1. Prioritising patients in the emergency department

Betsi Cadwaladr University Health Board

North Wales has introduced a system of prioritisation for patients arriving at the Emergency department on critical medicines through a notification system linked to their records. When patients arrive at the hospital, an email is generated to alert clinicians and pharmacists of their arrival.

Patients included are those with Parkinson’s disease, patients taking clozapine and those on immunosuppressants.  The system has led to a reduction of missed doses of these time critical medications. The pharmacist writes the prescription chart for the patients on these medicines to enable staff to administer so that patients do not miss doses. This also reduces the workload for the clinicians and potentially reduces the length of stay due to earlier review of patients’ medicines. 

"These alerts allow us to prioritise the patients that require pharmacy input the most to reduce omissions of time critical medicines."

Catherine Pollard, Pharmacist Team Leader for Unscheduled Care

2. Virtual Wards

Elderly man at home and smilingSwansea Bay University Health Board

In November 2021 Swansea Bay University Health Board launched the Virtual Wards. The aim of this service is to provide holistic, patient centred, high quality care through rapid assessment, multidisciplinary team involvement and wrap around care to patients within their own homes.

The original scope was to deliver a service for the those with frailty and used tools such as the electronic frailty index to identify appropriate patients. However, over time this has developed to include anyone who could benefit from wrap around care.

Referrals can be taken from a multitude of sources; primary care, secondary care, third sector and voluntary services, patients can re-refer (if previously been under the care of the service) and virtual ward staff members can identify suitable patients through In-reach work within our acute sites or from community home visits. Any patient who sits on a virtual ward can have a polypharmacy and medication review. 

The pharmacy role within this service is diverse. From high level polypharmacy medication reviews with a focus on de-prescribing, carrying out basic observations (such as blood pressure checks, pulse and gait), patient and family education to various clinical assessments such as, pain reviews, osteoporosis assessment, medication and falls assessment. There is a lot of networking between may services that branch both primary and secondary care.

Carrying out reviews in the patient’s own home has the maximum impact. You can fully visualise how patients are managing with their medication and what action needs to be done to improve patient outcomes and safety.

Over the first two years of the project, pharmacist interventions in the four original virtual ward clusters have prevented 28 hospital admissions and savings in terms of admission avoidance and drug costs of £95,073. 

"The virtual ward is an effective partnership involving all sectors of the health and social service with the ultimate aim being admission avoidance, improved quality of life and facilitated early discharge from hospital."

Lorna Collins, Principal Pharmacist, Primary Care

3. Nephrology and Transplant Pharmacy team

Cardiff & Vale University Health Board

The Nephrology and Transplant pharmacy team have been embedded into the home dialysis multi-disciplinary team (MDT) over the past couple of years. This includes attending weekly MDT meetings, monitoring patients' blood results and leading on the prescribing for renal anaemia, renal bone disease and vancomycin for peritonitis. This allows pharmacists to be the centre of medicine optimisation and allows for safe and reliable prescribing with continuous supply. 

Patients are counselled on any changes to their medication and have a supply ready for them to collect when they attend their clinic appointment. This service saves doctors time, as we take on the majority of the prescribing role for this group of patients. It also saves nurses time, as we organise appointments for patients to come in for intravenous iron or necessary blood tests.

“This introduction of pharmacist prescribers to the team has led to an increase in the time available for specialist nurses and doctors to see patients in the community.”

Gareth Bryant, Specialist Pharmacist – Nephrology and Transplant

4. Health Board Wide Mental Health Pharmacy Team

Hywel Dda Mental Health TeamHywel Dda University Health Board

Hywel Dda Health Board’s Mental Health and Learning Disabilities (MH&LD) Medicine Management service delivers specialist pharmacy services to patients across the region.

The team includes eight pharmacists,three technicians and one support worker, who between them provide ward pharmacy services, clozapine clinics, Community Mental Health Team involvement, an adult ADHD specialist pharmacist, a perinatal pharmacist, Early Intervention in Psychosis (EIP) specialist services and Community Drug and Alcohol Team work. This happens alongside giving advice to all staff within the directorate on medication management issues.

