Section 23 Report
“Managing the use of medicines in hospitals—A follow-up review”
The second item on our agenda is a briefing from the Auditor General for Scotland on a section 23 report on managing the use of medicines in hospitals.
Mr Robert Black (Auditor General for Scotland):
I invite Angela Canning, the assistant director who led the project, to introduce our study briefly.
Angela Canning (Audit Scotland):
The Auditor General's report, "Managing the use of medicines in hospitals: A follow-up review", was published on 16 April 2009. As part of their hospital treatment, almost all patients receive medicines, which costs the national health service more than £220 million a year. In order to maximise the benefit of medicines, they need to be used safely, appropriately and cost effectively.
Our report follows up on the progress that has been made against key recommendations in our 2005 baseline report, and it gives an overview of national developments since then. We would like to bring four main findings to the committee's attention. The first is that hospital medicines are an area of significant expenditure for the NHS. In 2007-08, the NHS spent around £220 million on hospital medicines, which represents about 6 per cent of overall hospital running costs. We considered the costs of four high-cost medicines in particular and found that they accounted for 12 per cent of the expenditure on hospital medicines in 2007-08. They put particular pressure on hospital budgets, as is highlighted in exhibit 2 on page 7 of the main report.
The NHS has made good progress in budgeting for new medicines. That work has been led by the Scottish Medicines Consortium, which was set up in 2001 to provide the NHS in Scotland with a single source of advice on new medicines. The SMC now produces annual reports that include information on the budget impact of new medicines that are expected to become available in the coming year and are expected to cost the NHS at least an additional £500,000 annually.
NHS Quality Improvement Scotland develops clinical guidelines for the NHS, but still does not routinely assess the impact of those guidelines on budgets. However, there was a recent pilot on five of the guidelines, and NHS QIS is expected to decide later this year whether it will extend the process to cover future guidelines.
Our second finding was that boards need better information to ensure that medicines are used safely and appropriately in order to achieve the greatest benefit for patients. Progress has been slow in developing a national hospital electronic prescribing and medicines administration system. A HEPMA system can provide staff with instant information on the medicines that are prescribed and administered for each patient, thus reducing the potential for mistakes. It can also provide monitoring information on the medicines that are used in hospitals. In our 2005 report, we recommended that a national system be developed and implemented, but Ayrshire and Arran NHS Board remains the only health board with a system like the HEPMA system. Case study 1 on page 8 of our report covers the Ayrshire and Arran experience and illustrates some of the significant benefits of its system. It looks unlikely that a national system will be put in place in the next few years, and the new e-health strategy does not set out clear plans or timescales to ensure that such a system will be in place in all hospitals.
Our third main finding was that the NHS is making progress in promoting safe and cost-effective use of medicines. All acute hospitals in Scotland are taking part in a national patient safety programme, which was launched in January 2008. One aim of the programme is to reduce the risk to patients from adverse drug events and near misses. There has also been good progress in developing local and national guidance on prescribing.
Progress has been slower in developing a national approach to incident reporting. All boards have their own systems in place, but there is still no national approach. NHS Quality Improvement Scotland is working with boards on the feasibility of developing a national approach, but it is still to decide on the way forward.
Our fourth main finding is that increasingly, although hospital pharmacy staff work directly with patients and staff, workforce planning is still not well developed. Although there have been changes to the way in which services are delivered, workforce planning has not kept pace. There is still no national framework for recognising or accrediting extended roles for pharmacy technicians, apart from two extended roles that need a formal qualification. There is variation among boards as regards whether some tasks are carried out as part of standard or extended roles. We have recommended that a national framework be developed to improve consistency among boards and to provide assurance on staff competency for extended roles.
Most boards are still experiencing problems recruiting and retaining hospital pharmacy staff, and identified agenda for change as the difficulty. By December 2008, only 10 boards had assimilated all hospital pharmacy staff into agenda for change. Since agenda for change was introduced, there has also been less national information available on hospital pharmacy staff—for example, no vacancy data are available.
