples:

In Leicestershire the Mental Health Services Trust receive all their pharmacy services from one in-house pharmacy service based at the Towers Hospital. The Community Trust receives all of its pharmacy services via a contracted provider (Glenfield Hospital).

In Norwich, until June 1996 Norfolk Mental Health Care NHS Trust received pharmacy services from the local Acute Trust pharmacies (5 in all) to its sites on an annual Service level Agreement. From November 1996, a new purpose-built pharmacy was opened to take over the services provided by parts of the 5 pharmacies, but continued to purchase computer, purchasing and on-call/emergency services from the acute trust.

In Derby, all the Pharmacy Services for both the mental health and Community Trusts are provided from one pharmacy based in the Mental Health Trust.

Others:

Can anyone add any other examples please?

Patterns of Pharmaceutical Service:

Describe your service here, including:

A survey of hospital based pharmaceutical services to people with mental health problems and learning disabilities (Branford 1997) found that the most common pattern of service was either for the Mental Health Trust to receive their services from the local district general hospital or more than one provider (usually a combination of district general hospital and a pharmacy based in a psychiatric or community hospital).

The benefits of an in-house pharmacy service:

Information to support this paper was obtained from a number of sources:

The key benefit of a full in-house pharmacy service are: -

1. There is complete control of the resources and the services received by the Mental Health Trust.

The small survey of 20 district general hospitals providing contracted out services revealed that many were involved in acrimonious disputes over escalating drug costs, the minimal levels of service, and the terms of the contract (Branford 1998). Both the Mental Health and Community trust in e.g. Leicestershire inherited pharmaceutical services involving more than one provider. Within both Trusts the quality of the pharmaceutical services improved significantly with the agreements for sole providers.

When brought together, the pharmacy staffing required to service the workloads of any particular Trust may be considerable and drug expenditure high. In the light of the escalating cost of psychotropic drugs, it would be surprising if a Mental Health Trust did not want to have complete control over its resources and the services provided.

SLAs often prove inadequate to provide the sort of consistent service a Trust requires. There are many cases of service provision significantly below that paid for in an SLA e.g. frozen posts, staff re-allocated, insufficiently experienced or untrained staff utilised etc. A Mental Health/Community Trust may often not be aware of deficiencies in services as the basic supply service will be provided, and there will be little publicity of short-falls by the provider Trust. Many acute hospital Trusts are suffering increased difficulty in recruiting pharmacists. In such situations, services to an external trust are likely to become compromised. The Mental Health Trust is unlikely to receive a quality service when pharmacists become in further short supply when the degree changes to four years, resulting in a "fallow year".

2. The pharmacy staff is seen as an integral part of the Trust and able to contribute to clinical activities, research and development, planning etc.

Pharmacists with their scientific and clinical educational background are well placed to contribute to both ward based and Trust based activities. These include involvement with quality issues, risk management, clinical audit, staff in-service education and research and development. When staff are employed by another Trust it is unlikely that they will be seen as effective contributors in either the multidisciplinary clinical teams or within the Mental Health/Community Trust.

Pharmacists have a unique "helicopter view" of drug use across the Directorates and Trust, but this may not be able to be utilised to the Trusts best advantage if part of another Trust. As drug therapy is an integral part in treatment of mental health problems, it is important to make use of available skills to develop services effectively.

Lack of consistency in pharmacy services from a range of providers will create operational problems e.g. one pharmacy will have one system, another a completely different one.

3. There is no conflict of interest regarding strategic direction and the setting of priorities.

A survey of hospital pharmaceutical services to people with mental health problems and learning disabilities (Branford 1997) identified this as one of the primary issues facing pharmacy managers of general hospitals. Inevitably staff will identify with their employer to whom they are responsible for the service and during times of staff shortage and other difficulties, the service to and the strategic direction of the parent Trust will remain the priority.

4. The ability to develop and police prescribing policies specifically for the Trust. Such policies are more likely to be effective if developed locally and implemented by staff with no conflict of interest

All Trusts are faced with the problem of effectively managing or controlling drug expenditure. This has become more prominent in recent years with the explosion of new drugs in the specialities of psychiatry and neurology e.g. Alzheimer’s Disease, atypical antipsychotics etc. Studies have consistently identified that prescribing policies are more likely to succeed if agreed locally. Pharmacists based in another Trust are unlikely to see controlling drug expenditure as one of their problems. Indeed, perhaps even the opposite. It is difficult to tell someone they can’t have a particular drug when that Trust is paying for it and you belong to another Trust. Acute Trusts need to concentrate on their core businesses.

