The IMPACT directive. It gets in the way, it frustrates. The limitations to practice, the feeling when another request comes through that will trigger a debate between the pharmacist, the requestor and if you are really luck hospital management.

But if you look at the directive and what it is in response of and what goal it is intended for it becomes clear that often frustrations that should be brought to bear on a log jammed bureaucratic process are transferred to a piece of paper.

There is (and was several years ago) consensus that the practice of hospital pharmacy has advanced to the point where the agreed employment structures for pharmacists within the HSE were no longer fit for purpose. Pharmacists in a significant number of hospitals were no longer confined to dispensaries, they were working closer to patients ensuring that all elements of medicines management were covered. Specialism was developed by pioneers in the profession and then became expected as the outcomes of this work filtered out. To this day a wide variation can be seen in the provision of clinical pharmacy services which is not linked to the size or complexity of the hospital covered.

By virtue of being the largest employer this situation impacts the whole of the profession, as both legal, regulatory and market factors are hugely influenced by both the HSE and the Department of Health.

The current career structure does not recognise the work of these pioneers, or give encouragement and support to those that today have the drive and commitment to improve the use of medicines for hospital patients in Ireland. Specialism is happening in a fragmented way, unsupported nationally and in many cases locally (without guidance and direction from national employers). In areas where specialism has occurred support for upgraded job descriptions has faltered once the operational necessity of having people in post has been satisfied. In the case of antimicrobial stewardship pharmacists, we have seen their work develop into a true speciality working as peers with Consultant and Registrar grade medical staff to ensure safe prescribing and monitoring is effective. Outcomes around antimicrobial stewardship have improved partly due to the work of this group of pharmacists. These pharmacists are not recognised by their employer as specialised. We have acted in good faith in the provision of new services but have waited for years for  agreed implementation of the career structure which has not been forthcoming from the HSE. In this way we devalue our contribution to Irish healthcare and our perceived value to the HSE.

Compare where we are to the Medical and Nursing profession. We work collaboratively with Doctors and Nurses every day. We are used to seeing individuals in both groups take up opportunities for further training and development in order to specialise and to be recognised as such. They have the apparatus to achieve this which brings a benefit to patient care. The concept of a Senior doctor or nurse who would know everything about anything due to the amount of time they have practiced is inconceivable. Why is this the case for Pharmacy? Specialism is rightly difficult and hard work to achieve but with it should come recognition from colleagues, managers and patients alike.       

The IMPACT directive is borne out of the HSE’s failure to implement what it agreed upon. An agreement that was made, based on the principle of providing a structure to enable modern pharmaceutical care for patients. A principle that holds just as true today. Hospital pharmacists are competent and confident that their roles could be expanded, with the underpinning support to drive better patient outcomes. Pharmacists are part of the solution to the question of how to manage increasing complexity in healthcare coupled to an ageing population with the corresponding increase in co-morbidity and polypharmacy.

The HPAI continues to represent Hospital Pharmacists at national industrial relations meetings in an effort to ensure the implementation of the Hospital Pharmacist career structure. The addition of a reference to the implementation of this structure in the HSE Operating plan for 2018 is welcomed by the HPAI. However the sustained support of the membership of the association and for the IMPACT directive is critical to ensure that Hospital Pharmacy is transformed, making it fit for the present and future.

There has been recent interest shown by the HSE in the consideration of the adoption of modern IT facilities both within hospital pharmacy dispensaries and on the wards in the form of prescribing software. The benefits of these systems are huge in several outcome areas. 

One of the few advantages of finding yourself behind the curve of adoption of technology is that others have had the chance to test and fix what was once novel and now mainstream pieces of software.  The HSE can, as a result look to a developed market and select a product that offers the best balance of features, safety, usability and value. 

In other health systems the adoption of this type of technology has empowered hospital pharmacy practice and has led to increased time at the patient's bedside for clinical work. The ability to alert pharmacists to new patients, dose changes, delayed administration or supply requirements all result in the work coming to the pharmacist rather than the pharmacist hunting for work amongst the drug kardexes.

The correct adoption of technology allows for seamless connection of dispensary  automation and drug storage units along with procurement to smooth logistics. 

To achieve these benefits, there needs to be a realisation that the adoption of technology is only a catalyst to drive changes in processes. Simply  buying the best software and hardware doesn't guarantee the best outcome. This is greatly swayed by the implementation, system administration and ongoing support for medicines management processes at ward and pharmacy level.

Pharmacists have proven that they are integral to the successful deployment of e-prescribing. However the disparity in the level of clinical pharmacy provision within HSE hospitals risks any implementation of such systems. 

In order to underpin the modernisation of processes, a modernisation of the Hospital Pharmacist profession is required. Without structures that can cope with taking the lead on all aspects of medicines management, the large investment required in infrastructure will be at risk. 

