Evidence submitted by the Association
of Independent Multiple Pharmacies, the Company Chemists Association,
the National Pharmacy Association and the Pharmaceutical Services
Negotiating Committee (EPR 22)
Providing community pharmacists with
appropriate role-based read and write access to both detailed
and summary care records has the potential to greatly improve
patient safety, support the development of new services for patients,
improve interdisciplinary working and increase the quality and
continuity of care provided to patients.
To maximise patient safety, community
pharmacists must have access to a pre-determined core data-set,
for example the medication profile, active clinical conditions,
allergies and previous adverse reactions. It would be beneficial
for patients, the NHS and pharmacists if supplementary information,
such as access to laboratory test results, is also available to
pharmacists to use where appropriate and with patient consent,
to support a particular role they are undertaking, for example,
the provision of an anticoagulation monitoring service.
All community pharmacies have robust
systems in place for handling patient confidential information
and are subject to a wide range of legal, ethical and professional
requirements. We welcome the proposed additional safeguards to
protect patient confidentiality including role-based access controls
and the ability for patients to choose to dissent from their information
We believe that community pharmacists
should be involved at an early stage in the implementation of
the NHS Care Records Service to study the benefits and challenges
that arise in joining-up care and to provide learning to support
the wider roll-out of the Service to other professionals and organisations
within the NHS.
1.1 Since the first announcement of the
development of the NHS Care Records Service, pharmacists and their
representative bodies have been calling for community pharmacists
to be provided with appropriate role-based access to patients'
1.2 Providing community pharmacists with
appropriate read and write access to both the detailed and summary
care records has the potential to greatly improve patient safety,
support the development of new services for patients, improve
interdisciplinary working and increase the quality and continuity
of care provided to patients.
1.3 To maximise patient safety, we believe
that community pharmacists must have access to a pre-determined
core data-set, for example the medication profile, active clinical
conditions, allergies and previous adverse reactions. This should
be agreed in full consultation with the profession. It would be
beneficial for patients, the NHS and pharmacists if supplementary
information, such as access to laboratory test results, is also
available to pharmacists to use, with patient consent, to support
a particular role they are undertaking, for example, the provision
of an anticoagulation monitoring service for the secondary prevention
1.4 More than one third of pharmacies in
England are already able to operate the Electronic Prescription
Service and we anticipate that the overwhelming majority of pharmacies
will be connected to the NHS network by the end of 2007. This
will provide the basic infrastructure for pharmacy connectivity
to other national functionality, as it becomes available, including
the NHS Care Records Service.
1.5 In the Department of Health publication
"A Vision for Pharmacy in the New NHS", (2003) the Government
signalled that it would consult on the elements of patient information
that community pharmacists may need to deliver appropriate healthcare
services as part of the NHS pharmacy contract. This was reiterated
in the 2006 Department of Health Annual Report. It is of great
concern that this consultation has not taken place and consequently
the uncertainty over when community pharmacists will be granted
appropriate role-based access continues.
1.6 It is unfortunate that community pharmacies
have not been invited to participate in the pilot of the Summary
Care Record at this key learning stage. The information that will
be shared during the initial implementation will be limited to
prescription information which pharmacies currently have access
to, as well as information on adverse and allergic reactions to
medication. This information is unlikely to be considered sensitive
by the public and could greatly improve the safety of the provision
of medicines to patients.
1.7 To study the benefits and challenges
that arise in joining-up care and to provide learning to support
the wider roll-out of the Service to other professionals and organisations
within the NHS, we believe that community pharmacists should be
involved at an early stage in the implementation of the Service.
1.8 In this paper, we outline the key benefits
to patients, pharmacists and other health professionals, of community
pharmacists being provided appropriate role-based access to the
NHS Care Records Service. We also detail the structures currently
in place to safeguard confidential patient information available
2.1 Appropriate access to the patient's
summary records is necessary for many reasons. In a recent observational
6.5% of admissions to the medical admissions unit in a teaching
hospital in Nottingham were judged to be drug related with 67%
of these judged to be preventable. Providing community pharmacists
with access to a patient's full medication profile and information
on current clinical conditions improves the safety of prescribing,
for example, by allowing pharmacists to check that newly prescribed
medication is not contraindicated by a coexisting disease or by
ensuring that medication does not interact.
2.2 Some medicines, such as tricyclic antidepressants,
can be used in different ways to treat different conditions. A
pharmacist would only be able to confirm the medication is appropriate
and the dose adequate if the clinical condition being treated
is known. Such information is currently available only by asking
the patient who may not be able to accurately provide the necessary
information or by contacting the prescriber directly which is
a time-consuming and disruptive operation for both parties.
