Northampton General Hospital NHS Trust

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Northampton General HospitalNHS Trust

Pharmacy

Clinical strategy

15th August 2009

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Page

Purpose and objectives of this document 3Strategic context 4What is Pharmacy? 13Pharmacy PESTLE analysis 14Pharmacy SWOT analysis 16Pharmacy strategic direction 21Pharmacy strategic bridge 22Pharmacy - ANSOFF matrix 24Pharmacy – five year plans 25Pharmacy strategic risk analysis 31Pharmacy – capital 32Pharmacy – Information management and technology 33Pharmacy – estates 34

Contents

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Purpose and objectives of this document

This document summarises the outputs from the pharmacy directorate business planning process.

This directorate strategy is a component of the Trust’s overarching clinical strategy which in turn is integral to the Trust’s integrated business plan and Foundation Trust application.

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Strategic context: vision and values

NGH has developed a clear, agreed vision for the future in response to the operating environment and changes in the target

market…

“The Trust’s prime focus is to provide excellent quality care to our patients, regardless of the setting where this is

undertaken”

In this context, the Trust’s vision is to….

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Strategic context: what the Trust vision means

Achieve excellent clinical outcomes for patients

Attain upper quartile benchmark for clinical outcomes, productivity and efficiency measures.Achieve year on year improvement of patient satisfaction, measured by the annual patient survey and local surveys/ forums/ complaints.Achieve / implement all patient safety related national targets and guidance.

Provide accessible services for all patients and commissioners

Equitable access to services for all of the local population including the disadvantaged and hard to reach.A reduction in the numbers of the local population leaving the county for treatment/ care.Waiting times that are shorter than the national targets.An increase in our market share from local commissioners.

Invest in our future – our staff, our services and our facilities

Re-invest surpluses to enhance our workforce in terms of attracting high calibre staff, training and education, team development and succession planning. Re-invest our surpluses and/ or realign service plans to embrace new clinical techniques and technologies in accordance with national best practice guidance.Re-invest our surpluses to re-provide or upgrade the physical estate to maximise clinical productivity, efficiency and patient satisfaction.

Be responsive to the changing environment

Flexible workforce to enable upsize/ downsize in capacity to meet demand.Innovation and willingness to create and adopt new ways of working including off site provision.Businesses agility to respond to commissioning intentions.

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Strategic context: strategic goals

The Trust’s vision will be achieved through three strategic goals:

• Continued improvement to the clinical quality, productivity and efficiency of existing services.

• Strengthening our specialist and tertiary services in order to provide care to the local population.

• Enhancing secondary care services in appropriate facilities away from the acute site, offering services closer to patients’ homes.

• All services will have excellent outcomes.• All services are supported by commissioning intentions.• Where there is statutory duty to provide a service, it will be provided.• All services will be financially viable.

Working towards this vision will ensure that…

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Strategic context: the operating environment 2009/10 – 2014/15

The operating environment 2009/10 – 2014/15 will be shaped by…

• Key national policies and initiatives especially:• NHS Next Stage Review: High Quality Care for All (‘Darzi’).• Transforming Community Services (TCS).• The development of World Class Commissioning (WCC).

• Local implementation of national policies and initiatives through:• Local commissioners’ WCC strategies and plans.• Specialist commissioning plans.

• The global economic downturn and resulting contraction in public spending at both national and local level.

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The combined impact of these mean an operating environment that will…

• Require even greater emphasis on quality, spanning three areas: patient safety; patient experience; and effectiveness of care. Patients’ perception of the quality of care they receive will directly impact on funding.

• Require holistic and collaborative approaches to service delivery, achieved by developing partnerships with a range of partners, depending on local need, to provide integrated services.

• Demand improved choice: providing patients with an informed choice of treatment and provider and piloting personal health budgets.

• Continue to push for improved access to services: including better services in the community and closer to patients’ homes.

• Drive the reinvigoration of practice-based commissioning, including piloting new integrated care organisations.

• Require financial savings, productivity and efficiency on a scale not seen before leading to downward pressure on tariffs, decommissioning of some services, increased market testing/tendering, ‘activity caps’ in contracts and further tariff unbundling.

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• Deliver higher quality services that meet patient and customer expectations.

