Ultimate guide for pharmacists working in urgent & emergency care

Pharmacists are an underutilised resource in the delivery of better urgent and emergency care. Pharmacists can:

  • Support the urgent care needs of people in a variety of healthcare settings
  • Reduce the need for people to access emergency care
  • With additional training, as part of a multi-disciplinary team provide emergency care under medical supervision.

We have developed this online ultimate guide to support pharmacists working in or with Urgent and Emergency Care. It will be useful for those thinking of a career in urgent and emergency care or for those already working in this area. This guide is relevant to pharmacists working in the following urgent and emergency care settings:

  • Community pharmacy
  • Emergency Department and Urgent and Acute Care
  • NHS 111, NHS 24 and NHS Direct Wales
  • Ambulance services
  • Integrated urgent care clinical hubs
  • Urgent care resource hubs
  • GP Practices and Out of Hours Services
  • Urgent and Emergency Care Vanguard Sites

The RPS has collected Good practice examples of pharmacists being utilised to support the Urgent and emergency care agenda.

What is urgent, emergency, and unscheduled care? What is urgent, emergency, and unscheduled care?

There are definitions of urgent and emergency care in RCGP's Urgent and Emergency Care Clinical Audit Toolkit; including the following defintions from the Department of Health guidance on telephone access to out of hours.

Emergency care: immediate response to time critical healthcare need.
 
Unscheduled care: services that are available for the public to access without prior arrangement where there is an urgent actual or perceived need for intervention by a health or social care professional.
 
Urgent care: a response before the next in–hours or routine (primary care) service is available

Within the RCGP toolkit a further definition of urgent care has been provided from the Department of Health in England definition for urgent care:

"Urgent care is the range of responses that health and care services provide to people who require–or who perceive the need for–urgent advice, care, treatment or diagnosis. People using services and carers should expect 24/7 consistent and rigorous assessment of the urgency of their care need and an appropriate and prompt response to that need."

Other definitions include:

CPPE has defined urgent care as “Urgent care refers to any medical or health-related condition which the individual believes they need to get help with that day.” This can be found in the distance learning programme – Urgent care – A focus for pharmacy.

The National Leadership and Innovation Agency for Healthcare (Wales) has defined unscheduled care as: “health and/or social care which cannot reasonably be foreseen or planned in advance of contact with the relevant professional. It follows that such demand can occur any time and that services to meet this demand must be available 24 hours a day seven days a week.

Unscheduled care, by definition, is urgent with the need to take action at the time of contact with services. Unscheduled care does NOT imply the delivery of routine or non-urgent services on an as required and uncontrolled basis 24hours a day.”

England England

Urgent and Emergency Care Review

The NHS England Urgent and Emergency Care Review published in 2013 made suggestions for improving the way urgent and emergency care can be delivered, pharmacists have a significant role in realising this ambition through:

  • Providing urgent care services outside of hospital
  • Utilising the “skills, experience and accessibility” of community pharmacists
  • Enhancing the NHS 111 service
  • Supporting self-care

NHS England Five Year Forward View - Vanguard sites

NHS England has stated:

Each vanguard site will take a lead on the development of new care models which will act as the blueprints for the NHS moving forward and the inspiration to the rest of the health and care system.”

The NHS England website contains details of the eight urgent and emergency care vanguard sites.

The NHS Confederation, the Local Government Association, NHS Clinical Commissioners and NHS Providers have produced factsheets to help understanding of the vanguards. Information on urgent and emergency care can be found on page 4 of 5 of the factsheets.

Further information on the progress that has been made with implementing vanguard sites can be found in NHS England: New Care Models: Vanguards – developing a blueprint for the future of NHS care services.


Pharmacy Integration Fund

NHS England has announced a Pharmacy Integration Fund (PhIF) of £42 million. This is “to support pharmacy to transform how it operates across the NHS for the benefit of patients over the next two years.”

Urgent and emergency care initiatives under the PhIF include:

“Two work streams aimed at integrating community pharmacy into the NHS’ national urgent care system, to run in parallel from December 2016 to April 2018: the urgent medicines supply service and the urgent minor illness care work with NHS 111.”
“From April 2017: there will be funding for pharmacists working in urgent care clinical hubs, such as NHS 111, integrated urgent care clinical hubs or GP out of hours services, and again this will include a prescribing qualification.”

It is worth noting that another initiative under the PhIF includes:

Educational grants for community pharmacists to access postgraduate clinical pharmacy education and training courses up to diploma level from April 2017.”

Scotland Scotland

The Pulling together: transforming urgent care for the people of Scotland report from the Scottish Government provides recommendations for expanding the role of pharmacists in supporting urgent care through:

  • Improving and extending minor ailments services 
  • Involvement in urgent care resource hubs
  • A greater profile and urgent care role for community pharmacy
  • Enabling access to electronic records
  • A greater use of national patient group directions (PGDs) to enable the assessment and management of more clinical conditions
  • Encouraging development of clinical skills and prescribing capability
  • Developing new roles in out of our hours care provision and accident and emergency services
  • Increased role within NHS24
  • Offering prescribing and medicines management support in general practice
  • Increased use of the National Patient Group Direction for the Urgent Supply of Repeat Medicines and Appliances
  • Engagement in anticipatory care planning
  • Developing a national direct referral and clinical handover framework
  • Enhancing pharmacist assessment and management skills
  • The National OOH (Out of Hours) Operations Group Submission has recommended standardised educational requirements and clinical competencies for pharmacists and working in an OOH setting

Wales Wales

NHS Wales Annual Operating Framework 2010/2011 highlighted the opportunity to develop improved unscheduled care pathways. 

In the Delivering Emergency Care Services - An integrated Approach for Delivering Unscheduled Care in Wales strategy, the Welsh Government has recognised the role community pharmacists have in emergency care services:

"Community Pharmacists provide a network of pharmacies and have a role in providing advice and helping people manage their medication. Community Pharmacists have a developing role in the provision of near patient testing, an important element in the management of people suffering from chronic conditions."

The strategy also mentions the inclusion of pharmacists in urgent care centres.

The National Leadership and Innovation Agency for Healthcare has produced a Guide to Good Practice: Unscheduled and Emergency Care Services, within which there is a recommendation that for primary care services to include pharmaceutical services in plans.  

An introduction to urgent and emergency care settings

Community pharmacy Community pharmacy

Community pharmacists, are well placed to support with urgent care as well as reducing the need for people to access emergency care. Community pharmacies are accessible in local communities when other health services are closed, particularly at the weekends. This can be supported with new developments such as access to electronic patient health records.

NHS England has produced a Quick Guide: Extending the role of community pharmacy in urgent care which describes how community pharmacy can relieve the pressure on urgent care. NHS England has produced a resource, Community Pharmacy- helping provide better quality and resilient urgent care, which shares good practice and related evidence.

The Scottish Government has produced Pulling together: transforming urgent care for the people of Scotland. One of the recommendations in the report is the Future Contribution of the Pharmacy Workforce, details of which can be found on page 95 of the report.
The RPS in Scotland worked proactively with Community Pharmacy Scotland and the Directors of Pharmacy group to provide a joint submission outlining the profession’s recommendations for pharmacy’s contribution to out of hours care.

Emergency departments, and urgent and acute care Emergency departments, and urgent and acute care

A number of emergency departments across the country have developed roles for pharmacists as advanced clinical practitioners. We are also aware of some emergency departments that have roles for clinical pharmacists in emergency departments. However it may be worth noting that there may be some overlap between the two roles. 

Clinical pharmacists in emergency departments are involved in supporting medicines management, drug history taking and medicines reconciliation, ensuring medicines safety, dealing with medicines related queries and support medicines optimisation.

Pennine Acute Trust has shared the job description for senior clinical pharmacist – emergency medicine. It is worth noting that this role is expected to advance as pharmacists develop their clinical skills and become more integrated into emergency department teams.

Health Education England - West Midlands (HEE-WM) has conducted studies both locally and nationally to identify the potential for pharmacist clinician roles within emergency departments.

HEE-WM, in consultation with the General Pharmaceutical Council (GPhC), the Royal Pharmaceutical Society, Centre for Pharmacy Postgraduate Education (CPPE) and regional and national stakeholders, aim to test and justify development of pharmacist clinician roles within the ED and wider urgent and acute care settings.

