COVID-19 Insight 9: Safe and effective use of medicines in NHS trusts

Introduction

Pharmacy services are a crucial activity in NHS trusts, helping to ensure people can access their medicines and receive support to take them. CQC’s Medicines Optimisation Team engages with chief pharmacists and those who are accountable for medicines optimisation in NHS trusts across England. This forms part of CQC’s ongoing monitoring of trusts and helps to assure us that trusts’ pharmacy services are facilitating safe, effective and person-centred care. Medicines optimisation is the safe and effective use of medicines to enable the best possible outcomes for people.

To understand how trusts were assuring themselves of safe medicines practice during the pandemic, we carried out a programme of virtual supportive conversations with chief pharmacists and medicines optimisation leaders within trusts between July and October 2020. Nearly all (98%) of the acute, community, mental health and ambulance NHS trusts participated in these conversations.

Even though pharmacy teams were exceptionally challenged, chief pharmacists told us how they assured themselves that they had oversight and systems in place to identify and minimise risks.

This article describes the challenges they faced, the good practice they had in place, and learning that can be taken forward.

Patient focus

Vulnerable patients and access to medicines

Chief pharmacists told us they developed various solutions to ensure that patients continued to have safe access to medicines prescribed in outpatient clinics when they needed it, particularly for patients who were more vulnerable, such as those who were shielding. Examples included:

• home delivery
• "drive thru" set-ups (for both supplying medicines and monitoring them, such as blood tests)
• using volunteers or re-deployed staff
• sending prescriptions directly to patients for dispensing in community pharmacies
• trialling the Electronic Prescription Service (EPS).

Many trusts had received positive feedback about changes to outpatient services and were looking to maintain them as business as usual.

Patient feedback

A small number of trusts said they actively asked patients for feedback when they made changes to pharmacy services. Some stated that they received feedback, including through their Patient Advice and Liaison service, and were happy to respond to concerns raised.

Others gathered feedback from national initiatives, like the ‘friends and family test’, but recognised that these were not specific to medicines. In some cases, there was a lack of insight into the value that feedback could provide.

A few pharmacy teams were creative in seeking out patients’ voices. This included using virtual platforms for patient focus groups to discuss changes to services.

Use of technology

The use of technology improved ways of working, not only in pharmacy teams, but also in multidisciplinary teams and within local health and care systems.

Chief pharmacists told us that services with more advanced technology were able to maintain oversight of clinical pharmacy more easily. However, some chief pharmacists said that not being able to have a face-to-face review of medicines with a patient made it harder to identify any recent changes to their medicines.

Some examples of innovations to minimise face-to-face contact included:

• virtual daily huddles to transfer information efficiently
• medicines reconciliation calls by telephone with patients or ward staff to ratify information and ensure the most recent medicines were prescribed
• virtual ward rounds
• virtual training and handovers for re-deployed or re-joined staff
• recording virtual staff updates for those who could not attend to watch later.

Conversely, challenges raised included:

• lack of guidance on medicines on some electronic systems due to the trust’s IT infrastructure
• not being able to order controlled drugs electronically
• problems for clinicians when working from home when homecare services used paper prescriptions
• delays in receiving the right IT equipment for staff working from home.

Trusts said they were at different points in procuring and setting up electronic prescribing and medicines administration (EPMA) systems, to replace more traditional methods. Those who did not have EPMA believed that it would have been useful in helping a more seamless response to the first wave of the pandemic.

We were told that providing a clinical service was extremely challenging for trusts that still used paper-based systems.

Workforce

Wellbeing

Chief pharmacists were unanimously proud of their teams and reflected on how their teams had “stepped up”, adapted and gone “above and beyond” in difficult and stressful times to maintain services and support patients with their medicines.

Some teams received positive feedback from their trust, recognising how integral they were in response to the pandemic.

Where leaders took an inclusive approach in seeking and listening to the views and experiences of all staff, teams were empowered to make improvements.