2.3 It is important, for patient safety
reasons for pharmacists to have access to information on allergies
and previous adverse reactions, so that a check on the suitability
of the prescribed product can be carried out at the point of dispensing.
The pharmacist's detailed knowledge of side effects and potential
interactions is relied on by many GPs.
2.4 Providing community pharmacists with
a baseline data-set which includes the full medication record,
active clinical conditions, allergies and adverse reactions would
support pharmacists in helping the Government meet its target
of reducing by 40%
the number of serious errors in the use of prescribed drugs and
help reduce the human and financial cost of prescribing errors.
3.1 Community pharmacy is changing. In April
2005, the community pharmacy profession entered into a new contractual
framework with the Government for the provision of pharmaceutical
services. The framework allows pharmacies to play a more central
role in patient care, with more scope for making clinical interventions
and better integration of pharmacists within the primary health
care team. As part of the new arrangements, community pharmacists
undertake Medicines Use Reviews, conduct public health campaigns
and advise patients on self care and the treatment of minor ailments.
Many pharmacists are also involved in providing other locally
commissioned services to meet the needs of patients in their locality,
for example diagnostic testing, substance misuse services and
services to care homes.
3.2 In addition to the basic dataset for
community pharmacists, required for the above reasons, pharmacists
should also be provided with additional role based read and write
access to specific types of information required to support that
role. For example, supplementary and independent prescribing can
only be effectively carried out in the community pharmacy setting
with electronic access to appropriate patient information such
as laboratory results and patient care plans.
3.3 The development of Practitioners with
a Special Interest was proposed by the NHS plan to improve access
and convenience. In September 2006, the Department of Health published
which acknowledged that "Pharmacists with a Special Interest"
can contribute to a broad range of service objectives including:
improving patient access, reducing waiting times, increasing capacity
in primary care, reducing demand on secondary care and delivering
value for money. The success of this programme is dependent on
community pharmacists having appropriate role based access to
3.4 One example of a service provided by
a small number of pharmacies is an anticoagulant monitoring clinic.
Patients receiving warfarin can attend a community pharmacy for
their regular blood test and dosage adjustment. This offers convenience
to patients as community pharmacies are more easily accessible
and have longer opening hours than secondary care clinics. This
service could be more effective if pharmacists had appropriate
read and write access to appropriate information about the patients
they were monitoring. For example, access to previous test results
and the ability to record electronically results they obtain,
to allow other health professionals involved in the care of the
patient to access this information.
3.5 Access to care records would also support
the role of pharmacists in providing urgent care. Pharmacy opening
hours are much longer than those of GP surgerieswith routine
evening and weekend openingand full integration of pharmacies
within the provision of urgent care will relieve the pressure
on A+E departments and out-of-hours providers.
4.1 Patients sometimes forget to ask their
doctor questions or misunderstand the information they are given
during a consultation. If pharmacists have access to records they
can reinforce important health messages and correct misunderstandingsthis
realises the benefits of an integrated health care system, the
raison d'etre of Connecting for Health.
4.2 Pharmacists, like other service providers,
must make reasonable adjustments to their service under the Disability
Discrimination Act 1995, so that people with disabilities are
able to access the service. Healthcare professionals, including
community pharmacists, who identify patients whom they believe
require support could, with patient consent, make an appropriate
entry on the NHS Care Record so that other healthcare professionals
are aware of the nature of the disability, and can make adjustments
to the services they provide.
5.1 Pharmacists based in hospitals and GP
surgeries have demonstrated the value that they bring to clinical
teams when they have access to clinical information about patients.
However, the value of community pharmacists has, to date, not
been fully utilised, as they have access only to clinical information
gathered from the prescription form or through discussion with
the patient. Providing community pharmacists with appropriate
role-based access to patient information would enable pharmacists
to work more closely and efficiently with the other members of
the primary healthcare team and improve the level of pharmaceutical
5.2 Under the new pharmacy contractual framework
pharmacies are required to maintain patient medication records
which include details of drugs supplied to patients and advice
given where the information is clinically significant. At present,
other health professionals, including other community pharmacists,
are unable to access and therefore cannot benefit from these records.
5.3 As patients have the freedom to use
any pharmacy this means that community pharmacists will generally
not have a comprehensive medication history for each patient.
By joining up the information held in pharmacy records through
the NHS Care Records Service, pharmacies will be able to provide
improved continuity and quality of care.
5.4 The NHS Plan
committed the Government to making a wider range of medicines
available over the counter. In recent years, products such as
the cholesterol lowering drug, simvastatin; the antibiotic used
in the treatment of conjunctivitis, chloramphenicol, and omeprazole
which is used in the treatment of gastro-oesophageal reflux disease
have been reclassified to allow sale through pharmacies without
prescription. This facilitates patient access to medicines, reduced
health inequalities and supports self-care, which was highlighted
in the NHS Plan as one of the key building blocks for a patient-centred
health service. Providing pharmacists with appropriate write-access
to the Care Records Service will ensure that the patient's general
practitioner can access clinically significant information when
products have been provided to patients over the counter, ensuring
these products are considered at the point of prescribing.