It is for this reason that the HPAI continues to work to ensure the implementation of the Hospital Pharmacist career structure, to ensure that Pharmacy is represented at senior levels to ensure medicines management related projects are expert led within all hospitals. 

Standard membership works out at approximately €6.90 per week with subscriptions this is reduced for Hospital Pharmacists earning less than €44,880

Example approximate costs are given below (although this is intended only as an indicative guide based on subscriptions in March 2017 - more information is available from IMPACT direct here)

The Medical Council and the PSI, the pharmacy regulator, have launched a joint initiative aimed at doctors and pharmacists, entitled ‘Safe Prescribing and Dispensing of Controlled Drugs’. 

European legislation for aseptic manufacturing is developed with a particular focus on the pharmaceutical industry. With certain exceptions, manufacturers of human medicines are required to hold a Manufacturer’s Authorisation. To obtain an authorisation to manufacture medicinal product, compliance with the principles of Good Manufacturing Practice (GMP) must be demonstrated.

Aseptic compounding in Irish hospital pharmacy is exempt from holding a Manufacturer’s Authorisation provided certain criteria are met (Medicinal Products (Control of Manufacture) Regulations, 2007. Section 5 – S.I. No. 539 of 2007). However, the ethos of GMP is equally paramount to ensure that all products compounded are of high quality, safe and effective. It is important, therefore, that the underpinning principals of GMP can be translated transparently and safely into the hospital pharmacy aseptic compounding unit.

In the absence of nationally agreed guidelines for aseptic compounding in Irish hospital pharmacy the Hospital Pharmacist Association of Ireland (HPAI) submitted a project to develop guidelines to the Medication Safety Forum in 2010. All pharmacy departments with compounding facilities were invited to contribute. Through consultation with the Health Information and Quality Authority (HIQA) and the Irish Medicines Board (IMB), the Pharmaceutical Inspection Convention and Pharmaceutical Inspection Co-operation Scheme (PIC/S) Guide to Good Practices for the Preparation of Medicinal Products in Healthcare Establishments (PE 010/3) was chosen as the most appropriate guidance to apply to aseptic compounding in Irish hospitals.

These guidelines were written by pharmacists working in aseptic compounding and reflect a consensus of the combined knowledge of these pharmacists. They are guidelines of professional practice as developed by practitioners and have been endorsed by Chief Pharmacists (Head of Departments) on 7th March 2013 and by the HPAI Executive on 7th November 2013.

HPICS-complete.pdf

Chief I Pharmacist/ Pharmacy Manager

Chief II Pharmacist

Basic and Senior Grade Pharmacists

What is the Hospital Pharmacy Review?

The Hospital Pharmacy Review (sometimes known as the Career Structure Review) was published in November 2011. The review aimed to create a structure for Hospital Pharmacy to best facilitate a consistent delivery of pharmacy services in line with best practice and recognised international standards. The current structures and grades, Basic, Senior, Chief II and Chief I were implemented in 1978 and in no way reflect the current complexity and specialist knowledge that is required to manage medicines in a modern hospital. In 1986 the HPAI notified Health Service Management of the need to conduct a new review in order to match changes in practice in European countries and further abroad.

The Review itself suffered much delay. In 1990 the PSI launched their “Commission of Inquiry into Pharmacy” which recommended a career structure overhaul. Unfortunately there was no restructuring after this report, however the 1990’s saw Hospital Pharmacists introduce specialisations that had a profoundly positive effect on patient safety and cost effectiveness. These specialisations included clinical pharmacy and aseptic compounding. In the next decade, specialisations were extended to include medication safety pharmacists and antimicrobial pharmacists. In the last decade, IT developments, cluster pharmacy services and automation projects, although isolated, emerged within hospital pharmacy and pointed to the next generation of creative developments.

A second review of structures within hospital pharmacy was approved by the Department of Health and Children in 2001. In 2005, the Department of Finance agreed to the finalisation of outstanding

reviews, such as that of hospital pharmacists, where service improvements were involved. Further delays were however incurred due to the establishment of the Health Service Executive (HSE) on January 1st 2005 and the commencement of the Pharmacy Act on the 22nd May 2007. In late 2009, Dr. Ambrose McLoughlin was appointed as Chair of the Review of Hospital Pharmacy.

In December 2011 the Hospital Pharmacy Review was signed off by the HSE and the HPAI and the expectation was that the Review would then proceed to implementation. However, despite the repeated efforts of the HPAI negotiation team, not a single aspect of the Review has yet been implemented.

Report on the Review of Hospital Pharmacy 2011 with 2102 JD included.pdf

The career structure implementation is badly needed - pharmacists are working as specialists without the commensurate support and recognition. The path has been long and challenging, here is a roadmap of the journey.