By Rosie Furner, member of the RPS Primary Care Pharmacy Expert Advisory Group
I am the Lead at the Community Health Services (CHS) pharmacy service within an integrated acute/community Trust at East Sussex. We are a small team providing pharmaceutical advice and support to community based services. These incorporate community nursing services, community therapy services and clinics, with some specialist multi-disciplinary teams. Our prime role is to ensure the safe, appropriate use and management of medicines, from prescribing, through supply and administration, to monitoring and disposal. Although locally we don’t provide a service to children (e.g. immunisations) or prisons, these services are often supported by CHS teams. There is a much larger team at the acute sites, and we benefit from their expertise, for example, easy access to Medicines Information services.
The bedded units take the majority of the team’s time. These patients are either step up (from home) or, more likely, step down from acute services. The national trajectory would be to increase step up use, avoiding admission and providing a local alternative to the acute hospital. These bedded units offer rehabilitation services, for example following a stroke or a hip fracture, respite care, and palliative care. The medical model differs between our bedded units, some have hospital doctors present, others have a short daily visit from a local GP. This is for Monday to Friday. The units are nurse and therapist led, and require a highly skilled team, especially in the absence of a medical team and out of hours, to identify the deteriorating patient, and when an emergency doctor or ambulance is needed. If a patient has a cardiac arrest, they dial 999, there is no resus team available, except that time the new nurse called 2222 and the anaesthetist holding the bleep was working on one of our sites – the sole resus team member running down the hill. The CHS pharmacy team undertake a medicines reconciliation for all new patients, arrange ongoing supplies and support a safe discharge process. This is a prime opportunity to undertake a medication review, often as part of a comprehensive geriatric assessment, as the patient may be with us for two to three weeks, allowing an incremental approach where needed.
Safe supply of medicines
A major role of the team is ensuring a safe supply of medicines to our services, whether that be patient-labelled or stock items. As we are an integrated Trust we benefit from the pharmacy supply service from the acute sites, removing the need for a wholesaler dealer license, a home office license, and FMD processes. The legislation to allow supply of medicines by a different organisation, whether that be an acute trust or a community pharmacy, has become more complex over the past few years, making it very difficult to establish a robust supply chain that meets all legislative requirements. This is a major challenge for some community health services. We also undertake a rolling programme of audit reviewing the safe and secure handling of medicines in all our locations.
Community and district nurses teams
Our district nursing teams provide a service to patients who are housebound. A large part of their work is around wound care or catheter care. However, there is a growing trend for administration of medicines, including IV antibiotics, in the patient’s home. Some of the prescriptions can be challenging, particularly when the prescriber is a hospital doctor who has discharged the patient with an unusual dose or frequency, or where there is inadequate supply – community pharmacies don’t often hold intravenous clarithromycin where we are. It’s worth remembering this is happening in a patient’s home, no infusion pump, no medical team, maybe no phone signal, and a dose that can’t be measured accurately.
The community nursing teams include many prescribers, both independent (nurse, pharmacist, physiotherapist and podiatrist) prescribers, and community nurse prescribers. The pharmacy team provide advice to our prescribing colleagues, and support audit processes and reviews of prescribing habits.
The world of community health services is diverse. They have matured responding to local needs, local services, and local vision for development. There is significant diversity in the services provided. This makes it difficult to provide a description of what a typical community services pharmacist, or pharmacy team, does. It provides a different challenge every day and gives great job satisfaction. Fundamentally it’s about supporting safe use of medicines outside of an acute hospital setting, whether that be in a community bedded unit or the patient’s own home, working with a variety of clinical and support staff, both health and social care, to deliver care to the patient in the safest way.
Find out more about the RPS Primary Care Pharmacy Expert Advisory Group.