In December 2008, the Minister for Public Health asked the chief pharmaceutical officer for Scotland to develop an action plan for pharmacy and medicines covering both hospitals and primary care. The action plan is due in September 2009 and it is expected to focus on several issues, including workforce planning, patient safety, information technology support for hospital prescribing, performance management and integration between hospitals and primary care. It is a welcome development because there has been no national pharmaceutical strategy in place since the first strategy ended in 2005. As ever, we are happy to answer questions.
Thank you very much. A couple of things in the report struck me. The first is that four drugs account for something like 12 per cent of the total medicine expenditure, which is staggering. When you look at exhibit 1 in the follow-up report, the percentage of total expenditure that hospital drug expenditure represents has not changed that much, but it is clear that there are major pressures, so I am interested in their implications.
Secondly, there seems to have been a successful pilot in NHS Ayrshire and Arran that has not been rolled out across Scotland, which seems to be a bit perverse, to say the least.
I offer a thought or two—both those points are absolutely vital. I am sure that Angela Canning and the team can give the committee more detailed information about the pressures and trends in prescribing in acute hospitals. However, looking to the future—this is borne out by work that we have done in the past—there is absolutely no doubt that the theme of pressure on drug budgets will re-emerge. As Angela Canning described, in the past few years since our baseline report, the NHS has been successful in controlling drug expenditure and has taken several initiatives to achieve that. Exhibit 2 on page 7 of the follow-up report refers to the four high-cost medicines, to which the convener referred, that now account for 12 per cent of expenditure on hospital medicines. That indicates a trend into the future.
I suggest that a related question is about the choice between medicines and hospitals. Some years ago we did a report on general practitioner prescribing in hospitals and identified tens of millions of pounds that could be released for redeployment in the NHS by doctors prescribing generic as opposed to branded drugs. We have revisited that three times—or was it twice?
Barbara Hurst (Audit Scotland):
It was twice.
We have seen the benefits coming through from that measure. We have found a similar issue in this report in the sense that the NHS needs to get good information systems about the patterns of prescribing and it needs a good knowledge of costs to ensure that budgets are being used well. However, cost pressures must be viewed alongside patient safety, which is one of the themes that runs through the report—a bit like the writing that runs through a stick of rock.
I will take a moment to describe what strikes me about the report in that regard. Angela Canning and the convener have mentioned the HEPMA system—the medical management system—that NHS Ayrshire and Arran has developed. We have included that as a case study because, on the basis of our evidence, the system works and has benefits for patient safety and management of medicines.
I encourage the committee to take a quick look at case study 1 on page 8 of the report, in which we say that the system gives NHS Ayrshire and Arran "reporting at ward level" about
"the medicines staff need to administer to each patient"
and about the timing of delivery of those medicines in the ward. It gives information about the risk of "adverse drug events" because of the interaction between different drugs, and about choices between drugs. Those seem to me, as a layman, to be very important strengths of the system.
It is worth noting, with regard to patient safety benefits, that it is reasonable to ask the NHS why it is not appropriate to roll out that system to other boards. There may be robust and entirely appropriate answers to do with the longer-term plans for the NHS as a whole. However, in the meantime, a number of boards do not have such a system, and there is a shortage of dedicated pharmacists, which is a point that is made later in the report.
Exhibit 8, on page 21 of the report, shows the wide variation in the percentage of beds that are covered by clinical pharmacy services. A number of the large boards do not have in-hours clinical pharmacy services that cover all their beds. If we view that alongside the underdeveloped nature of systems, we begin to see a pattern emerging in which clinical safety is linked to budget constraints—we need to make sure that the prescribing is going on there.
A second risk issue that emerges from the report is the fact that there is not really a national approach to analysing the pattern of unfortunate incidents in hospitals. A reasonable question to ask the NHS is how, at Scotland level, it learns from things that go wrong, and how it ensures that the information gets through the system to other parts of the NHS.
As Angela Canning and I have mentioned, there are issues around the standards of training for pharmacy technicians in particular, and around the availability of pharmacist expertise in hospitals. A lot of progress has been made on that, but we would expect more to be happening by now.