Capacity

Hospital pharmacy teams provide highly specialised services for patients. They require very specific training and experience to carry out the work to a high standard. Chief pharmacists told us that the pandemic has brought into focus the sustainability of these services. They gave examples, which included the following:

• some aseptic services, such as the preparation of pre-filled syringes of medicines for patients in critical care units, were suspended due to staff shortages
• some trusts trialled reducing ward-based clinical pharmacy in favour of a virtual service to reduce footfall, but also due to reduced capacity. However, some chief pharmacists told us that ward-based multidisciplinary teams asked for pharmacy staff to return to the wards
• increased demand meant that some trusts extended their pharmacy opening hours and implemented seven-day working. This posed a challenge where resources were limited.

The pandemic meant that pharmacists in their pre-qualification training year (pre-registration pharmacists) were not able to take their registration exam in June 2020 and qualify as fully registered pharmacists. This created a workforce capacity challenge for many trusts.

To minimise this challenge, a temporary provisional registration status was granted to pre-registration pharmacists by the General Pharmaceutical Council. This allowed them to carry out certain activities with limits. Chief pharmacists were grateful for their support and recognised their efforts.

Leadership and governance

Governance

Many pharmacy teams were well embedded into their trust’s governance and communication frameworks.

Where this was not the case, we were told about pharmacy teams experiencing significant challenges, including:

• problems with quality assurance processes
• staff not always being consulted about changes (including services being suspended) or new policies that could have an impact on their work
• staff not being asked to help with contingency planning for the future towards the end of the first wave of the pandemic.

We heard that in some cases, learning and reflections from the challenges experienced helped to strengthen relationships and raise awareness of the crucial work that pharmacy teams undertake.

Many chief pharmacists told us that medicines incident reporting had decreased at some point during the first wave of the pandemic. We asked how trusts responded to incidents to mitigate risks to patients. They told us that learning from incidents was shared within trusts and through wider networks.

Controlled drugs

The requirement for physical (not electronic) signatures for controlled drug prescriptions and ordering created practical challenges for providers, for example when prescribers were working from home conducting virtual clinics. Most providers told us they created patient-centred solutions, having risk-assessed the possible impact of these. However, chief pharmacists were concerned that there was less opportunity to consult a fuller range of stakeholders about decision making for these processes, and that they could be time consuming. We were also told that the requirements for physical signatures on prescriptions at discharge led to delays in people being able to leave hospital.

Chief pharmacists also raised concerns about a lack of knowledge among wider teams around controlled drug legislation relating to storage, particularly when wards were re-organised or moved, or when controlled drugs had to be transported with patients, both within and between providers.

Working together as a system

Chief pharmacists experienced challenges in working with other organisations as a local health and care system, but most said that the response to COVID-19 had either initiated or accelerated collaborative working and improved communication.

This often meant changing how they worked with different providers or organisations. For example, trusts told us about some of the work they did to help support care homes, including weekly support calls as well as visits if needed.

National guidance

While national guidance was welcomed, chief pharmacists said the way information was published and disseminated could be improved. We were told that trusts often made initial decisions themselves and then, when national guidance became available, they reviewed, adapted or adopted their decision. This led to duplication of work.

Messages were sometimes viewed as contradictory and confusing, requiring teams to be constantly updated and trained, which added to fatigue and pressure. Others thought that much of the guidance was not produced with their ‘type’ of trust in mind, such as community and mental health trusts.

Medicines supply

Procurement

Pharmacy procurement teams were vital in maintaining supplies of medicines in response to the pandemic. Many started to work from home to reduce the risk of COVID-19 infection, while maintaining capacity and supply.

Good practice included:

• automated dashboards, which gave a real-time view of medicines in stock
• bespoke checklists for rapid review of critical medicines.

Trusts told us that, due to the demand of the pandemic, at times, some medicines were in critically short supply. However, collaborative working and enhanced communication within the trust and the local system meant that, overall, supplies were maintained.

Oxygen

The pandemic led to an increase in demand for oxygen. Chief pharmacists said they assured themselves that all patients had adequate access to oxygen through good collaboration between pharmacy teams, facilities teams and external providers.

This collaboration was particularly needed where, prior to the pandemic, trusts had business cases awaiting approval for upgrades to their oxygen supply systems, which quickly needed to be actioned to meet new demand. They also said that the increased demand for oxygen through pipes, cylinders or concentrators occasionally had an impact on ward layouts, patient flow and delayed discharges.