The team also dispenses MH&LD medication and clinically checks all prescriptions, as well as reconciling medication during admission. The benefits mean that all MH&LD patients within the health board receive an enhanced specialist pharmacy services. This is especially pertinent in ensuring safe delivery of medicine to this patient group. Patients are referred into service from various avenues, including GP referrals, A&E referrals and have access to Crisis teams when needed.

The enhanced role of pharmacy within the wider multidisciplinary service has allowed increased capacity of services for example in adult ADHD, as well as development of new services for example for perinatal mental health, drug and alcohol services, EIP and Clozapine clinics. Patients receive a high standard of care and continuation of care from both a mental health and physical health perspective.

The department has developed over time as relationships across the professions have grown, with numerous business cases being submitted and funding streams being attributed specifically for certain services. It helps for the pharmacists to have the prescribing qualification so that they can see patients in their specialist MH&LD service area and prescribe for them. Induction and training, MDT involvement, laptops and phones have been essential components in their success.

Plans for the future involve pharmacists covering areas that currently have limited involvement in for example memory assessment services.

“This team improves the Pharmacy department skill mix, and provides and highlights the importance and benefits that having trained pharmacy professionals can provide in other services.”

Gwenllian Hughes, Lead Mental Health Pharmacist and Nathan Skyrme, Specialist Mental Health Pharmacist

5. Pharmacy Technician-led Chemotherapy Counselling Service

Patient speaking to Pharmacy TechnicianVelindre University NHS Trust

Prior to starting oral systemic anti-cancer therapy (SACT) patients are often unaware of the responsibility and safety aspects on how to take their treatment safely. Therefore, senior pharmacy technicians have set up an education service for patients starting their oral SACT treatment at Velindre Cancer Centre (VCC). The patients are prescribed their treatment at VCC outpatients, and then arrive at pharmacy to collect their treatment.

The pharmacy technicians are often contacted by the prescriber in advance to perform a one to one consultation with the patient and their family/carers on how to take the treatment safely, how to manage side effects including red flags on when to contact VCC. They then often follow up with the patient a week later to ask more pre-set questions around side effects and will alert their findings if necessary to the consultant team, pharmacist or treatment triage helpline within the hospital.

Pharmacy technicians use a variety of methods to deliver this education and support service; via telephone, virtual or face to face. The pharmacy education team see around 150 patients per month.

The service has demonstrated how the expanding roles of the pharmacy technician can lead to service improvements. The pharmacy technicians have developed clinical and leadership skills as this service is solely technician led. In addition, the service has provided an extra point of contact for patients, educating patients and providing opportunities to ask questions.

Patients also value the extra safety net call to identify side effects and clinical condition. The development of this area of the workforce has eased pressure from the consultant teams: It has led to more consultant teams asking for this support service as they see the benefit to their patients.

“They pharmacy technicians often develop relationships with patients who they have seen on many treatments as many SACT treatments are now oral in delivery, and are providing another contact route within the cancer centre.”

Sophie Harding, Advanced Oncology Pharmacist, and Sarah Gorman, Senior Pharmacy Technician

6. Pharmacist-led Interstitial Lung Disease Clinic

Cwm Taf Morgannwg Health Board

There is a weekly pharmacist-led drug monitoring clinic for Interstitial Lung Disease (ILD) alongside the respiratory consultant clinic at Ysbyty Cwm Cynon. There are local MDT meetings to review radiology monthly and a tertiary MDT once a month to discuss complicated patients.  This covers patients with ILD in the Merthyr and Cynon localities in Cwm Taf Morgannwg: via face to face or telephone consultations. 

Pharmacist talking to her patient in clinicThe introduction of the pharmacist-led drug monitoring clinic has allowed patients initiated on immunosuppressive agents to be appropriately monitored and optimised. Patients are followed up regularly between consultant reviews. This clinic has allowed the consultant to see more patients in clinic as appointments are not taken up by patients requiring drug monitoring. This has a positive effect on waiting times and the availability of the consultant to see more complex cases.

During set up of the clinic, the prescribing scope of the specialist pharmacist needed to be expanded to included immunosuppressive drugs, PCP prophylaxis and medications needed to treat side effects associated with therapy. Time was spent in clinic with the consultant initially observing consultations then progressing to reviewing patients independently, alongside discussions of treatment plans with a senior colleague.  As part of the extended scope a number of clinical logs were completed that included reflections, feedback on observed practice and cased based discussions.

