The Standards for Hospital Pharmacy Services

For providers of NHS and independent hospital pharmacy services including those in hospitals, mental health, community service, prison, hospice, and ambulance settings.

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Version 4: November 2022
Review date: 2024

Introduction

Since 2012, the Royal Pharmaceutical Society (RPS) has published professional standards for NHS and independent (private) sector pharmacy services in hospital, mental health, private, community service, prison, hospice, and ambulance settings. They apply whether services are provided internally or outsourced. These refreshed Standards replace the 2017 version of the Professional Standards for Hospital Pharmacy Services.

A key function of a professional leadership body is to provide professional standards that are supportive and enabling, but professionally challenging.

The importance of professional standards alongside regulatory standards in supporting patient safety are repeatedly emphasized (1-3). There is a clear requirement for providers of pharmacy services to use them to improve and develop services that are safe and put the needs of people first.

Professional standards are consistent with and complement relevant legal framework requirements as well as the minimum standards currently required by systems regulators, professional regulators, and insurers and may be used to help inform them.

Whilst they are not mandatory, they are developed and owned by the profession, and set out what constitutes "good" in terms of practice, systems of care, and working practices.

Figure 1 illustrates where RPS professional standards fit in relation to legislation, regulatory standards, other standards, policies, and procedures.

Figure 1. Where RPS professional standards sit

RPS Professional Standards figure 1

These Standards have been developed and updated to ensure with the implementation of new and increasingly integrated models of care they continue to be applicable for now and the future. They underpin a person’s experience of pharmacy services and the safe, effective management of medicines within and across organisations.

They aim to ensure that people using services receive a high-quality pharmacy service, from admission through to discharge, across multiple care pathways and healthcare providers. This helps protect them from incidents of avoidable harm and enables them to get the best outcomes from their medicines.

They have been updated using the RPS process for the development of standards and guidance.

The literature review underpinning the update can be found on the RPS website.

The development and updating of the Standards have been led by the pharmacy profession with lay input.

Appendix 1 contains details of who has been involved.

Purpose

The Standards describe quality pharmacy services or "what good looks like". They provide a broad framework to support pharmacy teams continually improve services, shape future services and roles, and deliver high quality care across all settings and sectors.

The Standards:

  • Ensure that in the design and delivery of pharmacy services people are placed at their core, allowing them to make informed decisions about their care which is joined up across the system
  • Assure that procedures are in place for the safe and effective use and supply of medicines
  • Support strong strategic, operational, personal and clinical leadership, systems of work and ensure the right skill mix, capacity and capability to deliver pharmacy services.

Scope

The Standards cover pharmacy services, whether provided internally or outsourced, and are applicable across the full range of service providers in the NHS and independent sector.

They are applicable in and across these and other services:

  • Hospitals (acute and non-acute)
  • Mental health
  • Community services
  • Prison
  • Hospice
  • Ambulance settings

They provide a framework for safety and quality that allows:

  • The whole pharmacy team to recognise, develop, and deliver the best possible outcomes from pharmacy services
  • The pharmacy senior leadership team to drive continuous improvement of services and innovation
  • Chief Executives and Board members assurance there is adequate professional input into medicines policy making within their organisation and across partner organisations and appropriate levels and quality of pharmacy services are being provided
  • Commissioners/purchasers of pharmacy services, regulators, insurers, governments, and legislators to inform and complement their own standards and outcomes
  • Development of more detailed standards for other areas, for example homecare services and secure environments.

Using the standards

The Standards can be used to support benchmarking in the acute, community, mental health, and commissioning sectors.

RPS has produced benchmarking metrics for acute hospitals to support consistency in the way that acute hospitals measure performance. Associated resources on the RPS website provide links to legal and regulatory frameworks, international standards, core standards required by systems regulators, as well as signposting to more detailed guidance, resources, and support tools.

Individuals and organisations are encouraged to submit examples of good practice to RPS as well as further feedback on the standards ([email protected]).

The Professional Standards for Hospital Pharmacy Services

Structure of the professional standards

The standards contain three overarching domains:

  1. The Person's Experience
  2. Medicines Assurance
  3. Delivery of the Service

Under these overarching domains sit eight standards. These are further subdivided into descriptors which support attainment of a standard. An overarching standard and descriptor outcome gives an overview of what each aims to achieve. Supporting statements explain how a descriptor can be achieved.

The standards refer to people using services throughout. This is used as an umbrella term to cover the full range of those using pharmacy services across sectors and includes children and young adults, service users and clients as well as their carers.

The Standards

Figure 2. The professional standards for hospital pharmacy services

RPS Hospital Standards figure 2

Standard One: Putting People First

Standard outcome:

The principle of "no decision about me, without me" underpins the design and delivery of pharmacy services ensuring that people using services can make shared decisions about their treatment and medicines. Appropriate support is provided to people to ensure effective medicines use.

Descriptor 1.1: Person focused services

Descriptor outcome: People, their families, and circles of support are put at the heart of health, care, and wellbeing and care is focused on the needs of the individual.

The pharmacy team provide the expertise, leadership, and systems support to ensure that:

  1. People are treated with compassion, dignity, and respect by all members of the pharmacy team
  2. The pharmacy team introduce themselves, their role and purpose consistently
  3. People’s values, circumstances, and preferences about treatment and care are understood
  4. People are involved in decisions about the pathways under which they receive care and information (e.g., in person or remotely/virtually)
  5. Views are routinely sought from people, their families, and circles of support to inform the development, improvement, and delivery of pharmacy services, ensuring people have direct input into the services that they receive.