Picking up on the point that the report makes about the HEPMA system, I would like some clarification about paragraph 13 on page 8 of the report. It seems to suggest that the HEPMA principle is being somehow integrated within a wider management plan. I hope that it has not been discarded, but is still being considered as a wider part of medicines management in hospitals.
With regard to the case study report on NHS Ayrshire and Arran that you mentioned, I have seen for myself the pharmacy robotics system at Crosshouse hospital—it is amazing what that can do and the time that it saves. It is encouraging that NHS Ayrshire and Arran intends to connect that system with the HEPMA system.
Lessons appear to have been learned in Ayrshire and Arran, and I would be interested in finding out in the future other boards' views of the system, and whether the principle is being enshrined within a wider medicines management policy. Can you clarify whether that is the case?
I think you are right—the plans are to introduce HEPMA along with a wider patient management system. Perhaps Tricia Meldrum can give more history on why the system was piloted in Ayrshire and Arran, and an update on where the Government's thinking is now.
Tricia Meldrum (Audit Scotland):
The system in Ayrshire and Arran was introduced more than 10 years ago. It is very much driven by staff at local level, who took the initiative as they wanted to develop something that was fit for purpose and that would work with their local systems. They have worked very closely with their IT providers to develop a system that works with their drug control and pharmacy systems and can take information from their patient management systems. It has been developed piece by piece over the past 10 or 12 years. A couple of years ago, the Government examined what was needed to implement a system across the country. What is in Ayrshire is fit for purpose in Ayrshire, but would not necessarily work with IT systems in other hospitals.
A group was put together to examine the principles that would be needed for a national HEPMA system. That group recommended against a stand-alone system because there is a need to link in to other patient systems to get demographic information, lab results and other such information. What is needed is for it to be part of an integrated patient management system. That is what is being taken forward through the e-health strategy. However, we are concerned that it includes HEPMA only as an optional module. When will it happen? When it does, will the boards be able to choose not to take on board the optional module component of it? The principles have been signed up to: that is the national approach but it may be that not all boards will necessarily implement that model. We do not have clear timescales.
That is quite encouraging. It sounds like a systems integration issue rather than an abandonment of the principle of managing the medicines. We still want to press for progress on that, at some point.
Our idea of timescales is getting a bit clearer. We see it as something that should be put in place sooner rather than later, in order that we can get the benefits.
In passing, it is encouraging that the health secretary has agreed to give a £3 million loan to the Western Isles NHS Board. That obviously follows up from the work that Audit Scotland did and that we did in producing our recommendations. That was very encouraging.
However, less encouraging is the progress that has been made. Audit Scotland will know that I have a bee in my bonnet about following up of their reports. The reports are excellent, but I am very sceptical as to whether they are always followed up by the officials in the Scottish Executive, the health boards and other bodies around the country.
Angela Canning referred to some of the recommendations of a report from 2005. In some cases, those are exactly the same recommendations that we are making now, four years later. Nothing has been done about them. That underlines my concern that when the reports are produced, the Scottish Executive officials say they are very good but then put them aside and the health boards get on with what they had always done before. Can continuous pressure be exerted by Audit Scotland or by the committee on the following up of recommendations in such reports?
I agree that the Ayrshire and Arran pilot should be used as an example for other boards, but I am less optimistic than others that it will be taken up. I do not know what the officials in the health department do on a day to day basis. There are a lot of them. What do they do? Do they sit around sending out circulars? They really ought to be chasing up some of your recommendations. Does Audit Scotland have any ideas on what we can do to try to get the recommendations implemented more thoroughly and quickly?
In relation to the report, our balanced view would be that the health service as a whole has made progress in some areas. However, as Angela Canning pointed out earlier, there has in a number of areas been more progress, so it would be appropriate for the committee to ask why and how the health boards see those issues being taken forward more effectively, and why there has not been progress.