From December 2013, HEE-WM finalised their initial consultation and launched a world-first pilot study. The pilot methodology would follow a dual-site, cross-sectional, observation study of patients attending Emergency Departments in the West Midlands.  The project pharmacists, with support from their ED teams and supervised by an EM consultant, surveyed a cross-section of ED patient presentations over a five week period during  2014 “winter pressures” and categorised according to whether the patient could be managed:

  1. “CP:”   By a community pharmacist (avoided ED attendance)
  2. IP:”     By an Independent Prescriber pharmacist as part of a multi-disciplinary ED team.
  3. “IPT:” By an Independent Prescriber pharmacist in the ED, with an additional 12 months of clinical skills training, aligned to an “advanced practice” framework (See Table 1 - as part of a multi-disciplinary team approach)
  4. “MT:” By the medical team only – unsuitable for pharmacist intervention.

Primary and secondary categorisation of data was undertaken by the project pharmacists, their EM consultant supervisors and ED nurse triage teams.

The Health Education England – West Midlands team commissioned an external evaluation through Aston University – the report can be downloaded from the HEE website.

The West Midlands observational study was conducted across three sites to establish the potential for pharmacist clinical management. Of the 782 patients surveyed over the three sites, the study suggested that 48.2% of patients could be managed by a pharmacist practising within a multi-professional clinical team, where those patients present with symptoms likely to be seen in the Minors Area of the ED, under the overall supervision of a doctor.

With the West Midlands pilot raising interest in a wider study, HEE commissioned a national project to investigate whether pharmacist prescribers, trained in clinical diagnostics and examination through an Advanced Clinical Practice programme, could have a positive impact on patient care in the A&E. The project would build on the West Midlands pilot and, through a similar methodology aim to evidence an enhanced role for pharmacist clinicians in the A&E.

The national study (“PIED-ENG”) commenced in March 2015, covering a cross-section of 49 English Emergency Departments. A total of 18,613 sets of patient data were received, making this the largest (known) study of its kind to date, in the world.  Patient presentations were analysed from a cross-section of attendees, to reflect a “normal” patient flow through A&E.

The pharmacists, with support from their A&E teams and each supervised by an Emergency Medicine consultant doctor, categorised patient data.

PIED-Eng Outcomes

In summary, categorization of 18,613 ED cases evidenced the potential for pharmacists to clinically manage up to 36% of study patients. With existing training, pharmacists could manage 8% of study cases. However, with a maximum 12 months’ further training - aligned to the Advanced Clinical Practice training pathway - the potential of pharmacists to manage study cases rose to 28% of all cases.

“Further training” for the purposes of this project included a 12 month (Postgraduate Diploma) Advanced Clinical Practice training course - with modules in Clinical Examination Skills and Clinical Health Assessment and Diagnostics. Such a training programme would be aligned to the Advanced Clinical Practice framework, currently being delivered by Health Education England, in cooperation with national stakeholders and course providers. Within the ED, the pharmacist would typically practice within a multi-professional clinical team, under the overall supervision of a doctor.

From the study data, clinical groupings where pharmacists were felt to have the highest potential impact were identified as: General Medicine, Minor Trauma, Cardiology, General Surgery and Respiratory. Impact index findings suggested that pharmacists with advanced training (“IPT” category) may be most usefully directed to patients in the general medicine and orthopaedic clinical groupings. If training were tailored to concentrate on these two areas, then (achievable) IPT becomes 19%.

It is contended that the pharmacist clinician who follows such a training pathway could confidently and competently conduct advanced clinical practice as a “specialist generalist” clinician in Urgent, Acute and Emergency care, working as part of the multi-professional, multi-skilled team, under the supervision of a doctor.

NHS 111, NHS 24, and NHS Direct Wales pharmacist advisors NHS 111, NHS 24, and NHS Direct Wales pharmacist advisors

NHS 111, NHS 24 and NHS Direct Wales are 24-hour telephone based health services. There is now an ambition to develop and expand the role of pharmacists in these services.

NHS England  has produced commissioning standards for integrated urgent care . These standards have identified areas where pharmacists working in NHS 111 contact centres have been make a significant contribution in NHS 111 contact centres:

  • Medicines enquiries
  • Health information enquiries
  • Requests for urgent repeat medication
  • Medicines advice for minor illness.
  • Poisons and accidental overdoses
  • Contraception advice.

A review of the contribution that pharmacists working at Yorkshire Ambulance Service NHS 111 Service as well as the roles pharmacists had in a London NHS 111 provider contact centres can be found on page 46 of the NHS England commissioning standards

Pulling together: transforming urgent care for the people of Scotland, a report from the Scottish Government, provides recommendations for expanding the role of pharmacists in supporting urgent care. The report recognises the current key role pharmacists have within NHS 24, as well as recognising that pharmacists “with additional prescribing capability would enhance the multidisciplinary urgent care team working OOH hours.” The report also highlights the vision to expand pharmacist input into NHS 24.


Personal specification and job descriptions

Yorkshire Ambulance Service (YAS), an NHS 111 provider has shared the specification below for pharmacists working within their team. Pharmacists have been employed in NHS 111 services since early 2013 and the role has developed substantially since this time. Initially there were two key functions undertaken by pharmacists:

  • Taking calls from the patient (Front-ending);
  • Taking medication related calls off the clinical callback queue call list for resolution or onward referral.

Further development of the role has seen more advanced clinical pharmacists engaged in activities such as:

  • Floor-walking to provide clinical support to call handlers;
  • Assisting clinical colleagues (paramedics/nurses/other clinicians);
  • Support to the YAS 999 Emergency Operations Centres (EOC), to enable additional support to on-scene crews
  • Promoting the range of advice and minor ailment consultations that a community pharmacist could provide and the benefits to patients in increasing the referral rate to these services by NHS 111 staff;
  • Supporting the development and delivery of training materials to NHS 111 clinicians

Working within NHS 111 services as a pharmacist is a highly skilled role requiring excellent communication skills and we are aware that some job descriptions for these roles require a minimum of three years’ clinical pharmacy experience with a postgraduate Diploma in Clinical Pharmacy.  In addition, it would also be advantageous to have an independent prescribing qualification.

Ambulance services Ambulance services

Association of Ambulance Chief Executives' NHS Ambulance Services - Leading the way to care guidance has information about the role the NHS ambulance services has in delivering urgent and emergency care.

Ambulance services around the country employ pharmacists in an advisory role. They support with many areas such as:

  • Governance
  • Interpreting legislation
  • Medicines advice
  • Medicines choice
  • Education
  • PGDs and Guideline
  • Safe and secure management
  • Controlled Drugs

We also have an online Ambulance Pharmacists Network, that provides an opportunity for pharmacists working for ambulance services across the UK to share good medicines management practice.

Joint Royal Colleges Ambulance Liaison Committee provide clinical advice to UK Ambulance services.

Integrated urgent care clinical hub (England) Integrated urgent care clinical hub (England)

NHS England has produced commissioning standards for integrated urgent care. The standards are intended to support commissioners in redesigning the NHS urgent care ‘front door’ and recommend “commissioners include an “urgent care clinical advice hub” in local commissioning specifications.

The vision is that the clinical hub will have access to a wide range of clinicians (generalists and specialists) and will also offer advice to health professionals in the community. It is expected that usually these hubs will usually include one or more prescribing pharmacists.
The clinical hub will serve two purposes –

  • “Provide clinical advice to patients contacting the NHS 111 or 999 services”
  • “Providing clinical support to clinicians”

Page 22 of the commissioning standards contains further details of this.

Our section on the Pharmacy Integration Fund (under 'England') has further information on funding available from April 2017 for pharmacists posts in integrated urgent care clinical hubs. 

Urgent care resource hub (Scotland) Urgent care resource hub (Scotland)

In the Urgent Care Review, the Scottish Government has described establishing Urgent Care Resource Hubs. NHS 24 is expected to be the first point of entry to out of hours services. NHS 24 would triage calls and provide referral to Urgent Care Resource Hubs for patients requiring timely urgent clinical care. The Urgent Care Resource Hub has been described as “a community health and social care co-ordination and dispatch centre where its function is to co-ordinate, mobilise and orchestrate the most appropriate care response”. The Hubs are expected to include a range of community based health and care services including community pharmacy.