5. The development of specialist clinical pharmacy expertise.

Pharmacists provide clinicians with advisory services at various levels. These range from the routine scrutiny of prescriptions to identify obvious errors, or interactions through to the in-depth study of patients to formulate with the clinician the most effective drug therapy. Ward-based clinical pharmacists exist in the UK. The level of the clinical service provided has depended upon funding, the skill, knowledge and motivation of the pharmacist.

Few Trusts are prepared to accept the risk of no oversight of prescriptions by pharmacists although many because of historical underfunding currently receive such a minimal clinical service that patients will inevitably be put at risk. The UK Psychiatric Pharmacy Group produced a document that included minimum clinical pharmacy standards in mental health (Taylor 1996). Regrettably those that fall below the minimum standard are mostly the District General Hospital/Teaching hospitals that have little or no expertise in mental health.

It has been the experience across the UK that:
a) Psychiatric wards and elderly wards receive services from the most junior of pharmacists, untrained and seeing mental health as an unpopular area.
b) Such wards are the first to lose such service when there are staff shortages.
c) Specialised clinical services, including patient education about drugs (as opposed to just information), have been shown to improve patient services considerably

In future years, the change of the Pharmacy Degree course from three to four years will exacerbate the shortage of pharmacists. Any Trust purchasing services will have difficulty ensuring that pharmacists of adequate specialisation, expertise and commitment are available to the Trust both at the moment and over the forthcoming years. Those that run their own services will find recruitment and retention of staff considerably easier.

The previous experience of the service to acute wards at Leicester General Hospital and Queens Medical Centre Nottingham support the above findings. Leicester has in the past been at the leading edge in the development of clinical pharmacy and the re-engineering project at Leicester Royal Infirmary has maintained that situation with the development of the near-patient system. An in-house pharmacy service for the new Mental Health and Community Trust would have the potential to develop a similar level of service to patients.

A "small autonomous group given freedom, with motivation to provide better service by innovation" is often quoted as being an ideal efficient unit. A Trust pharmacy service could be such a unit.

6. Maintenance of drug formulary and consistent policies.

Drug and Therapeutics Committee present difficulties, placing a high level of financial and legal risk on Directorates/Trust e.g. rising drugs costs. Lack of control over e.g. clozapine expenditure.

References: -

Branford D. (1997), Hospital based pharmaceutical services to people with mental health problems and learning disabilities. UK Psychiatric Pharmacy Group

Branford, D. now Kingsway Hospital, Southern Derbyshire Mental Health Trust

Taylor B. (1997), NHS Community Trusts. How do they affect Acute Trust Pharmacy Managers. Pharmacy Management 13 (3) 28-31

Taylor D. (1997), Clinical Pharmacy Standards for Mental health, UK Psychiatric Pharmacy Group.

Examples of option Appraisals

The following are some options that may be worth using as a starter for your current situation. Not all will be applicable. Add more using the main document, the details from Beth Taylors paper etc. Some sample advantages and disadvantages are included.

Options; -

1. No change

Enter details of current service and arrangements.

Advantages (depending upon the starting point of course);-

Little disruption
Support (e.g. computers, finance, staffing) organised and provided by others
Part of larger peer support systems
Experienced Professional Heads in place

Disadvantages;-

Service run by a Trust with less interest or expertise in mental health
Non-dedicated services
Overheads/charges difficult to calculate accurately

2. Complete stand-alone in-house pharmacy service

Mental health/Community Trust manage and run their own Pharmacy Service from dedicated premises

Advantages;-

Savings on core charges can be better used e.g.: personnel, drug information, stores district/regional services
May be able to sell specialist services
Feeling of belonging for staff
Attracting appropriate staff easier/feasible

Disadvantages;-

May need new premises and service structure
Relatively small service might be only borderline viable if staff losses occurred
Would have to recruit expertise in e.g. purchasing, computers etc
Staff transfers would be needed and current employing Trusts might not release quality staff

3. Some split (many variations possible, you’ll have to consider your own)

e.g. use Acute Trust for purchasing, computers, on-call etc. but manage and run its own service (e.g. Norwich)
Trust just employs a single Pharmacist to manage contracts - this is not recommended
Trust employs clinical pharmacists and purchases in the supply side from an Acute Trust (e.g. ???)