There were barriers to efficient service provision, as some patients have difficulty attending in person - this has been overcome with the introduction of telephone reviews. Other obstacles are more challenging; patients are still required to travel blood tests, with phlebotomy services in secondary care, this is not always convenient. Future expansion of the drug monitoring clinic will allow mid-week review of bloods taken during clinic, plus time for writing letters and contacting patients with concerns prior to their next appointment.

“This clinic allows patients to get the best from their medication. It means patients who need to have medication changed to an alternative agent are identified sooner and side effects are addressed earlier.”

Nadia Higgi, Advanced Pharmacist, Respiratory

7. Referrals for post-discharge medication support

Powys Teaching Health Board

The Pharmacy Team at Powys Teaching Health Board assess the requirements of patients who may need support with medication administration on discharge from hospital and are now able to directly refer patients to domiciliary care and reablement teams where it is needed.

Previously there was no formal assessment in place and no consistency of decision-making process: Often patients were referred for medication administration support when there were other options such as a compliance aid. Pharmacy can assess patients whilst they are still inpatients on their post discharge medication support requirements and assign a level of support required in line with All Wales guidance. If level 2 support with medicines administration via a Medicine Administration Record chart is required, Pharmacy can now directly refer to community pharmacy to set this up.

Patients are place on the correct level of medication support which means they can maintain the correct level of support or independence, whichever is appropriate. Resource limits restricts the activities of the team. However the team also supports the wider MDT with knowledge on assessments, particularly working closely with Occupational Therapy.

This can mean that patients are not unnecessarily placed onto a higher level of medication support (for example receiving full administration support) relieving some pressure from stretched domiciliary care services.

This service is currently limited to inpatient setting and would support the community MDT if pharmacy was also able to undertake domiciliary visits post discharge. This would allow assessment of ongoing medication support needs and reassessment of level of support needed.

“Pharmacy leads on this aspect of discharge as part of the MDT, helping to support more efficient discharge and reduced risk of readmission to hospital. We have also developed good links with social services teams since starting this project which will have undoubtedly improved the care for patients.”

Jayne Price, Head of Community Services Pharmacy

8. Implementation of a supply shortage dashboard

Aneurin Bevan University Health Board

A Supply Shortage Dashboard via SharePoint was commenced in the early part of 2022. The idea is to have a one stop solution for all medicine shortages that affect the health board. It is designed for on-call or ward pharmacists to access quickly and allows them to make decisions on pre-determined drug alternatives effectively.

When procurement staff members find a shortage, they submit an alert using a Microsoft Form. Using a Microsoft power automate workflow, this distributes a standardised message via teams and email to senior staff.

Senior pharmacists and technicians hold a weekly meeting to assign a pharmacist to the shortage that’s been found and formulate a plan or alternative drug for the health board to follow.

This plan is then updated on the ABUHB shortage dashboard and provides clear guidelines and plans for all staff members when faced with a drug shortage. As a result, action can be taken in advance so that patients do not miss doses and ward pharmacists are more informed at the point of prescribing so can ensure timely alternatives are chosen.

A further benefit is work is not duplicated by stores and procurement teams throughout the health board. All sites are aware of shortages and the clear pro-active plans that are put in place which enables time to be spent on other tasks. In 2023 alone we have found and managed 179 individual drug shortages relevant to ABUHB.

The implementation of the Supply Shortage Dashboard has revolutionised the way medicines shortages are handled within ABUHB, allowing robust and early communication of issues to all of the Pharmacy team. This allows the service to quickly formulate plans to ensure we minimise the impact to our patients, positively influencing patient experience and avoiding any unnecessary delays in treatment. I am very thankful to John and the team for compiling this great resource and rolling out successfully across the HB.

Lisa Forey, Head of Pharmacy

The Medicines Supply Shortage Dashboard has allowed an integrated approach between pharmacy procurement and the clinical teams to effectively and efficiently communicate strategies to manage supply shortages. The dashboard has enhanced intelligence of supply issues and demonstrates the key relationship between medicines procurement and clinical pharmacy, enhancing the availability and knowledge of alternative therapeutic options to ensure continuity of patient care and patient safety at the point of delivery.

Bethan Jones, Pharmacy Manager RGH