• Find greater efficiencies and levels of productivity across all our service lines.

• Find new ways of collaborating with others to deliver services.

• Develop greater responsiveness to our commissioners’ needs and plans.

• Improve access to services for our population.

In summary, the new operating environment will need us to…

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Strategic context: our target market

• The local population - we provide general hospital services to around 370,000 people in and around Northampton.

• Specialist commissioners and a wider catchment population for some services - as a designated Cancer Centre we provide specialist services to approximately 880,000 people in East Northamptonshire, and parts of North Buckinghamshire and South Leicestershire.

• NHS Northamptonshire - our main commissioner of services.

• Nene Commissioning - a practice-based commissioning organisation representing 76 participating practices across key areas of the County; it is responsible for a budget of £275m to cover day case, elective and non-elective activity.

Our target market is…

Our aim is to remain the provider of choice in all of

our target markets

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Strategic context: factors driving demand

As illustrated opposite, the key factors driving demand are: national policy, demographics, health, healthcare of the Trust’s operating markets, age and gender within the Trust’s core catchment area, health risks, birth rates, current economic downturn and associated effects and other factors including political direction – contestability and plurality.

Socio-demographicsHealth needDisease prevalence

National policy

Technological changesModels of care

Market share/ Consumer choice

Local health economy strategiesLocal health economy financesCommissioner intentions

Current competitors

New market entrants

Trust strategy

Market place opportunities

and risks

Factors that influence demand

Factors that influence supply

Models of care

Socio-demographicsHealth needDisease prevalence

National policy

Technological changesModels of care

Market share/ Consumer choice

Local health economy strategiesLocal health economy financesCommissioner intentions

Current competitors

New market entrants

Trust strategy

Market place opportunities

and risks

Factors that influence demand

Factors that influence supply

Models of care

Other competitive factors and demand drivers include:

• The threat of substitution – There are increased healthcare options available to patients in the local markets e.g. laparoscopic rather than open surgery and an increased focus on self-care models and community based care.

• Bargaining power of suppliers – There is a high fixed cost base preventing ability to limit costs to meet reduced tariffs.

• Bargaining power of customers – There is a range of hospitals at which GPs and patients can choose to access healthcare.

• Threat of new entrants. • Competitive rivalry.

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Strategic context: demand for our services is likely to be shaped by…

A rapidly expanding population, with particular growth in the number of older people, which will increase demand for our services.

The leading causes of death in our catchment - circulatory disease (heart disease and stroke) and cancer - which will maintain demand for specialist services.

NHS Northamptonshire’s strategy, which makes provision for:• A reduction in growth monies from 5.3% in 2009/10 to 3% in 2012/13. • Clear metrics to measure improvement in key areas such as stroke and cancer. • A commitment to providing patients with a choice in how and where their care is

provided. • Plurality of provision to deliver services.• The development of cancer services at NGH, including enhanced provision of

radiotherapy.• The provision of additional services in the community by NGH where

appropriate.

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What is Pharmacy?

F/Planning/Pharmacy Model of Care/April 05

NGH

Pharmacy

NHT, PCTs, BMI Three

Shires, Two Shires Ambulance,

GPs, Chemists

etc

GPs, Community,

PCT

PCTs: Cynthia Spencer,

Favell House, BMI Three Shires

Danetre

Med-N Discharge Scheme

E Midlands, London Anglia,

Clinical Networks

MKGH, KGH, PCTs BMI Three Shires

MKGH, KGH,

Hinchingbrook

Electronic Data

Interchange, REVIVE etc

Patients’ Own Medicines Scheme

Community Students (Pre-registration)

Porters

NPAG PCT GPs

Contractual and Other Support:

Oxford Radcliffe Trust, LNR WDC, UWCC Diploma, UKCPA, Leicester College,

Others

Pharmacy Model of Service v6

Procurement & Supply (Procurement, Distribution and

Dispensing)

All Wards/Depts

Aseptic Services (Manufacturing and Dispensing)

Patients/ wards

Quality Assurance (Environmental Monitoring, Gas Testing)

Theatres, SSD

Medicines Information

(Advice on Medicines)

Patients, Healthcare

Practitioners IT Support &

Development (Pharmacy EDS System

& Other Systems) Clinical Services

(Clinical Advice)