Pharmacists working in GP practices and out-of-hours GP services Pharmacists working in GP practices and out-of-hours GP services

General practice based pharmacists can play a significant role in reducing the need for patients to access emergency departments. With widening access to GP practices over evenings and weekends, pharmacists can support further with access to urgent care.

For more information on pharmacists working in GP practices see our ultimate guide for pharmacists working in GP practices.

Seven day services Seven day services

The NHS England Five Year Forward View states that to reduce variations in when patients receive care, a framework would be developed for how seven days services can be implemented. 

NHS England has developed 10 clinical standards for Seven Day Services to end variations in outcomes at the weekend.

The RPS has produced a report on Seven Day Services in Hospital Pharmacy: Giving patients the care they deserve. The RPS Professional Standards for Hospital Pharmacy Services were updated in 2014 to reflect the move towards seven day working.

The NHS in Scotland has produced a Seven Day Services position paper.

At the 2016 RPS Annual Conference NHS England launched their report Transformation of Seven Day Clinical Pharmacy Services in Acute Hospitals. The document outlines how hospital pharmacy services could operate more efficiently and safely, and makes 13 recommendations of how clinical pharmacy services in hospitals can be strengthened, particularly at weekends, to benefit patients.

Applying for jobs Applying for jobs

The role of pharmacists within urgent and emergency care continues to be an emerging area of development.  As such it is expected that new positions for pharmacists will be created across England, Scotland and Wales. 

Current posts are requiring at least three years’ clinical practice and a postgraduate Diploma in Clinical Pharmacy and it would also be beneficial for pharmacists to have an independent prescribing qualification. Skills in clinical assessment, such as physical examination and knowledge of common presenting complaints in emergency medicine would be beneficial for pharmacists undertaking these roles.

Posts are often advertised on the NHS Jobs website, or the NHS Scotland Recruitment site.

Roles may also be advertised on:

It may be worth contacting your local NHS Trust or Health Board to enquire about any vacancies.

Further information about applying for jobs and vacancies in Scotland are available on the NHS 24 website. You can find further information about working for NHS Direct Wales on their website.

Community pharmacy

Urgent and emergency care roles Urgent and emergency care roles

Support urgent access to repeat prescription medicines Support urgent access to repeat prescription medicines

Community pharmacists are well placed to support with urgent requests for repeat medications as they have experience in providing emergency supplies at the request of patients.

Some areas in England have commissioned schemes such as Pharmacy Urgent Repeat Medicine Service (PURM) which include service level agreements for the supply of urgent repeat medication from community pharmacy. You can find further details of this in the Commissioning Standards for Integrated Urgent Care. NHS England has produced guidance on commissioning an emergency repeat medication supply service

NHS England has produced Urgent Repeat Medication Requests: Guide for NHS 111 Services How to refer directly to pharmacy and optimise use of GP out of hours services. There was announcement in October that there will be a national pilot for a community pharmacy Urgent Medicine Supply Service. Final details of this are yet to be announced, however the PSNC has current information on their website.

In Scotland, there is a National Patient Group Direction for the Urgent Supply of Repeat Medicines and Appliances. The Scottish Government has recommended that there should be an increased use of the National Patient Group Direction for the Urgent Supply of Repeat Medicines and Appliances. Further information on the national patient group direction can be found on the NHS Scotland website.

In Wales  a national enhanced service template for an emergency supply service has been developed, many health boards have commissioned this. Individual health boards should be contacted for further detail.

The Royal Pharmaceutical Society has produced professional guidance on emergency supply. Although this guidance does not cover the request of an emergency supply through a PGD, it does help individuals to identify the information you need to gather in order to decide whether an emergency supply requested by a prescriber or patient is appropriate or not. It also provides information on record keeping and labelling of medicines supplied.

We have also produced a professional judgment quick reference guide, to support you in the decision-making process.

Support self-care of minor illnesses and injuries Support self-care of minor illnesses and injuries

Support for self-care forms part of the NHS community pharmacy contractual framework. You can find the service specification for England on the PSNC website. Details of the service in Scotland can be found on the NHS Scotland website. You can find out more about the pharmacy contract and services in Wales on the Community Pharmacy Wales website.

In England there are a variety of locally commissioned minor ailment services (MAS).
NHS Scotland website has details of the national minor ailments service in Scotland.
The Welsh Government website features details of the announcement for a national Choose Pharmacy Service.
 

Useful resources

For patients

  • NHS Scotland  has produced Medicines Sick Day Rules Card. A useful resource for patients, carers and health professionals.
  • NHS Choices is a useful website, providing health information in the form of articles, videos and tools for patients, pharmacists may choose to signpost patients to this.
  • NHS Inform  is a health and care information service for people in Scotland.

PGDs for common clinical condititions (EHC, UTI and COPD exacerbations) PGDs for common clinical condititions

A Patient Group Direction (PGD) is a written direction that allows the supply and/or administration of a specified medicine or medicines, by named authorised health professionals, to a well-defined group of patients requiring treatment for a specific condition. PGDs have been used in community pharmacy to enable pharmacists to supply or administer certain medicines.

Various Scottish health boards have PGDs in place for common clinical conditions, for example NHS Forth Valley have one for place for Supply of Prednisolone by Community pharmacists to patients with an exacerbation of COPD.

NHS Education for Scotland (NES) has produced a resource on common clinical conditions and minor ailments. The resource includes an overview of the most common clinical conditions (including signs, symptoms and alarm symptoms), and advice on how to respond to these conditions, be that through provision of advice or medication, or to refer to another profession or service.

Supporting people with dental pain Supporting people with dental pain

The NHS England Quick Guide: Extending the role of community pharmacy in urgent care identified that dental pain is the second most common reason for calls to NHS 111. Community pharmacists are able to support patients with dental pain, and the Quick Guide states that:

"Early referral to community pharmacy to provide support for dental pain is critical. Analgesics available from community pharmacy can be effective if started early."

UK Medicines Information has produced dental pain guidance.

NHS England has produced a flowchart for the management of dental pain.

Support patients on discharge and preventing readmission Support patients on discharge and preventing readmission

The Royal Pharmaceutical Society’s Innovator’s Forum has produced a new free online toolkit and handbook, Hospital Referral to Community Pharmacy, endorsed by the Royal College of Physicians, on how you can set up an electronic referral system in your area.  It provides the business case for investment in an e-referral system and gives practical advice on how to implement it, along with helpful case studies.

Triage and red flag identification Triage and red flag identification

We have stated in our urgent and emergency care campaign that we believe pharmacists in the community could play a greater role in urgent care requests from people with common self-limiting ailments, both as a triage and referral service but also as an end point for self-limiting common ailments.
 

Triage + Treat Service (Wales)

Selected pharmacies in Wales are offering this service to help patients who have a low level injury, such as minor abrasions, superficial cuts and wounds. Further detail can be found on the NHS Wales website.
 

Red flag Identification

Community pharmacists are ideally placed to identify red flag symptoms and provide support and onward referral where appropriate.

RCGP has produced an e-learning programme for the self-care for minor ailments. You can find this on the CPPE website.  A learning objective of this programme is: “identify red flag symptoms, or signs that indicate a potentially dangerous condition in minor ailments” 

Practical guidance Practical guidance

Consultation skills Consultation skills

You will be taking an increasingly patient-facing role as you support medicines optimisation and the public health agenda. The Royal Pharmaceutical Society report, Now or never: shaping pharmacy for the future, outlines the need for pharmacy to be proactive in patient care.

The Consultation Skills for Pharmacy Practice website has been developed to support when speaking and consulting with patients and people about their medicines and lifestyle choices. The practice standards for consultation skills set out the knowledge, skills, behaviours and attitudes you need when communicating and consulting with patients.

WCPPE (Wales) has also produced a learning programme to support development of consultation skills.

Access to electronic health records Access to electronic health records

Information on the current status of Electronic Health Records (EHR) for England, Scotland and Wales can be found on our Electronic Health Record resource page.
We have published guidance to support pharmacists accessing patient record: ‘Electronic Health Records (EHR): Guidance for Community Pharmacists and Pharmacy Technicians’. The guidance informs pharmacy professionals on key principles concerning the maintenance and use of EHRs of all types, including pharmacy Patient Medication Records, GP systems or national NHS electronic record services. It describes some of the issues associated with using EHRs in pharmacy professional practice and makes recommendations to pharmacy professionals concerning best practice use of EHRs to support high quality practice and patient care.