Advantages;-

Purchasing expertise maintained
Lower disruption to service
etc etc

Disadvantages;-

Recruitment
etc etc

PART TWO - Operational aspects

Aspects of a "stand-alone" pharmacy service to a Mental Health Trust;

If a Trust accepts the need for a specific pharmacy service, the following need to be included when considering future service configuration. This will usually be done by Tender Documents, although not necessarily:

On-call/out-of-hours and Saturdays/Bank Holiday drug supplies

Computer system options

Purchasing and manufacturing

Some manufactured items may need to be purchased e.g. pre-packs, rare sterile products etc. from Acute Trust
Drug purchasing, either;-

  1. Buy from Acute Trust
  2. Buy direct from local wholesalers or manufacturers.
  3. A mixture of these

Transport

Finance

Personnel

Drug information

Recruitment

Training

Place of pharmacy within Mental Health Trust structure

Pre-registration Pharmacists

Job security

Salaries

Drug budget

Miscellaneous considerations

Functions of a Trust managed pharmacy service

The function of the pharmacy department could be as follows:

Some aspects of setting up a new pharmacy service

Structure" of management, staffing and responsibilities

Responsibilities need to be clearly defined, including full job description. Tasks include:
Direction, budgets, SLA's, trouble shooting, D&T, Trust management liaison, financial reporting, training, DI, Annual report, staffing, leave, dispensary, stores, top-ups, clozapine, directorate pharmacists, clinical services, drug information, news sheets, rotational induction and continuing education, in-service training on drugs and drug therapy, management and professional issues, dispensary, medical gasses, Crash boxes, Mercury spillage kits, Returns, stores, purchasing, computer system control, emergency cupboards, reserve stocks, ordering, legislation, CD's, out-of-hours, on call, stock control, secretarial, filing etc

Other things to consider:

OPERATIONAL POLICY (sample)

1. Philosophy

1.1 Mission statement of pharmacy

To provide to the Trust, within a framework of quality standards and resources available, a comprehensive yet flexible pharmaceutical service by combining professional and technical skills and effective self-management. The safe, reliable and cost-effective distribution of pharmaceuticals and pharmaceutical education will be at all levels of care, achieved through liaison, communication and co-operation.

1.2 Service principles

1.2.1. To provide a comprehensive and accessible range of quality pharmaceutical care services, both within the Trust and for when clients are discharged, thus facilitating seamless care. This will be flexible, collaborative and needs related and include negotiations with the Directorates to ensure shared values and direction and anticipate needs. We will communicate effectively both internally and externally to ensure widespread knowledge of the facilities, services and abilities available.

1.2.2. To promote the safe and effective use of drugs by providing regular and planned education and training to professionals, carers and patients etc.

1.2.3. To provide accessible, appropriate, evaluated and effective drug information and clinical inputs for all professional staff and carers.

1.2.4. To support service users by ensuring widespread and easy access to information on drugs for themselves, family and other carers.

1.2.5. To provide high quality drug distribution and dispensing activities, under the supervision of a pharmacist, to agreed standards of performance, ensuring ready availability of stocks of drugs on wards and optimum stock holdings ensuring optimum use of nursing and medical time e.g. by system of top-ups, low stock levels, no expired stock, convenient, responsive service etc.

1.2.6. To income generate.

1.2.7. To achieve our mission, standards and service objectives in the most cost effective way.

1.2.8. To recognise the talents, dedication, loyalty and integrity of staff to provide a natural quality and to continue training for future needs.

CASE STUDY

PHARMACY SERVICE TO NORFOLK MENTAL HEALTH CARE NHS TRUST

From April 1994 Norfolk Mental Health Care NHS Trust had purchased pharmacy services from the local Acute Trust (NNH). NMHC decided at its Operational Board meeting in April 1996 to approval a proposal to provide its own in-house Pharmacy services. This took effect from 1.11.96.

Key issues in the decision to investigate the viability of a dedicated pharmacy service

The following were some issues in influencing NMHC to consider running its own pharmacy service:

Issues considered by NMHC Operation Board Appraisal;-

  1. Pharmacy premises – NMHC built a new Pharmacy for the Trust
  2. Computer dispensing/stock control/finance system requirements and availability
  3. Rotation pharmacist scheme, ensuring professional contacts maintained
  4. Staff shortages - there was some concern by NMHC that staff (specifically pharmacist) recruitment was being allocated to Acute Trust service rather than NMHC
  5. On-call - a review indicated that an in-house Saturday service coupled with a contract for Acute Trust provision of emergency duty would serve NMHC better
  6. NMHC management of service - costs of NMHC providing personnel and financial support were considered
  7. Human resources - staff would be able to transfer on current terms and conditions

A number of options were considered, which included;-

  1. No change
  2. Complete separation
  3. Cessation of SLA but retention of computer, purchasing and on-call

Option 2 was approved.

Some questions existing pharmacy staff may have:

Is my job in danger?
Can I retain my current terms and conditions?
Why is this change occurring?
Is this a cost-cutting exercise?
Can we "trust" the new Trust?
What will our relationships with previous employer Trust pharmacy be in the future?
What about the training budget. Will we have to compete?

Prepared by Stephen Bazire, Pharmacy Services Director, Norfolk Mental Health Care NHS Trust and Vice Chairman of UKPPG, but this version has not been seen by the committee so the UKPPG can't take corporate responsibility for it. It's all mine.

Version 3. 12.9.98

All comments gratefully received!