Patient Safety Spotlight: managing the risks associated with providing community pharmacy clinical services
In this article, co-produced by one of our specialist inspectors Aileen O’Hare and Helen Williams, Consultant Pharmacist for CVD, South-East London ICS, we highlight the GPhC standards to focus on when delivering clinical services, using the Community Pharmacy BP Check Service as a case study example.
The BP Check service tackles health inequalities through the early identification of hypertension in patients at high risk of cardiovascular disease and the promotion of healthy lifestyles/behaviours.
By increasing access to BP checks, the service can be used to address established health inequalities in CVD, including inequalities driven by social deprivation and ethnicity.
The King’s Fund recently highlighted studies in the UK and across the Indian diaspora (e.g., Europe, Fiji, Singapore, South Africa, USA, and Canada) consistently show a higher incidence, prevalence and mortality from CVD in South Asian groups compared with the white group or national average. South Asian groups have the highest mortality from heart disease and also develop heart disease at a younger age. As with heart disease, stroke incidence and mortality are also higher in the South Asian population. CVD mortality is high and rising in South Asia, in contrast to the declining trend elsewhere.
The King’s Fund also identified that black groups have higher-than-average incidence of and mortality from hypertension and stroke, and they have strokes at a younger age. The prevalence of hypertension, a risk factor for stroke, is high in Africa and the West Indies.
System leaders can utilise the SHAPE Atlas tool to link national data sets, clinical analysis, public health, primary care, and demographic data with information on healthcare estates performance.
Inspectors have identified situations where pharmacy teams provide inadequate risk assessments, consultation documentation, patient medication records, clinical audits, and staff training with respect to community pharmacy clinical services.
Pharmacy teams do not always communicate effectively with the patient’s regular prescriber, identify appropriate referral routes, and fail to adequately ensure equipment is fit for purpose and appropriately maintained.
The GPhC Principle steps to safe and effective clinical services
How does the Clinical Service Specification link to the GPhC standards for registered pharmacies?
There are several standards that pharmacy teams should focus on to ensure they are delivering a safe and effective community pharmacy clinical service.
Below we use the example of a community pharmacy setting up a BP check clinical service, to highlight best practice, and set out the key elements of the standards under each principle to support safe and effective pharmacy practice when setting up and providing this service.
Governance arrangements should be in place to ensure full and comprehensive risk assessments are completed for each new clinical service.
We would expect community pharmacy teams to identify the risks associated with the delivery of a community pharmacy BP check service and consider how those risks are managed and reduced.
Pharmacy staff would be expected to provide documentary evidence of contemporaneous clinical consultation records and BP measurements in the pharmacy clinical record system.
Where an urgent or non-urgent referral to other healthcare professionals, Urgent Care or A&E is required, we would seek evidence that pharmacy teams have sent an email including the patient details and any relevant BP measurements using a secure NHSmail account or other secure digital process.
We would expect the pharmacy team to show evidence of feedback on the provision of new clinical services including any patient surveys, to ensure they are reviewing and optimising service provision and delivery.
Pharmacy teams should be able to demonstrate clinical service evaluation, audit, and continual monitoring for any clinical services they provide, either through a formal service level agreement or informal clinical audit to demonstrate the outcomes of the clinical service.
Staff empowerment and competence
Inspectors would seek assurance that pharmacy staff have been trained to provide the BP check service and are able to perform BP and ABPM monitoring.
Training logs should be recorded for all pharmacy staff involved in providing the service and pharmacy teams should be able to demonstrate their knowledge of the advanced service specification and NICE Hypertension Guidance (NG136) and what constitutes Low, Normal, High and Very High BP results as per the advanced service specification.
Pharmacy teams should consider the environment of their premise, consultation room and any equipment storage arrangements in advance of implementing a new clinical service. Teams should assess the size and capacity of their consultation rooms and any storage requirements for ambulatory BP monitors (ABPMs).
GPhC inspectors will seek assurance that pharmacy teams are providing patient information leaflets and patient counselling about the BP monitoring equipment and clinical service.
Pharmacy teams should be able to demonstrate that the service is explained to the patient and consent has been obtained by recording the information in the pharmacy clinical record system.
Teams would be expected to work collaboratively with Primary Care Networks (PCNs) and other system healthcare partners to optimise patient care and timely referral.
In line with Healthy Living Pharmacy (HLP) framework we would expect to see evidence of behavioural change support and signposting by the pharmacy team (salt intake, physical activity, weight loss, alcohol, and smoking cessation).
Cleaning logs for BP equipment and cuffs should be maintained and made available at inspection.
Pharmacy teams would be expected to provide assurance that any BP equipment used or provided as part of the service complies with the British and Irish Hypertension Society (BIHS) recommended lists in line with the advanced service specification. Calibration and equipment maintenance records should be made available during inspections. We would expect staff to demonstrate training in the assessment of cuff size for all relevant patient groups and have a variety of cuff sizes available for use within the pharmacy.
GPhC standards and guidance
The standards for registered pharmacies specify that pharmacy teams should ensure that:
1.1 The risks associated with providing pharmacy services are identified and managed
1.2 The safety and quality of pharmacy services are reviewed and monitored
1.4 Feedback and concerns about the pharmacy, services and staff can be raised by individuals and organisations, and these are taken into account and action taken where appropriate
1.6 All necessary records for the safe provision of pharmacy services are kept and maintained
1.7 Information is managed to protect the privacy, dignity and confidentiality of patients and the public who receive pharmacy services
2.2 Staff should have the appropriate skills, qualifications and competence for their role and the tasks they carry out or are working under the supervision of another person while they are in training
3.5 Pharmacy services are provided in an environment that is appropriate for the provision of healthcare
4.2 Pharmacy services are managed and delivered safely and effectively
5.2 Equipment and facilities are:
- obtained from a reputable source
- safe to use and fit for purpose
- stored securely
- safeguarded from unauthorised access
- appropriately maintained
The standards for pharmacy professionals highlight that pharmacy professionals should provide person centred care, work in partnership with others, communicate effectively, maintain, develop and use their professional knowledge and skills, and use their professional judgement.