Ward Visits

MMC/ FC

Formulary & Dressings Formulary

Administration/ Management

Training/ Support

Doctors in Training, Nurses, Healthcare

Professionals

DH Licences, MHRA NHS PASA Thames Valley Consortium

Homecare

Patients at Home

Directorate Support Pharmacy PMH

NHT KGH

Nuclear Medicine

GPs, Community, Ambulance Service

20% of work is not done

for NGH

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Pharmacy PESTLE analysis Political- The following “political” areas have/will have an impact on the pharmacy directorate and need to be

managed/considered in line with future strategic plans administered: - With patient choice, co-payments will mean that patients may elect to pay for non-NHS funded medicines in

addition to their NHS care.- In the national in-patient survey the discharge questions lead to focus on pharmacy provision of discharge

medicines and there is a perception that delays are due to pharmacy. - Care Quality Commission (CQC) and the NHS Litigation Authority (NHSLA) Standards and NHS targets impact

on each part of the medicines pathway from admission, in-patient stay through to discharge. All aspects require increased pharmacy focus with same or reduced staff numbers.

- The directorate and the Trust also needs to consider independent sector competition. Community pharmacy chains/commercial sector may look to provide parts of hospital pharmacy services.

- There is a workforce challenge which has to be met. An increase in the number of non-medical prescribers would improve convenience and possibly the efficiency in supply.

Economic- The following “economic” issues have/will have an impact on the pharmacy directorate and potentially

beyond and need to, therefore, be managed/considered in line with future strategic plans administered: - Within the PbR framework there are no HRGs/ tariffs for specifically for pharmacy.- With regards to the risk sharing schemes, NICE is approving more medicines for NHS use linked to funding/

reimbursement schemes with manufacturers.- The changes anticipated in NHS Funding is another reality which all the directorates will need to consider as a

key variable in their strategy. There are already shortfalls in pharmacy provision and the financial climate will lead to less funding and not more. Pharmacy's activity contributes around £1,000,000 per annum towards medicines savings/containment. The achievement of this is threatened by the need for pharmacy itself to achieve its cost improvement plan.

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Pharmacy PESTLE analysis Socio-Cultural- The shift in population changes are being reflected in numbers of admissions. - With regards to population demographics, more patients will be elderly, more will have diabetes, more will have

heart disease etc, leading to more complex medicines treatment with expected reduced length of stay. This forecasted scenario will require prioritisation/focussing of clinical pharmacy activity on the wards.

- The labour market is also a key issue. There is a shortage of qualified hospital pharmacy staff. It is an aim of the directorate to make the NGH pharmacy directorate the best pharmacy to work in.

Technological- Extend automated dispensing, the procurement of an e-chemotherapy prescribing system, the change from

Revive e-discharge system to Teleologic and e-prescribing for DGH [2013/14] will all have a positive impact on the directorate.

- Technological advances such as the pneumatic tube delivery system, more biologicals and targeted therapies and more oral chemotherapy, and less injectable would improve delivery and governance arrangements.

Legal- Key legal challenges are based around NICE technology appraisals and the increase in the number of National

Patient Safety Agency (NPSA) alerts related to medicines, achieving the good manufacturing practice and good distribution practice level to ensure manufacturer's and wholesale dealer's licence is maintained. There is also pressure from the monitoring use of controlled drugs to consider.

Environmental- Key issues here are around pharmacy and car parking space. More is required as it is constraining the ability to

manage workload safely.

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Pharmacy SWOT analysis Strengths

Good portfolio/range of functions [compared to surrounding DGHs].Department of Health licensed specials unit and licensed wholesaler dealer.Integration into clinical teams in some areas, e.g. heart and kidney centre, HIV.Several specialist posts.Services provided to other Trusts/organisations.Strong formulary and medicines management committees.Effective MM technicians and patients own medicines scheme [in some areas].Robust formal training [Trainee MTO, pre-registration pharmacists, diploma].Low sickness absence.Automation.Physical location of NGH pharmacy.Pharmacy staff access to IT hardware, systems, expertise.Accurate discharge medicines information for GPs.