Descriptor 1.2: Information about medicines

Descriptor outcome: People using services are supported to understand* the benefits and risks of medicines, their alternatives or doing nothing. People can decide about a preferred course of action based on good quality evidence-based information and their personal preferences.

*When people lack capacity, appropriate procedures should be followed, including those for deprivation of liberties, safeguarding and covert administration.

The pharmacy team provide the expertise, leadership and systems support to ensure that services:

  1. Allow people the opportunity to have meaningful discussions about their medicines, or alternative options with an appropriate pharmacy team member or other professional during a care episode and, where appropriate, after transfer to another care setting through face-to-face or virtual pharmacy services
  2. Provide people with information such as when and how to take their medicines, taking other medicines at the same time, advice about side effects, any associated costs or other relevant information in a form that they can access and understand
  3. Advise people who to contact or where to go if they need more information about their medicines, who will prescribe continuing treatment and how to access further supplies or dispose of medicines
  4. Discuss with the person information about their medicines in a form that they can understand and refer back to before discharge or transfer to another service
  5. Where appropriate, offer information in a format that is culturally sensitive or accessible to people with additional needs such as physical, sensory, or learning disabilities, and to people who do not speak or read English
  6. Partner with people and the multidisciplinary team across the system to identify, assess, and resolve barriers to actively promote and facilitate the provision of clear, understandable information about medicines.

Descriptor 1.3: Support with effective medicines use

Descriptor outcome: Systems are in place to identify people who may need support, or to allow people to request support with medicines choice and use.

The pharmacy team provide the expertise, leadership, and systems support to ensure that:

  1. People's beliefs, expectations about, and experiences of, taking their medicines are explored to identify those requiring support
  2. People in need of pharmacy support and pharmaceutical care planning are identified and necessary support is documented in their record. If required, further specialist input is provided by an appropriate member of the healthcare team
  3. After assessment and in partnership with the person, reasonable adjustments are made to support medication adherence
  4. Liaison with other healthcare professions or agencies within the system is undertaken where ongoing support with medicines is needed
  5. If care is transferred to another setting, people are referred or signposted to appropriate follow up or support with their medicines
  6. People are signposted to pharmacy support to improve health and wellbeing using public health services and activities when appropriate
  7. Measures to identify and support people at high risk of experiencing problems with their medicines on transfer to another care setting are in place.

Standard Two: Episode of Care

Standard outcome:

People's medicines are reviewed for accurate medication history, experiences of their medication and clinical appropriateness.

Descriptor 2.1: Individual episode of care

Descriptor outcome: At pre-admission, admission, transfer, or discharge, people’s medicines are reviewed to ensure an accurate and complete medication history and to identify medicines related admissions. People are encouraged to bring their own medicines to the care setting, or they are made available when needed

The pharmacy team provide the expertise, leadership, and systems support to:

  1. Reconcile people’s medicines and optimise treatment to identify and avoid potential medication-related discrepancies before a planned admission
  2. Reconcile people’s medicines in accordance with national guidance to avoid potential medication-related discrepancies
  3. Effectively document people’s medication histories and identify medicines related admissions as part of the admission process
  4. Identify potential medicines related problems affecting discharge or transfer to another care setting so that they can be addressed to avoid risks to patient care and extending the person’s episode of care
  5. Ensure people’s medicines are available from the time that their next dose is needed, minimising missed doses of medicines and ensuring timely administration of critical medicines
  6. Enable people to bring their own medicines into the care setting with them; and ensure policy and procedures are available that enable staff to support appropriate self-administration of medicines.

Descriptor 2.2: Medicines related outcomes of treatment

Descriptor outcome: As part of the multidisciplinary team, the pharmacy team understand people’s goals and experiences of their medicines.

The pharmacy team provide the expertise, leadership, and systems support to:

  1. Understand people’s views, knowledge, outcomes, and experiences of their medicines
  2. Monitor people’s responses to their medicines, including any unwanted effects. Appropriate action is taken where problems (potential or actual) are identified
  3. Help people to avoid and/or minimise adverse events resulting from their medicines
  4. Document and report adverse events that arise through relevant systems, appropriately managing them whilst recognising duty of candour and the need for transparency and shared learning from incidents.
  5. Empower people to take an active role in the safety and effectiveness of their treatment.

Descriptor 2.3: Care of the person

Descriptor outcome: People have their medicines clinically reviewed by pharmacy team members who play an active role in medicines management. People can access the pharmacy expertise that they need to ensure that their medicines are clinically appropriate, and their outcomes from medicines are optimised.

The pharmacy team provide the expertise, leadership, and systems support to ensure that:

  1. Treatment requirements are clinically reviewed to optimise outcomes from any medicine prescribed with the frequency and level of review adjusted according to individual need
  2. In partnership with the person, medicines regimens are simplified as far as possible, doses optimised, and medicines stopped when agreed it is in their best interests
  3. The pharmacy team, in partnership with the multidisciplinary team, work to ensure that medicines are available and administered on time to avoid omissions and delay in treatment. Appropriately trained pharmacy team members may also administer medicines to people independently and/or support others during medicines administration rounds
  4. Pharmacy team members are integrated into multidisciplinary teams across the organisation and provide person facing clinical services to ensure safe and appropriate medicines use for all, whatever the setting
  5. Pharmacy team members optimise treatment for people, identifying high-risk medicines and antimicrobials. Teams ensure that medicines are used in accordance with local policies and/or reflect what is recognised as good clinical practice
  6. Pharmacist prescribers are integrated into relevant care pathways and are prescribing regularly
  7. Advanced/consultant level pharmacists work in clinical specialties to maximise the availability of expert resource to other members of the multidisciplinary team for the benefit of those receiving care in that area.