5.5 Looking to the future, products such
as oral contraceptivesmay
be available for sale without prescription through pharmacies.
Access to relevant information about the patient would improve
patient safety and help ensure joined up care.
5.6 Securely sharing information amongst
appropriate health professionals would also help improve the efficiency
of some existing services. For example, the NHS Medicines Use
Review service could be developed to the benefit of patients both
through allowing pharmacists access to appropriate information
about the patient and allowing a summary of the review to be made
available electronically to other health professionals involved
in the care of the patient.
5.7 Under the repeat dispensing service,
patients with stable long term conditions can collect their medicine
from a pharmacy at regular intervals for up to a year without
the need to return for repeat prescriptions from their prescriber.
When dispensing medication, the pharmacist has a duty to check
if the patient's circumstances have changed. Appropriate read
access to the patient's record would support pharmacists in carrying
out this check and appropriate write access for clinically significant
interventions would support the continued care by the patient's
5.8 There are also instances where patients
choose not to collect medicines prescribed for them. Allowing
pharmacists to write to the record would highlight these instances
and improve the medication record by logging medicines prescribed
and received rather than simply prescribed.
6.1 Appropriate role based access to the
NHS Care Records Service could support the seamless transfer of
care between primary and secondary care.
6.2 There are risks
inherent in the discharge of patients from secondary care and
in the general transfer of care. Research has demonstrated that
discharge medication summaries provided to the patient, GP and
the patient's nominated community pharmacist help reduce re-admissions.
6.3 Providing community pharmacists with
relevant role-based access to patient information will greatly
improve patient safety at the primary and secondary care interface
with the potential for pharmacists to have up-to-date information
and the medication prescribed to patients. If a patient's medication
therapy has been changed in hospital, it can result in patient
misunderstandings or problems with duplicated medicines which
community pharmacists can help resolve if they have access to
7. HEALTH AND
7.1 The Government has indicated
that it is serious about tackling violence and the threat of violence
against community pharmacists and many positive steps have been
taken to tackle this problem.
7.2 It is proposed that a "violent
warning marker" may be included on the NHS Care Records Service.
At present some trusts operate paper based systems to alert staff
about patients who have previously assaulted NHS staff and continue
to pose a potential risk. This information necessary for the protection
of pharmacists is currently not accessible. We believe that appropriate
role-based access should be available, particularly if the pharmacist
is undertaking a service that involves visiting the patient in
8. SUPPORT FOR
8.1 It is also worth noting that it is not
just the profession that believes that access to the NHS CRS is
necessary for the full potential of pharmacy to be realised. In
their recent written submission to the All Party Pharmacy Group
inquiry into the future of pharmacy, Which? stated: "Consumers
want and expect continuity of care and all healthcare professionals
(including pharmacists) involved in their care to have access
to their medical record. Without this, how can care be patient
9.1 We are aware that as community pharmacies
are readily accessible to the public, pharmacy must be able to
demonstrate that confidential information will be stored securely.
All community pharmacies already have robust systems in place
for handling patient confidential information and are subject
to a wide range of legal, ethical and professional requirements.
9.2 Pharmacy contractors are required to
comply with the legal obligations of the Data Protection Act 1998,
Human Rights Act 1998 and the common law duty of confidence and
under the NHS community pharmacy contract, pharmacy contractors
and their employees must also conform with the NHS code of practice
on confidentiality. The clinical governance framework assures
compliance by including polices for ensuring staff are appropriately
trained and that all staff contracts include clauses on patient
9.3 Pharmacists are also bound by the Royal
Pharmaceutical Society of Great Britain's (RPSGB) professional
"Code of Ethics and Standards" and can be held accountable
for breaches. Disciplinary action that can be taken may include
the pharmacist being removed from the professional register and
therefore being prevented form working as a pharmacist.
9.4 Pharmacists and their staff have worked
within these regulatory frameworks for many years. However we
welcome the additional safeguards that are being introduced into
the NHS Care Records Service to safeguard information. This includes
the use of smart cards to control access with PCT Registration
Authorities providing external control on the granting of individuals'
access rights, legitimate relationships, sealed envelopes and
the ability for patients to choose to dissent from their information
being shared. We believe that PCTs should be supported by national
guidelines to ensure consistency in permitting additional access
to Connecting for Health.
On behalf of the Association of Independent Multiple
Pharmacies, the Company Chemists' Association, the National Pharmacy
Association and the Pharmaceutical Services Negotiating Committee
15 March 2007
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