We have also produced guidance on using Summary Care Records (SCR) and a decision tool  to support professional judgement for use of Summary Care Records.

NHS Digital (formerly known as HSCIC) has produced a factsheet for pharmacy professionals  which includes the benefits for community pharmacy, training, consent, pharmacy use of summary care records, and insurance and liability. NHS Digital has also produced information on how access to summary care records can help with emergency supply.

The NHS England Commissioning Standards  – Integrated Urgent Care has further information on access to records which can be found on page 25-26. Across urgent care settings there are a number of locally held patient records for “Special Patient Notes” and to support end of life care.

In Scotland  currently emergency care summary access is limited to A&E units, the Ambulance Service, some hospital wards and NHS24. Community pharmacists can contact NHS24 to receive this information unless part of pilot roll-out testing. NHS Scotland has produced information about how community pharmacists, with the patient’s consent, can contact NHS 24 if they require further information within the patient’s Emergency Care Summary (ECS).

The Welsh GP Record  is available to doctors and nurses routinely in out of hours services, and is being rolled out for unscheduled care services. Further development of a web-based application called Choose Pharmacy will enable community pharmacists in Wales to access the Welsh GP Record when required, to provide emergency supplies of medicines.

Urgent care training Urgent care training

Community pharmacists can support in the delivery of advanced care for patients through the development of their ability to assess, diagnose and manage patients.

The following CPPE learning programmes can be useful for pharmacists interested in advanced practice:

Legal and regulatory framework Legal and regulatory framework

NHS complaints procedure NHS complaints procedure

The British Medication Association (BMA) has published information and guides on the NHS complaints procedure in England, Scotland and Wales.

Patient group directions (PGDs) Patient group directions (PGDs)

A PGD is a written direction that allows the supply and/or administration of a specified medicine or medicines, by named authorised health professionals, to a well-defined group of patients requiring treatment for a specific condition.

It is important that pharmacists involved with PGDs understand the scope and limitations of PGDs as well as the wider context into which they fit to ensure safe, effective services for patients.

The supply and administration of medicines under a PGD should only be reserved for those limited situations where this offers an advantage for patient care, without compromising patient safety. A PGD should only be developed after careful consideration of all the potential methods of supply and/or administration of medicines, including prescribing, by medical or non-medical prescribers.

The following useful resources relating to patient group directions: 

Indemnity and insurance Indemnity and insurance

It is a regulatory requirement for all registered pharmacists to "make sure that all your work, or work that you are responsible for, is covered by appropriate professional indemnity insurance".

The RPS is not regulated by the Financial Conduct Authority and cannot recommend professional indemnity insurance providers, however NHS Employers has published guidance and a series of questions and answers regarding professional indemnity insurance.

The GPhC website contains information on Professional indemnity requirements.

Record keeping Record keeping

Record keeping is an integral component of clinical governance and safe practice. The GPhC standards for registered pharmacies state that “all necessary records for the safe provision of pharmacy services are kept and maintained” and that you must “keep full and accurate records of the professional services you provide in a clear and legible form”.

NHS East & South East England Specialist Pharmacy Services has produced a document about the retention of pharmacy records. It includes guidance for all pharmacy settings as well as some sector specific information.

Professional guidance and ethical issues Professional guidance and ethical issues

Consent and confidentiality Consent and confidentiality

The need to protect patient confidentiality and obtain patient consent is layered through legislation, regulation and contractual frameworks.

Useful resources include:

Registered pharmacists also need to be aware of GPhC regulatory guidance for consent and confidentiality:

 

Covert administration

UKMI has published comprehensive information on What legal and pharmaceutical issues should be considered when administering medicines covertly?

NICE has produced Quality Statement 6: Covert medicines administration.

CPPE run a workshop on The Mental Capacity Act 2005 and covert administration of medicines

The Mental Welfare Commission for Scotland has published the Good Practice Guide Covert Medication which applies to situations in which an individual lacks capacity to make a decision regarding medical treatment and refuses treatment.

Betsi Cadwaladr University Local Health Board (East) has published NEWT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. (Please have a look at the guidance on the NEWT Guideline website on how to use the information obtained on each drug in practice).

The  Handbook of Drug Administration via Enteral Feeding Tubes, 3rd Edition (March 2015) Rebecca White and Vicky Bradnam, Pharmaceutical Press , covers the technical, practical and legal aspects that you should consider before prescribing or administering drugs via enteral feeding tubes. 

Safeguarding Safeguarding

The Royal College of Paediatrics and Child Health has worked with 19 different bodies to produce Safeguarding children and young people: roles and competencies for health care staff; a framework for healthcare staff, which describes the level of competency and training required for different roles.

Other sources of information include:

Clinical guidance and support tools Clinical guidance and support tools

NICE guidelines and pathways NICE guidelines and pathways

Evidence-based clinical guidelines support community pharmacists in the decision making process and when undertaking clinical checks of prescriptions.

NICE guidelines are evidence-based recommendations for managing specific conditions.
SIGN produce similar guidelines for use in Scotland.

NICE clinical pathways are clinical flow decision trees designed to help clinicians to make decisions.

Medicines Complete (subscription required) is a platform that provides online access to a range of drug and healthcare reference sources.

Older people Older people

NICE has published a range of guidance and clinical pathways to help with the care of older people.

The United Kingdom Clinical Pharmacy Association (UKCPA), a partnership group of the Royal Pharmaceutical Society and a member association for clinical pharmacy practitioners, have a special interest group for care of the elderly.

CPPE has published an older people learning programme to highlight health and medicines use and polypharmacy in older people. The consulting with older people workshop is part of the consultations skills for pharmacy practice programme and helps you support the older person in making decisions about their medicines.

WCPPE (Wales) has published Older people: managing medicines (Level 1) an online course which will provide you with the key issues affecting medicines management and older people.

You might also find useful the Decision aid for diagnosis and management of suspected urinary tract infection (UTI) in older people, produced by the Scottish Antimicrobial Prescribing Group.

Pharmacists working in urgent, emergency, and acute care settings

Roles Roles

Health Education England has investigated the role of pharmacists in emergency departments through national and local pilots (West Midlands, Health Education England PIED-ENG ED Pharmacy Study, 2015). HEE-WM proposed that a pharmacist prescriber may be utilised in the emergency department to provide services including:

  • Medicines-focussed duties in the ED; eg: pre-discharge medicines optimisation, medicines reconciliation, TTO preparation.
  • Undertaking minors-focussed clinical duties within ED and clinical decision teams.
  • Extending urgent and acute service to community and primary care practice.

The national study identified that the clinical groups where pharmacists can potentially have the highest impact are:  

  • General Medicine
  • Minor Trauma
  • Cardiology
  • General Surgery
  • Respiratory

Training needs for pharmacists were identified across themes:

  • Clinical examination and assessment
  • Diagnostic skills
  • Medical management and treatment

You can find below the top 10 subthemes for each of the themes.  

Several higher education providers in the West Midlands and the North West Regions of England offer advanced clinical skills and independent prescribing training, which we understand to be broadly aligned:  

  • Health Education England -West Midlands and West Midlands Higher Education Institutes (HEIs) developed a Clinically Enhanced Pharmacist Independent Prescribing (CEPIP) Programme. CEPIP provides (GPhC accredited) Independent Prescriber training, alongside Advanced Clinical Practice training in Health Assessment and Diagnostics. The programme has trained over 200 pharmacists since April 2014, from primary, community and secondary care and is run across five West Midlands HEIs.
  • University of Manchester has developed an Advanced Specialist Training in Emergency Medicine course.

The following learning resource may also be useful:



Clinical examination and assessment Clinical examination and assessment

Subtheme (top 10)
  1. X-ray request and interpretation
  2. Body examination (e.g. external body)
  3. Clinical examination and assessment 
  4. Clinical skills
  5. Neurological assessment
  6. Paediatrics
  7. Chest examination
  8. Respiratory assessment or examination
  9. Eye examination
  10. Observations

Physical examination skills

Pharmacists working in urgent and emergency care settings could be involved in the assessment of patients, including physical examination.
  