Standard Three: Integrated Transfer of Care

Standard outcome:

As part of the local health and social care system, the pharmacy team ensure safe and timely transfer of information about the person and their medicines between care settings.

Descriptor 3.1: Medicines transfer at care interfaces

Descriptor outcome: Accurate and complete information about a person’s medicines is provided to the patient and transferred to the health or social care professional(s) taking over care of the person at the time of transfer. Arrangements are in place to ensure a safe supply of medicines for the person and ongoing support where necessary.

The pharmacy team provide the expertise, leadership, and systems support to enable the organisation to:

  1. Transfer information about a person’s medicines to the professional(s) taking over care of the person in accordance with national guidance following discharge
  2. Ensure the accuracy, legibility, and timeliness of information transfer as far as practicably possible
  3. Ensure that people have access to an ongoing supply of their medicines (based on local agreement and individual need) and share information so that their medicines can be reconciled by the health professionals taking over responsibility for care
  4. Monitor, identify, and minimise delays to people’s discharge or transfer due to problems in medicines being supplied
  5. Engage with people, their families, and circles of support as active partners in managing their medicines at the time of transfer. A complete list of medicines is given to the person and/or those supporting them at the time of transfer with an explanation of why they are taking them, and when and how to take them as well as a description of any changes made
  6. Communicate information about people’s medicines in a way that is timely, clear, and unambiguous. It should be generated and transferred in the most effective and secure way, preferably electronically.

Descriptor 3.2: Integration

Descriptor outcome: The pharmacy team, in collaboration with those across the system, strive for effective, joined up, and smooth transitions of care for people.

Within the pharmacy service, the pharmacy team:

  1. Work in partnership with those across the system to ensure transitions of care are seamless for people
  2. Foster closer working relationships between pharmacy teams across all settings to ensure timely and seamless support for people
  3. Have a clear picture of pharmacy resources in their local area and use this in planning services
  4. Maximise the potential and capacity of pharmacy resources in the local area.

Standard Four: Medicines governance

Standard outcome:

Pharmacy expertise is consistently available whenever people need the service to lead the safe and effective use of medicines. The pharmacy team leads a multidisciplinary approach to safe medication practices across the organisation and within systems.

Descriptor 4.1: Safety culture

Descriptor outcome: The pharmacy senior leadership team ensure that medication safety is embedded, both within their organisation and partner organisations, including those providing outsourced services. Services are risk assessed and reviewed regularly to ensure safety.

Within the pharmacy service:

  1. The Chief Pharmacist, or equivalent, has overall responsibility for medication safety and has direct access to Board support for the management of medicines safety in the organisation
  2. The organisation has a lead for medication safety with suitable experience, time, and resource, who is accountable for overview, reporting, and learning from adverse events or near misses
  3. The lead for medication safety leads on training for all pharmacy team members to embed a safety culture and ensure that medication safety is part of all job roles within pharmacy
  4. The lead for medication safety, or a nominated deputy, represents pharmacy on all high-level medicines safety and governance groups which include representation from people using services
  5. Controlled drugs are managed in line with the requirements of the Misuse of Drugs Act. Regular updates and concerns about controlled drugs are reported to the Controlled Drugs Accountable Officer
  6. The lead for medication safety, or a nominated deputy, must lead or be party to, serious incident investigations directly involving medicines or involving harm from the use of medicines
  7. Systems and processes are in place to ensure other medication incidents are identified, recorded, monitored, appropriately reported, investigated and practice changed and shared to minimise recurrence
  8. The pharmacy team actively works with, and where necessary, intervenes with prescribers, other healthcare professionals, and people using services to ensure medicines are used as safely and effectively as possible
  9. The pharmacy team, in partnership with other healthcare professionals, ensure that there are systems in place to identify trends in practice and outcomes that give rise to safety concerns
  10. Systems are in place to ensure people who have experienced a medication error are informed, apologised to, and understand any action being taken to rectify the error in line with duty of candour
  11. Themes identified from near misses, medication errors, and systems failures related to medicines are shared with the multidisciplinary team and the whole organisation if appropriate. Action is taken to change practice to prevent or minimise the risk of reoccurrence of identified themes
  12. Shared learning is reviewed and reported at Board level on a regular basis, and shared within the organisation, professional networks, and systems.

Descriptor 4.2: Safe systems of care

Descriptor outcome: The pharmacy senior leadership team lead a multidisciplinary approach that ensures all aspects of medicines use, arrangements, and processes within the organisation are safe.

Within the pharmacy service:

  1. The Chief Pharmacist, or equivalent, ensures that pharmacy services operate a safety culture that aligns with organisational, national, regulatory, and professional guidance
  2. The pharmacy team lead on developing, monitoring, reporting, managing, and improving metrics relating to safe use, administration and storage of medicines
  3. The pharmacy team actively facilitates the timely implementation of medicines-related aspects of relevant national therapeutic guidance and national patient safety guidance and priorities
  4. Systems are in place to ensure appropriate and timely responses to national alerts. These include national patient safety alerts, and Medicines and Healthcare products Regulatory Agency or supplier-led defective medicines alerts and recalls, and medicines shortages.

Descriptor 4.3: Effective management of medicines

Descriptor outcome: Medicines policy aims to improve outcomes both on an individual and population basis maximising safety, effectiveness, sustainability, and the value obtained from medicines use.