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Pharmacy SWOT analysis

Weakness

Some gaps in service provision:- Reconciliation on admission [45-50%].- Audit of medicines use and practice.- Pre-op assessment.- A&E.- Theatres.- Obstetrics.- Corporate medicine incident monitoring and management.- Week-end and out of hours (OOH) access to pharmacy.

Little training/ education for pre-and post-registration doctors/nurses.Functional responsibility for ‘safety’ within pharmacy structure.Supervision and management of junior pharmacists.Matching staff numbers/skills to discharge and dispensing workload.Poor IT systems to audit medicines use for governance and expenditure reporting.Tracking and apportioning medicine CIPs.Physical space at NGH pharmacy and departmental configuration.

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Opportunities

NHS and NGH safety focus.More integration of pharmacists into directorates.Linking cost improvement plans on medicines to pharmacy cost improvement plans and better ‘tracking’.Service improvement projects within Trust.More non-medical prescribers for convenience and efficiency.Electronic prescribing of chemotherapy.Replacement of revive with Teleologic [e-discharge system].Replacement of pharmacy computer system [2010/11].Out-reach. Danetre? And homecare?Closer working with primary care trust in managing long-term conditions and prescribing costs.Pharmacy White Paper and recognised need for pharmacy input at strategic health authority level.Physical space problems now recognised by Trust.

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Threats

National shortage of qualified pharmacy staff.Reductions/changes to NGH services eg. cancer status, stroke, vascular etc.National and local pressure on points of admission, in-patient stay and on discharge, leading to conflicting priorities.Cash releasing cost improvement can only come from pharmacy staff budget.Loss of income from BMI Three Shires.High cost and commitment to training and reductions in HWD funding.Provision of hospital pharmacy services by the private sector.Likely agenda for change (AfC) changes to emergency duty remuneration.Insufficient funding for medicines.Increasing numbers of risk sharing schemes supported by the national institute for health and clinical excellence systems.Introduction of co-payments/top-up systems.‘Responsible Pharmacist’ regulations?New care quality commission standards relating to self-administration in hospital [from 2010].

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Summary weaknesses, opportunities and threats

Key weaknesses to address:Gaps in provision [surveillance].

Gaps in provision [access].

Safety ‘function’ in pharmacy.

Space.

How to address them:Prioritise and negotiate with directorates.

Develop options for improving access with Trust eg. Sundays; one-stop/pre-packs etc.

Re-organise in pharmacy.

Identify and occupy space [Billing House?].

Key opportunities to address:Directorate integration.

Service Improvement eg. emergency care.

Increase in oncology activity and outreach.

More non-medical prescribers.

Self-administration [2010 care quality commission standards].

How to address them:Service level agreements and developments via Trading a/cs.

Implement recommendations.

Redesign; shared care; ‘homecare’?, satellite dispensaries?

Pharmacy/nursing/directorate strategies.

Extend MM technicians responsibilities.

Key threats to mitigate:National pharmacy staff shortage.

Pressure on admission, in-patient stay and on discharge, leading to conflicting priorities.

Cost improvement plans [medicines and pharmacy].

Funding for training.

Increase in weekend discharges.

How to address them:Make NGH best pharmacy to work in.

Agree priorities with Trust via modernising medical careers (MMC)/governance/ directorates.

Agree system with DoF; directorate integration.

Stop/reduce or fund from elsewhere.

Agree process and support to enable.

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Pharmacy strategic direction

To maintain the efficiency of core services eg. ordering, receipt, storage, distribution, dispensing, prescription surveillance and to maintain MRSA licences.

To develop services by focusing and prioritising with the emphasis on safety and efficient discharge , within the context of increasing complexity of treatment with medicines, increasing expenditure on medicines, reduced length of patient stay, reduced doctor’s hours etc.

To link cost improvement/cost minimisation of medicines to pharmacy activity.

To work with the primary care trust and other organisations to improve the safe use of medicines at transitions of care [admission, discharge, out-reach, off-site provision and more services within primary care].

To create a pharmacy culture with two themes: safety in the use of medicines, and an environment of support for staff.

To ensure tasks are done by appropriate staff whilst also ensuring safety and adequate training; in particular to further develop technical staff to work with patients to improve their adherence and make savings by the efficient use of medicines.

To support specialisation and personal development within the context of NGH developments and a possibly reducing Trust workforce.