Support with venous thromboembolism assessments for patients that have been admitted

Pharmacists in emergency departments may be in involved in supporting with venous thromboembolism assessments for patients that have been admitted. NICE has produced Quality Standards - Venous thromboembolism in adults: reducing the risk in hospital.


Diagnostic skills Diagnostic skills

Subtheme (top 10)
  1. ECG
  2. Bloods
  3. Urine testing
  4. Arterial blood gas interpretation
  5. Differential diagnosis
  6. Troponin T
  7. D-dimer test request
  8. CT Scan interpretation
  9. Blood pressure
  10. Doppler
We have produced practice guidance for Diagnostic testing and screening services, which includes 10 principles of good practice. 

Understanding pathology results – monitoring 

Pharmacists working in urgent and emergency care roles could be involved in understanding and interpreting pathology results such as blood tests and the monitoring of conditions. 

 

Medical management and treatment Medical management and treatment

Subtheme (top 10)

  1. Trauma and injury management
  2. Wound care
  3. Analgesia
  4. Paediatric
  5. Fracture management
  6. Minor illnesses
  7. Pain management
  8. Nosebleeds
  9. Respiratory treatment
  10. Skin conditions
     

Case management of appropriate presentations

King's Fund has produced a paper on Case management - What it is and how it can best be implemented.
 

Trauma

NICE has produced guidelines for Major trauma: assessment and initial management.
 

Sepsis

NHS England has produced a report, Improving outcomes for patients with sepsis – a cross-system action plan.
 

Patient management plans

Pharmacists may be involved in developing patient management plans as well as working with other members of the emergency department multidisciplinary team to draft treatment protocols for the management of patients in the emergency department.
 

Providing self-care and minor ailments advice 

For patients

  • NHS Scotland  has produced Medicines Sick Day Rules Card. A useful resource for patients, carers and health professionals.
  • NHS Choices is a useful website, providing health information in the form of articles, videos and tools for patients, pharmacists may choose to signpost patients to this.
  • NHS Inform  is a health and care information service for people in Scotland.
     

Wound/injury management

NICE has produced a summary of the evidence-base on wound care products.

WCPPE has produced a learning programme on wound management.

CPPE has produced a distance learning programme on wound management.

NHS Education for Scotland  has produced the following learning resource:

Respiratory 

NICE has produced guidelines for respiratory conditions
CPPE has produced a distance learning programme on Respiratory disease: evidence-based management of.

WCPPE has created the following resources:

NHS Education for Scotland has produced the following resources:

Supporting safe use of medicines and medicines-related questions Supporting safe use of medicines and medicines-related questions

Responding to medicines related questions in practice

Pharmacists will need to respond to requests for information on medicines from colleagues and patients.

CPPE, NES and WCPPE, together with UKMI, have produced learning programmes to support pharmacists responding to medicines-related questions.


Identifying and responding to adverse drug reactions

The Medicines and Healthcare Products Regulatory Agency (MHRA) has produced guidance on adverse drugs reactions, which includes a classification of adverse drug reactions. Pharmacists play a significant role in the identification and reporting of adverse drug reactions and as a result can help prevent hospital admissions caused by adverse events. 

The RPS has produced Professional standards for the reporting, learning, sharing, taking action and review of incidents

NHS Digital (formerly known as HSCIC) has produced information on how access to summary care records can help reduce adverse reactions.

Welsh Medicines Resource Centre has published a bulletin on medicines-related admissions. The bulletin states that medicines-related admissions could be caused by the following ways:

  • Unwanted side-effects
  • Errors or incidents
  • Poor adherence

Yellow Card Centre Scotland and NHS Education for Scotland have developed a learning resource about adverse drug reactions, including "their incidence and public health implications". It explains the different classifications of ADRs and drug allergies, how to identify if a patient is experiencing an ADR and subsequent management.”


Medicines reconciliation on admission

NICE describes medicines reconciliation as accurately listing the all of a person’s medicines including prescribed, over-the-counter, and complementary medicines. Pharmacists working in emergency departments can help recognise admissions that have been caused by issues relating to medicines.

You might find our Medication history quick reference guide helpful when conducting a medicines reconciliation. Download our medicines reconciliation checklist.

East and South East England Specialist Pharmacy Services has produced Medicines Reconciliation: Best Practice Resource and Toolkit.

East & South East England Specialist Pharmacy Services - Which patients benefit most from medicines reconciliation? A collaborative evaluation of the outcomes of pharmacy-led medicines reconciliation in community health and mental health care settings

NHS Education Yorkshire and the Humber Pharmacy Development Unit have produced a document to assist in the training and development in Medicines History Taking.

Pharmacists working in urgent and emergency care settings may be involved in taking a patient medical history. This is an important opportunity to gather vital information about the patient and their presenting complaint.


Medicine discharge optimisation

NICE has produced guidelines on Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes

NICE guidelines describe medicines optimisation as “the safe and effective use of medicines to enable the best possible outcomes.

We have created a wide range of resources on medicines optimisation; including good practice guidance, a patient leaflet, and briefings on optimising medicines for a number of conditions.

NICE has also developed a medicines optimisation pathway, covering the decision making processes used to help optimise a person’s medicines; including medicines reconciliation and medication review.

NHS England has developed a Medicines Optimisation Dashboard England, which is designed to further understanding of how patients are being supported with medicines use locally. NHS England has stated that: “Reducing unwarranted variation and increasing value through medicines optimisation is a crucial element of NHS RightCare’s innovation work.” You can find more information on the Right Care programme here. Tools and products to optimise the use of medicines can be found on the NHS England website, these have been brought together by NHS RightCare and partner organisations, including NICE and CQC.

CPPE has produced the following e-learning programmes relating to medicine optimisation:


Pharmaceutical Care (Scotland)

NHS Education for Scotland has produced a learning resource for the pharmaceutical care of people with dementia.

The Scottish Neonatal and Paediatric Pharmacists Group, in conjunction with NHS Education for Scotland have produced a distance learning pack on An Introduction to Paediatric Pharmaceutical Care.

NHS Education for Scotland has produced a learning resource for the pharmaceutical care of the eye.


Pharmaceutical Care and Prudent Pharmacy Wales

Your Care, Your Medicines: Pharmacy at the heart of patient-centred care presents a vision for pharmacy in Wales.

Further information on the prudent agenda can be found at www.prudenthealthcare.org.uk


Medicines safety

Pharmacists working in emergency departments can support with the safe use of medicines through:

  • Preventing omitted doses
  • Ensuring doses are administered correctly
  • Engaging with GP/Community Pharmacy/Care Homes

Polypharmacy

Pharmacists have a role in supporting the reduction of inappropriate polypharmacy.

PrescQIPP has produced a Polppharmacy & Deprescribing Webkit which includes a range of information and resources. 

The Scottish Government  has created polypharmacy guidance for the safe and effective use of multiple medicines to manage long term conditions.

SIGN Polypharmacy guidance.

The King’s Fund published a report on medicines optimisation and polypharmacy. Exploring systems for managing polypharmacy and offering recommendations for improving care for older people and those who have two or more chronic medical conditions.

CPPE has produced a learning programme to help develop your knowledge and skills in working with patients and other health and social care professionals to enable patients to get the best possible outcomes when they are taking multiple medicines.

WCPPE  has produced a learning programme to help pharmacy professionals understand the physiological changes that occur in the elderly and the impact of polypharmacy and reducing medicines wastage.

All Wales Medicines Strategy Group  has produced Polypharmacy Guidance for Prescribing.

NHS Wales has developed guidance on Polypharmacy: Guidance for Prescribing in Frail Adults.


Preparing and implementing pharmaceutical care plans

Pharmacists may work with patients to help identify individual pharmaceutical care needs and develop a care plan to support this.

The Your Care, Your Medicines Report  describes how pharmacists can support with pre-screening and unscheduled care through the development of a pharmaceutical care plan. You can find more information about this in the report.


Medicines adherence

Poor medicines adherence can lead to hospital admissions and difficulty in managing conditions.

Further information can be found in the RPS quick reference guide Medicines Adherence and NICE clinical guidelines on Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence.  


Antimicrobial stewardship

Pharmacists have an important public health role to play in educating people about antibiotic resistance.