Within the pharmacy service:

  1. The pharmacy team are integral members of a multidisciplinary group that provides a focal point for the development of medicines policy, procedures, and guidance within the organisation and across the system
  2. The pharmacy team leads the development and implementation of processes that ensure supply, prescribing, de-prescribing, monitoring, and review of medicines are safe, evidence-based, and consistent with local, regional and/or national commissioning and purchasing arrangements. This is linked to treatment guidelines, protocols, formularies, and pathways locally and across the system
  3. The environmental impact of medicines is considered when supplying, prescribing, reviewing, procuring, and disposing of medicines
  4. Horizon scanning processes enable early discussions with clinicians, local partners, and commissioners/purchasers about the financial pathways and service implications of the introduction of new medicines, new indications, or new therapeutic practices
  5. Governance arrangements, aligned to medicines regulations, are in place for the management of all medicines. This includes off-label use of licensed medicines, unlicensed medicines, radiopharmaceuticals, Investigational Medicinal Products, Advanced Therapy Medicinal Products and emerging advances in medicines and medicines technology.

Descriptor 4.4: Digital technology and informatics to support medicines use

Descriptor outcome: The pharmacy senior leadership team, in partnership with the multidisciplinary team, lead the development, implementation, integration, utilisation, optimisation and ongoing monitoring of digital technology and informatics that support medicines use across the organisation and the wider health system.

Within the pharmacy service:

  1. Digital technology, including automation, is utilised to underpin and transform delivery of medicines and optimisation of therapeutic outcomes
  2. Prescribing, dispensing, referral and service data is used to drive improvements for safety, clinical efficacy, and cost effectiveness
  3. An accountable individual is fully integrated in decisions relating to the procurement, implementation, operation and development of digital technology and informatics
  4. An accountable individual works together with informatics leaders to ensure that digital systems comply with required standards and enable interoperability and commonality of language
  5. The pharmacy team have the necessary skills to maximise the use of systems and technology to support optimisation and transformation of medicines use
  6. Information generated through digital technology is used to optimise care with medicines and to support benchmarking and performance management (accommodating information governance and privacy regulations)
  7. Business continuity plans are in place to ensure that any system content relating to medicines is appropriately governed and backed up. This includes looking for and managing unintended consequences of content changes or updates.

Descriptor 4.5: Support with effective medicines use

Descriptor outcome: The pharmacy team support all health and social care staff who are prescribing, handling, administering, or monitoring the effects of medicines. They ensure access to relevant, up-to date evidence-based information, policies, and pharmaceutical expertise.

Within the pharmacy service:

  1. The pharmacy team supports induction, and ongoing training and education in best practice use of medicines for relevant clinical and support staff across organisations and systems
  2. Pharmacy team members are accessible in, or to, clinical areas/teams, either in person or virtually, to provide advice for other health and social care staff on the choice, use and handling of medicines
  3. Access to a Medicines Information service, who are working to national standards for medicine information, is available to health and social care teams
  4. The pharmacy team works to ensure that those who are involved with handling, administering, or monitoring medicines are supported with readily accessible information and guidance
  5. The pharmacy team works to ensure that prescribers are supported in their everyday activities with readily accessible information and guidance on medicines use.

Standard Five: Efficient Supply of Medicines

Standard outcome:

Medicines are available or can be readily made available to meet people’s needs whenever there is a requirement for them.

Descriptor 5.1: Medicines procurement

Descriptor outcome: Medicines procurement is managed by pharmacy teams with relevant specialist expertise and knowledge in a transparent and professional way. Quality assured medicines are procured through robust and appropriate processes.

The pharmacy team provide the expertise, leadership and systems support to ensure:

  1. All medicines (licensed and unlicensed) are assessed and assured to be of appropriate quality and suitable for specific patient groups
  2. Procurement decisions are informed by clinical practice and formulary systems and other medicines governance processes
  3. Medicines procurement accounts for nationally, regionally, or locally negotiated contracts and the quality, safety, and reliability of the products
  4. Contingency plans and systems are in place to manage product recalls
  5. Contingency plans and systems are in place for managing and communicating shortages of medicines to ensure continuity of care
  6. Medicines procured are safely and securely received and stored in pharmacy, in accordance with relevant professional guidance, legislation, and local policies.

Descriptor 5.2: Storage, access, and return of medicines

Descriptor outcome: Medicines are safely and securely stored in a suitable environment. Those accessing, handling, distributing, and supplying medicines prior to administration can do so in a timely manner in line with professional guidance and local policies.

The pharmacy team provide the expertise, leadership and systems support to ensure:

  1. As far as practicably possible, medicines supplies are available in the right places at the right times
  2. Supply systems ensure that clinical areas have timely access to routinely required medicines. Medicines needed urgently outside core pharmacy service hours can be obtained
  3. Policies, standard operating procedures, and systems underpin the legal, secure, and appropriate handling and storage of medicines wherever they are located
  4. Audit trails and governance processes are in place that underpin the supply, storage, and return of medicines.

Descriptor 5.3: Prepared or manufactured unlicensed medicines

Descriptor outcome: Any medicines custom-made by, or for, the organisation, are quality assured and appropriate for their intended use.