I absolutely identify with the comment about the need to follow up and ensure impact, which is an area where the committee itself can play a very important role. As you know, there are arrangements in place whereby the committee goes back to the Government as a whole to check on progress on some of the key findings in Audit Scotland reports. As I said at a previous meeting, we do not really have the resources to follow up every single item in every single report, so we take a strategic approach. When we produced the 2005 report, it seemed to us that there was so much in it that we should follow it up in 2008. We will follow up other areas as part of the planned programme. In our forward programme, certain studies are clearly follow-ups to previous studies, but that is more a spotlight than a floodlight, if you like; we simply do not have the resources to shine a floodlight on all the recommendations in all the reports—to return to the light bulb analogy that was used in the previous meeting.
I agree with George Foulkes that the reports are thorough, comprehensive and full of good recommendations and key messages. I would have thought that we are entitled to follow them up and ensure that recommendations are implemented.
I do not want you to think that we have read only page 8 of this report, but I want to ask about the HEPMA system, too, because I am intrigued by it. Whenever there are solutions, I like to establish the link with the real problems that people have brought to me.
I want to check that I have got this right. We have talked about improving the timing of medicine administration, on which all MSPs have been approached by the Parkinson's Disease Society at some point. I was interested in the concern that the society raised, because my late mother-in-law had Parkinson's disease. The society was concerned that, although in most wards there are two medicine rounds—morning and afternoon—people with Parkinson's, as well as people with other long-term conditions, absolutely must take their medication at set times. Their body is used to receiving medication at a set time and then, I think, at four-hour intervals. I know from personal experience that if they do not get the medicine at those times, they deteriorate quickly. People with Parkinson's found that they were not able to get their medicine at the times that suited their body. Both my parents are nurses, so I know that staff on wards are extremely busy and I know where the difficulties lie. As I understand it, the HEPMA system would address such issues.
You said that the HEPMA system is unlikely to be rolled out throughout Scotland in the short to medium term. Are NHS boards telling you that that is because of a lack of willingness or interest, or because the Government has not set timescales for the boards to buy into the system?
Carolyn Smith (Audit Scotland):
The HEPMA system would provide real-time information. When we went to see NHS Ayrshire and Arran, we saw that there was a kind of flashboard at the nurses station, which showed when patients were due to get their medication. The information was flagged up in real time, so that the nurses knew that certain patients were due to get their medication at a certain time, which perhaps was not during a drugs round.
That is excellent.
I presume that if the administration of a medicine were missed, that would be recorded automatically, so staff could come back and examine why it happened. Hopefully, that would avoid a build-up of the problem. I recognise the issue of Parkinson's, which is a very good example.
Perhaps Barbara Hurst or Angela Canning can tell you about the change of direction of the national e-health strategy and the reasons why the Ayrshire and Arran HEPMA system has not been rolled out throughout Scotland.
When we did the original study back in 2005, we had an active advisory group. A lot of pharmacists were keen to be involved in the study. At the time, there was absolute enthusiasm for adopting something like the HEPMA system more widely. There was quite a lot of envy about what was happening in Ayrshire and Arran and the benefits that the system was bringing.
Tricia Meldrum has already raised the point that, as the e-health strategy has been dusted down and refocused, the view has been taken that, although everybody can see the value of the strategy, it needs to be integrated, and it would not be right to keep having one-off solutions. The boards that were going ahead and trying to implement their own systems were told to hold on, because of the forthcoming integrated system.
Given the benefits that can be derived from the HEPMA system, we think that it needs to have a bit more impetus behind it, and it should not be merely an optional extra once an integrated package is in place. It is clearly good for patient safety and for ensuring that people get their drugs at the right time, so why would it not be introduced if it is affordable?
As our report says, the aim is to have a national contract for a HEPMA module by August 2009. Is that correct?
That applies to contractors starting to develop the patient management system. Electronic prescribing will be part of that, but I do not think that it will be part of the first stage.
No, it will not, and the reason why we have said that we do not see electronic prescribing happening in the short to medium term is not due to the unwillingness of boards, and it is not because they do not see the benefits; it is because electronic prescribing is now linked into the wider issues around the patient management system. Boards are at different places and are on different timescales in their need for a new patient management system. Some of them already have patient management systems, the contracts for which still have a number of years to run. It will take some time before everybody moves on to the one national system.
Are you confident that progress is being made at a national level, or is there something that we need to do to push it forward?