We have worked with University College London to create an online resource, www.AMSportal.org, which signposts to resources and information to promote learning about microbiology and antimicrobial stewardship.

RCGP is offering a free e-learning course about antibiotic resistance for all primary care health professionals in the UK.

The TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools Antibiotics Toolkit) aims to help influence prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing. It includes a range of resources that can each be used to support prescribers’ and patients’ responsible antibiotic use, helping to fulfil CPD and revalidation requirements. Using the resources in the TARGET Antibiotics Toolkit will enable organisations to demonstrate compliance with the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. The Toolkit also supports recommendations made in the recent NICE guideline: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (August 2015) and is linked within the guideline.

NICE guideline [NG15] Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (August 2015) covers the effective use of antimicrobials (including antibiotics) in children, young people and adults. It aims to change prescribing practice to help slow the emergence of antimicrobial resistance and ensure that antimicrobials remain an effective treatment for infection.

Scottish Antimicrobial Prescribing Group: Antibiotics – an information leaflet for staff in care homes and community hospitals

CPPE  has produced an e-learning programme on Antimicrobials and infection management and a reducing antimicrobial resistance.


Therapeutic drug monitoring

Pharmacists may be involved in therapeutic drug monitoring and also advising others involved in this.

The BNF contains information around drug monitoring.

"The Monitoring section specifies any special monitoring requirements, including information on monitoring the plasma concentration of drugs with a narrow therapeutic index (e.g. theophylline, p. 238). Monitoring may, in certain cases, be affected by the impact of a drug on laboratory tests (e.g. hydroxocobalamin, p. 837), and this information is included in Effects on laboratory tests."
In some cases, when a drug is withdrawn, further monitoring or precautions may be advised (e.g. clonidine, p. 137): these are covered under Treatment cessation.”

(How to use BNF, BNF 72)

There are often local guidelines for therapeutic drug monitoring which you can refer to, we have highlighted an example below. London and South East Medicine Information Service, South West Medicine Information Service and Croydon Clinical Commissioning Group has produced suggestions for Drug Monitoring in Adults in Primary Care.


High risk medicines

High risk medicines can often be the cause of admission to urgent and emergency care settings. Pharmacists can support with the safe use of high risk medicines and help prevent admissions as a result of their use. When patients are admitted to urgent and emergency care settings, pharmacists may identify high risk medicines when conducting medicines reconciliation, and make appropriate recommendations.  

Scottish Patient Safety Programme in Primary Care aim to reduce events which could cause avoidable harm from healthcare delivered in any primary care setting and has developed a number of tools and resources to support this. The Safer Medicines workstream focuses on the prescribing and monitoring of high risk medicines.


Falls due to medicines

Standard 6 of the National Service Framework for Older People is falls. Falls are a common cause of emergency department attendance and medicines can be a common cause of falls. Pharmacists can support with the prevention of falls.

CKS website contains guidance on sssessing risk of falling and managing people at high risk of falls.

NHS Doncaster – Community pharmacy falls prevention service. You can find further detail of this on the PSNC website

The British Geriatrics Society has produced Fit for Frailty guidance on the recognition and management of older patients with frailty in community and outpatient settings.

All Wales Medicines Strategy Group  has produced polypharmacy guidance for prescribing, this contains key considerations for prescribing in frail adults.

NICE has produced guidance on Falls in older people: Assessing risk and prevention.

Support and management of patients presenting with drug overdoses, poisonings, and toxic ingestion Support and management of patients presenting with drug overdoses, poisonings, and toxic ingestion

The National Poisons Information Service (NPIS) "promotes, supports and develops best practice for the management of cases of poisoning in UK health facilities". NPIS provide a 24-hour telephone information line, 0344 892 0111 (UK only) which "provides clinical staff with case-specific advice on more complex cases".

Toxbase® service is the primary clinical toxicology database of the NPIS.
Toxbase® e-learning modules can be used by UK NHS staff who would like to learn more about the TOXBASE® database and the management of patients with poisoning.

The NHS England Commissioning Standards for Integrated Urgent Care contains recommendations on For Medicines and Poisons training on page 34.

Patient information leaflets may contain information for patients on what to do if they take too much of a medication.

College of Emergency Medicine and National Poisons Information Service have produced guidelines on antidote availability for emergency departments, together with an appendix.

Novel Psychoactive Treatment UK Network (NEPTUNE) has produced guidance on the clinical management of acute and chronic harms of club drugs and novel psychoactive substances.

Triage Triage

In urgent and emergency care settings, triage is a useful process to determine the urgency of presenting patients.

The Royal College of Emergency Medicine has produced a position statement on triage, which defines “the activities of triage, initial assessment and streaming and indicate the added value of each to the patient pathway in the emergency/urgent care settings.” 

NHS Pathways  provides triage over the telephone for a variety of settings such as NHS 111 and GP out-of-hours. The NHS Digital website has further information. NHS Digital was formally known as HSCIC.

Telephone consultation skills Telephone consultation skills

Royal College of General Practitioners run a Enhance your telephone consultations and triage course, which pharmacists can attend. 

Emergency life support Emergency life support

Employers may offer basic life support and advanced life support courses. The Resus Council has produced Quality standards for cardiopulmonary resuscitation (CPR) practice and training.

The Human Medicines Regulations allows the administration of listed parenteral medicines to human beings in an emergency for the purpose of saving life. The list of medicines for use by parenteral administration in an emergency can be found in Schedule 19 of The Human Medicines Regulations 2012 (www.legislation.gov.uk).

An example is administering adrenaline injection 1 in 1000 (1mg/ml) for the emergency treatment of anaphylaxis.

Adrenaline is a prescription only medicine and is given intramuscularly for the treatment of anaphylaxis. Brands of adrenaline intramuscular injections in your pharmacy may include Epipen®, Emerade® and Jext®.

Where a pharmacist is expected to recognise and treat an anaphylactic reaction as part of their usual clinical role (for example, if they are offering a vaccination service), they must have access to an anaphylaxis pack (as outlined in the Green Book) and have received the required training in the recognition of anaphylaxis and administration of adrenaline. The anaphylaxis pack will include ampoules of adrenaline and syringes and needles or prefilled syringes which should be used preference to auto injectors such as those listed above.

Anaphylaxis is a severe, life-threatening, systemic hypersensitivity reaction resulting in rapidly developing

airway and/or breathing difficulty and/or hypotension. Other features of an allergic reaction are often present, including skin and mucosal changes such as urticaria and angio-oedema of the face. Anaphylaxis is an emergency which should be treated immediately once identified.

Regulation 238 of the Human Medicines Regulations 2012 allows adrenaline to be administered by anyone for the purpose of saving life in an emergency.

Therefore pharmacists using their professional and clinical judgement can administer adrenaline in an emergency to persons presenting with symptoms of anaphylaxis.

If a pharmacist administers adrenaline they must also ensure that an ambulance is called by dialling 999 and reporting that there is a case of suspected anaphylaxis.

Out-of-hours support to care homes Out-of-hours support to care homes

Pharmacists working in services such as NHS 111 and NHS 24 frequently support care homes through a variety of ways including:

  • Medicines enquiries
  • Advice on toxic ingestion
  • Requests for urgent repeat medication
  • Access to medicines
  • Medicines advice for minor illness. 

Major incident planning Major incident planning

Pharmacists may have a role in emergency planning.

Ursula Gotel has written an article which “covers changes that have brought emergency planning to the fore, practical guidance on where to start and lessons learnt in an acute hospital environment.”

Information on what the Governments are doing about emergency health planning can be found on the following pages:

Clinical guidance and support tools Clinical guidance and support tools

NICE guidelines and pathways NICE guidelines and pathways

Evidence-based clinical guidelines support community pharmacists in the decision making process and when undertaking clinical checks of prescriptions.

NICE guidelines are evidence-based recommendations for managing specific conditions.
SIGN produce similar guidelines for use in Scotland.

NICE clinical pathways are clinical flow decision trees designed to help clinicians to make decisions.

Medicines Complete (subscription required) is a platform that provides online access to a range of drug and healthcare reference sources.

BMJ best practice BMJ best practice

BMJ Best Practice provides access to information when making diagnosis and treatment decisions. 

Older people Older people

NICE has published a range of guidance and clinical pathways to help with the care of older people.