To develop IT systems and processes to improve safety, efficiency and audit.

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Pharmacy strategic bridge

Extensive safety work, audit etc, but little focus and co-ordination. No corporate analysis of medication incidents.

46% of admitted patients have a pharmacy reconciliation of their medicines; EAU covered five hours per weekday.

35% of discharge medicines dispensed as one-stop; use of pre-packs out-of-hours.

57% of e-discharges and 25% of in-patient prescribed items require pharmacy intervention; little MM training of medical and nursing staff.

Extend reconciliation on admission to reduce medicines management

problems.

Facilitate safe, efficient and effective discharge.

Improve appropriateness of prescribing via training and IT solutions

2009/10Improved safety in the use of medicines evidenced by audit and indicators in quality accounts, NHSLA and CQC standards.

90% of patients to have a pharmacy reconciliation on admission via extending input at points of admission and pre-op assessment.

Most patients to be self-administering, discharged with pre-packs or one-stop dispensed medicines all high risk patients with a pharmacy care plan.

Full e-prescribing with decision support and prescribing competence assessment.

2014/15

Develop ‘safety function’ within pharmacy

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Pharmacy strategic bridge

Full integration of pharmacy into directorates to improve safety, economical use of medicines, service planning, cost improvement plans etc.

Less than 1% stock-outs, 90% of dispensed items to be completed in less than one hour.

More specialist dispensing eg. chemotherapy, HIV.

100% of staff with 15 month appraisal. Extended use of national development frameworks.

More non-medical prescribers.

Consultant pharmacist post.

Consolidate technical services to maximise efficiency within pharmacy

[procurement, dispensing, etc].

Improve staff development

Medicine and pharmacy issues only integrated into some directorate teams to limited extent; levels of service unquantified.

Out-of-stock occurrences too frequent and process times for dispensed medicines too variable.

Limited ‘specialist’ dispensing.

75% of staff with 15 month appraisal. Limited use of competence frameworks.

Two pharmacist prescribers.

2009/102014/15

Integration of pharmacy into directorate teams

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Clinical surveillance/ reconciliation on admission to: A&E, pre-admission clinic, obstetrics.

More time on EAU; paediatrics.

Patient’s Own Medicines schemes on more wards.

More pharmacist prescribers.

More training of medical and nursing staff.

MM technicians assessing for self-administration.

Medicines management in theatres.

Corporate medicines Incident management.

Paediatric total parenteral nutrition (TPN) production [KGH same day service].

Focus on core pharmacy services.

National patient safety agency (NPSA) safety alert management.

Medicine use/practice audit.

Sunday pharmacy service?

Paediatric total parenteral nutrition production.

Existing

E

xist

ing

New

(wid

er)

Pharmacy - ANSOFF matrix

Services New

Markets

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Pharmacy five year plans: Priority service developments [1]

Priority 1Safety

Create safety function in pharmacy.

Corporate analysis of medication incidents.

Refined medicine safety indicators and robust audit programme.

Priority 2Consolidation

Improve stores & dispensary performance.

Expand space available.

Refocus clinical service.

Review patients own medicines scheme.

Combine oral and parenteral chemotherapy dispensing.

HIV and trials dispensary?

Automate robot filling.

Priority 3 =Reconciliation

Refine current systems and recording.

Directorate discussion: extend EAU coverage? start pre-op assessment? extend prescription only medicines?

See also directorate integration workstream.

Integrated primary and secondary care information.

Developments over the next five yearsYear 1 Year 2 Year 3 Year 5Year 4

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Priority 3=Discharge

Increase use of pre-packs where appropriate.

Service Improvement project.

Case for Sunday service.

Targeted one-stop dispensing.

Enhanced performance management of discharge process.

Issues also tackled via directorate integration workstreams.

Priority 3=Technology

Implement e-Rx in chemotherapy.

Change to Teleologic.

Plan for replacement of Pharmacy system.

Replace Pharmacy system.

Integrate pharmacy with e-discharge and e-Rx chemo.

Implement national e-prescribing solution in NGH.

Priority 3=Cost improvement plans

Agree management of cost improvement plans on medicines.

Enhance system of tracking and apportionment.

Issues also tackled via directorate integration workstreams.


