Key messages
Managing the use of medicines in hospitals
A follow-up review 

Prepared for the Auditor General for Scotland 
April 2009

The Auditor General 
The Auditor General for Scotland is the Parliament’s watchdog for ensuring propriety and value for money in the spending of public funds. 

He is responsible for investigating whether public spending bodies achieve  the best possible value for money and adhere to the highest standards of financial management. 

He is independent and not subject to the control of any member of the Scottish Government or the Parliament. 

The Auditor General is responsible for securing the audit of the Scottish Government and most other public sector bodies except local authorities and fire and police boards.

The following bodies fall within the remit of the Auditor General: 

•	directorates of the Scottish Government
•	government agencies, eg the Prison Service, Historic Scotland 
•	NHS bodies 
•	further education colleges 
•	Scottish Water 
•	NDPBs and others, eg Scottish Enterprise.

Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Government and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds.

If you require this publication in an alternative format and/or language, please contact us to discuss your needs. 

You can also download this document at: 
www.audit-scotland.gov.uk
Audit Scotland, 110 George Street, Edinburgh EH2 4LH
T: 0845 146 1010  F: 0845 146 1009

ISBN 978 1 906752 42 2 	AGS/2009/4

Background

1. Almost all patients receive medicines as part of their treatment when they are in hospital so medicines need to be used safely, appropriately and in a cost-effective way to maximise their benefit. 

2. This report follows up the key recommendations from our 2005 report and gives an overview of national developments since then.1 It focuses on acute hospitals.

Key messages

1Hospital medicines are an area of significant expenditure in the NHS. 

3. Acute hospitals in Scotland spent £222 million on medicines in 2007/08, approximately six per cent of overall acute hospital running costs. Total spending on medicines in acute hospitals increased by 76 per cent in cash terms between 2002/03 and 2007/08, from £126 million to £222 million. The growth has stabilised in recent years. 
 
4. Medicines with a high cost per patient are a particular pressure on hospital budgets. Eleven NHS boards spent over £25 million on four high cost medicines in 2007/08, 12 per cent of total medicines expenditure in their acute hospitals.

5. The NHS now has better information for planning medicines budgets. The Scottish Medicines Consortium produces annual reports that include budget impact information on medicines expected to become available over the coming year and to incur higher costs. 

2
Boards need better information to make sure medicines are used safely and appropriately to maximise the benefit to patients.

6. Boards do not have the electronic information systems needed to help ensure medicines are used safely and appropriately. These systems should be developed on a national basis but progress has been slow. 

7. A Hospital Electronic Prescribing and Medicines Administration system records the medicines prescribed and administered in hospital for each patient, providing staff with complete and up-to-date information. This helps ensure that medicines are used safely. It also provides monitoring information on what medicines are used, allowing staff to review prescribing and identify areas for improvement. 

8. NHS Ayrshire and Arran is the only board with this system in place. A national system is unlikely to be in place in all hospitals in the short to medium term.

9. NHS National Services Scotland is piloting a national hospital medicines utilisation database which should provide high-level information on medicines used in hospitals. This is due to be rolled-out to all boards by 2010. 

3
The NHS in Scotland is making progress in promoting the safe and cost-effective use of medicines. 

10. Hospitals in Scotland are taking part in a national patient safety programme, which includes the safe use of medicines in hospitals. One of the programme’s aims is to reduce adverse drug events – mistakes or near misses involving medicines which result in actual or potential harm to the patient.  

11. All boards have an adverse incident reporting system but there is still no national approach in Scotland to ensure that the lessons learned from incidents are shared across boards.

12. The Emergency Care Summary contains key patient information from GP records. It is intended to give staff information to help manage patients safely in an emergency, when they do not have access to the patient’s full records. Boards have rolled out the Emergency Care Summary in most emergency departments and wards that patients are admitted to as emergencies. However, staff reported concerns about the quality of data in the summary and the limitations in what it covers.

13. Prescribing guidance helps prescribers decide on the most appropriate medicines to use to maximise the benefit to patients and to promote the safe and cost-effective use of medicines. The NHS in Scotland has made good progress in developing local and national prescribing guidance. 

4
Hospital pharmacy staff increasingly work directly with patients and staff but workforce planning is still not well developed. 

14. There is a lack of evidence to show if most boards base their hospital pharmacy workforce projections on local service needs. However, four boards use clear processes to do this.2  

15. The Scottish Government is developing an action plan for pharmacy and medicines and this is expected to include actions to support workforce planning. The action plan is due in summer 2009.

16. Most boards are still experiencing problems recruiting and retaining hospital pharmacy staff and identified Agenda for Change as a difficulty. 

17. By December 2008, only ten boards had assimilated all hospital pharmacy staff onto Agenda for Change. At this date, over a third of assimilated hospital pharmacy staff had requested a review of their grade. Almost 90 per cent of staff whose reviews were complete by December 2008 had or will have a change of 
pay band.3 

18. Since the move to Agenda for Change, there has been little published national information on hospital pharmacy staffing. There are no current national data on vacancy rates for hospital pharmacy staff in Scotland. 

19. There is no national framework for recognising or accrediting extended roles for pharmacy technicians, apart from two extended roles that require technicians to have a formal qualification. There is variation across boards in whether some tasks are carried out as part of standard roles or extended roles. 

Key recommendations

The Scottish Government should:

•	work with boards to develop a plan and timescales to ensure that a Hospital Electronic Prescribing and Medicines Administration system is implemented across all boards in Scotland as soon as possible and that the data can be centrally collated and analysed to support planning and monitoring across Scotland   
•	work with NHS Education for Scotland (NES), the Information Services Division of NHS National Services Scotland and the boards to develop national pharmacy workforce planning information that supports boards in taking forward workforce plans and workforce development
•	work with NES and the boards to develop a national framework for recognising and accrediting extended roles and setting training standards for pharmacy technicians.
The Scottish Government and boards should:

•	ensure that the Agenda for Change assimilation and review process for pharmacy staff is completed as a matter of urgency.
NHS boards should:

•	ensure that pharmacy workforce plans are based on an assessment of need, which considers the appropriate numbers, skill mix and other resources such as automation, to meet future needs for dispensary, clinical and other work.
NHS Quality Improvement Scotland should:

•	work with the boards to develop a system to share learning and action points from medication incidents and near misses across Scotland, supported by trend analysis and consistent local reporting.

1	A Scottish prescription – Managing the use of medicines in hospitals, Audit Scotland, 2005.
2	NHS Grampian, NHS Greater Glasgow and Clyde, NHS Tayside and State Hospital.
3	Staff who did not request a review may have a change of band if staff in equivalent roles have a change of band following a review.