The United Kingdom Clinical Pharmacy Association (UKCPA), a partnership group of the Royal Pharmaceutical Society and a member association for clinical pharmacy practitioners, have a special interest group for care of the elderly.

CPPE has published an older people learning programme to highlight health and medicines use and polypharmacy in older people. The consulting with older people workshop is part of the consultations skills for pharmacy practice programme and helps you support the older person in making decisions about their medicines.

WCPPE (Wales) has published Older people: managing medicines (Level 1) an online course which will provide you with the key issues affecting medicines management and older people.

You might also find useful the Decision aid for diagnosis and management of suspected urinary tract infection (UTI) in older people, produced by the Scottish Antimicrobial Prescribing Group.

The Silver Book: Quality Care for Older People with Urgent and Emergency Care Needs gives an overview of some of the most pressing, clinical and social problems met by older people when they present in an emergency.

Vaccination Vaccination

The Green Book (Immunisation against infectious disease) contains the latest information on vaccines and vaccination procedures in the UK.

NHS Education for Scotland has produced a learning resource on the storage and handling of vaccines.

Practical tools and guidance Practical tools and guidance

NHS pathways and directory of services NHS pathways and directory of services

NHS Pathways allows for a clinical-based triage of patient symptoms in order to assess the care needs of the patient. NHS Pathways has specific NHS 111, 999 and face to face versions of the clinical assessment algorithms. NHS Pathways is used by most Ambulance Trusts now to run their 999 service but they have a separate version of clinical content for their call handlers.

Evidence would suggest that up to 80% of calls could be managed by non-clinicians with clinical support and the remaining 20% of calls are cases that require additional assessment by clinical advisors.  Following the identification of a care need the NHS Pathways system matches patients with a service in their area who have:

a) The clinical skills required to treat the patient
b) Which services are open within the timeframe of the final disposition (as outlined by commissioners on the Directory of Services)
c) Who has the capacity to see the patient

  • Data network of clinically based questions which support telephone triage to assess symptoms
  • Used by specially trained call handlers, i.e. Health advisors  and clinical advisors
  • Linked to the national Directory of Services (DoS) database, this is managed by local commissioners
  • The NHS 111 service safely manages 1 - 1.3 million calls per month nationwide (NHS 111 Minimum Data Set 2015-16);
  • NHS 111 is a single point of contact commissioned locally and nationally coordinated through telephony systems;
  • All NHS 111 service providers use NHS Pathways as their clinical decision support system but it is not mandated. The key function of any clinical assessment system must be the ability to call an ambulance if clinically required.

NHS Digital (formerly known as HSCIC) has further information on NHS Pathways and its benefits on their website.

The Directory of Services (DoS) is “a central directory - which is integrated with NHS Pathways - provides the call handler with real time information about services available to support a particular patient.”
It is important that all NHS providers of urgent and emergency care are included in the directory with up to date details. Community pharmacy service data about opening times for supplementary hours and bank holidays is particularly important. Local commissioners of NHS 111 services take responsibility for keeping the information updated in the DoS. Local Pharmaceutical Committees and local DoS leads can work together to ensure all entries are updated. Further information on the Directory of Services can be found on the NHS Digital website.

Page 13 of the NHS England Commissioning Standards for Integrated Urgent Care contains information on the Directory of Services.

NHS safety thermometer NHS safety thermometer

"The NHS Safety Thermometer provides a 'temperature check' on harm that can be used alongside other measures of harm to measure local and system progress in providing a care environment free of harm for our patients."

Further information is available on the NHS Safety Thermometer website. The tool is useful for a range of settings including the patient’s own home.

Department of Health has produced guidance to support the NHS in implementing the NHS Safety Thermometer.

The following tools have also been developed:

Access to electronic health records Access to electronic health records

Information on the current status of Electronic Health Records (EHR) for England, Scotland and Wales can be found on our Electronic Health Record resource page.
We have published guidance to support pharmacists accessing patient record: ‘Electronic Health Records (EHR): Guidance for Community Pharmacists and Pharmacy Technicians’. The guidance informs pharmacy professionals on key principles concerning the maintenance and use of EHRs of all types, including pharmacy Patient Medication Records, GP systems or national NHS electronic record services. It describes some of the issues associated with using EHRs in pharmacy professional practice and makes recommendations to pharmacy professionals concerning best practice use of EHRs to support high quality practice and patient care.

We have also produced guidance on using Summary Care Records (SCR) and a decision tool  to support professional judgement for use of Summary Care Records.

The NHS England Commissioning Standards  – Integrated Urgent Care has further information on access to records which can be found on page 25-26.

In Scotland currently emergency care summary access is limited to A&E units, the Ambulance Service, some hospital wards and NHS24. 

The Welsh GP Record  is available to doctors and nurses routinely in out of hours services, and is being rolled out for unscheduled care services.

Prescribing guidance Prescribing guidance

Becoming a prescriber

Pharmacists working in urgent and emergency care settings may take on prescribing duties as part of their role. Find out more about becoming a pharmacist prescriber in our dedicated section.
NHS Education for Scotland (NES) offers education and training for pharmacist prescribers

Prescribing framework for prescribers

In 2015, the RPS started the process of updating the framework with the backing of NICE and in collaboration with all the prescribing professions UK wide. The updated single prescribing competency framework was published on in July 2016, for all regulators, professional bodies, and prescribing professions.


You might also find the Pharmacist Prescribing Discussion Group, our online network, to be useful.

Clinical audit Clinical audit

Pharmacists working in urgent and emergency care settings may be involved in clinical audits. The Royal College of General Practitioners has produced an urgent and emergency care clinical audit toolkit.

Consultation skills Consultation skills

The Consultation Skills for Pharmacy Practice website has been developed to support when speaking and consulting with patients and people about their medicines and lifestyle choices. The practice standards for consultation skills set out the knowledge, skills, behaviours and attitudes you need when communicating and consulting with patients. This includes information on telephone consultations. 

WCPPE (Wales) has also produced a learning programme to support development of consultation skills.

The role of an NHS 111/NHS 24/NHS Direct Wales Pharmacist will involve communicating with either patients over the telephone or other staff working with the service. Excellent communication skills are therefore essential for this role. Pharmacists should consider the importance of safe telephone consultation skills (including assessment of red flag symptoms and appropriate safety-netting). The GMC has produced Prescribing guidance: Remote prescribing via telephone, video-link or online, pharmacists may find some of the overarching principles of this guidance useful to consider when conducting telephone consultations. 

Quality improvement Quality improvement

We have produced a quality systems resource for pharmacy, Pharmacy QS. Its purpose is to introduce quality systems and quality improvement, acting as a hub to the fantastic improvement resources of others, and as a platform for sharing pharmacy experiences in quality improvement.

The Royal College of Emergency Medicine has also developed resources for Quality Improvement.

In services such as NHS 111, NHS 24, and/or NHS Direct Wales ongoing audit of pharmacy calls will normally be undertaken by the clinical governance lead of each Urgent and Emergency care organisation. In addition, it is best practice to provide a peer-review service of auditing other Pharmacists work as well as self-audit to provide a degree of reflective learning.

Working with a multi-disciplinary team Working with a multi-disciplinary team

Pharmacists working in urgent and emergency care settings will work with a range of other healthcare professionals as part of a multi-disciplinary team. This may involve training or mentoring multi-disciplinary colleagues, in prescribing and medicines optimisation.

We have developed a leadership framework and tools which includes a section on engaging your team which may be helpful. We also provide a mentoring database and support tools to help train and mentor colleagues.

Other resources which may be useful include:

United Kingdom Clinical Pharmacy Association (UKCPA) has an online forum for emergency care for pharmacists to share good practice.

Working with community pharmacy colleagues and transfer of care Working with community pharmacy colleagues and transfer of care

The Royal Pharmaceutical Society’s Innovator’s Forum has produced a free online toolkit, Hospital Referral to Community Pharmacy, endorsed by the Royal College of Physicians, on how you can set up an electronic referral system in your area.  It provides the business case for investment in an e-referral system and gives practical advice on how to implement it, along with helpful case studies.

NHS England  has produced Urgent Repeat Medication Requests: Guide for NHS 111 Services How to refer directly to pharmacy and optimise use of GP out of hours service.