The pharmacy team provide the expertise, leadership and systems support to ensure:

  1. Use of any type of unlicensed medicine, clinical trial medicine, Advanced Therapy Medicinal Product or radiopharmaceutical, including those that are aseptically or extemporaneously prepared, is clinically justified and used in line with regulatory requirements, adhering to the principles of risk/benefit to the person and using licensed medicines wherever possible
  2. Where possible, standardised presentations of medicines are available and used
  3. Aseptic preparation in-house or outsourced is routinely subject to internal and external audit. This is conducted in accordance with good manufacturing practice and good distribution practice
  4. Appropriate systems are in place to ensure protection of operators and products
  5. Appropriate quality assurance and control systems underpin the selection, management, and use of all unlicensed medicines, whether made in-house or outsourced.

Descriptor 5.4: Dispensing

Descriptor outcome: Medicines that are clinically appropriate are dispensed or prepared accurately, and available when needed in and out of hours. Systems and processes are risk assessed to ensure safe supply of medicines.

The pharmacy team provide the expertise, leadership and systems support to ensure:

  1. Before dispensing or preparation of named person supply, prescriptions are reviewed for clinical appropriateness by a pharmacist
  2. Systems are in place to prioritise dispensing to minimise the risks of omitted and delayed doses of medicines or of delayed discharge/transfer. Particular attention is paid to medicines where potential harm to the person could occur if omitted or delayed
  3. Dispensing processes make appropriate use of technology, efficient ways of working and skill mix
  4. Systems are in place to allow traceability of all dispensed medicines
  5. Medicines are labelled in line with legal requirements and professional guidance
  6. Systems are in place to identify and review the causes of near misses and dispensing errors to learn from and minimise future risk of these reoccurring. Investigations begin with an initial intent to determine systemic and human factor causes of an incident
  7. Successful patient safety improvements are shared widely within the organisation and more broadly with other healthcare providers.

Standard Six: Leadership

Standard outcome:

Pharmacy has a clear strategic vision, effective organisational processes, governance, and controls necessary to ensure people using services are safe and get the best from their medicines. This is underpinned by strong personal, professional and clinical leadership.

Descriptor 6.1: Strategic leadership

Descriptor outcome:The pharmacy senior leadership team ensures that the organisation maintains a clear vision for pharmacy services, ensuring timely access to medicines as well as their optimal use across the organisation and wider healthcare system.

Within the pharmacy service, the pharmacy senior leadership team:

  1. Are accountable for the quality of pharmacy services across the organisation, the quality of medicines used and ensuring that the organisation has safe and legal medicines policies and procedures
  2. There is board level sign up to the vision for pharmacy services within the organisation
  3. Provide assurance to the Board about the safe and effective use of medicines within the organisation through routine governance processes and risk management reporting
  4. Ensure the organisation has a strategy and implementation plan that has Board approval and support to ensure that people get the best outcomes from medicines which is regularly reviewed
  5. Ensure a long-term plan is in place for succession planning and workforce leadership development at all levels from trainee through to senior posts
  6. Collaborate on transformation of and innovation in service delivery to better meet people’s needs, including the adoption of national initiatives and guidance, and encouraging active involvement
  7. Engage with the health community to develop a whole system approach to medicines and public health, including health inequalities, sustainability, interoperability’s, emergency preparedness, resilience, and response.

Descriptor 6.2: Operational leadership

Descriptor outcome: Pharmacy services are safe, effective, and efficiently delivered in line with organisational, regional, and national priorities and performance indicators, and the range and level of healthcare commissioned/purchased.

Within the pharmacy service:

  1. The statutory role of “Chief Pharmacist” is appointed to someone within the organisation whose duty is to ensure the safe and effective running of the pharmacy service
  2. The type and level of resources required to deliver a safe, effective, and efficient service are identified and available to support the safe and secure use of medicines
  3. Agreed key performance and quality indicators are in place to enable internal and external assessment of the operational performance of pharmacy services
  4. All outsourced and shared pharmacy services, including homecare and supply functions, are performance-managed through Service Level Agreements and contract quality monitoring. Timely action is taken if services fail to meet contracted standards
  5. There are clear lines of professional and organisational responsibility established which are regularly reviewed
  6. There are effective feedback systems from people using services, staff, and anyone involved in the service is sought to ensure patient safety, continuous learning, and service improvements
  7. The pharmacy team is supported to identify and utilize opportunities for adoption, collaboration, networking and sharing of best practice internally and externally.

Descriptor 6.3: Personal and professional leadership

Descriptor outcome: The pharmacy team take responsibility for their work, recognising they have a duty of care to people and to act in their best interests. They are supported to achieve this by the senior leadership team.

Within the pharmacy service:

  1. Leadership at all levels across the pharmacy team is encouraged and developed
  2. Clinical supervision is an integral part of pharmacy team development
  3. The pharmacy senior leadership team lead by example through commitment, encouragement, compassion, and a continued learning approach
  4. The pharmacy senior leadership team promote a just, open, and transparent culture which recognises and values diversity of background and thought
  5. Governance arrangements, aligned to medicines regulations, are in place for the management of all medicines. This includes off-label use of licensed medicines, unlicensed medicines, radiopharmaceuticals, Investigational Medicinal Products, Advanced Therapy Medicinal Products and emerging advances in medicines and medicines technology.
  6. The pharmacy team behave in a candid, open and honest way encouraging diversity, equality, and inclusion
  7. All members of the pharmacy team are encouraged and empowered to raise any concerns they may have both from within the pharmacy service, and from other parts of the organisation
  8. All members of the pharmacy team feel safe and able to speak up about anything that gets in the way of delivering safe, high-quality care or affects their experience in the workplace including a clear route of escalation if unresolved
  9. All concerns are investigated and, if substantiated, dealt with at an appropriate level in line with the organizational policy
  10. All members of the pharmacy team manage conflicts of interest in line with organisational, national, regulatory, and professional guidance.