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Priority 4=DirectorateintegrationOncology

Clarify services currently provided to directorate.Agreement to

up-grade to recruit.

Discuss with directorate re. managing growth, cost improvement plans, access, audit, NMP etc.

Medicines and pharmacy issues fully integrated into directorate plans.

Priority 4=DirectorateintegrationMedicine

Clarify services currently provided to directorate.

Discuss with directorate re. invest/divest to save and/or improve quality eg. EAU cover, cost improvement plans , A&E, extend prescription only medicine/ reconciliation, NMP?


Priority 4=DirectorateintegrationSurgery/anaesthetics/critical care


Discuss with directorate re. invest/divest to save and/or improve quality eg. pre-op assess, theatres, cost improvement plans, extend prescription only medicines / reconciliation, NMP?



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Priority 4=DirectorateintegrationChild Health

Clarify services currently provided to directorate.Clarify current discussions re. investment.

Discuss with directorate re. production of TPN, cost improvement plans, NMP etc.HIV service?

Medicines and pharmacy issues fully integrated into directorate plans

Priority 4=DirectorateintegrationTrauma and Orthopaedics


Discuss with directorate re. invest/divest to save and/or improve quality eg. extend prescription only medicine/ reconciliation, cost improvement plans, NMP?


Priority 4=DirectorateintegrationObstetrics and Gynaecology


Discuss with Directorate re. invest/divest to save and/or improve quality eg. obstetrics, cost improvement plans, CNST 2/3, NMP?



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Priority 4=DirectorateIntegrationHead and Neck


Discuss with directorate re. invest/divest to save and/or improve quality eg. extend prescription only medicines/ reconciliation, cost improvement plans, NMP?



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Pharmacy five year plans: Priority service developments

Oncology:- Growth in oncology.- Loss of cancer centre status.

Child health – countywide child surgery service/development of HIV service could have big implications for pharmacy.The two areas listed above are the developments the pharmacy directorate will watch and keep talking to other directorates about.

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Pharmacy strategic risk analysis

Source of risk

Trust service changes

Supply of qualified staff

Cost Improvement

Available funding/zero growth

Pharmacy objective threatened by risk

Stability of all pharmacy services.

Improvements in performance, access, reconciliation, e-chemo Rx implementation, prescription only medicine savings, paediatric HIV etc.

Funding for adequate staff.

Development of pharmacy via directorate integration.

Risk description

Loss/reduction of oncology, stroke, trauma etc will require pharmacy costs to be removed.

Lack of staff limits development; increased use of locums; prioritisation.

Pharmacy cost improvement plan from staff costs unless linked to medicines savings or other Trust activity.

Directorates may look to reduce pharmacy costs rather than from medicines.

Action / treatment

Protect non-NGH work; better financial analysis.

Make NGH pharmacy best place to work; train own staff; skill mix.

Link pharmacy cost improvement plan to medicines/Trust activity.

Discuss with directorates.

Responsibility Chief pharmacist and finance.

Chief pharmacist. Chief pharmacist and finance.

Chief pharmacist.

Sources of assurance

Scorecard. Scorecard. Finance monitoring. Directorate performance meetings?

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Pharmacy - capital

Key capital requirements

August 2012,

Robot lease

2013/14.

2 x ASU laminar airflow cabinets (£60,000).

1 x Positive pressure isolator (£30,000)

Details from finance asset register

Implication Capital requirementsYear 1 Year 2 Year 3 Year 5Year 4

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Pharmacy – information management and technology

Key information management and technology requirements

2010/11

Replace pharmacy EDS system.

Interface with e-chemo prescribing system

2013/14

NGH e-prescribing interface to pharmacy system.

PPM/

replacement

PPM/

replacement.

PPM/

replacement.

PPM/

replacement.

PPM/

replacement

Implication Information management and technology requirementsYear 1 Year 2 Year 3 Year 5Year 4

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Pharmacy - estates

Key estate requirements

More space; Billing House Identified as option.

Aseptic support room expansion.

Consider direct delivery to pharmacy [rather than via Main Stores].

Consider re-configuration to improve patient and visitor reception.

Implication Estates requirementsYear 1 Year 2 Year 3 Year 5Year 4

Documents

Northampton General Hospital NHS Trust