Legal and regulatory framework Legal and regulatory framework

CQC, HIS, and HIW inspection CQC, HIS, and HIW inspection

The Care Quality Commission (CQC) are the independent regulator of health and social care in England. They monitor, inspect and regulate services to ensure they meet fundamental standards of quality and safety. CQC has produced guidance for providers.

Health Improvement Scotland  are the health improvement organisation for Scotland. As well as providing quality improvement support, Health Improvement Scotland also provide clinical standards, guidelines and advice.

Health Inspectorate Wales  are the independent inspectorate and regulator of health care in Wales.

Indemnity and insurance Indemnity and insurance

It is a regulatory requirement for all registered pharmacists to "make sure that all your work, or work that you are responsible for, is covered by appropriate professional indemnity insurance".

The RPS is not regulated by the Financial Conduct Authority and cannot recommend professional indemnity insurance providers, however NHS employers has published guidance and a series of questions and answers regarding professional indemnity insurance.

The GPhC website contains information on Professional indemnity requirements.

Hospital pharmacy professional standards Hospital pharmacy professional standards

We have published a set of professional standards for hospital pharmacy services, that provide the profession with developmental standards that are supportive, enabling and professionally challenging.

They were developed to help organisations across Great Britain (GB) to ensure patient safety – making healthcare safer by the development of quality services. These professional standards provide a broad framework to support Chief Pharmacists, Directors of Pharmacy and their teams to improve services, and to shape future services and pharmacy roles to deliver quality patient care. The standards are relevant to providers of pharmacy services in or to acute, mental health, private, community service, prison, hospice and ambulance settings. 

Controlled drugs Controlled drugs

NHS Protect has prepared, on behalf of the Ambulance Pharmacists Network,Security standards and guidance for the management and control of controlled drugs in the ambulance sector.

Patient group directions (PGDs) Patient group directions (PGDs)

A PGD is a written direction that allows the supply and/or administration of a specified medicine or medicines, by named authorised health professionals, to a well-defined group of patients requiring treatment for a specific condition.

It is important that pharmacists involved with PGDs understand the scope and limitations of PGDs as well as the wider context into which they fit to ensure safe, effective services for patients.

The supply and administration of medicines under a PGD should only be reserved for those limited situations where this offers an advantage for patient care, without compromising patient safety. A PGD should only be developed after careful consideration of all the potential methods of supply and/or administration of medicines, including prescribing, by medical or non-medical prescribers.

Since the 23 April 2012, pharmacists have been empowered by legislation to supply, offer to supply and administer diamorphine or morphine under a PGD for the immediate, necessary treatment of sick or injured persons. Further information about this is available from the NHS PGD website.

The following are useful resources relating to Patient Group Directions: 

Record keeping Record keeping

Record keeping is an integral component of clinical governance and safe practice. The GPhC Standards state that you must "keep full and accurate records of the professional services you provide in a clear and legible form".

NHS East & South East England Specialist Pharmacy Services have produced the Retention of Pharmacy Records document. This document includes guidance for all pharmacy settings as well as some sector specific information. 

Professional guidance and ethical issues Professional guidance and ethical issues

Consent and confidentiality Consent and confidentiality

The need to protect patient confidentiality and obtain patient consent is layered through legislation, regulation and contractual frameworks.

Useful resources include:

Registered pharmacists also need to be aware of GPhC regulatory guidance for consent and confidentiality:

The Royal College of Emeregency Medicine has produced Best Practice Guidelines on Consent, Capacity and Restraint of Adults, Adolescents and Children in Emergency Departments.

Covert administration

UKMI has published comprehensive information on What legal and pharmaceutical issues should be considered when administering medicines covertly?

NICE has produced Quality Statement 6: Covert medicines administration.

CPPE run a workshop on The Mental Capacity Act 2005 and covert administration of medicines

The Mental Welfare Commission for Scotland has published the Good Practice Guide Covert Medication which applies to situations in which an individual lacks capacity to make a decision regarding medical treatment and refuses treatment.

Betsi Cadwaladr University Local Health Board (East) has published NEWT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. (Please have a look at the guidance on the NEWT Guideline website on how to use the information obtained on each drug in practice).

The  Handbook of Drug Administration via Enteral Feeding Tubes, 3rd Edition (March 2015) Rebecca White and Vicky Bradnam, Pharmaceutical Press , covers the technical, practical and legal aspects that you should consider before prescribing or administering drugs via enteral feeding tubes. 
 

Deprivation of Liberty safeguards (DoLS)

The Deprivation of Liberty safeguards, exist as part of the Mental Health Act 2005 to protect vulnerable patients in hospital and people in care homes who lack the mental capacity to consent to treatment or care they may need.

Further information on DoLS can be found on the Department of Health website.

Safeguarding Safeguarding

The Royal College of Paediatrics and Child Health has worked with 19 different bodies to produce Safeguarding children and young people: roles and competencies for health care staff; a framework for healthcare staff, which describes the level of competency and training required for different roles.

Other sources of information include:

Acknowledgements Acknowledgements

Working group 

The Royal Pharmaceutical Society is grateful to the individuals and organisations who have provided contributions and comment to help develop this ultimate guide.

  • Alexandra Gibbins
    Head of Prescribing and Medicines Management ABMU Health Board
  • Anne Joshua
    Head of Community Pharmacy Strategy – NHS England  
  • Anuja Bathia
    Highly Specialist Pharmacist - Acute Medicine: A&E, UCCs and EMU Guy's and St Thomas' NHS Foundation Trust Pharmacy Department
  • Catherine Lowe
    Senior Pharmacist - NHS Shropshire CCG
  • Christopher Poole
    Head of Pharmacy – The Pennine Acute Hospital NHS Trust 
  • Christine Johnson
    National Clinical Lead - RCGP
  • David Terry
    Director - Pharmacy Academic Practice Unit, Aston University 
  • Ed England
    Medicines and Research Manager – South Central Ambulance Services NHS Foundation Trust
  • Elizabeth Brown
    Emergency Department Pharmacist - East Lancashire Hospitals NHS Trust Pharmacy Department, Royal Blackburn Hospital
  • Hirminder Ubhi
    Clinical Pharmacist – Birmingham Childrens Hospital
  • Jon Craig
    Deputy Medical Director – Greenbrook Healthcare
  • Karen Wragg
    Regional Manager - Centre for Pharmacy Postgraduate Education
  • Kym Lowder
    Medicines Optimisation & Pharmaceutical Advisor 
  • Matthew Aiello
    Urgent and Acute Workforce Development Specialist, West Midlands, Health Education England
  • Rahul Singal
    Clinical Fellow to the Chief Pharmaceutical Officer at NHS England
  • Robbie Turner
    Chief Executive Officer – Community Pharmacy West Yorkshire 
  • Sandra Martin
    Clinical Academic Lecturer, “Advanced Clinical Skills” Course Leader, Manchester Pharmacy School, University of Manchester.
  • Siobhan Smith
    Practice Pharmacist – NHS Fife
  • Tim Denman
    Specialist Clinical Pharmacist, Emergency Medicine, Leeds Teaching Hospitals NHS Trust
  • Timothy Banner
    Consultant Pharmacist - Community Healthcare (All Wales)
  • Ursula Gotel
    Highly Specialist Pharmacist - Acute Medicine: A&E, UCCs and EMU Guy's and St Thomas' NHS Foundation Trust Pharmacy Department
  • Usha Kaushal
    Lead Operational Pharmacist and Specialist Palliative Care Services Lead NHS 111, Yorkshire Ambulance Service
  • Victoria Heald
    Lead Pharmacist for Emergency Admissions and ED – Cambridge University Hospitals NHS Foundation Trusts

RPS Colleagues 

  • Aileen Bryson
    Practice and Policy Lead (Scotland)
  • Annamarie McGregor
    Professional Support Pharmacist
  • Catherine Duggan
    Director for Professional Development and Support
  • Elen Jones
    Practice and Policy Lead (Wales)
  • Heidi Wright
    Practice and Policy Lead (England)
  • Ruth Wakeman
    Associate Director for Professional Development and Support
  • Sabes Thurairasa
    Lead Author, and Professional Support Pharmacist
  • Wing Tang
    Senior Professional Support Pharmacist: Standards and Guidance
  • Zoe Boult
    Website Content Executive
Details