Descriptor 6.4: Clinical leadership

Descriptor outcome: The pharmacy team are recognised as leaders on medicines, medicines use, and innovations in medicines technology both within the organisation and across the health system.

Within the pharmacy service, the pharmacy team:

  1. Provide advice, education, leadership, and support to other clinicians and support staff about safe, appropriate, and cost-effective medicines usage
  2. Ensure that their input is an integral part of the design of any service involving medicines
  3. Support the development of integrated care pathways that involve medicines as a treatment option, as well as the utilisation of pharmacy roles across systems
  4. Provide or seek leadership and education on the introduction of complex therapies, such as genomics, personalised and precision medicine in collaboration with the multidisciplinary team. The potential implications for service delivery are understood and services involving complex therapies are planned and designed around the needs of people using services.

Standard Seven: Systems of work

Standard outcome:

Systems of work are in place and maintained which support the maintenance of good practice, learning from mistakes, and improvement of services whilst having clear business and financial arrangements.

Descriptor 7.1: Systems governance

Descriptor outcome: Systems of work are established that are accountable, safe, regularly audited, and comply with relevant regulations.

Within the pharmacy service:

  1. All pharmacy team members are trained in information governance to safeguard patient-identifiable information about care/medicines supplied
  2. Governance systems are in place for working with the pharmaceutical industry
  3. Working environments are planned and maintained in line with Health and Safety requirements, regulatory, and professional best practice standards
  4. Equipment and systems are maintained and operated only by appropriately trained members of the team or appropriate external contractors
  5. Standard operating procedures are in place for the delivery of all pharmacy services across the organisation
  6. Business continuity plans are developed, tested, and maintained for all services
  7. Risk registers with appropriate escalation mechanisms are maintained.

Descriptor 7.2: Research, audit, and quality improvement

Descriptor outcome: The pharmacy team actively participate and conduct research, audit, or quality improvement projects to improve outcomes of pharmacy services.

Within the pharmacy service:

  1. The continuous improvement and development of pharmacy services is informed by a programme of research, audit and/or other improvement techniques/methodologies
  2. The pharmacy team is supported to develop skills to participate in, conduct, and lead research, audit, and quality improvement projects
  3. The pharmacy team is supported to identify gaps in the evidence base
  4. The pharmacy team seek opportunities for collaboration at system, regional and national level to work with academia and other research partners, including involving and engaging with patients and the public
  5. A named individual ensures there are appropriate governance mechanisms in place for conducting research, audit, and quality improvement projects
  6. Care contributions are documented and audited to demonstrate the impact of the service on patient outcomes.

Descriptor 7.3: Business and financial management

Descriptor outcome: Effective business and financial planning alongside sustainable cost improvement programmes and reporting are assessed and evaluated on a regular basis.

Within the pharmacy service:

  1. A business plan incorporating finance, service, capacity, and workforce plans, linked to the organisation’s corporate plan is developed, implemented, and monitored
  2. Local, regional, and national initiatives and guidance relating to medicines and pharmacy are incorporated into service planning activities
  3. Medicines use and expenditure reports are regularly interpreted and used to support budget management and monitoring of prescribing and service data
  4. The pharmacy team regularly engages with commissioners and primary care to review prescribing to deliver value across the health system
  5. Proactive horizon scanning is undertaken to identify and understand emerging transformational technologies and services and the impact of these on business and financial planning
  6. Operational performance is benchmarked against other relevant organisations using key information sources.

Standard Eight: Workforce

Standard outcome:

The pharmacy team has the right skill mix, capability, and capacity to provide safe, quality services to people whilst being supported to maintain their personal development and health and wellbeing.

Descriptor 8.1: Workforce planning

Descriptor outcome: The pharmacy team has appropriate levels of staff available to deliver a safe, high-quality service now and in the future.

Within the pharmacy service:

  1. Workforce data is collected and analysed, with trends identified and acted upon. This is linked to the organisational strategic workforce plan
  2. The pharmacy senior leadership team maximise the use of systems, such as digital rostering, to inform optimum use of pharmacy staff resource dependent on hospital workflow
  3. The training pipeline secures sustainable numbers within all parts of the pharmacy team through collaboration with local commissioners
  4. Imbalances in supply and demand for pharmacy staff are understood and corrective measures put in place considering quality, accessibility and acceptability for people using services and the organisation
  5. Succession planning arrangements are in place and are linked to workforce training and personal development plans
  6. Modelling is undertaken to predict future workforce requirements.

Descriptor 8.2: Workforce development

Descriptor outcome: The pharmacy team is supported to develop new skills and attributes to meet the needs of people using services, their families, and circles of support across the health and social care system.

Within the pharmacy service:

  1. Workforce development is included in the pharmacy strategic plan. This is linked to the organisational strategic workforce plan
  2. Workforce development takes a needs-based approach focusing on future service needs and new models of care, and engaging with local service planners, education commissioners and members of the multi-disciplinary team
  3. Skill mix is reviewed across the pharmacy and wider clinical team considering changing demographics, advances in technology, and the effective use of available and future staff resources
  4. All staff are given appropriate training to their role to ensure they can provide a safe and effective service
  5. Roles are designed that support models of integrated care that enable collaboration across the wider multi-disciplinary team in all sectors
  6. The outcomes of workforce development plans deliver cost-effective use of staff practising at their highest skill level
  7. The development of advanced pharmacy roles achieves the right balance between generalists and specialists necessary to meet the needs of people and the organisation.