The HEPMA system is definitely optional. Even when the supplier that is selected starts developing the patient management system, the HEPMA system will not necessarily be developed alongside it; it could come later. The supplier that is chosen might not be able to develop a HEPMA module, in which case it will try to match it up at a later date and integrate it later. That has not been decided on yet.
Rolling out a HEPMA system to all boards carries huge cost implications. The Scottish Government and Ayrshire and Arran NHS Board evaluated the HEPMA system that operated in that area, which brought up some implications for rolling out the system across Scotland, including the capacity of individual boards to roll it out and the associated costs. The Government has committed the costs to cover the hardware for the patient management system and the HEPMA system, but there is no resource to support those systems locally, which could present an issue for rolling them out across all hospitals.
What is the way forward for the committee? It would seem sensible to draw together the recommendations from the 2005 report. Presumably, the Government and its Health Department had discussions with Audit Scotland and accepted the recommendations. We should ask why the recommendations have not been implemented, and marry that up with the recommendations in the follow-up review. We should be asking questions about where we go from here. We might all come up with good ideas, but if they just lie gathering dust they are no good.
Questions about what we will do next will be taken under agenda item 4.
I was interested to read on page 6 of the report that the total cost of medicines in the NHS—including hospital medicines and medicines prescribed by general practitioners and other staff in the community—is £1.2 billion per year. Did you get a chance to examine the cost of discarded medicines? I understand that when people come into hospital they leave behind their existing medicines and new medicines are prescribed to them; the same may happen when they leave. That must be a huge cost. Medicines may be discarded at various stages in the treatment process, even if a person is receiving the same medicine throughout. Managing the process a bit more effectively could lead to a heck of a saving.
Systems are in place or are being rolled out by boards to enable patients' medicines to be used more. When a patient brings their medicine into hospital, they may use it after the pharmacist has checked it. One issue is whether patients have bedside lockers, as there must be somewhere to store the medicines. Systems are being rolled out, but they are not all in place yet. The thinking behind the measure is that it will ensure continuity and provide cost savings, because hospitals will not have to redispense medicines that they have thrown out. That was one of the recommendations of the previous pharmacy strategy, which ran until 2005, but actions are still being implemented.
That is encouraging, to a degree. Managing the process properly could lead to a heck of a saving, whether or not that involves a HEPMA system.
I realise that the report is concerned mainly with medicines, but exhibit 1 shows that in the five-year period from 2002-03 to 2007-08, there was something like a 70 per cent increase in net hospital running costs. Are you looking at that issue separately?
Our overview report always looks at expenditure. You will remember that a number of big pay agreements were reached in the health service during the period concerned. Capital costs also started to hit, although the exhibit relates to running costs. As the Auditor General mentioned, in the overview report we aim to identify the cost pressures, because they will really start to bite in the health service in the next few years. We are interested in finding out why hospital running costs are rising at such a rate, over and above the rate of inflation.
Notwithstanding the pressures that you have identified, elected representatives are interested to know whether there have been improvements in delivery and service quality commensurate with the investment that has been made and the huge rise in costs, over and above the rate of inflation, that has taken place. At some point, we need to ask not only whether the investment in health and education that has been made is justified but whether it is delivering what it was intended to deliver. Today we are looking at medicines, but we are all interested to know whether there have been improvements commensurate with the investment that has been made in hospitals and the NHS generally.
We intend this year to produce an overview of the health service that will link the performance information that we can access to the finances of and financial pressures on the service. With the support of the committee, we have fallen into a pattern of doing that every second year. In the intervening year, we produce a narrow report on financial performance. This year we are looking more widely at performance as a whole.
For the health service it is difficult to link benefits to any one year, because much of the information on outcomes relates to periods of five years or more. We will always have to tackle that challenge.
You reported that NHS Western Isles did not supply any data for the study. Have you any idea why that was the case?
We tried repeatedly to get the board to return information for the study. We eventually had some communication with the chief executive, who was very apologetic. We aim to give the comparative information to the health board so that it can at least see where it sits in relation to other boards.
Thank you for the report. We will return to the issue later in the meeting.