Descriptor 8.3: Workforce quality assurance

Descriptor outcome: Operational policies, procedures, and plans are in place to ensure that the pharmacy workforce is managed and appropriately resourced to support service quality, productivity, and safety.

Within the pharmacy service:

  1. All members of the pharmacy team are clear about their role and responsibilities and aware of their level of performance and competency as part of a robust annual appraisal, and performance and talent review process. Personal development plans highlight appropriate professional, managerial and leadership frameworks, tools, and assessments
  2. Staffing levels are reviewed and set to ensure the delivery of safe services. The senior leadership team determines levels locally taking account of national guidance where it exists
  3. A culture of continuous learning is apparent, and all members of the pharmacy team acknowledge their role as learners, educators, and trainers. Tutors, mentors, and supervisors are trained appropriately and meet any relevant standards and guidance
  4. Continued learning and professional/personal development opportunities are provided for all members of the pharmacy team
  5. Pharmacists, pharmacy technicians and non-registered pharmacy staff have access to early years vocational training and development programmes and support.

Descriptor 8.4: Inclusion and wellbeing

Descriptor outcome: The pharmacy team has a culture of belonging which champions inclusive and authentic leadership, challenges inclusion and diversity barriers and promotes positive mental health and wellbeing.

Within the pharmacy service, the pharmacy team:

  1. Champion an inclusive, diverse culture of belonging by treating their team with kindness and respect, ensuring the diverse voices of colleagues are represented, heard, valued, and included in decision making
  2. Commit to better understand and respect each other’s backgrounds, experiences, beliefs, boundaries, and choice. They support all to be their authentic self when at work
  3. Understand their own personal biases and look to be an ally for under-represented groups
  4. Have zero tolerance for any form of discrimination, bullying or harassment and can raise concerns without fear of repercussions
  5. Collect and understand workforce data relating to equality and diversity and have an action plan to address any identified inequalities
  6. In partnership with the senior leadership team commit to providing a healthy work-life balance for the pharmacy team through encouraging them to take their full allocation of breaks and flexible working options where appropriate
  7. Feel empowered to look after their own mental and physical health and wellbeing and can speak up when work expectations and demands are too much
  8. Are actively aware of what support is provided for wellbeing and how to access it.

Glossary

Accountable individual: An operational leader who ensures that organizational requirements are reflected in operational frameworks, procedures and plans.

Advanced therapy medicinal products: Advanced therapy medicinal products (ATMPs) are medicines for human use that are based on genes or cells. ATMPs can be classified into four main groups: gene therapy medicines; somatic-cell therapy medicines; tissues-engineered medicines; and combined ATMPs. See European Medicines Agency overview

Chief pharmacist: A statutory term and duty under the Rebalancing medicines legislation and pharmacy regulation to allow pharmacy professionals working in hospital pharmacy services to rely on the defences of section 63 and 64 of the Medicines Act.

Circle of support: One or more people who support an individual on a regular basis. This could be in a paid or unpaid capacity. They support a person to make their own decisions about their life.

Clinical supervision: A formal process of professional support and learning that enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice, and enhance patient protection and safety of care in a wide range of situations. It is an activity that brings two or more professionals together in order to reflect upon and review clinical practice.

Deprivation of liberties: The Deprivation of Liberty Safeguards is the procedure prescribed in law when it is necessary to deprive of their liberty a resident or patient who lacks capacity to consent to their care and treatment in order to keep them safe from harm. See Deprivation of Liberty Safeguards

Duty of candour: Health professionals must be open and honest with patients when things go wrong. This is also known as "the duty of candour". See Regulators statement

Informatics and clinical informatics: Informatics is a general term used to refer to biomedical informatics and its many areas of application and practice (e.g. bioinformatics, clinical informatics, public health informatics). Clinical informatics involves the capture, communication and use of data and clinical knowledge to support health professionals.

Interoperability: With new models of care emerging and evolving, there is a clear need for more effective information sharing between care settings, organisations and geographies, as well as between professionals and citizens, to optimise patient outcomes and quality of care. Interoperability describes the ability of IT systems across health and care to exchange and make use of information.

Medication errors: Any unintended or unexpected incident, which could have or did lead to harm for one or more people receiving NHS care. Medication errors are any "patient safety incident" (PSI) where there has been an error in the process of prescribing, preparing, dispensing, administering, monitoring or providing advice on medicines. These PSIs can be divided into two categories: errors of commission or errors of omission. The former include, for example, wrong medicine or wrong dose. The latter include, for example, omitted dose or a failure to monitor, such as international normalised ratio for anticoagulant therapy.

Named individual: Someone who is responsible for setting overall framework and policy standards across a specific healthcare setting

Person: Used as an umbrella term to cover the full range of people using pharmacy services across sectors this includes children and young adults, service users and clients as well as their carers.

Pharmacy team: Pharmacy team encompasses all staff working in the delivery of pharmacy services.

Appendix 1: Acknowledgements

Task and finish group for the 2022 review

Name

Role/Affiliation

Representing

Rob Duncombe*

Chair of T&F Group
Chief Pharmacist, The Royal Marsden

HEAG

Melinda Cuthbert*

Associate Director of Pharmacy, NHS Lothian

HEAG

Catherine Picton*

Consultant

HEAG

Karen Harrowing*

Quality Systems & Pharmacy Consulting

HEAG

Ngozi Onyele

Pharmacist Specialist

CQC

Sue Ladds

Regional Chief Pharmacist – South East, NHSE&I

Regional Chief Pharmacists

Uzo Ibechukwu

Chief Pharmacist, Royal United Hospital Bath

Chief Pharmacist (Non HEAG)

Jagjot Chahal

Clinical Fellow, NHSE&I

Chief Pharmaceutical Officer’s Clinical Fellow

Aileen O’Hare

Clinical Fellow, GPhC

Chief Pharmaceutical Officer’s Clinical Fellow

Marian Salek

Clinical Fellow, NHSE&I

Chief Pharmaceutical Officer’s Clinical Fellow

Ravijyot Saggu

Clinical Fellow, NHSE&I

Chief Pharmaceutical Officer’s Clinical Fellow

Denise Rosembert

Clinical Fellow, SPS

Chief Pharmaceutical Officer’s Clinical Fellow

Kalveer Flora

Clinical Fellow, LPP

Chief Pharmaceutical Officer’s Clinical Fellow

Stephanie Ghartey

Clinical Fellow, NHSE&I Transformation Directorate

Chief Pharmaceutical Officer’s Clinical Fellow

Fatema Jessa

Clinical Fellow, NICE

Chief Pharmaceutical Officer’s Clinical Fellow

Mary Rehman

Clinical Fellow, NHS Digital

Chief Pharmaceutical Officer’s Clinical Fellow

Natasha Callendar

Future Practice Advisor, NHSE&I

NHSE&I

Alison Bell

Lead Pharmacist, Dumfries and Galloway Royal Infirmary

National Acute Pharmacy Subgroup (NAPS), Scotland

Dianne Burnett

National Lead for Medicines Information, Wales

UKMI

Lisa Forey

Head of Pharmacy – Operational Services, Aneurin Bevan University Health Board

Welsh Chief Pharmacists Group

Judith Green

MSO/Governance Lead, Betsi Cadwaladr Health Board

Hospital Employees

Claire Steele*

Head of Pharmacy Medicines Supply & Quality, NHS Fife
President of APTUK

APTUK

Mohamed Rahman

Chief Pharmacist and Clinical Director of Medicines Optimisation, Sherwood Forest Hospitals NHS Trust
Chair of UKCPA

UKCPA

Pavitar Gandham

Lead Pharmacist for Medicines Optimisation (SWFT and GEH) and UKCPA Director

UKCPA

Dipak Vaidya

Group Chief Pharmacist for Aspen Healthcare

Chair of the Independent Sector Chief Pharmacist Group

Independent Healthcare Providers

Peter Hawkes

Lay representative

 

Nigel Westwood

Lay representative

 

*Also members of RPS HEAG

 
RPS staff

Name

Role

Sarah Crawshaw

Lead Author & Chief Pharmaceutical Officer’s Clinical Fellow 21/22

Wing Tang

Interim Associate Director, Pharmacy Membership & Experience

Regina Ahmed

Guidance Manager, Professional Standards Team

Amandeep Doll

Head of Professional Belonging

Heidi Wright

Practice & Policy Lead, England

 
RPS Hospital Expert Advisory Group (HEAG)

With thanks to the following members of the RPS Hospital Expert Advisory Group who supported this refresh.

Name

Jatinder Harchowal

Oweikumo Eradiri

Roger Fernandes

Raliat Onatade

David Campbell

Graeme Richardson

Yousaf Ahmad

Tracy Rogers

Melanie Bryan

Paula Russell

Mark Borthwick

Rahul Singal

David Cook

Steve Tomlin

Andrew Davies

 

 
Consultation respondents

Name

Role

Ahmed Al-Nagar

Chief Operating Officer

Alison Brailey

Chief Pharmacist on behalf of Chesterfield Royal Hospital

Amanda Duggan

Pharmacy manager

Andrew Down

Deputy Chief Pharmacist and Non-Medical Prescribing Joint Lead

Arlene Shaw

Lead Clinical Pharmacist

Caroline Parker

Consultant Mental Health Pharmacist

Dr Paul Buckley

Chief Pharmacist

East London NHS Foundation Trust

Elizabeth Hackett

Principal Pharmacist for Medicines Information

Emma Cramp

Lead Pharmacist for Professional Development, Kettering General Hospital NHS Foundation Trust

Emma Kirk

Lead Medication Safety Pharmacist – SPS

Fiona Ashworth

Lead Pharmacy Technician for Education and Training

Graeme Kirkpatrick

Head of Patient Safety (Advice & Guidance) – NHS England

Healthcare Improvement Scotland, Medicines and Pharmacy Team

Hugo Leung

Clinical Pharmacist – Emergency and Acute Medicine, Barts Health NHS Trust

James Baker

Principal Pharmacist for Medicines Optimisation

Joela Matthews

Pharmacist

Joseph Wilson

Pharmacist

Michael Marven

Chief Pharmacist on behalf of Oxford Health NHS Foundation Trust

Mo Azar

Chief Pharmacist on behalf of Alder Hey NHS Foundation Trust Pharmacy Department

Nigel Gooding

Consultant Pharmacist (Neonates & Paediatrics)

Paula Thoms

Pharmacy Technician

Pauline Lockey

Patient Safety Clinical Lead (Medication Safety) - NHS England

Ruth Brown

Chief Pharmacist, Kent Community Health NHS Foundation Trust

Scottish Pharmacy Quality Assurance Group

Stephen Jones

Chief Pharmacist on behalf of Derbyshire Healthcare NHS Foundation Trust

Susan Watkins

Chief Pharmacist, Shropshire Community Health NHS Trust

Tony Jamieson

Clinical Improvement Lead (Medicines Safety Improvement Programme) – NHS England